It is therefore self-evident that, instead of a reformed profligate making a good husband, he must make a very diseased one. It has therefore been suggested that the parents of the prospective bride should demand from the intended groom a certificate of freedom from all venereal diseases by a physician of their own selection. Also that there should be legislation upon the subject, and that before a man is granted a license of marriage, he should have a certificate from the health officer of freedom from syphilis, gonorrhea, and tuberculosis.

The Proper Length of Time for the Engagement.— A period not shorter than three months, nor longer than one year, should elapse between the engagement and the marriage.

There are strong physiologic reasons against long engagements: they keep the affections and the passions in an excited and unnatural condition, which after a time tends to weaken the nervous system and undermine the health. These evil consequences are common to both sexes. It is far better that the subject of marriage should not be entertained at all unless the circumstances are such that the union might with propriety be effected at once.

The Right Time of the Year to Marry.— When woman marries she enters upon a new life, and a very trying one. Extreme heat and extreme cold are both very taxing to the human economy. Midsummer and midwinter are therefore both objectionable, but especially the former.

The Selection of the Wedding-day.— This is by common consent left to the bride. She should select a time about ten or fifteen days after the end of one of her menstrual periods, as this is the time of comparative sterility, and it is most desirable that the first sexual relations should be fruitless.

PART II.— MARRIAGE.

CHAPTER VII.

THE ETHICS OF MARRIED LIFE.

The Wedding Journey; the Ethics of Married Life; Shall Husband and Wife Occupy the Same Bed? the Comsummation of Marriage; the Marital Relation; Times when Marital Relations Should be Suspended.

"If it is possible to perfect mankind, the means of doing so will be found in the medical sciences."— DESCARTES.

The Wedding-journey.— The wedding-journey, which was formerly the cause of so much discomfort to both husband and wife, has fortunately gone out of vogue; and in its place has come the retirement to a quiet country or seaside spot, away from the prying eyes of friends. Thus the nervous strain incident to sight-seeing and travel is avoided.

The Ethics of Married Life.— It has been said that God set men and women in pairs in order that they might perfect each other and complete each other's happiness. The secret of all true happiness in life lies in the spirit of altruism; one must be able to wholly forget herself and to find her happiness in the welfare of others.

The woman who exhausts herself physically and financially on the preparation of her trousseau and her wedding does her husband a wrong by bringing him a wife who is on the verge of nervous prostration.

The secret of a happy married life depends to no small extent on the very beginning: the relation is so entirely new, and much lies hidden in the character of each that was never suspected by the other.

Between husband and wife there must always be mutual concessions, forbearance, and sympathy; a mutual helpfulness to attain all that is best. This, of course, implies that the life of each is an open book for the other to read; that there is an unreserved exchange of thought; and that no privilege is claimed by the one that would not willingly be accorded to the other.

"How many men," says Balzac, "proceed with women as the monkey of Cassan with the violin; they have broken the heart without knowing it, as they have tarnished and disdained the jewel whose secret they never understood. Almost all men are married in ignorance of women and of love. They have commenced by forcing open the doors of a strange house and have wished to be well received in its salon. But the most ordinary artist knows that there exists between him and his instrument— his instrument which is made of wood or ivory— a sort of indefinable friendship. He knows by experience that it has taken years to establish this mysterious rapport between an inert material and himself. He could not have divined at the first stroke all its resources and caprices, its faults and its virtues. His instrument only became a soul for him and a source of melody after long study; he only came to understand it as two friends after the most learned interrogation.

"So the world is full of young women who grow pale and feeble, sick and suffering. The ones are a prey to inflammations more or less severe; the others remain under the dominion of nervous attacks more or less violent. All these husbands have caused their own unhappiness and ruin. Never begin married life with a rape. To demand of a young girl whom one has seen forty times in fifteen days to love you because of the law, the king, and justice is an absurdity.

"Love is the union of necessity and of sentiment. Happiness in marriage is the result of perfect understanding between the spirits of husband and wife. From this it happens that in order to be happy, a man is obliged to bind himself to certain rules of delicacy and honor. After taking advantage of the social laws which consecrate the necessity, it is necessary to obey the secret laws of nature, in order to make the sentiments flourish. If a man places his happiness on being loved, it is necessary that he should love sincerely; nothing resists a veritable passion."

Shall Husband and Wife Occupy the Same Bed?— Among civilized nations custom differs in this regard; in Germany, for instance, the husband and wife occupy separate beds in the same room; formerly in this country it was almost the universal custom for husband and wife to occupy the same bed. The current of opinion has changed in this respect, and it is now considered in the highest interests of both that they shall occupy not only separate beds, but separate rooms; these rooms communicating through a door which connects their respective dressing-rooms. This is unquestionably the best arrangement from the hygienic as well as from the ethical point of view. Health requires that one-third of the time shall be spent in sleep; the bed was made for sleep; and the most refreshing sleep can only be obtained by occupying the bed alone. If two persons occupy the same bed and one is restless, the sleep of the other is necessarily disturbed. Again, two persons occupying the same bed necessitates the same hour for rising and retiring, which is not always convenient or agreeable. Balzac writes on this subject: "To put the system of separate bed-rooms into practice is to attain to the highest degree of intellectual power and of virility. By what syllogism man arrived at establishing as a custom that of man and wife sleeping together, a practice so fatal to happiness, to health, to pleasure, and even to self-love, would be curious to seek out." If for financial reasons it is not possible to have separate bed-rooms, the German custom of having separate beds should be adopted.

The Consummation of Marriage.— The consummation of marriage is often attended with difficulty owing to the rigidity of the hymen; this, if present, must usually be ruptured before connection takes place. Great gentleness and care must be exercised by the husband if it does not readily yield, the use of hot vaginal injections should be kept up for several weeks before the trial is repeated. These usually relax the parts very considerably; but if coitus is still found impossible, it is better to consult a physician at once, when a simple operation will generally remove the trouble and the woman is spared much suffering. In no case is any violence on the part of the husband allowable, as it might produce irreparable injuries.

There is always more or less suffering on the part of the wife at first, partly due to the rupture of the hymen, and partly to the forcible dilatation of the vagina and she should be allowed a sufficient time for nature to repair these injuries. By so doing, the constitutional disturbances and the nervous disorders which are so very prevalent may be prevented. Too frequent indulgence at this period is a prolific source of inflammatory diseases, and often occasions sterility and ill-health.

The first nuptial relations should be fruitless, in order that any indisposition arising therefrom should have had time to disappear before the woman becomes pregnant.

The Marital Relation.— It is most important for the interest of both parties that there should be chastity in the marriage relation as well as out of it. Many young couples have had their lives ruined by excessive sexual indulgence. The effect is usually most severe upon the husband, yet the wife becomes weak, nervous, and excitable. Sexual excess is also the grave of domestic affection. The general rule given is that coitus should never take place oftener than every seven or ten days. When coitus is succeeded by langour, depression, or malaise, it has been indulged in too frequently.

Among civilized people there are three widely diferent views as to the proper course to be pursued:

First, those who maintain that sexual intercourse should not take place except for the propagation of the species.

Second, those who believe that the act is a love relation, mutually demanded and enjoyed by both sexes, and serving other purposes besides that of procreation.

Third, those who hold that sexual intercourse is a physical necessity for the man, but not for the woman.

The first theory, "that the sexual relations should never be sustained save for the purpose of procreation," has many advocates. They teach that there are other uses for the procreative element than the generation of offspring, and far better uses than its waste in pleasures. They claim that a life of total chastity increases the physical and mental vigor; and there will result a procreation on the mental and spiritual planes, instead of on the physical ones.

They also claim that to woman belongs the creative power; that she must choose when a new life shall be evolved; and that only by adhering to this law can she be protected in the highest function of her being— the function of maternity.

The adherents of the second theory, "that the act is a love relation, mutually demanded and enjoyed by both sexes, and that it serves other purposes besides that of procreation," claim that the female sexual life indicates that the healthy woman is neither indifferent nor passive in the generative act. It has much the same effect as in man— a powerful increase in her sensations, whole groups of muscles are set in motion, and the uterus as well as the entire nervous system are in an excited condition and activity. And that it is the province of the mother to decide when a new life should begin.

The third theory, "that sexual intercourse is a physical necessity for the man, but not for the woman," is by far the most widely accepted. We will consider, first, the practical results of this last theory; and, second, the scientific basis on which it rests.

It is generally acknowledged that this practice has done more to cause domestic misery, sickness, and death than that dreadful scourge of the human race, tuberculosis.

This man, accustomed all his life to gratify his sexual passions promisculously, marries a virtuous young girl. In her menstrual periods she has had to do only with the secondary phenomena; with the expulsion of the ova not at all. She has had no instruction in the corresponding physiologic life of the man, and is astonished at the male sexual indications, and is led to believe in their physiologic necessities. The result is that she not only suffers physically, but feels outraged and disgraced. She is liable to the chance of maternity at any time; and such offspring will probably be sickly.

