Chapter VI: Part 6

=Suppression of the Menses.=—The cessation of the periods may be due to other causes, but it is usually the first indication of pregnancy. Conception may take place and menstruation yet continue. It usually occurs but once or twice, and then only where conception took place immediately before an expected period.

=Morning Sickness.=—Nausea and vomiting continued for any length of time is almost a certain sign of pregnancy. It may begin as soon as conception takes place and last for many months; sometimes it may occur toward the end of pregnancy, or occasionally not at all.

=Salivation.=—The excessive secretion of saliva often accompanies the morning sickness. The secretion is tenacious and difficult of expectoration. Heartburn, abnormal appetite, longing or loathing for particular articles of food, toothache and the like may be present.

=Quickening.=—The first feeling of fetal life felt by the mother is usually between the fourth and fifth months, but may be experienced occasionally as early as the third month, or be deferred until the sixth. Quickening occurs as soon as the uterus comes in contact with the abdominal wall. Improper elimination of the bowels, causing gastro-intestinal trouble, may produce movements not unlike this indication; therefore, this symptom is not reliable.

=Enlargement of the Breasts.=—The breasts grow larger toward the end of the second month. In some cases the enlargement is very marked, but in others there is scarcely any increase in size during the whole term of pregnancy.

=Pigmentation.=—Coloring of the skin takes place in different parts of the body. The face may show brownish spots. The skin darkens in the axilla and in the areola of the breasts. A dark line presents itself down the middle of the abdomen. The vagina takes on a violet tint, the cervix becomes purple, the various colors becoming more marked with the progress of pregnancy.

=Changes in the Abdomen.=—The abdomen grows larger gradually, and with it the gait and carriage of the woman change, to counterbalance the weight of the abdomen. It enlarges symmetrically unless the uterus is displaced by adhesions, or by a tumor in the uterus or external to it. The tearing of the under layer of the skin of the abdomen while distended produces streaks (stria), first pink and then white, which remain after the form resumes its natural shape; any other enlargement of the abdomen, especially when caused by a tumor, may produce the same result. The various conditions mistaken for pregnancy, due to changes in the abdomen, are fibroid in uterus; metritis; swelling of the tubes and ovaries, distended bladder, a pendulous belly; excessive fat; extra-uterine pregnancy; and inflammatory conditions, such as peritonitis. Pregnancy and any of the conditions named may coexist, and the former may be overlooked, while the latter is recognized.

=Fetal Heartbeat.=—The heart sounds are generally audible between the fourth and fifth months. The rate is from 120-140 a minute, being double that of the mother’s pulse. About midterm is heard the uterine souffle, a blowing sound, quite unlike the fetal heart, and its origin is the rushing of the blood through the enlarged and twisted arteries.

=Ballottement.=—In normal cases there is no pain on palpation. The uterine wall varies in consistence, being alternately soft and firm. The fetal parts may be felt through the abdominal wall in the late months.

=Lightening.=—In the last two weeks, especially in primiparæ, the child’s head sinks into the pelvis, and its body falls a little forward. The uterus sinks down and forward with the child. The waist-line lowers, the stomach region is flatter, the navel more prominent. The patient breathes easier, but does not walk as well.

=Duration of Pregnancy.=—Average time is 280 days; protracted, 314; a short term about 245 days. There is no positive period.

=Prediction of the Date of Labor.=—Count 9 calendar months from the beginning of the last menstruation and add 7 days. An error of 2 or 3 weeks, however, is possible. (See Table on page 178.)

=Premonitory Symptoms of Labor.=—(1) _Lightening._—Dropping may be attended with slight pains similar to labor pains.

(2) _False Pains._—These vary in nature and quality. They may be short and sharp, or long and continuous, or irregular. As a rule, they are marked by irregularity. They are mostly abdominal, rarely like true pains beginning in the sacral region and moving around to the region of the pubes. They may be caused by cramps in the abdominal wall, intestines, or in the distended bladder. They may be due to old inflammatory areas within the abdominal and pelvic cavities. They are frequent in cases in which there is marked bowel irregularity, and in conditions of over-fatigue. Some authors believe that they may be produced by irregular contractions of portions of the uterine wall. One important test is the condition of the uterine body during the pain. If there is no genuine contraction, the uterus will not become hard when pain is felt. This indication is not always reliable, however, since palpation may be unsatisfactory on account of the woman’s nervousness, her sensitiveness, or the thickness of the abdominal wall. If the cause be contractions of the uterus, partial hardening may be felt.

TABLE FOR CALCULATING THE PERIOD OF UTERO-GESTATION.

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January | 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31|
OCTOBER | 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1 2 3 4 5 6 7|NOV.
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February | 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 |
NOVEMBER | 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 1 2 3 4 5 |DEC.
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March | 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31|
DECEMBER | 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1 2 3 4 5|JAN.
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April | 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 |
JANUARY | 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1 2 3 4 |FEB.
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May | 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31|
FEBRUARY | 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 1 2 3 4 5 6 7|MAR.
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June | 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 |
MARCH | 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1 2 3 4 5 6 |APRIL.
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July | 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31|
APRIL | 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 1 2 3 4 5 6 7|MAY.
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August | 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31|
MAY | 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1 2 3 4 5 6 7|JUNE.
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September | 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 |
JUNE | 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 1 2 3 4 5 6 7 |JULY.
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October | 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31|
JULY | 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1 2 3 4 5 6 7|AUG.
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November | 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 |
AUGUST | 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1 2 3 4 5 6 |SEPT.
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December | 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31|
SEPTEMBER | 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 1 2 3 4 5 6 7|OCT.
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EXPLANATION.—Find in top line the date of menstruation, the figure below will indicate the date when confinement may be expected, _i.e._, if date of menstruation is June 1st, confinement may be expected on March 8th, or one day earlier if leap year. (Dr. ELY.)

