The Mother and Her Child

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.

MORNING SICKNESS

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 piece 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.

HEARTBURN

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 depresses 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."

IRRITABILITY OF THE BLADDER

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.

LEUCORRHEA

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 of 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.

THREATENED ABORTION

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:

1. Heavy menstrual pains.
2. Backache.
3. Hemorrhage.

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.

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 ABDOMINAL PAIN

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.

MISCARRIAGE

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 automobile riding, and such taxing labor as sweeping, lifting, washing, running the sewing machine, window cleaning, the hanging of pictures, draperies, etc.

CRAVINGS

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.

CONSTIPATION

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 do with this difficulty. A regular time should be set apart each day for attending to this important matter.

HEMORRHOIDS

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

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

Cramps are sharp, exceedingly painful muscular spasms occurring in the muscles of the calf of the leg, the toes, etc. The 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.

SWELLINGS

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.

GOITRE

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 concern. 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 nearby 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.

PERNICIOUS VOMITING

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 her 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.

INSOMNIA

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.

HEADACHE

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.

HIGH BLOOD-PRESSURE

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.

TOXIC SYMPTOMS

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:

1. Headache.
2. Dizziness.
3. Blurring of the vision.
4. Swelling of the feet and hands, or puffiness of the face.
5. Diminished urine.
6. Vomiting.
7. High blood-pressure.
8. Albumin and casts in the urine.

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:

1. Drink more water or lemonade.
2. Take a mild cathartic.
3. Avoid eating much meat and other highly protein foods.

CONVULSIONS OF PREGNANCY

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.

CARDINAL SYMPTOMS OF TOXICITY

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 proper 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:

1. Persistent, dull headache.
2. Presence of casts in the urine.
3. Persistent high blood-pressure, with tendency to increase.

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. 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.

ECLAMPSIA PREVENTED

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 day 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 headache, 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.

THE FINAL WEEKS

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, 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.

SELECTION OF THE HOME

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.

SANITARY PREMISES

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 millions 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.

ENGAGING THE DOCTOR

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.

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 out 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.

THE NURSE

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, awaken 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.

PREPARATIONS FOR A HOME DELIVERY

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:

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.

THE PREPARATION OF THE SUPPLIES

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 fastened 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.