Passion is presented to the young wife in so hideous a guise that it will take the utmost consideration of her husband afterward to enable her to completely overcome her repugnance. If she be worn and weary of excesses in the early days of her married life, the husband will have only himself to blame if he is bound all his life to an apathetic and irresponsive wife. Husbands place great strains upon the affections of their wives, and lower themselves almost past reinstatement in their respect and esteem.

Lastly, on what scientific basis does this "physilogic necessity" for sexual gratification on the part of the male rest? Analogy with the lower animals does not bear it out. Among animals, except in rare instances under domestication, the female admits the male in sexual embrace only for procreation. Among many savage tribes this same rule has but few exceptions. The analogies between the male and the female sexual organs; between seminal emissions and menstruation; between the sexual life of the male and of the female, only go to accentuate the fact that this so-called physiologic necessity on the part of the male has arisen chiefly through the difference of education; so that it has come to be that the woman is chaste and the man is degraded; that the woman is too sentimental and the man too passionate. From a purely medical standpoint, the most eminent physicians and physiologists of the day all unite in advocating a chaste and continent life, simply for the sake of the man's own health, independently of all other considerations.

Times when Marital Relations Should be Suspended.— The marital relations should always be suspended during the menstrual period. During pregnancy intercourse should never, or at least very rarely, be indulged in. At this time the mother needs to conserve all her strength and energies for herself and child; and any sexual relations during this time increase the sufferings of the mother and impair the vitality of the child. It has been even suggested that much of the pain during parturition would be avoided by entire continence during pregnancy. Intercourse during the early months of pregnancy is a frequent cause of abortion. Women who have supposed that they have never been pregnant have in reality been having abortions every second or third month.

A woman should never be subjected to coitus until three months after delivery. During lactation intercourse should never, or at least very rarely, be indulged in; as the function of lactation makes a heavy drain on the strength of the mother, and anything which would further weaken her would tend to impoverish the quality of the milk and thus the child would suffer.

CHAPTER VIII.

SEXUAL INSINCT IN WOMEN.

Sexual Instinct in Women; Excessive Coitus; Causes of Sexual Excitability.

"Virtue, the strength and beauty of the soul, Is the best gift of heaven."

— ARMSTRONG.

Sexual Instinct in Women.— After careful observation of the sexes in the married state, it is found that the sexual appetence is less in women than it is in men. Much of this difference in sexual appetence is doubtless due to the chastity of their lives, coupled with and resulting from the difference of education. The girl is taught repression, and the boy expression; that girls must be chaste; that chastity for boys is impossible.

According to the intensity of the sexual instinct women have been divided into three classes: A larger number than is supposed have little or no sexual feeling. Second, those who are subject to strong passion; this class is larger than the first, but small as compared with the whole of their sex. Third, those in whom the sexual appetite is moderate; this class comprises the vast majority of women.

And, even granting to woman more pleasure in sexual indulgence than usually comes to her by largest allowance, it is safe to say that in nine cases out of ten maternity, with its early pains and later cares, greatly lessens her power of enjoyment; and that for the larger part of her married life she is either positively distressed by the apparently necessary demands of her husband upon her, and irresponsive to them, or kept to a cheerful response by a self-abnegation and regard for his comfort, not to say fear of his moral aberration, which is a positive drain upon her health and strength.

Excessive Coitus.— Those who are most frequently found to suffer from venereal excesses are the newly married; especially if they have weak constitutions and excitable temperaments. A great deal of mischief is done by two persons of unequal constitutions being matched together; the husband may exhaust the wife or vice versa, the weaker party being constantly tempted to exceed their strength. In all sexual matters there must be a consideration for others. It is not so much from selfishness as from ignorance that such a mistake is made. The ignorance comes from a lamentable morbid delicacy which prevails on all sexual matters, and which prevents all open and rational conversation on them, even between those who have the most intimate knowledge of each other.

When the conjugal act is repeated too often, the man will become gradually conscious of diminished strength, diminished nerve force, and diminished mental powers. Excess weakens a man's energies, and enervates and effeminates him. Moreover, it renders him liable to an infinity of diseases and a readier victim to death.

Not only is the strength of the constitution lowered by the excessive expenditure of force and matter requisite for the perpetuation of the species, but this lowered standard of vitality is transmitted to children. There can be but little doubt that this is one of the reasons why so many healthy parents beget sickly children, who die early. They have exhausted themselves of the material from which a new life is created, and so it is not properly started at the beginning and never reaches its highest development. To the truth of this statement attests the mental imbecility, the pallid and attenuated forms, of the children who are the earlier products of marriage. The effect of excessive coitus in women is seen by the confirmed ill health of so many women after marriage and repeated child-bearing. A large number of these cases are dependent upon alteration and diseases of the genitalia; but a considerable number are unconnected with local disease, and in many other cases the health is never regained after all local phenomena have disappeared.

Sexual excitement in the woman causes certain congestion of the genital organs; and at the time of the orgasm there is a reflex movement which corresponds to erection, and which consists of a peristaltic movement of the tubes and uterus; to the uterus also is ascribed an act of suction by which the spermatozoa are drawn up into its interior. Even when pregnancy does not follow, the too frequent excitation and activity of the uterus in weak constitutions causes illness, first of the genital organs and then of the nervous system.

Local diseases caused in women by excessive coitus are: vaginal catarrh, acute catarrh of the vulva, acute inflammation of the lining membrane of the uterus as well as of the uterus itself, inflammation of the ovaries, and even peritonitis. It is also known to be an important factor in the origin of blood-tumors and of cancer of the uterus. Especially is coitus at a time of great physical fatigue liable to be provocative of uterine inflammations. Aside from ethical considerations, coitus during the menstrual period may be the cause of rupture of the impaired blood-vessels, thus causing blood-tumors. Excessive coitus is a well-known cause of chronic inflammation of the uterus; that is, a habitual congestion of the uterus is induced by excessive sexual intercourse. This has been frequently mentioned by authors as leading to enlargement of the uterus in the non-pregnant condition; and it is a still more potent factor in the recently impregnated organ, whose tissues are succulent and the vessels enlarged, a condition inviting congestion and enhancing the susceptibility to engorgement.

The general manifestations of impaired health in women due to excessive coitus are: chronic anemia, with malnutrition; impaired and altered functions in all the organs, especially those of the nervous system. Menorrhagia is apt to be induced by overstimulation of the ovaries, together with exhaustion and sexual apathy.

The source of so much misery is the increasing physical weakness of the female and the increasing nervous weakness of the male, with an increasing sexual excitability, two factors of tragic effect for the wife. Here is seen the unfortunate result of teaching two kinds of morals, one for men and another for women.

Causes of Sexual Excitability.— Too frequent genital irritation, onanism, too frequent intercourse, alcohol, too rich and too highly seasoned foods, lack of exercise.

Treatment of Sexual Excitability.— Avoid alcohol and precocious puberty. Strictest attention must be paid to the diet; everything is to be avoided which is difficult of digestion or which retards it. The following articles of diet must all be avoided: cheese, foods seasoned with pepper and curry, highly salted and acid foods, and all rich foods; and meat must be eaten only in moderate quantities. Constipation irritates the genitalia directly and increases the inflammation. The close relation of Venus and Bacchus is known not only in mythology. Carbonated waters are to be especially avoided, such as soda, seltzers, Preblauer, Geisshubler, and acid waters; also champagne and beer, heavy Italian, Spanish, and English wines. All alcoholic drinks must be forbidden.

As heavy gymnastics as the strength of the individual will admit, and plenty of exercise out-of-doors must be taken. There must also be constant mental and physical employment. In women sexual excitability is often caused by local diseases, and passes off with their cure; if not, she must use her will-power, and take the various forms of cold baths. Sexual intercourse not oftener than once in two or three weeks, and avoid all intimate approaches; if this is not sufficient, she will have to leave her husband for a few months.

CHAPTER IX.

STERILITY.

Sterility; the Prevention of Conception and the Limitation of Offspring; the Crime of Abortion; Infidelity in Women.

"Never let yourselves do evil that good may come. If you do, you hinder the coming of the real, the perfect good in its due time."

— PHILLIPS BROOKS.

Sterility.— Conception is least apt to take place from the tenth day after one period until the third day before the next; but there is practically no time during a woman's sexual life when she may not be impregnated; in this connection it must be remembered that the spermatozoa stay alive in her for more than a week.

During lactation women are generally sterile, especially in the first months which follow the accouchement, because the vital forces are then concentrated on the secretion of milk.

The age of the wife at the time of marriage has much to do with the expectation of children. As the age increases over twenty-five years the interval between the marriage and the birth of the first child is lengthened. For it has been ascertained that not only are women most fecund between twenty and twenty-five years, but that they begin their career of child-bearing sooner after marriage than either their younger or older sisters.

A wife who has had children and ceases to conceive for three years will probably bear no more.

When marriages are fruitless, the wife is almost always blamed; but it is by no means the wife that is always at fault; many husbands are absolutely sterile. Every man is not prolific who enjoys good health and is vigorous. Gross states that in one case out of six the sterility was due to the male. Kehrer, after a series of carefully conducted experiments, has arrived at the conclusion that in at least a third of the cases of sterile marriages the husband was the party at fault, and that gonorrhea was the cause of the barrenness.