(3) _True Pains._—The contractions of the uterus as they become stronger, in the great majority of cases, cause the woman pain. For this reason “true pains” is used synonymously with “uterine contractions.” With their appearance the woman becomes restless, likes to sit down, to bend forward and to press on the sacrum. “True pains” are felt in the sacral region, gradually moving around toward the pubes. They begin slowly, increase in intensity, and slowly pass away. The pains are involuntary, and the woman tries to complain or cry out. Differences in this largely depend upon the nervous temperament of the patient, though they are also related to variations in the physical factors. “True pains” must be distinguished from “false pains.”

(4) _The Show._—Within twenty-four hours before labor really begins there is a discharge from the vagina of thick mucus, more or less stained with blood. This is called the “show,” and is the plug of mucus which fills the cervical canal during pregnancy. Sometimes the show is absent or appears after labor has been in progress for awhile. If there is much pure blood with the discharge it is unusual, and the physician should be notified.

LABOR.

=First Stage.=—The first stage extends from the time of the labor pains to the complete dilatation of the os uteri. It may come on very slowly or act quickly. Slow dilatation occurs normally in a woman over thirty years of age; and it may be due to inflammatory conditions or appear in cases where the membranes lining the uterus are adherent. On examining the vagina there is found a bulging (which is a main factor in dilatation of the cervix) and a discharge of mucus tinged with blood. The dilatation increases until it is 4 in. across, and the bag of membranes bulges like a saucer. In abnormal cases it comes down into the vagina in the shape of a tube. When the os is fully dilated the membranes rupture, a rush of water escapes down the vagina, and the first stage of labor is ended. Not all of the water comes away, for the head comes down and acts as a plug. It is very important for the nurse to recognize the true rupture and not mistake it for incontinence of urine.

=Second Stage.=—This comprises the period from the time of complete dilatation of the cervix to the end of the expulsion of the child. The patient has some relief after the first stage, and when the second stage comes on she holds her breath and contracts the abdominal muscles as much as she can in making expulsive efforts. The pains become of longer duration and more frequent; and upon examining the vagina the head is found down, the tissues bulge, the rectum becomes stretched, the majora and minora separate, and then, while the pain is on, there is some change in the position of the head as it recedes and advances again. Nature brings it slowly, for if the head plunged down it might produce complete laceration of the perineum. If the head is delayed too long there is swelling of the scalp. The most painful period is when the head passes the perineum. Then there comes a marked change in the position of the fetus, and it lies in that position for some time; following, comes a rotation to one side, the shoulders turn, and birth occurs. The cord is still in the vagina, and the third stage begins with a flushing of amnii fluid. The placenta is still in place in the uterus. The child may cry, and the pulsation may continue in the cord for as long as fifteen minutes, but ordinarily for about five minutes, while a new circulation is established in the infant and more blood is drawn from the placenta.

=Third Stage.=—The patient has a rest for some minutes. Then the contractions of the uterus continue until the membranes and placenta are expelled. The pains begin again; the uterus is smaller, firm, yet will recoil; it is rounded, and the fundus lies even with the umbilicus. If the fundus is above the umbilicus something is wrong. Painful contractions of the uterus follow and cause a squeezing off of the placenta. There is a flow of blood, the placenta follows, passes out of the vagina, dragging the membranes after it. The fundus sinks, and the uterus, hard, contracted and firm, lies in the pelvis. In some cases it becomes soft, rises up and then relaxes. If it becomes too soft, the relaxation which follows may induce hemorrhage. The uterus should be carefully massaged until it hardens.

=Period of Labor.=—Fourteen hours is a normal range. First stage usually lasts about twelve hours; second stage about one hour, and the third stage from fifteen to thirty minutes.

=Complications of Labor.=—Labor may be brought on by extreme mental anxiety. The child may be born without any actual pain. It may be expelled while the patient has an evacuation of the bowels, especially if the bowel movement has been induced by enemata or a purgative. Children may be born without the usual progression of labor, yet with all normal conditions present. In cases where the mother dies during labor the uterus continues to contract until the child is born about fifteen minutes later. The child in such cases is sometimes saved by a Cesarean section.

CARE OF THE OBSTETRIC PATIENT.

=Diet.=—Diet should be regulated and consist of light, nutritious and predigested foods. Milk should be prepared in various ways palatable to the patient. Wine and fruits and vegetables in season may be included. For malnutritious patients, malt and beef extracts may be added. Starches prepared in fat, and rich pastries should be avoided.

=Elimination.=—The bowels must move regularly, and laxatives may be given if necessary. Alkalies should be given before bedtime, and effervescent powders in the morning. Enemata should not be resorted to unless absolutely necessary, as the sudden expulsion of the contents may produce abortion. The kidneys may be regulated by giving simple diuretics; plenty of pure water is the best. The condition of the kidneys is a most important factor in pregnancy. The urine should be clear and of sufficient quantity. Meats should be eaten but sparingly, as they over-produce albumin.

