After-pains are caused by the same physiologic process that causes labor pains— namely, by the contractions of the uterus. After the first confinement the after-pains are, as a rule, not severe; attention to the regular emptying of the bladder and bowels also lessens the severity of the after-pains; these pains seldom last after the second day.

The Lochia.— The discharges of the mother continue for about two weeks, and are called lochia. For the first twenty-four hours they are pure blood; the second and the third day they are of the character of bloody water; from the fourth to the sixth day they have a, greenish-yellow color, and from the tenth to the twelfth day they become pure white. Soiled napkins and dressings should never be allowed to remain in the patient's room.

Duration of the Lying-in.— This lasts for six weeks. During this time the organs of generation are returning to their normal size and condition. In order that the woman may be in the best condition possible at the end of this time, it is essential that for the first two weeks she should remain in bed; and so long as there is any blood in the discharge the woman should not be allowed to sit up. The first sitting up should be in bed, the patient being supported by a bed-rest. During the second two weeks the patient may be allowed to divide her time between the bed and the couch; in the latter part of this time she may be allowed to go around her room a very little; and for two weeks more she should remain on the same floor. The first sitting up should not last more than half an hour. Getting up and going around too soon after the confinement, "being too smart," is one of the most prolific sources of falling of the womb, and all manner of uterine trouble, by which the general health of the woman is greatly impaired.

Lactation.— If it is at all possible, every mother should nurse her own child; in the interests of both the mother and the child. So far as the mother is concerned, the process of lactation is beneficial because it hastens the return of the uterus to its normal size. Wet-nurses are known tyrants, and if the quality of the milk has anything to do with the disposition of the child, as is believed to be the case, the idea is distasteful of having a woman who belongs to the lower classes provide nourishment for your child; and artificial feeding is one unmitigated trouble.

A deficiency of the quantity or the quality of the mother's milk can generally be remedied by the diet and attention to the health of the mother; if the deficiency in quantity persists, the mother's milk can be supplemented by artificial feeding.

There may exist certain conditions of the mother in which nursing her own infant would be inadvisable or even impossible. Syphilis contracted late in the pregnancy, and tuberculosis, are contraindications, owing to the danger of the mother infecting the child. Inversion of the nipples, their excoriation, or persistent sensitiveness may make it impossible. In marked general debility of the mother from any cause whatever, it would be injurious to the mother and the child.

After the mother and the new-born infant have had some hours of rest and sleep, it is advisable to apply the child to the breast, to receive by this first effort the small quantity of milk which is an especial provision to act as a natural purge and to start the bowels of the child into a healthy activity; this also excites the milk glands to secretion. The mother's milk in full supply may be expected in from forty to sixty hours after delivery.

Nursing.— When the mother's nipples are of the normal size and well formed, the healthy infant instinctively suckles at once when placed at the breast, but sometimes it has to be taught; by squeezing out a few drops of milk to wet the nipple, the child will usually take hold, or a little sugar and water may be put on the nipple; a little patience and tact are all that is necessary to insure success. But the infant must be taught to nurse at once before the breasts become engorged with milk.

Under ordinary circumstances the child is to be kept at the breast for one year. But if within this time the menstrual period should recur and be profuse, or should the woman again become pregnant, the quality of the milk becomes poor, and necessitates the immediate weaning of the child; the character of the milk is also altered, and even its secretion may be checked. Nervous agitation may so alter the quality of the milk as to make it poisonous. A fretful temper, fits of anger, grief, and sudden terror not only lessen the quantity of the milk, but render it thin and unhealthful, inducing disturbances of the child's bowels, diarrhea, and so forth.

Position of the Mother When Nursing.— When in bed in the recumbent position, the mother should lie on that side from which the infant is going to nurse; when up, the mother should sit erect.

Care of the Nipples.— Immediately after each nursing the nipples should be washed off in a saturated solution of boric acid in cold water, and dried with a soft cloth. If they are disposed to crack, anoint them with cocoa-butter immediately after each cleansing. If the skin of the nipple is very sensitive, a nipple-shield should be used for the first few days; or should the nipple become sore at any time, the shield can be resorted to. The nipple-shield must fit tightly; the best ones are made of glass with a rubber tip. In the intervals of nursing the nipple-shield should be kept in cold water after it has been thoroughly cleansed by being brushed on both sides.