Venereal diseases have their share of influence, and the gonorrheal infection is a potent cause of sterility. It is by no means proved that syphilis has any unfavorable influence on conception, though abortions due to this are frequent.

Gonorrhea often prevents conception by the inflammation traveling up the womb, and along the Fallopian tubes to the ovaries, whose covering is rendered thick and dense, so that the ovum cannot escape, or if it does, the fimbriated end of the tube is so agglutinated that it cannot grasp the ovum.

Alcoholism is considered a cause of sterility. It evidently does diminish the sexual potency in the male, and for this the female is often blamed.

It does not follow because a woman has not given birth to a child that she has not conceived. The life of an infant for a long time after birth is a frail one, and before birth its existence is extremely precarious; it often perishes a few days after conception. A period coming on a few days late, and at the same time one which is unusually profuse, is the only evidence which the young wife may have of an abortion. Among prostitutes, the frequent delay of menstruation, then abundant hemorrhage, is in many cases only habitual abortion, and leads to changes in the generative organs which must result in sterility. A tendency to miscarriage may therefore be all that stands in the way of having a family; this can frequently be remedied.

Sexual incompatibility is well known to exist; prominent examples being Augustus and Livia; Napoleon and Josephine. It is also a well-known fact that frigidity is a cause of barrenness. A short separation of husband and wife is often salutary in its influence upon fertility.

It is a well-established fact that the time immediately before the period, but still more that immediately following the period, are the most favorable times for conception to take place; the remaining quiet in bed of the woman after the generative act is also favorable to conception.

The most frequent causes of sterility in women are inflammation of the lining membrane of the uterus, or of the neck of the uterus, or of both. The source of this condition in women who have had children is most frequently due to parturition or abortion. In the newly married it may be due to a previously existing slight uterine catarrh in a displaced uterus, or it may be a manifestation of a run-down state of the system. In a majority of the newly married, however, the inflammation of the endometrium is probably due to the first efforts at conjugal approach. Many young women as the result of the preparation of the trosseau, augmented by a round of gaities at the time of marriage, enter the married state in a condition bordering on physical and nervous exhaustion; and then begin engorgements and inflammations which lead to future suffering and to sterility. Displacements and flexions of the uterus also cause sterility. Such displacements of the neck of the uterus may occur that, instead of lying in a pool of semen, as it should, it is above, in front of, or away from it, and this may prevent conception.

Vulvar and vaginal hyperesthesia, inflammations of the vulva, undue shortness of the vagina, unless great care is exercised by the husband, will induce painful coitus, and may bring about sterility by favoring the formation of a copulation sac outside of the axis of the uterine canal, and consequently misdirection of the semen.

Scrofula, probably by its effects on the general condition, leading to deficient development of the whole body, the genital organs included, may be productive of sterility.

The female being less passionate than the male, the orgasm comes on later with her, or the male orgasm occurs so soon that she may not reach that stage at all. If both were simultaneous, it is reasonable to suppose that conception would be more likely to occur.

Ovulation is doubtless more frequently performed in some women than in others. Some women conceive with more or less regularity every fifteen or eighteen months, and others at intervals of several years.

The effect of repeated coition, provided that impregnation does not take place at once, is to engorge the uterine vessels, to alter the nature of the glandular secretions, to cause profound reflex disturbances, and thus to produce such changes in the endometrium as to lead to local inflammation and to general nervous exhaustion. Backache, leucorrhea, and irritable bladder are the first symptoms of this disorder; but frequently there are added to these, headache, indigestion, rectal tenesmus, painful and profuse menstruation. In many cases the disease continues in a mild catarrhal form, giving the woman little inconvenience besides the slight leucorrheal discharge which stains her clothing; but often this is indicative of such a change of the lining membrane of the uterus as to render it unfit for the fixation and development of the ovum, even should impregnation take place.

Under normal conditions, during the intermenstrual period, a plug of clear viscid mucus, which is secreted by the glands of the cervical canal, blocks up that passage, but is washed away each month by the menstrual discharge. Under ordinary conditions this obstruction must seriously interfere with the entrance of the spermatozoa into the cavity of the uterus, and renders the former theory, recently revived by Bossi, quite tenable, that impregnation is most likely to occur just after the menstrual epoch.

The vaginal secretion under certain pathologic conditions may become so acid that it induces sterility. Women who suffer m severe vaginal catarrh are frequently sterile, the spermatozoa being found dead in the vagina some hours after copulation, although an examination a shorter time afterward revealed them still alive. In cases where conception takes place in spite of a very acid condition of the vaginal secretion, it is probable that some of the spermatozoa enter the uterus before the secretion has had time to act on them, or possibly the spermatozoa being injected in a mass, the acid secretion is unable to penetrate and kill them all.

The reaction of the normal vaginal mucus is always acid, that of the cervix alkaline; but as the result of the inflammatory condition, the reaction of each is often intensified, especially that of the vagina, which has an exceedingly sour and penetrating odor. This acid discharge, bathing the neck of the uterus, penetrates more or less into the cervical plug and causes coagulation of the alkaline mucus.

The chief constituent of the semen is albumin; agents which affect albuminous substances influence the functional activity of the spermatozoa— heat, concentrated acids, and probably concentrated alkalies. In normal conditions the alkalinity of the seminal fiuid seems to be sufficient to neutralize the acidity of the vaginal secretions, so that the spermatozoa may remain seventeen days or more (Bossi) within the vaginal canal, even during a menstrual period, without having their vitality destroyed.

When hyperacidity of the vaginal secretion is present, it is probable that the fertilizing element is at once rendered inert; but should some of the spermatozoa succeed in reaching the interior of the cervical canal, the increased alkalinity of the secretion there would in all probability put an end to all further progress.

The conditions, then, which appear to prevent fecundation are: First, the absence of the proper nidus for the ovum; second, the obstruction of the cervical canal by a mucus plug; third, increased alkalinity of the cervical secretion, often accompanied by the increased acidity of the vaginal secretion. Three conditions must, then, be determined: First, are there spermatozoa in the semen? Second, do they get into the uterocervical canal? Third, do the secretions in the canal poison the spermatozoa?

"For those who are very anxious for offspring," wrote Marion Sims, "I usually order sexual intercourse on the third, fifth, and seventh days after the flow has ceased; and on the fifth and third days before its return. For the most obvious reasons this would always be before going to bed at night, instead of just before rising in the morning. The horizontal position favors the retention of semen; the erect its expulsion. I am satisfied that too frequent sexual indulgence is fraught with mischief to both parties. It weakens the semen; in other words, that this is not so rich in spermatozoa after too frequent indulgence; and when carried to the extent of a debauch, the fiuid ejaculated may be wholly destitute of spermatozoa. Thus it will be seen that it will be much better to husband the resources of both man and wife."

The Prevention of Conception and the Limitation of Offspring.— Some of the contraindications to procreation are when either parent suffers from a disease which is transmissible, and such diseases frequently manifest themselves only after marriage; when the pregnancy would endanger the mother's life, or even where the pregnancy is a nine months' torture to her; where either parent is suffering from ill health; or where for economical reasons no more children are desired.

If there exists no condition in either parent or in their circumstances why they should not have children, the next consideration due to their children, is how the same may be procreated under the most favorable conditions possible; this condition can only be secured by making the circumtsances such that the mother shall be able to choose the time for their conception when both parents are in the best physical condition. That children should be brought into the world haphazard, as the result of accident, is to degrade the human race below that of the lower animals, where the female admits the male only at the time of the rut, which in the majority of cases occurs only once a year.

Another requisite to bearing healthy children is that the pregnancies shall not follow each other too rapidly. Aside from the consideration for the health of the mother herself, she must be in good physical condition to bear the healthiest children she is capable of giving birth to; and for this there must be from two and a half to three years between the successive pregnancies. The results of overproduction on the children are frequently, that they are sickly, short-lived, or suffer from rickets, cerebral paralysis, idiocy, or imbecility.

And last, but certainly not least, many women become chronic invalids, or are hastened to premature graves, by having children as fast as they possibly can.

The most natural and moral way for the artificial prevention of conception, when on account of ill health or for economic reasons no more children are desired, is to abstain from sexual intercourse. But in the majority of cases the husband will not agree to this, and so the greatest number of methods have come to be used to prevent conception.

Perhaps the most frequent method use to prevent conception is withdrawal before the ejaculation of semen. While this is most injurious to the husband— debility, nervous prostration, and even paralysis are said to ensue— the health of the wife also suffers. If, this interrupted sexual congress is continued for years, there develop gradual nervous disturbances on both sides, and a serious disease of the uterus makes itself felt. The generative organs become engorged with blood, but are not permitted to enjoy relaxation consequent upon the full completion of the act. This engorgement may lead to undue local nutrition, and diffuse growth and proliferation of the connective tissue may take place. Hence the uterine walls become dense and thickened and the nerves compressed. Of course, pain and tenderness and a sense of bearing down will be the result. Flexions and versions may be consequent upon the engorgement. The nerves become shattered, and the woman will be fortunate if she contracts no serious womb trouble.