=Baths.=—Daily bathing in tepid water is very essential to encourage the elimination through the skin and to promote cleanliness. A cold sponge is stimulating and very agreeable to some patients.

=Exercise.=—Exercise should be moderate. Light work about the home may be encouraged, care being had to avoid over-lifting, over-reaching, etc. Walking should be insisted upon, to maintain correct carriage and posture of the body. Outdoor enjoyments may be had if indulged in with discretion. Tiredness may be overcome by the patient lying down on an incline, the head lower than the body, thereby relieving all tension of the muscles and nerves. Any recumbent position for comfort is beneficial.

=Breasts and Nipples.=—Plenty of room should be given to permit full growth and to encourage the nipples to prominence. Their inversion or depression may be remedied by massage and manipulation. No alcohol or other strongly astringent washes should be used. The nipples must not be hardened, but should be kept soft and pliable; cocoa-butter or other healing ointments may be applied. Cracks and fissures not only render nursing difficult or impossible, but may lead to mastitis and subsequent abscess formations. There should be perfect cleanliness, to promote pure secretion and prevent sepsis.

=Pelvic Organs.=—Pelvic organs do not, under normal conditions, require douches. The normal vagina cleanses itself, and a hot douche may induce abortion.

LYING-IN PERIOD.

=Confinement Room.=—A quiet room should be selected, in which there has been no recent sickness and which is not in proximity to any sewerage. The room should be well ventilated, with no draughts, and at a temperature from 65°-75° F. The furnishings should be plain and few as possible. They should consist of a table or two, a few chairs, and a narrow iron bed of medium height. If the bedspring is soft, a few boards may be placed under it to make it firm. If the patient is to be delivered in bed, it should be made up as follows: (1) Long rubber sheet; (2) long muslin sheet; (3) rubber draw-sheet; (4) muslin draw-sheet; (5) a large pad, 3 ft. square and 3 in. thick. All sheets should be fastened with large safety-pins, and the pad left free to draw the patient to either side, if the bed is of the low-and-wide variety commonly used in many homes. The ideal way is to deliver the patient on a settee, or on two tables, covered with a small mattress; the physicians and nurses have less work to do and they work to a better advantage. Moreover, when the patient is carried from the table to her clean, warm bed she gets immediate comfort and avoids the usual disturbance and uncleanliness attending the clearing away of soiled linen, etc.

=Preparatory Treatment for Patient.=—The patient should have a warm bath, and the genitals should be scrubbed thoroughly with soap and water. Shaving the parts is much to be desired if the patient has no objection, then an antiseptic pad should be applied. The nurse must be sure the bladder is empty; it is very important that a dribbling from an over-distended bladder should not be mistaken for frequent urinations; this is to prevent the danger of ruptured bladder from the constant pressure of a contracting uterus; also a distended bladder makes labor hard by interfering with the passage of the head.

=During the First Stage.=—The patient may be out of bed and encouraged to take exercise. She should not walk about too freely before the head is engaged, lest this induce a malpresentation or malposition. The patient’s crying should not be prevented, and she should be told not to press down. She may have a cup of hot water or tea, but no stimulant, as an anesthetic may become necessary.

=During the Second Stage.=—All clothing should be removed but the night-dress. Pin the gown up under the arm, put on perineal drawers, and a sheet around the body, then place the patient in bed. The pain in the back may be relieved by pressure over the sacrum, and the patient should be encouraged to hold her breath. The nurse should now use tact to quiet the patient, having hitherto managed, if possible, to encourage calmness. For cramps in the limbs, the muscles may be moved and firm pressure applied. A handkerchief bound tightly around the affected part may relieve it. A sheet may be tied to either side of the bed, for the patient to grasp, and a block placed at the foot of the bed for a brace for her feet.

=Patient After Labor.=—The soiled skin should be gently and quickly bathed with warm solution, the vulva and perineum carefully cleansed and an antiseptic pad applied. The binder should be pinned firmly about and below the hips, allowing freedom over the upper part of the abdomen. If there is any anxiety that the uterus may relax after kneading it, a tightly folded towel may be placed over the fundus, and kept in position by the binder. A vaginal douche is never given without orders from the physician. External douches of lysol, 1 or 2 per cent., are given three or four times daily until the lochia becomes scant. The patient should be watched during the first few hours for symptoms of hemorrhage. The room should be kept quiet and dark, and light, warm covering be used on the bed. The patient may have a cup of hot water or milk to induce sleep and relieve thirst.

=Diet.=—During the first twelve hours the patient should be kept on liquid diet. On the second day, butter toast, milk toast, oyster stew, and chocolate may be added. On the third day, if the bowels move freely, soups, with rice or barley, and cereal foods may be given. Stewed fruits (omitting those strongly acid) may be included. After the fourth day, fresh fish, a chop, chicken, and pigeon may be given. Even after ordinary diet is ordered, heavy meats and rich pastry should be avoided for a while.

=Bowels.=—The bowels are usually constipated for the first few days. A dose of castor oil may be given, to be followed in six hours by a saline enema. The patient should be encouraged to drink freely of pure water, to secure proper elimination of the kidneys. If the patient can not urinate, after the different methods to produce urination have been tried, she may be catheterized. The urine should be measured for some days to ascertain if the quantity is sufficient.