The breasts are sometimes distended from an over-secretion of milk; this is relieved by saline cathartics, by abstinence from liquids, and by the use of a compression breast bandage. This is made of a straight piece of muslin, with a shallow notch cut in one edge for the neck, and, a deep one for each arm; the bandage is closely applied over the breasts, and the ends pinned in front; it is also pinned over the shoulders.

In debilitated women the supply of milk may be insufficient; the most reliable evidence of this is the fact that the infant ceases to gain in weight.

CHAPTER XIII.

THE NEW-BORN INFANT.

The Infant's Toilet; the Crib; Feeding of Infants; Artificial Feeding; the Wet-nurse; Characteristics of Healthy Infants; the Stools; Constipation; Urination; Dentition.

"O thou child of many prayers, Life hath quicksands; life hath snares."

— LONGFELLOW.

The Infant's Toilet.— So soon as the mother has been made comfortable, the toilet of the infant is attended to. This should be made near the register or stove; and the lap of the nurse should be covered with a small flannel blanket. The baby's body will be found to be covered over with a white, greasy, somewhat cheesy substance; some sort of grease is needed for its removal; rendered lard, sweet oil, and lanolin are the best; vaselin is less effective. All of this cheesy substance must be at once removed; the most difficult parts will be in the folds and creases. The nurse should grease the palms of her hands, then take the head of the child between them, and thoroughly grease it; particular attention must be given to the ears; then come the neck, shoulders, arms, chest and back, groins, external genital organs, and lower extremities. After the child has been thoroughly gone over, the grease should be rubbed off with a soft towel.

A rectal injection of one tablespoonful of warm water is given at once to unload the bowels of the meconium; this generally acts before the baby's toilet is completed. The meconium is the first discharge from the infant's bowels after birth, and that which had collected in the intestines during the pregnancy.

The Baby's Bath.— The baby's bath-tub is filled about one-third full of water at a temperature of 100 F., tested by the thermometer. The baby is then gradually immersed in the water, with the exception of the head; this is supported on the left wrist of the nurse, which passes under the infant's neck, while her hand grasps the left shoulder; with the right hand the nurse quickly rubs over the child's head and body; the entire bath should not occupy over five minutes. The infant is then lifted out into the lap of the nurse, on which is spread a soft, warm towel, with which it is carefully dried. One of the important points in giving the infant its bath is to be sure that the groins, arm-pits, and genitals are thoroughly well dried; otherwise excoriation at these parts is sure to occur.

After this a daily tub-bath is given in the same way; soap is rarely needed; when it is, castile soap should be used; its constant use is not necessary and would only irritate the skin. These daily baths strengthen the nervous system and prevent coughs and colds. The bath should be given during the morning, one hour after feeding, and should not last more than five minutes. The mother herself, just as soon as she is able to go around, should superintend the bath; in this way she is assured that if properly given, and will also recognize any incipient affection of the child. These daily baths should be continued till the child is four years old. Powder is not essential; but if it is desired, a plain talcum powder may be used.

The Dressing of the Cord.— After the bath the ligature which was tied around the cord at the birth of the child will be found slightly loosened; this should first be made tight, and then the cord, doubled back on itself, should be tied by the ends of the same ligature. A square of soft sterilized linen or gauze is slit up to its center; the cord is allowed to pass through this slit, which looks toward the child's right; the stump of cord is laid on the left and the ends of gauze are folded over this; the whole is kept in place by the abdominal bandage. As there is some exudation from the cord, it is necessary to change these dressings twice a day; as this exudation is of a somewhat gluey nature, it will be found that the dressings stick to the cord. In removing the gauze great care must be used not to make any traction on the cord; when the infant is placed in the bath, the water loosens the dressing and it falls off in the water; at other times it must be removed with the greatest care. There should never be any odor about the cord; it usually drops off about the fifth day.