"It is strange," says John Stuart Mill, "that intemperance in drink or any other appetite, should be condemned so readily, but that incontinence in this respect should always meet not only with indulgence, but with praise. Little improvement can be expected in morality until the producing of too large families is regarded with the same feeling as drunkenness, or any other physical excess."

Sismondi writes: "When our true duties toward those whom we give life are not obscured in the name of a sacred authority, no man will have more children than he can properly bring up. If a woman has a right to decide any question it is how many children she should bear. Whenever it becomes unwise that the family should be increased, justice and humanity require that the husband should impose on himself the same restraint which is submitted to by the unmarried."

In the opinion of Dr. Edward Reich, it is very much to be wished that the function of conception should be placed under the domain of the will. But the strongest appeal has been made for the sake of morality itself; namely, to prevent the crime of abortion. Dr. Raciborski, of Paris, took the position that the prevention of offspring to a certain extent is not only legitimate, but it is to be recommended as a means of public good.

Continence, self-control, and a willingness to deny himself— that is what is required of the husband. But suffering women assure us that this will not suffice; that men refuse to restrain themselves; that it leads to loss of domestic happiness, to illegitimate amours; or that it is injurious physically and mentally; that, in short, such advice is useless because it is impracticable.

Dr. Napheys writes: "Is it amiss to hope that science will find resources, simple and certain, which will enable a woman to let reason and sound judgment, not blind passions, control the increase of her family?"

The Crime of Abortion.— From the moment of conception a new life begins, a new individual exists; another child is added to the family. The mother who deliberately sets about to destroy this life by want of care, or by taking drugs, or by the use of instruments, commits a great crime, and is just as guilty as if she strangled her new-born infant. The crime she commits is child-murder. Women in their frenzy at finding themselves in this condition, and with no slightest idea of the sin that they are committing, are constantly guilty of committing abortions on themselves, or going to professional abortionists to have this crime of child-murder committed. This is another of the sins due to the ignorance of the sex in all matters pertaining to reproduction; and it is a fearfully prevalent one.

Infidelity in Women.— "We have now reached the last infernal circle of the divine comedy of marriage; we are at the depths of the inferno. There is something, I do not know what, terrible in the situation in which a married woman finds herself when an illegitimate love has ruined her for the duties of a wife and mother. As has been so well and strongly expressed by Diderot, infidelity in woman is like incredulity in a priest; it is the last step in human forfeitures; it is for her the great social crime, for it implies all the others.

"Weigh the sufferings of the future, the agonies of years by the ecstasy of half an hour. If this conservative sentiment of the creature, the fear of death, does not stop her, what could be expected of laws? Oh, sublime infamy!"— (Balzac).

PART III.— MATERNITY.

CHAPTER X.

PREGNANCY.

Nature of Conception; Pregnancy Defined; Duration of Pregnancy; the Signs of Pregnancy; Quickening; the Determination of Sex at Will; the Influence of the Male Sexual Element on the Female Organism; Heredity; Hygiene of Pregnancy; Causes of Miscarriage.

"Happy he With such a mother, faith in womankind Beats with his bood, and trust in all things high Comes easy to him, and though he trip and fall, He shall not bind his soul with clay."

— TENNYSON.

Nature of Conception.— Conception, or impregnation, is the union of the germ and the sperm cell, the result of which is a new being. On coition, the semen being received into the female organs, which are at that time in a state of turgescence, the spermatozoa, by means of their own vibratile activity, find their way into the Fallopian tubes, and here come in contact with the ovule.

The ovule is a minute cell with a transparent membrane, within which is the yolk containing the germinal vesicle. The spermatozoon penetrates into the ovule and becomes fused with it. The processes of development begin at once to occur. There is congestion of the uterine mucous membrane out of proportion to the rest of the uterus; the ovum finds lodging here, and becomes surrounded by a membrane which incloses it in a separate sac.

Pregnancy Defined.— Pregnancy begins with conception and ends with parturition; it provides for the nutrition and the expulsion of the embryo and for its nutrition for a short time after birth.

The average duration of pregnancy is ten lunar months, or two hundred and eighty days. The date of the confinement is calculated by reckoning from the date of the last menstrual flow; count backward three months from the date of the first appearance of the last menses; to this add twelve months and seven days, five days being for the average menstrual duration and two days for the possibility of fecundation.

Duration of Pregnancy.— Many difficulties are experienced in determining the date of the expected confinement. As most pregnancies occur in married women, we cannot base any calculations on a single act of coitus. And even if there was but one, all physiologists agree that there is a variable period in different women, and in the same woman at different times, between insemination and the fertilization of the ovum. It is the moment of fecundation, or the union of the germ and sperm cells, which marks the beginning of pregnancy. The uncertainty becomes still greater owing to our inadequate knowledge as to the length of time during which the sexual elements, the ova and the spermatozoa, retain their vitality after liberation from their respective sources. While it is not certainly known, it is probable that the ovum is capable of impregnation any time during its sojourn within the oviduct and before reaching the uterus, or probably for a period of about one week from the time of its escape from the Graafian follicle. The remarkable vitality of the spermatozoa even under less favorable circumstances— direct observation shows that these elements retain their movements for over nine days outside of the body— renders it almost certain that their powers of fertilization are maintained for a long time after they are deposited within the healthy female genital tract; it is believed that the spermatozoa are capable of fertilization after a sojourn of three or more weeks within the oviduct.

Consideration of these facts renders apparent the impossibility of fixing with certainty the date of the beginning of pregnancy, since conception may result from the union of the ovum liberated at the beginning of the period with the spermatozoon introduced at the end of that time; or it may result from the meeting of the male elements already within the oviduct with an ovum discharged a day or two before the occurrence of the menstrual period.

The Signs of Pregnancy.— The cessation of the menstrual period is the sign of the greatest value in women who have been regular; but it must always be remembered that there may be an irregularity of menstruation for the first few months after marriage. The appetite is capricious; morning sickness or nausea in the morning on first getting up is a very common symptom in the early months of pregnancy; enlargement of the abdomen; in the first two months of pregnancy the abdomen is flattened and the umbilicus is depressed; after this the abdomen begins to enlarge. There is also an increase in the size of the breasts, with a deepened color of their areolae and later a watery secretion. The external genitals become swollen and of a bluish color. Feeling of the fetal movements— that is, the movements of the small parts of the child in the womb— by the mother is not always reliable, since gas in the intestines has sometimes been mistaken for this. These signs are more valuable when several exist together.

The nausea and vomiting of pregnancy, the so-called morning sickness, consists of nausea accompanied often by vomiting or retching of a glairy fiuid, showing itself most frequently on rising in the morning, but sometimes appearing after breakfast. It is aggravated by the assumption of the erect position. It may begin within a few days, but as a rule it does not show itself until the fourth week of pregnancy; and it generally ceases about the fourth month, rarely persisting throughout the entire time. In the majority of cases it does not sensibly impair the health. It is a sympathetic disorder reflected from the uterus; it is aggravated by indigestible food, by sexual excitement, and by emotional disturbances; it is most marked in first pregnancies and in women of highly emotional natures. It is not infrequently due to some inflammation of the uterus or erosion about the external orifice, and disappears on the removal of the cause.

Mammary Changes.— During pregnancy the mammary glands are in immediate sympathy with the growing reproductive organs of the pelvis; consequently a genuine physiologic enlargement commences in these organs from the beginning of gestation. Their glandular structure becomes larger, fuller, and firmer; a sensation of weight or pricking is felt by the patient; the veins become more prominent. The nipples also become enlarged, more elongated, and somewhat erect. Surrounding the nipple is the areola; this becomes darker in color.

In most women a drop of watery fiuid, the so-called colostrum, may be squeezed out from the nipple at the end of the third month of pregnancy.

The signs of pregnancy are divided into the presumptive, the probable, and the positive. The presumptive signs are: menstrual suppression, morning sickness, irritable bladder, mental and emotional phenomena. The probable signs are: mammary changes, abdominal enlargement, changes in the neck of the womb, and certain changes which are felt on bimanual examination. The positive signs are: feeling the various parts of the fetus, active movements of the fetus, and hearing the fetal heart sounds.

Functional disturbances of the bladder are quite often noticeable in the early part of the pregnancy. In the first part of the pregnancy the bladder is dragged upon, and later it is pressed upon by the enlarged uterus so that the bladder capacity is lessened and frequency of urination is the result. In the fourth month, when the uterus ascends into the abdominal cavity, these bladder symptoms subside, until the very close of the pregnancy, when by the descent of the now greatly enlarged uterus there may be even incontinence of urine.

Changes in the Abdomen.— During the first two months of the pregnancy there is a flattening of the abdominal surface, due to the descent of the uterus into the pelvic cavity, thus slightly dragging the bladder downward and drawing the umbilicus inward. In the latter part of the fourth month there is noticeable a slight abdominal enlargement, and the umbilicus is no longer sunken. By the end of the fourth month the base of the uterus has risen two inches above the symphysis, and at the end of the thirty-eighth week it touches the lower extremity of the breast-bone; the umbilicus has been for many weeks protruding; during the last two weeks of pregnancy the uterus again descends and the woman feels more comfortable.