=Colostrum.=—The first secretion in the breasts contains no nourishment, but is a laxative for the child. The baby should be put to the nipple as soon as the mother has had some sleep and feels rested. Nursing assists the uterine contractions, preventing hemorrhage from the torn placental vessels and cleansing the organs from secretions still being discharged at intervals.

=Breast and Nipples.=—The nipples should be cleansed after each nursing with warm boric solution. If they are cracked and sore a lubricating ointment should be applied and a nipple shield should be used. If the breasts become distended they should be massaged gently every two or three hours, and they may be pumped if necessary. In this state the patient must not have regular liquid diet, and the bowels must be kept freely open with saline laxatives. A compressed binder is comforting and beneficial. If the child, for some reason, does not nurse, the secretion may be dried by an application of belladonna in the form of a plaster, permitting the nipples to protrude through an opening cut into the center of it. The belladonna ointment is good but very unclean. Atropin may be given internally.

=Conditions During which the Child Should Not Nurse.=—Depressed or cracked nipples; inflammation of the breasts; poor health of the mother; marked anemia; kidney or heart disease; nervous or general febrile afflictions; tuberculosis; syphilis.

_Menstruation._—If the return flow of the menses occur during the nursing period the milk becomes impure, and the child may suffer from the effects of it. If menstruation takes place normally and the child does not become ill, it is because the mother is strong and can endure the drain upon her system with no other bad result than losing flesh. In such a case it is best to wean the baby, especially after it is nine months old.

CARE OF THE BABY.

=Upon Birth.=—As soon as the eyes are cared for, by flushing them with warm boric solution (the physician may use Credé’s method—1 to 2 per cent. nitrate of silver solution, followed by weak salt solution), the baby should be wrapped in a warm, soft, sterile cloth (cotton flannel), and placed in a warm crib until the mother has been attended to. After that the baby should be anointed with warm olive oil, especially in the groin, axilla, in the folds of the neck and behind the ears. The nurse should then wash and sterilize her hands to dress the cord. Apply alcohol, 95 per cent., and then boric acid powder or any other antiseptic dressing the physician may order; it may be kept in place by a thin flannel binder, going around the abdomen but once and be fastened in the back (not too tightly) by sewing it together. Pins of any kind should be used only where absolutely necessary. The baby should be dressed in as few garments as possible.

=Bathing.=—Until the umbilicus is healed the child should not be put in the full bath. The face, hands, and head may be sponged daily with tepid water. Gently massaging the body every day with warm olive oil, and rubbing with a soft towel, will not only keep the baby clean, but prove beneficial. The genitals should be washed well once daily and sponged after each evacuation of the bowels. During the first few weeks a little oil rubbed into the parts is better than powder; in most cases powder will dry the skin too quickly and rub off the delicate epithelium.

=General Care of the Baby.=—The eyes, the mouth, and navel should be given the usual daily attention. The bowels, if constipated, should be encouraged by small doses of castor oil given with a medicine dropper. If the urinations are not clear and of sufficient quantity the baby may have warm water, about 1 oz. at a time, three or four times daily. Leave the infant with the mother _only_ during the nursing period.

=Nursing the Baby.=—Practical experience is daily upsetting the theory that a set of rules and regulations can be laid down and followed for the nursing of all babies; that nursing must be done at certain hours and after certain intervals. While babies are alike in nearly every respect, speaking physiologically, there are only a few who can be awakened at regular intervals to be nursed by the mother or fed by the bottle. Some babies can not be awakened sufficiently for nursing, even after four or five hours’ sleep. Others will nurse for twenty minutes (the rules say it should not be longer than ten minutes) at two- or three-hour intervals during the day and then sleep all night.

Of course, where the child can be fed regularly, this helps the mother to regulate her own habits, and is comforting to all concerned. Therefore, nurses should not lack in determination to encourage such a system. But no such regularity should be insisted upon where both baby and mother suffer during the interval when nursing is denied; the former, hungry and crying lustily, and the mother under a nervous strain that is harmful to both. Let there be no hard-and-fast rules. Babies who feed as often as they feel like it (being allowed proper, though not necessarily long, intervals for digestion) generally suffer no ill effects and are healthy and strong. Mother’s milk, the natural feeding, should always be given, rather than any artificial food, when the supply is sufficient and good.

OBSTETRIC SUPPLIES.

=Solutions:=
Antiseptic solutions.
Normal salt solution.
Spiritus frumenti.
Fluid extract of ergot.
Plenty of sterile water (hot and cold).

=Articles:=
Rubber sheeting.
Plain roll of absorbent cotton.
Abdominal binders.
Vessel to receive placenta.
Large drainage-pan.
Large- and medium-sized safety-pins.

=Sterilized Accessories:=
One half-dozen sheets.
One dozen towels.
One night gown.
One doctor’s gown.
Accouchement pad.
Two dozen vulva pads.
Receiving pad for baby.
Maternity leggings.
Gauze sponges.
Cotton pledgets.
Applicators.
Tape for the cord.
Rubber and glass catheters.
Douche points.
Douche bag.
Vaselin.

SUPPLIES FOR BABY BASKET.

Blunt-pointed scissors.
Needle, thread and thimble.
Medium-sized and small safety-pins.
Rectal and bath thermometer.
Bar of pure mild soap.
Jar of pure olive oil.
Wide-mouthed bottle of alcohol, 95 per cent.
Wide-mouthed bottle of boric solution.
Sterile gauze to dress the navel.
Sterile applicators.
Two slips.
Two shirts.
Abdominal binders.
Diapers and old soft cloths.