On the inspection of the abdomen of a pregnant woman there will be noticed a brown line which extends from the umbilicus to the pubes, and all over the surface the presence of striae, or long purple grooves, due to the distention of the abdomen; on the sides of the abdomen and down the thighs, red, blue, or white markings, like cicatrices, may be seen.

Quickening.— Quickening is the sensation experienced by the mother as the result of the active fetal movements of the child in the womb. These movements are first felt between the eighteenth and the twentieth week; the common rule is that quickening occurs at the middle of pregnancy; that is, at four and a half months. As pregnancy advances these active motions increase in frequency and become more marked. When felt or seen by the physician, as can be done in the sixth month, fetal movements constitute a positive sign of pregnancy.

The Determination of Sex at Will.— Although this has always been a question of great interest, and the subject of much experimentation, no rule can as yet be given by which the parents can know in advance of the birth of the child what the sex will be. Dr. Schenck's theory is that the ruling factor in determining the sex is the food partaken of by the mother.

Furst believes that the differentiation may occur before, during, and a little while after the impregnation; that the chances of the development of one or another sex in one and the same woman may vary before final differentiation occurs. It is impossible to determine the sex of the embryo before the tenth week of fetal life. The cause of the differentiation, he believes, lies largely in the good or bad state of the health of the parents; in the first instance there being an excess of females, and in the latter an excess of males, relatively speaking. He believes that there is an excess of male children when conception takes place during the post-menstrual anemia. He has investigated one hundred and ninety-three cases carefully in regard to the probable date of conception after menstruation, and there is a notable increase of male births over female in the cases where conception occurred in the first five days after menstruation; that is to say, where the woman is not so well nourished as later.

Dr. J. Griffith Davis gives as the result of her experiments in this direction, that when conception takes place three days before the menstrual period or within forty-eight hours afterward, the child will be a girl; when conception takes place ten days after the period, the child will be a boy.

Although there are a greater number of the female than the male sex in all parts of the world where reliable statistics have been taken, in all civilized countries the proportion of male births is greater than that of females. There is a greater tendency of the male offspring to die earlier, and this is seen even before birth, in the proportion of three to two. For this reason the stronger sex as applied to men has been regarded by some authors as a misnomer. They are physically weaker in early life and succumb more readily to noxious influences.

The relative age of the parents is said to be another factor in determining the sex of the children. Seniority on the father's side gives an excess of male children; equality in the age of the parents gives a slight preponderance of females; seniority on the mother's side gives an excess of females. Men, and especially scholars, who pass a sedentary life and who exhaust their nervous force to a great extent, beget more girls than boys; so, also, a very advanced age on the part of the man diminishes the number of male offspring.

The Influence of the Male Sexual Element on the Female Organism.— Dr. Alexander Harvey, of Aberdeen, has adopted the theory of fetal inoculation. He believes that the effect is first due to the influence of the male element upon the ovum, which, in consequence of the subsequent close attachment and freely inter-communicating blood-vessels between the modified embryo and the mother, inoculates the condition of the mother with the qualities of the male; and so, on the subsequent impregnation by another male, the offspring resembles the first male and not its real parent. He even goes further, and says that it is conceivable, by successive impregnations effected by him, that the influence may be increased, and if so the younger children begotten by him, rather than the elder, might be expected, ceteris paribus, to bear their father's image. And as regards the mother, he suggests the question, whether there is not something in the popular notion that in the course of years the wife comes to resemble the husband; and that not merely in respect of temper, disposition, or habits of thought, but in bodily appearance, which may be referable to this influence exerted by the husband on her constitution, through the medium of the fetuses in utero.

"Yet it shall be; thou shalt lower to his level day by day, What is fine within thee growing coarse to sympathize with clay. As the husband is the wife is; thou art mated with a clown, And the grossness of his nature will have weight to drag thee down. He will hold thee, when his passion shall have spent its novel force, Something better than his dog, a little dearer than his horse."

Darwin, on the other hand, considers it a most improbable hypothesis that the mere blood of one individual should affect the reproductive organs of another individual in such a manner as to affect the subsequent offspring. The analogy, he says, from the direct action of the foreign pollen on the ovaries and seed coats of the mother plant strongly supports the belief that the male element acts directly on the reproductive organs of the female, and not through the intervention of the crossed embryo.

Dr. John Brown, in reviewing the subject, says it must be conceded that the male element has an influence on the female, over and above its fertilizing influence upon the ovum. The limit of this influence is at present unknown.

Heredity.— Girls are more apt to resemble their fathers in mental traits, disposition, and constitution; while boys take after their mothers. Boys procreated by intelligent mothers will be intelligent; while it does not always follow that the sons of intelligent fathers are intelligent. The poets Burns, Ben Johnson, Goethe, Walter Scott, Byron, and Lamartine were all born of women remarkable for vivacity and brilliance of language.

Hygiene of Pregnancy.— The health and perfection of the child depend largely upon the health and perfection of the parents at the time of its conception, as well as upon the condition of the mother during the pregnancy. Even when both parents possess a strong constitution, but one or both of them is suffering from a temporary exhaustion or malaise, the child will be born below the standard of health it ought to possess. Children born during the first year of married life seldom equal in health the children born of the same parents later; they are not only apt to be sickly, but the liability to premature death is greatly increased. For this reason it is better that the first year of married life should be allowed to pass without conception taking place. A child begotten in an intoxicated or depraved condition of a parent may be depraved itself in the same way, and is apt to be feeble-minded or idiotic.

It must be borne in mind that prenatal culture of some sort begins at the time of conception; and that on the mental as well as on the physical state of the mother, the health as well as the disposition of the child will depend to no slight extent. The prospective mother who constantly gives way to her feelings does a wrong to her unborn child. The mother is at this time more impressionable, more nervous, and more irritable than is natural to her; and while her family should make a certain allowance for her condition, she, on her part, should not allow herself to give way to her morbid feelings. The prospective mother should not lead a life of self-indulgence, on the one hand, or, on the other, should not be weighed down with cares; she should interest herself in her usual duties, and be relieved of all anxiety possible.

Dress.— The clothing must be loose, and all compression about the waist and abdomen must be especially avoided. If the woman wears corsets, she must take them off at once, and substitute a Ferris or some similar hygienic waist. The corset prevents the proper development of the abdominal muscles, which play so important a role in the expulsion of the child from the womb, as well as in the proper growth and development of the fetus itself. If the woman has already borne children, and toward the end of the pregnancy the abdomen becomes pendulous, she will very materially add to her comfort by swearing a muslin abdominal bandage.

A woolen undersuit, or undervest and drawers, with high neck and long sleeves, must be worn winter and summer; the grade of the wool to be adapted to the season of the year. The especial necessity for wearing wool next the skin during the pregnancy is because of the intimate relation between the skin and the kidneys. Any chilling of the body at this time is apt to lead to the congestion of the kidneys. If there is already any congestion of the kidneys present, or any abdominal pain, in addition to the undersuit an abdominal bandage should be worn. These bandages come woven in ribbed woolen, and fit the body snugly. This bandage is to be constantly worn, and, of course, changed at night. During the cold weather the stockings should also be of wool. Under no circumstances are garters allowed to be worn, as they form a constriction around the leg and interfere with the return of the venous blood to the heart, and so increase the tendency to the formation of the varicose veins. It is better not to use any means to hold the stockings up; they will be kept sufficiently well in place by the under-drawers. Low shoes should never be worn except in the hottest weather. It is of the greatest importance that the woman should be impressed with the necessity of the avoidance of taking cold, since any lung or kidney trouble is a serious complication of pregnancy.

Diet.— The diet is the same as that at any other time, only it is more necessary to guard against anything which is likely to cause indigestion. In other words, the diet should be plain, simple, and easy of digestion; nutritious and partaken of at regular intervals. In the latter part of pregnancy owing to the pressure of the enlarged uterus on the stomach, the food may have to be partaken of in smaller quantities and at shorter intervals. At this time also the appetite is abnormally large. Where it does not disagree with the patient, milk is the best adjuvant possible to the diet.

Constipation.— Constipation is the rule of pregnancy. This is due to the great pressure that the enlarged uterus makes on the bowel; and as important as it is at all times to keep the bowels regular, it is at this time more necessary than ever that the woman should have the bowels well evacuated every day. A retention of fecal matter in the body causes the reabsorption into the blood of the toxic matters, with the resulting headaches, dizziness, loss of appetite, and intense nervousness. To obviate this tendency to constipation, plenty of fruit and vegetables should be eaten, as well as cereals if the woman is taking a good deal of outdoor exercise, otherwise the latter had better be omitted. The woman should drink plenty of water— at least three pints a day; this acts as a laxative as well as to flush out the kidneys. If, in spite of all these measures, constipation still persists, as it probably will, a seidlitz powder can be taken the first thing on rising in the morning; or from one teaspoonful to one tablespoonful of the effervescing granules of the phosphate of soda in a glass of water, also to be taken on rising in the morning; or one-half grain of the solid extract of cascara sagrada night and morning. The object of these is to keep the bowels open, but purgation must always be avoided.

Bladder Symptoms.— If there is any irritability of the bladder, any scalding on urination, or a very great frequency of emptying the bladder in the early months of pregnancy, a physician should be consulted at once; in the last months of pregnancy there is a desire to evacuate the bladder frequently, and sometimes at the last there is an incontinence of urine, which is due to the descent of the uterus and the great pressure on the bladder; this condition disappears with the confinement.

Leucorrhea.— If this is present to any marked degree, the vaginal douche should be continued throughout the pregnancy; the temperature of the douche should be from 110 to 112 F.; it must never be taken very hot or very cold. The fountain syringe should be used, and the bag should not be hung more than three feet above the bed, so that there shall not be too much force to the stream of water.

Baths.— Warm tub-baths may be taken throughout the pregnancy, but never oftener than twice a week, and the woman should never stay in the tub longer than is absolutely necessary for the bath, as otherwise the bath is too enervating. A daily sponge-bath of cool or cold salt water at a temperature of from 80 to 70 F., and in the proportion of a pint of rock or sea salt to a gallon of water is most invigorating, and counteracts many of the nervous symptoms and promotes sleep and good digestion. The temperature of the room in which this bath is taken should be 72 F. Shower-baths cause too great a shock to the nervous system, and they as well as foot-baths must be prohibited. Sitz-baths at a temperature from 110 to 90 F. may be taken just before retiring throughout the pregnancy. The frequency and duration of the bath as well as the temperature should be regulated by the attending physician. In cases of intense nervousness and insomnia these baths have an excellent sedative effect. A pregnant woman must never under any circumstances take ocean baths, since there is always great danger that the shock of the waves will cause an abortion. Sea-voyages should be avoided because of the severe nausea and vomiting, as well as the danger that the lurching of the vessel may cause miscarriage.

The sewing-machine is a tabooed thing for the pregnant woman, because of the jarring of the pelvis which it produces. Sweeping of heavy carpets is also injurious. There must be no lifting of heavy pieces of furniture, and especially no lifting from the floor, as it interferes with the circulation in the uterus and is apt to produce miscarriage.

Driving in an easy carriage over smooth roads is permissible; dogcarts, or any conveyance which produces much jolting, must be avoided; and while driving is good, the woman should not do her own driving, on account of the danger of the jars that would be caused by the sudden pulling of the horse upon the lines. Horseback-riding and bicycling are, of course, forbidden, as are also golf, tennis, and dancing.

Exercise.— Exercise in the open air should be taken every day, when the weather is suitable, and walking is the best form of exercise. The amount will be regulated to some extent by what the woman has been accustomed to taking, and it should always stop short of fatigue. The woman should live as much as possible in the open air, and she should attend to her ordinary duties about the house. Long railway journeys are always objectionable.

Hemorrhoids or piles are very often troublesome toward the close of the pregnancy. To overcome this, the patient should lie down immediately after the bowel movement, and remain in the recumbent position for ten or fifteen minutes. In addition, care should be taken to secure a loose movement of the bowels. Should the piles come down, applications of cloths wrung out of hot water, and held well pressed against the bowel, should be made; the piles should then be pressed back until the finger feels that the mass has been pushed above the second constriction of the bowel, which is felt to exist at about two inches above the sphincter ani muscle. Should these means not suffice, the physician must be consulted at once.

Swelling and pain of the external genitals and of the lower limbs are best relieved by the recumbent position. Should the veins of the legs be much enlarged or the feet swollen, the patient should have compression made by the wearing of elastic stockings. Or in some cases a bandage is sufficient; in this case the bandage may be made of muslin; it should be three inches wide, and, beginning at the toes, should extend up as high as the enlargement of the veins continues. This bandage should be freshly applied every morning before rising.

Pain caused by the stretching of the skin may be relieved by the inunction of the skin with cottonseed or cocoanut oil. For severe pain in the small of the back, rubbing with soap liniment or alcohol will be found useful.

Mental Occupation.— Important as this always is, it is doubly so now. The mind should be constantly and pleasantly occupied, but no severe study should be indulged in. The emotional susceptibility is generally somewhat increased. The pregnant woman, quite excitable and irritable, readily responds to influences by which in the non-gravid condition she could not be affected. Sometimes she feels unusually well, is intellectually brightened and more active, and says she is positively happier. At other times she is despondent and morose.

Physiologists admit and observation proves that maternal emotions do affect the development and the exterior of the fetus; likewise the mental organization of the fetus may be affected. All unpleasant news, frights, and physical shocks, also scenes of suffering and distress, must be avoided, as the mind is particularly impressionable at this time. Around the patient should be thrown a gentle and protective care, and she should be treated with the considerate kindness which her condition demands. Theatres and all places where there will be a large assemblage of people should be avoided, as the close air and general bad ventilation are apt to produce vertigo and sometimes attacks of fainting.

Sleep.— During pregnancy a large amount of sleep is required; there should be eight hours spent in sleep at night, and one hour every afternoon. Pregnant women should never do any night watching. There is unusual necessity for good ventilation during sleep at this time.

The Marital Relation.— Coitus is, as a rule, distasteful to pregnant women. It is for the best interest of the wife as well as for that of the child that all marital relation should be suspended at this time. Even uncivilized nations have condemned the privilege of sexual intercourse during pregnancy, and have visited punishment on the offender. If these relations are not wholly suspended, they must at least be at those periods which correspond to the time at which the woman would have been unwell had she not been pregnant. To the continuance of these relations throughout the pregnancy is due much of the suffering of the wife, not only then, but at the time of the labor as well; and the nourishment of the child is interfered with.

Causes of Miscarriage.— Hemorrhoids; straining at stool; excessive intercourse in the newly married; nursing; ocean-bathing; overexertion; overexcitement; a fall; any violent emotion; anger; sudden or excessive joy; a fright; running; dancing; horseback-riding; riding in a heavily built carriage over rough roads; great fatigue; lifting heavy weights; the abuse of purgative medicines; disease or displacements of the womb; and a general condition of ill health.

The danger of miscarriage is greatest during the first three months of pregnancy. Miscarriage is a fruitful source of disease and often of danger to wives; it is said that thirty-seven out of every hundred pregnant women miscarry. Miscarriage is most apt to occur during the first pregnancy; and great care should be taken to prevent this, as the habit is easily established, and after one miscarriage has occurred, another is likely to follow, so that it is sometimes with the greatest difficulty that the woman can be made to carry the fetus to full term. Artificially produced abortions are not an infrequent cause of sterility; the young wife becomes pregnant, and has an abortion produced because she is not yet ready to give up all her pleasures; and eventually when she does become very anxious to have a child such an extent of uterine disease has been produced by the abortions that she cannot conceive.

To Prevent Miscarriage.— The life must be free from all excitement, and must be as quiet as possible without becoming monotonous; especial care must be exercised at the return of the dates for the menstrual periods.

The symptoms of miscarriage are a show of blood, more or less profuse, with intense abdominal pain; on the slightest show of blood the patient should go to bed at once and the physician should be sent for.

CHAPTER XI.

THE CONFINEMENT.

Preparation for the Confinement; Signs of Approaching Labor; Symptoms of Actual Labor; the Confinement-bed; the Process of Labor.

"To my conception one generation of educated mothers would do more for the regeneration of the race than all other human agencies combined; and it is an instruction of the head they need, and not of the heart. The doctrine of responsibility has been ground into Christian mothers above what they are able to bear."

— ISABELLE BEECHER HOOKER.

Preparations for the Confinement.— The right time to engage the physician who is to take charge of the woman at her confinement is just so soon as the woman knows that she is pregnant. It used to be argued that, since giving birth to children was a physiologic process, there was no necessity for the woman to consult the physician until he was sent for when the labor pains began. Take the case of the woman who is for the first time pregnant; she is absolutely at sea; she has not the least idea how she ought to feel, what she ought to do or to leave undone; the result is that she often has a miscarriage which is the source of the greatest disappointment to her husband and herself, or she suffers very unnecessarily throughout the entire pregnancy, has a difficult labor, and perhaps gives birth to a sickly child.

The educated physician will explain to her what symptoms are normal and what are pathologic, and often he will be able to entirely cure the latter. It is now a well-established fact that the most serious complications of the pregnancy, and of the labor itself are caused by severe congestion or disease of the kidneys. The condition of the kidneys can only be determined by frequent examinations of the urine; during the early months of pregnancy these examinations are made once a month, and during the last month they are made every week. The amount of urine passed in the normal condition is three pints a day.

Nowhere, perhaps, is the constant vigilance of the physician so well rewarded as in the careful oversight of the pregnant woman. She goes through her entire pregnancy feeling well, and often the greatest discomfort that she suffers is due to her size; her labor and her lying-in are normal, and she gives birth to a healthy child.

Engagement of the Nurse.— This is generally left to the physician in charge of the case, since he is responsible for the safe delivery of the woman; but if the patient has any decided choice in the matter, it is acceded to unless there should be some very valid objections, and the physician always sends the nurse in view for that case to see the patient in order to ascertain if she is personally agreeable to the patient.