BABY SLEEP.

A young baby sleeps eighteen hours out of twenty-four. At six months of age a baby sleeps about sixteen hours. A one-year-old child sleeps about fourteen hours, and at two years of age at least twelve hours. Daytime naps should be continued as long as possible.

FETAL CIRCULATION.

_From Kimber’s Anatomy._

The peculiarities of the fetal circulation, leaving details aside, are: the direct communication between the two auricles of the heart, through an opening called the foramen ovale; the communication between the pulmonary artery and descending portion of the arch of the aorta, by means of a tube called the ductus arteriosus; and the communication between the placenta and the fetus, by means of the umbilical cord.

The arterial blood for the nutrition of the fetus is carried from the placenta along the umbilical cord by the umbilical vein. Entering the fetus at the umbilicus, the blood passes upward to the liver and is conveyed into the inferior vena cava in two different ways. The larger quantity first enters the liver, and, alone or in conjunction with the blood from the portal vein, ramifies through the liver before entering the inferior vena cava, by means of the hepatic veins. The smaller quantity of blood passes directly from the umbilical vein into the inferior vena cava, by a tube called the ductus venosus.

In the inferior vena cava the blood from the placenta becomes mixed with the blood returning from the lower extremities of the fetus. It enters the right auricle and, guided by a valve—the Eustachian valve, passes through the foramen ovale into the left auricle. In the left auricle it unites with a small quantity of blood returned from the lungs by the pulmonary veins. From the left auricle the blood passes into the left ventricle and is distributed by the aorta almost entirely to the upper extremities by the superior vena cava, the blood enters the right auricle, and, passing over the Eustachian valve, descends into the right ventricle, and from the right ventricle into the pulmonary artery. As the lungs in the fetus are solid, they require very little blood, and the greater part of the blood passes through the ductus arteriosus into the descending aorta, where, mixing with the blood delivered to the aorta by the left ventricle, it descends to supply the lower extremities of the fetus, the chief portions of this blood, however, being carried back to the placenta by the two umbilical arteries.

From this description of the fetal circulation it will be seen:

1. That the placenta serves the double purpose of a respiratory and nutritive organ, receiving the venous blood from the fetus, and returning it again charged with oxygen and additional nutritive material.

2. That the greater part of the blood traverses the liver before entering the inferior vena cava; hence the large size of this organ at birth.

3. That the blood from the placenta passes almost directly into the arch of the aorta and is distributed by its branches to the head and upper extremities; hence the large size and perfect development of those parts at birth.

4. That the blood in the descending aorta is chiefly derived from that which has already circulated in the upper extremities and, mixed with only a small quantity from the left ventricle, is distributed to the lower extremities; hence the small size and imperfect development of these parts at birth.

NURSING IN DISEASES OF CHILDREN.

=Spasmodic Croup.=—Spasmodic croup is due to a sudden closure of the glottis.

_Causes._—Exposure to a cold, damp atmosphere, indigestion, or irritation of the throat. There may be some hoarseness a few hours preceding the attack and the child awakens suddenly in the paroxysm of the sharp croup cough, experiences difficulty in breathing and has the cyanotic appearance so terrifying to the mother, but which need give no cause for serious alarm.

_Treatment._—Apply hot compresses about the throat. If the attack is severe give an emetic—one dram of salt or mustard in one-half cup of warm water, and repeat in twenty minutes if necessary; an enema of warm water should be given and steam inhalation resorted to. Keep the child in an even temperature, restrict diet for a few days, and keep bowels active.

=Parotitis (Mumps).=—An infectious disease characterized by inflammation of the parotid glands. Incubation is from two to three weeks.

_Symptoms._—The disease comes on with a mild chill, pain below the ear and swelling of the glands. There is great discomfort and the tension is very disagreeable.

_Treatment._—Keep patient in bed during the height of the disease. Give liquid and soft diet. Bowels should be opened freely. No medicine is required unless fever is high. Apply cold compresses to the affected part, though, if preferred, hot ones may be used. A pad of cotton with oiled silk is the best application. In cases of extreme redness or tenderness of the glands, leeches may be applied. In cases of delirium use the ice-cap. For orchitis, lubricate the parts with camphorated oil and support with a soft cotton pad.

Duration of disease, from seven to ten days.

=Whooping-Cough.=—An infectious disease, beginning with catarrh of the air-passages, like an ordinary cold. The short expiratory coughs following each other in rapid succession and the period of drawing a long breath give rise to the whoop characterizing pertussis.

_Incubation._—A week to ten days.

_Treatment._—Isolate patient and if attack is severe put him in bed. Fresh air is the most essential element. If the cough is distressing, ipecacuanha wine and paregoric may be given. During convalescence the child should be watched carefully, as at this period bronchopneumonia and tuberculosis are apt to develop. Change of air is advisable. Tonics and cod-liver oil should be employed. The diet should be easily digestible, nourishing food. After each paroxysm and after the child has recovered from the exhaustion it produces give nourishment. There will be a partial if not complete absorption of the food before another attack. Duration of the disease from six to twelve weeks.

=Colic.=—_Causes._—Constipation, indigestible foods, flatus, overfeeding, improper foods and exposure to cold.