Choice of Room for the Confinement and Lying-in.— The room should be light, sunny, and well ventilated; it should not be too near a water-closet. In the city as quiet a room as possible should be selected, and one that is well removed from the rest of the house, so that if necessary perfect quiet can be maintained. The room should be as cheery as possible.

The dress of the mother during the lying-in consists of a merino undervest, with high neck and long sleeves, and a nightgown, which shall be open all the way down the front. The gowns should be made of light muslin or of cambric; and there should be a sufficient number so that they may be changed every day.

Six abdominal bandages should be provided. These are made of light muslin, and they should be eighteen inches wide and long enough to go once and a third around the patient's hips at the sixth month of pregnancy, or about one yard and a quarter long; they may be made straight or to fit the patient at the sixth month. This bandage is fastened down the front; it is applied directly after the labor, and adds greatly to the patient's comfort during the lying-in.

The vulvar pads used during the lying-in are the antiseptic absorbent pads which can be obtained at any place where surgical dressings are sold; they are made of absorbent cotton, covered with cheesecloth, and sterilized.

There must be a sufficiently generous supply of sheets so that they can be changed every day, and the drawsheet as often as may be required. Nothing is so important to a good lying-in as to have a clean, well-ventilated room, and plenty of fresh bed-linen. Cleanliness is the first requisite to antisepsis, and this is the secret of avoiding puerperal fever.

Articles to be provided for the confinement are: 1. An oblong douche-pan of agate-ware. 2. An agate bed-pan. 3. A bath thermometer. 4. Two pieces of rubber sheeting; one, one yard square, and the other two yards square. 5. Two sterilized bed-pads, 30 inches square by 3 to 4 inches thick. 6. Three dozen antiseptic absorbent pads. 7. One pound of sterilized absorbent cotton; twelve yards of cheese-cloth. 8. Six abdominal bandages, eighteen inches wide, preferably made to fit the figure at the sixth month of gestation. 9. Two hand-scrubs. 10. Four ounces of the tincture of green soap. 11. Bottle of corrosive sublimate tablets. 12. Four ounces of powdered boric acid. 13. Half a pint of good whisky. 14. Two ounces of aromatic spirits of ammonia. 15. Two ounces of aqua ammonia. 16. One pint of alcohol. 17. Two tubes sterilized white vaselin. 18. Plenty of large and small safety-pins. 19. Hot-water bag. 20. New fountain syringe, to hold four quarts; with glass nozle. 21. One small basin for vomited matter. 22. Two very large agate basins or wash-bowls for washing doctor's hands and for antiseptic solutions. 23. Vessel for after-birth. 24. Three large pitchers; one for boiling water, one for cold boiled water, and one for antiseptic solution. 25. Tumbler for boric acid solution for washing baby's eyes, with fine old linen sterilized. 26. One dozen freshly laundered sheets, and two dozen towels. 27. Stocking-drawers, muslin. 28. Change of night-clothing warmed for the mother. 29. A warm blanket to receive the baby. 30. An infant bath-tub. 31. A large piece of oil-cloth to protect the floor.*

* Van Horn & Co., Park Avenue and 41st Street, New York, keep an obstetric outfit, containing many of the above articles, cleansed, sterilized, and packed in a box ready for use, so that they remain intact until needed. The price of this outfit is $16.50.

Baby's Outfit.— Four flannel bandages, to be made of fine, soft flannel, four inches wide, to go once and a third around the body. The edges may be pinked or whipped, but should never be hemmed; a tape is sewed on double, the ends passing around the body, and so the bandage is fastened without pinning.

Six merino shirts, with high neck and long sleeves, made to button down the front.

Cotton diaper napkins, not too large; old soft ones are preferable.

Long merino stockings which can be pinned to the napkin.

Flannel petticoats, not too long; these may be made on muslin bands, which are held up on the shoulders by means of straps. The essential in all the clothing is that it should be sufficiently loose.

Dress-slips should not be so elaborate that they cannot be washed and changed with sufficient frequency; and not so long that the baby's feet will be hampered in their movements by them. All of baby's clothes but the dress should be fastened by safety-pins.

Baby's basket should contain: 1. One outfit of clothes. 2. One tube of sterilized tape. 3. A pair of blunt-pointed scissors. 4. Large and small safety-pins. 5. Pieces of fine old linen; old handkerchiefs are the best. 6. A soft hair-brush. 7. A powder box and puff, with talcum powder. 8. Two tubes of sterilized white vaselin. 9. Two soft towels. 10. Castile soap. 11. Single-bulb syringe; so-called "eye and ear syringe." 12. A woolen shawl or wrap.

If there is no nurse available before the labor sets in, and it is necessary for the patient to see to the sterilizing of the above articles, she should first scrub off all pitchers, basins, and other utensils, as well as the douche-pan, fountain syringe, and rubber sheeting, with a brush and hot soap-suds; the hand-scrubs are to be well washed; then each article should be pinned separately in coarse towels, and put to boil for half an hour in an ordinary wash-boiler. The articles so boiled are then dried without removing the towels, put away, and not opened till the time of the labor.

The abdominal bandages must be laundried and pinned up in separate towels until they are needed. The cheese-cloth must be laundried and then sterilized.

The vulvar pads should be pinned in an old napkin, in packages of half a dozen each; and one package is sterilized at a time by placing it in the oven until the outer covering is scorched. The linen for the baby's eyes and the cheese-cloth are treated in the same way; they are to be cut up into small pieces and sterilized as needed.

Signs of Approaching Labor.— About two weeks before labor there is a sinking of the womb. At the beginning of the ninth lunar month this was at the end of the breast-bone; it now descends to a point midway between this and the navel; the abdomen becomes smaller, the pressure on the lungs is relieved, and the woman breathes more freely. But at the same time that the woman is relieved of the pressure on the chest, she experiences increase of the troubles in the lower extremities. There is an increase of the bladder symptoms, with a desire for frequent unrination. Constipation becomes more troublesome, and there may be hemorrhoids; the veins of the lower extremities may become greatly enlarged.

There is an increased fullness of the external genitals and a greatly augmented amount of mucous discharge. There is a feeling of anxiety and nervousness, with depression of spirits.

During the last two weeks of pregnancy patients are apt to have cramp-like pains in the lower part of the abdomen. These are often mistaken for labor pains. True labor pains are characterized by starting in the back, extending around the abdomen and toward the pubes and down the thighs; they come at more or less regular intervals of half to three-quarters of an hour, and increase in intensity with a decrease in the intervals. A strong pain is apt to be followed by two weaker ones. The so-called false pains are irregular in their occurrence.

Symptoms of Actual Labor.— First is generally the show; this is a discharge of mucous tinged with blood; at the same time the true labor pains set in. When the patient or nurse is in any doubt as to the character of the pains, or when the show appears, the physician should be summoned at once. Other symptoms are frequent desire to empty the bladder and bowels, and a sensation of shivering.

The Confinement-Bed.— A single bed is much more convenient, but it is rarely found in a private house. The double bed is arranged as follows: The hair mattress is covered with a large rubber sheet, which is pinned with safety-pins at the corners and tucked well under the mattress; the rubber sheet must not be drawn too tightly for fear of tearing. Over this comes the sheet, and over the upper half of the bed, the draw-sheet; this is a sheet folded four double, which goes across the bed so as to come under the hips of the patient, and is tucked under the mattress at both sides. The object of this is so that it may be frequently and easily changed without disturbing the patient. The sheet, blanket, and spread which are to serve as a covering after delivery are folded back and placed on the left side of the bed.

The lower right-hand corner of the bed— the right side of the bed is that side which is toward the right hand as one stands facing the foot-board— is arranged for the confinement; on this is fastened the smaller rubber sheet, and over this the sheet is folded, and both are fastened down with safety-pins. The pillow for the patient should be placed at the upper and inner corner of the square. After the delivery the patient is lifted to the upper part of the bed and the temporary dressing is removed. A sheet and blanket are used for a covering during the confinement.

Before the labor begins it is well to fasten up the vest and gown, so that they will not be soiled, as it is important that the patient shall be moved as little as possible after the labor, as all movements tend to increase the bleeding.

The floor oilcloth must be spread at the side of the bed which is made up for the confinement, and should extend slightly under the bed.

A bureau in the room should contain the mother's and baby's clothing, bed-linen, towels, and any other articles which will be needed, all properly arranged.

The clothing for the mother and baby will be placed where it will keep warm, and the infant bathtub will be in readiness in case of sudden need for it.

All water used about the confinement must have been carefully sterilized in advance. The best way to sterilize the water is by boiling it in a large wash-boiler; whatever vessel is used must be scrupulously clean, and ought to be new. The vessel is covered over, and the water is allowed to boil for half an hour; it is then, still covered, set aside to cool. There should be three gallons each of sterilized hot and cold water; since in case of an emergency there must be plenty of water ready for use.