_Symptoms._—Child cries out very suddenly and sharply. There is a convulsive movement of the extremities, the hands are tightly closed, abdomen is tense.

_Treatment._—Gentle pressure and massage with warm oil over the abdomen and a few doses of hot or peppermint water will expel the gas. Burnt brandy is good. The simple warm enema is a common remedy. Wrap warm flannels around the lower parts of the body and keep the hands warm.

=Diarrhea.=—Frequent loose evacuations without tenesmus.

_Causes._—Impure water or food; irritating secretions poured into the bowels; bottled milk.

Diet should be restricted to cereal and albumin water. Flush the bowels very gently with warm water.

=Dysentery.=—_Symptoms._—Fever, tenesmus and frequent small mucous, bloody stools. Treat as diarrhea. Keep child warm, especially about the abdomen.

=Cholera Infantum (Summer Complaint).=—_Symptoms._—Fever, intense thirst, continuous vomiting, and purging of the bowels. Stools soon become watery and pale-green in color, and the child has all appearances of complete prostration.

_Treatment._—Stomach washing and intestinal irrigation carefully given. Restrict diet to barley water containing a few drops of brandy and give hourly for a few days.

=Rickets.=—A disease of infants, characterized by impaired nutrition of the entire body and alteration of growing bones.

_Causes._—Not positively known. Heredity may be a predisposing factor. Another theory given is want of sunlight, impure air, prolonged lactation, and suckling. As it is a constitutional disease it is almost certain to be due to a disturbance of nutrition. _It is much less found in the breast-fed than in the artificially fed and more common when the artificial feeding is bad than when it is properly given._

=Scurvy= is a constitutional disease of metabolism _due to a faulty diet_. Probably the absence of some constituents in the nature of vitamins. _Scurvy and rickets are two distinct diseases_, and yet both may be due to _impure, improper infant feedings_.

_Three General Symptoms of Great Importance._—First, a diffuse soreness of the body, so that the child cries when an attempt is made to move it; second, slight fever; third, profuse sweating. Deformities may often be prevented if, in the early stages, constant care is taken that the child is properly held.

=Thrush.=—_Aphthæ._—Small white, furry mouth ulcers developing during the first and second year of infancy.

_Cause._—Lack of cleanliness in the care of the mouth, especially after feeding with bottled milk. The patches are tenacious, grow larger, until sometimes they involve the entire gastro-intestinal tract, resulting in acute indigestion and bowel disorders.

The first symptom is usually some evidence of painful distress in the infant’s efforts to nurse; fever, diarrhea and vomiting occur and the trouble may become acute.

_Treatment._—Absolute sterile cleanliness in the preparation and administering of the patient’s food. The mouth must be cleansed with warm boric acid solution after every feeding. The patches should be touched gently with the same solution, and the lips anointed with a soothing lotion.

=Convulsions.=—The principal predisposing causes are infancy conditions affecting the nutrition of the brain and hereditary influences. The brain grows more during the first year than in later life, and this rapidity of growth is in itself an important predisposing cause of functional derangement. After infancy attacks of convulsions are much less frequent, and after seven years they are relatively rare. Death may take place from a single attack in very young infants, especially those who are rachitic.

Convulsions may be thought to indicate the onset of some acute disease when they occur in a child over two years old, and when they come on suddenly or with only slight premonition in a child previously well; but the most important point is that they are accompanied by a high temperature—104°-106° F. Acute meningitis is the only other condition likely to produce these symptoms. Whether the convulsions mark the onset of lobar pneumonia, scarlet fever, malaria, or some other disease can be determined only by carefully watching the patient’s symptoms for 24 or 36 hours.

In convulsions depending upon some disorder of the alimentary tract, we may get a history of chronic constipation or improper feeding, and in nursing infants, sometimes of passion or intoxication in the wet-nurse. Convulsions are so frequently due to digestive derangement that the condition of these organs should be one of the first things to be looked into. Examination of the urine should never be omitted in any case of convulsions of doubtful origin, even where no dropsy is present. This, both in infants and older children, is too often overlooked. In all cases of convulsions of doubtful or obscure origin occurring in infants, rickets should be suspected as the underlying cause, and the child carefully examined for other evidences of that disease.

_Treatment._—Cold should be applied to the head, best by means of an ice-cap or cold cloths, and dry heat and counterirritation to the surface of the body and extremities.

_The Mustard Pack._—The child is stripped and laid upon a blanket, and the trunk is surrounded by a large towel or sheet saturated with mustard water. This is made as follows: 1 tablespoonful of mustard, 1 quart of water. In this the towel is dipped and, while dripping, wound around the entire body. The patient should then be rolled in the blanket. This pack may be continued for 10 or 15 minutes; at the end of which time there will usually be a very decided redness of the whole body. It may be repeated, according to indications. Where it is desired to produce general counterirritation, the mustard pack is not quite as efficient as the mustard bath, but it has the advantage in causing much less disturbance to the patient. The mustard pack is useful in the conditions of collapse, or of great prostration from any cause whatever, in convulsions, and in cerebral or pulmonary congestion. The degree to which the counterirritant of the skin should be carried will depend upon the condition of the pulse and the cyanosis. The feet may be placed in mustard water while the child lies in its crib (Holt).

A FEW NOTES ON MEDICAL DISEASES.

RHEUMATISM.

A constitutional disease, characterized by fever, inflammation in and around the joints, occurring in succession, and a great tendency to induce the condition of endocarditis or pericarditis.

=Cause.=—Usually exposure to cold—chilling of the body—damp atmosphere.

=Treatment.=—Rest in bed is important. The bedding should be yielding, and the patient wear loose flannel night-clothes. Sleeping between blankets promotes perspiration, increases the activity of the skin, prevents exposure to cold and may reduce the liability to heart trouble. Change bed-clothing frequently.

_Diet._—Should be easily digested food. Milk is the most suitable. Dilute with alkaline or mineral water. Barley- or oatmeal-water and lemonade may be given. Broths and soups may be substituted for milk at times. Regular feedings every two hours until patient convalesces.

GOUT.

Gout is characterized by sudden attacks of severe pain in the smaller joints, especially that of the big toe. There is a gradual deposit of urate of sodium in and about the joints, and presence of uric acid in the blood.

=Causes.=—Intemperate living, excess in drinking wines and liquors, overindulgence in rich foods, change of climate.

=Treatment.=—Proper elimination. Free use of all kinds of mineral waters, abstention from alcoholic drinks and moderation in eating. Exercise by walking and living in the open air may counteract any hereditary tendency to the disease. Cold baths, followed by massage, may be given to the sthenic patient, while the warm and tepid bath should be substituted for the asthenic type. Protect the body from exposure to cold. Flannel underwear should be worn.

_Diet._—Milk for liquid—no coffee or tea. Vegetables and fruit, excepting bananas, strawberries, tomatoes, oranges, lemons; fish, oysters and soup in small quantities; no fresh meat should be allowed for a time. Avoid hot breads, pastry of all kinds, spices and eggs.

DIABETES MELLITUS.

A disorder of nutrition, characterized by an accumulation of sugar in the blood, and excreted in the urine. The amount of urine is greatly increased, accompanied by progressive loss of flesh and strength.

=Treatment.=—Regulate diet, exercise and mode of living. A warm bath every other day and a Turkish bath every two weeks are very beneficial.

_Diet._—Avoid sugar, starch and all liquors. Patient may eat soups without vegetables and flour; fish of all kinds; meats and fats cooked in any way except with flour; gluten bread. Of vegetables—lettuce, cucumbers, spinach, tomatoes, onions, celery, radishes, cauliflower, cabbage, egg-plant. Of desserts—custard, nuts, acid fruits, ice cream without sugar. Of drinks—coffee, tea and buttermilk, lemonade, beef-tea, chicken broth, and egg-nog.

Fluid diet must be moderate, and sugar and flour must not be used in any form.

BRIGHT’S DISEASE.

(Acute Nephritis; Inflammation of the Kidneys.)

=Due= to the action of cold or toxic agents upon the kidneys.

_Causes._—Cold, poisons of specific fevers, toxic agents, pregnancy, blows and injuries of the back, lesions of the skin as in burns or in chronic skin diseases.

=Symptoms.=—Fever, pain in the back over the kidneys, nausea, vomiting, frequent desire to urinate, puffiness of the face, swelling of the ankles, extreme pallor of the skin, shortness of the breath, with the general appearance of complete exhaustion. The urine is very scanty and highly colored.

=Treatment.=—Rest in bed until all symptoms disappear. To promote activity of the skin and kidneys, alcohol or steam sweats should be given daily. To eliminate and purge the bowels give saline cathartics; and alkaline mineral waters may be used freely.

_Diet._—Buttermilk, gruels made of barley or arrowroot, or oatmeal water; animal broths and oysters; substitute cream-of-tartar lemonade or plain lemonade for tea or coffee. Pure milk should be taken freely.

UREMIA.

Uremia occasionally develops during the course of acute or chronic Bright’s disease and other maladies, the result of the retention or accumulation in the blood of an excrementitious material, supposed to be urea, the flow of urine being either normal, lessened, or increased.

TREATMENT FOR TUBERCULOSIS.

Fresh air and sunshine, a rest in bed from one to three months, and proper food are the three vital points of importance. Do not give too many baths.

=Diet= should consist of starch foods—60 per cent. Stale bread and crackers may be prepared in variety. Give albuminoids and tender meats. Milk and eggs should be given about six times a day.

FOR PATIENT IN SITTING POSITION.

A contrivance easily made and very useful in nursing cases where the patient is to be kept in the semirecumbent or sitting position, as, for instance, in pneumonia, or in operations on the upper abdomen, is arranged by taking a broomstick with the broom part sawed off. Wrap around this stick a blanket, large pillow, or something to make it resemble a knee bolster. Place this under the knees of the patient, and to each end of the broomstick attach a stout cord, which may be securely tied to the bed-posts at the head of the bed. This will add to the comfort of the patient in preventing the constant sliding down which is so difficult to prevent. It will also save the nurse a great deal of tugging and lifting.

MISCELLANEUOS NOTES AND REMEDIES.

COLDS.

This was one of the subjects of discussion at one of the meetings of the New York State Medical Association.

One physician thought that cold was only a predisposing factor in these cases, microbes being the chief element in the affection. At the beginning of an ordinary cold in the head the serous flow was an effort of nature to relieve the congestion and eliminate the infection, hence it should not be interfered with at this stage.