The various articles ordered in the confinement outfit will be at hand ready for use. It is the duty of the nurse to have everything ready for the doctor before his arrival. The patient should have a full warm tub-bath, fresh night-clothes put on, and an enema should be at once given to unload the bowels, and this even though there may have been a bowel movement only a few hours previously. The patient should remain in bed until the arrival of the doctor. After an examination has assured the latter that all is right, she may be allowed to go around the room, with a wrapper thrown on over the night-gown.

Conveniently near the bed should be a small table, covered with one or two freshly laundried towels. This table should have on it a wash-basin, a hand-brush, soap and hot water, an antiseptic solution, scissors, a ligature for the navel, and a suitable aseptic lubricant for the hands.

The Process of Labor.— The process of labor is divided into three stages. The first stage is that of dilatation; by which is meant the stretching of the mouth of the womb so that the child may pass through. At the first confinement this stage lasts about fifteen hours; at subsequent labors the length of this stage is much shorter, the average time being eight hours. The pains during this stage are sharp and cutting, and they are accompanied by a slight show of blood. The patient is fretful and nervous

The second stage of labor is called that of expulsion, because in this stage the uterus contracts down together with the abdominal muscles to expel the child from the womb and the vagina into the world. The duration of this stage in the first confinement is about an hour and a half.

The third stage of labor includes the time from the expulsion of the child till the coming away of the after-birth; the average length of this stage is from twenty minutes to half an hour.

The average length of time for the first labor is seventeen hours; and for subsequent labors from eight to eleven hours.

The bag of waters is the sac of membranes in which the child is inclosed. It contains a liquid in which the child floats; the object of the water is to protect the child from sudden shocks or any kind of injury during pregnancy. During labor this membrane with its contained water serves as a dilating wedge to assist in the opening of the womb, and it also protects the child from the direct contraction of the uterus upon it. When the waters break prematurely, the labor is much longer and more tedious; normally this should not occur before the mouth of the womb is fully dilated.

The pains of the second stage of labor are of a bearing down character, and constantly increase in force and frequency; the climax being reached as the head passes through the vulvar orifice.

A child usually lies in the womb with the head downward; the reason of this is that there is more room in the upper part of the uterus, and as the small parts of the child as it is folded upon itself take up the most space, they occupy this position, while the head lies just above the pubes. The normal position of the child is: the head is flexed on the chest, the legs on the thighs and the thighs on the abdomen, and the hands are folded across the chest. And so the child is usually born head first.

During the stage of expulsion the head of the child is forced down slightly during each pain, to recede a little during the intervals between the pains; in this way the vagina and its external orifice are gradually stretched so that the head of the child may pass through without tearing the parts. If the head is allowed to pass through suddenly, or where the labors are rapid, as in the case of women who have given birth to several children, much mischief may be done by tearing the soft parts.

After the birth of the head there is a short interval of rest, when the shoulders are born; the rest of the body easily slips out; and with the expulsion of the after-birth the labor is over.

At the very beginning of labor the patient should be given a full warm tub-bath, and make an entire change of linen. She will usually prefer to be dressed in her night-clothing, over which during the first stage she may wear a loose wrapper; a sterilized napkin should be worn over the vulva during this stage. During the first stage, as a rule, the patient should not be confined to bed until the dilatation is well advanced; she is generally more comfortable if she is allowed to move around the room, and the pains are thereby advanced.

The only way in which the physician can determine whether labor has begun is by making an internal examination; and this will enable him to decide as to whether it is necessary to remain or not.

The nurse should always wear a wash dress in the confinement and lying-in room.

If the labor is long, nourishment in the form of beef-tea, broths, and milk may be given. No stimulants should be given without the direction of the physician. The frequent taking of cold water is permissible.

At the beginning of the labor the family and friends must be excluded from the room, and it must be kept as quiet and as cheerful as possible.

Toilet of the Patient.— The newly born child is received in a small blanket, is well wrapped, and laid in a warm place. The nurse then turns her attention to the mother; the external genitals and soiled parts of the body are cleansed with sterilized cheese-cloth wrung out of an antiseptic solution; if the body-linen has become soiled, it is also changed, and all blood-stained articles are removed from the bed. The patient is then carefully lifted up on the permanent bed, and the vulvar pad and the abdominal bandage are applied; after which the patient is allowed to rest.

CHAPTER XII.

LYING-IN.

Management of the Lying-in; Lactation; Nursing.

"'Tis is ourselves that we are thus or thus. Our bodies are our gardens; to the which, our wills are gardeners."— "Othello."

Management of the Lying-in.— Immediately after the delivery the first essential for the patient is absolute quiet and rest; the room must be kept quiet and darkened, and ordinarily the patient is allowed to fall into a light sleep. During the first few hours after labor the best position for the mother is flat on the back, with only a small pillow under the head. After the first twenty-four hours the patient may be allowed to turn on the side as she prefers. Since absolute rest is the first requisite for the patient, she must be left alone with the nurse, who must see that she does not fall into too deep a sleep. If the child's cries disturb the mother, it must be taken into another room.

The lying-in room must be kept free from all odors, all soiled clothing must be at once removed from the room, and good ventilation must be insured, being careful to prevent any drafts.

While the patient is asleep, and after the baby has been attended to, the nurse should place all blood-stained articles in cold water to soak. If in the city, the after-birth may be burned in the furnace or range; it should be well covered with coal. In the country the after-birth can be buried in a deep hole.

During the first two or three days the vulvar dressings should be changed from every three to six hours, and at all times as often as they are soiled. Each time that the dressing is renewed the external genitals and their immediate surroundings are to be carefully cleansed with sterilized water, and finally washed with a solution of boric acid, in the proportion of one tablespoonful of boric acid to one quart of water. It is convenient to keep this solution mixed and on hand, as it takes some little time to prepare it; it should be kept in a strength double that which is desired, so that it may be diluted with warm water to give the desired temperature. This solution may be poured over the parts from a small pitcher, the douche-pan having been placed under the patient before the washing began. After labor the vulva is very sensitive, so that while the greatest care must be used to remove all clots of blood and the discharge, there must be no brisk rubbing of the parts. No blood-stained linen should be permitted to remain about the patient or the bed.

Since the lying-in woman perspires freely, her skin ought to be frequently cleansed by sponging with a weak solution of alcohol in tepid water; this should be followed by friction with a towel until the skin is in a glow. Cleanliness of the bed is promoted by the use of a draw-sheet, which is a sheet folded to four thicknesses and placed beneath the patient's hips in such a way that the upper edge of the sheet shall come under the lower part of the pillows. Air and light must be freely admitted at all times in order that the room may be bright and cheerful. For the first few weeks the eyes of the new-born infant should be shielded from all strong light.

Visitors.— For the first week after the confinement the patient should see no visitors. Even the husband or mother should not remain in the room long at a time. Nothing of a disagreeable nature should be told to the patient; and whoever goes into the sick-room should always carry the most cheerful manner, as it is highly necessary that the patient should be kept mentally as well as physically quiet at this time.

Diet.— For the first twenty-four hours the diet must be restricted to liquids, and in most cases nothing is given until the patient has had a few hours' rest. The first thing that is given to the patient should be a cup of warm milk or tea. Milk is the best diet; this may be varied with beef-tea, bouillon, mutton or chicken broth; any of these broths may be made with rice or barley to vary the flavor, but these must not be given to the patient. The patient should have six ounces of the liquid every two hours during the day and every three hours during the night.

On the second day bread well toasted through may be added to any of the liquids. On the third day stewed or baked apples should be added to the diet. On the fourth day, and from this on, the patient will have regular meals, but the diet must be a plain one. For breakfast, stale bread, a soft-boiled egg, fruit, and a cup of tea, not too strong. For dinner, which should always be given in the middle of the day, an oyster-stew or clam broth, a lamb chop, or a very small piece of beefsteak or chicken; but with these there must be no gravies or dressings; a potato baked in the skin; raw tomatoes, if in season; apple sauce or cranberry; celery; junket, plain corn-starch, lemon jelly, plain cup-custard. From this list the diet must be arranged so as to give as much variety as possible from day to day. Midway between breakfast and dinner, and again in the middle of the afternoon, the patient should have a glass of milk. The diet should be generous, but simple.

Urination.— The feeble condition of the bladder in the first few hours after delivery frequently leads to the retention of urine. Owing to the copious secretion of urine which is so common at this time, painful and injurious distention of the bladder may result. The patient should therefore endeavor to pass her urine in at least six hours after labor, whether she feels any inclination to do so or not; the sound of running water or warm fomentations over the bladder, warm water in the douche-pan, and moderate pressure applied by the hand over the suprapubic region, are often effective in accomplishing the desired result. If all these means fail, the catheter must be used as the last resort. During the entire lying-in the bladder should be emptied every six hours.

Evacuation of the Bowels.— There should be an evacuation of the bowels in from twenty-four to thirty-six hours after the labor. For this purpose a seidlitz powder may be given, or the liquid citrate of magnesia. If this does not suffice, an enema of warm water, to which a little soap or two teaspoonfuls of glycerin have been added, may be given. Two pints of water should be prepared; the patient will retain as much as she comfortably can, and as long as she can. The bowels should be opened daily after the first day.