Another doctor said that while cold was a separate disease in the minds of the laity, to physicians it always meant a condition secondary to something else. A person with nasal polypi, for example, would complain of almost constant stuffiness of the nose; one with an enlarged lingual tonsil became hoarse after very slight use of the voice in singing.

Dr. —— —— ——, of New York, took up the treatment of colds. He thought some colds in the head are communicable, and that isolation might sometimes be a useful protective measure. Cod-liver oil was a good preventive for those who were in the habit of constantly catching cold. If the temperature was over 100° F., he insisted on the patient staying in bed, or at least in the house. A moderate dose of quinin and Dover’s powder at night, followed in the morning by a laxative, would cut short some colds. A hot mustard foot-bath increased the comfort of the patient. Rhinitis tablets were effectual if taken early, but persons susceptible to belladonna should be careful in using them. The alkaline treatment was often satisfactory—one dram of bicarbonate of soda in half a glass of water, with a few drops of lemon juice. Camphor internally and by inhalation often yielded good results. He was not a great believer in local treatment, though admitting that irrigation with saline solution was often useful. It was, however, dangerous except in skilful hands. When colds showed a tendency to recur, he advocated tincture chlorid of iron in large doses for two or three days, also cod-liver oil, quinin, or the vegetable bitters. Sometimes change of climate was the only cure.

=Cold a Germ Disease.=—Walsh, in the _Medical News_, says a very striking indication that cold is due to _microbic invasion_ is to be found in the fact that the process is nearly always accompanied by _fever_. A distinct period of incubation can be traced, and the efficient cause of the illness is commonly farther off than the patient imagines. The treatment advised when fever and chilliness occur is the use of calomel and hot drinks, especially cream-of-tartar lemonade, which acts as a diuretic as well as a laxative. A diaphoretic at the beginning of the affection will always give the patient comfort and may unload the system of enough depressed toxic material to enable it to react and bring about the abortion of a cold.

Other medical men objected to calling everything an infection. A common cold, they thought, was nothing else than the effect of the lowered temperature on the human system. The dry air of houses caused a chronic postnasal catarrh, which at times increased. To overcome susceptibility to catching cold, overdressing should be avoided and cold baths taken.

TREATMENT OF HYPERIDROSIS.

In sweating of the feet a single application of diluted formaldehyd will bring about permanent relief. For the axilla, use 10 drops of formaldehyd to 2 ounces of water.

TREATMENT OF ERYSIPELAS.

Apply a thick layer of white vaselin twice a day. Protect with linen and gauze bandages.

TO DISTINGUISH CHICKEN FROM SMALLPOX.

If the vesicle in chicken-pox is pricked with a needle, its contents can be completely evacuated and the cell will collapse; whereas, in small-pox the vesicle can be pricked twenty times and it will be impossible to empty it.

TREATMENT OF FELON.

A felon _may sometimes be_ aborted by the application of pure alcohol under exclusion of air. Cover the phalanx with a thin layer of absorbent cotton saturated with alcohol; over this put on a rubber finger-stall. In severe cases the tissues should be deeply incised.

TREATMENT OF BOILS.

Apply hot dressings; incise if necessary. The application of pure alcohol dressings and a plug of cotton saturated in the same solution and inserted in the wound promotes rapid healing.

TO DISLODGE AN INSECT FROM THE EAR.

Saturate a piece of cotton-wool in salt and vinegar. Fill the ear with it. Have patient lie on the ear and give firm pressure with the hand. The insect may be found on the cotton when the plug is taken out. Oil may be used as a substitute.[B]

[B] Foreign bodies in the ear usually cause far less trouble and harm than does the attempt to remove them by anyone not expert.

RELIEF FOR EARACHE.

Make a small funnel of paper, and saturate a ball of cotton with chloroform; drop it into the funnel. Place the funnel in the ear, draw a long breath and then blow the breath into the large end of the funnel; the fumes of the chloroform are thus carried into the ear, and all pain ceases at once. No doubt, heat is the best remedy of all.

RELIEF FROM FLIES AND MOSQUITOES.

Pour into an atomizer half a teaspoonful of lavender oil. Add to this as much alcohol as will make a saturated solution. Use as a spray. Sweet clover hung about the room will banish flies and mosquitoes. The drier the clover becomes the more effectual it is.

A BIT OF ANATOMY.

The entire adult skeleton consists of 200 distinct bones, as follows:

The spine or vertebral column
(sacrum and coccyx included) 26
Cranium 8
Face 14
Os hyoids, sternum and ribs 26
Upper extremities 64
Lower extremities 62
———
200

The patellæ are included as separate bones; the smaller sesamoid bones and the ossicula auditus are not counted. The teeth belong to the tegumentary system.

BLOOD-CORPUSCLES.

The average number of red blood-corpuscles per cubic millimeter is about 5,000,000 for men, and somewhat less for women. The number is much increased in people who live in altitudes of about 8000 feet or more. The greatest decrease occurs in anemia, when they may number less than 1,000,000, and in leukemia, when there may be not more than 2,000,000.

The average number of white blood-corpuscles per cubic millimeter varies from 5000 to 10,000. The number is usually decreased in anemia, and much increased in leukemia, when they may number 500,000 per cubic millimeter.

Blood should contain 100 per cent. hemoglobin. Hospital patients seldom have this amount. Patients are not considered safe for operation who have less than 50 per cent., and can not live long if they have 10 per cent. or less.

INDEX.