The process of ulceration by which the cord falls off leaves an open surface on the child's body which offers an avenue for septic infection. Great care must therefore be taken that the nurse's hands or anything which comes in contact with this surface should be perfectly clean. The dressings used must be thoroughly antiseptic.

Care should be used not to fasten the abdominal bandage too tightly; the bath is given on an empty stomach, and allowance should be made for this; the binder should be loose enough to allow two or three fingers to easily slip under it.

The Meconium.— The First discharge that comes from the bowels is of a dark, greenish color, and should come away during the first twenty-four hours; if it does not, the baby may suffer a good deal of pain, and an enema of warm water must be given. As this substance is very difficult to be washed out of napkins, the first ones used should be old and afterward be burned.

Cleansing.— Every time the napkin needs to be changed, even if it is only wet, the baby should be washed with warm water. A napkin should never be used twice without washing; it chafes the child, and it is an unsafe as well as a filthy practice; the napkin must always be removed as soon as it is wet.

The Infant's Toilet.— After the application of the binder and napkin, comes the undervest; the fingers of the nurse are passed up through the sleeve to seize the infant's hand and pull it through; as soon as it gets a little older the child will grasp a finger laid in its palm, which greatly facilitates this part of the toilet. The stockings are next put on and pinned with safety-pins to the napkin; then comes the petticoat, the band of which is also loosely fastened with safety-pins, and with the slip the toilet is complete. All the clothing should be changed night and morning.

The eyes and mouth should be washed out with separate pieces of gauze or old linen. For the mouth, a small piece of cloth wet in warm water is wrapped around the little finger of the right hand, going into the left angle of the baby's mouth and coming out at the right, going between the gums and cheeks as well as over the tongue. This procedure should be gone through with every time preceding and following the nursing, and in this way the milk is prevented from souring in the mouth, and the digestion is kept in good condition. A sore mouth in a baby indicates carelessness on the part of the nurse.

A soft hair-brush may be used, but the scalp is too tender to permit the use of a comb.

After the toilet has been completed, the baby is laid in its crib, on the right side of the body, and warmly covered. The weaker the baby, the more attention must be paid to the external warmth. It may be necessary to place a warm-water bottle in the crib, but this must never touch the infant.

The Crib.— The infant must have its own crib, without rockers, and it must on no account be put to sleep in the same bed with its mother. In its early life it should never be taken out of its crib except to be fed, to have its clothing changed, or to be bathed. There should be no holding on the lap, no dangling, no carrying or fussing over the new-born infant; and the more the baby is let alone, the better and healthier it will be. If baby cries, look at once to see if it needs a fresh napkin; if not, if any pins are sticking into it, if the clothing is possibly too tight; if none of these things are wrong, give it a sup of water and turn it over on the other side. The baby often becomes restless by sleeping for several hours in the same position. But on no account take the infant up out of its crib simply because it cries.

Cheerfulness and good nature on the part of the infant are dependent on its general good health. A healthy infant should not have colic, but if such is the case, there is a peculiar look of distress on the face, which indicates that the child is in pain; what is needed is warmth or medication according to the severity of the case, but never floor walking. Begin the latter procedure, and you may hope to keep it up for several years.

Ventilation.— The air is sometimes vitiated for children's uses in various ways; their nervous susceptibilities are greater than those of older people. A very little odor of tobacco may cause nausea and discomfort to an infant in arms. The atmosphere of the room should be sweet and pure and unscented. All scents and perfumes affect the nervous system, and by constant excitation do it damage. A bouquet of flowers renders the air of a closed room too heavy.

Feeding of Infants.— During the day the infant should be put to the breast once every two hours, and once every three hours during the night. This interval of time between the feeding is necessary in order that there may be sufficient time given for digestion to take place. Regurgitation of milk soon after feeding is a sign that the stomach has been overfilled. As the infant usually falls asleep after nursing, it is necessary to waken it up at the time for the next nursing, as good digestion depends upon regularity of feeding.

For the first nursing the infant may be put to the breast in from two to six hours after the labor if the mother is sufficiently rested; from ten to twenty minutes is long enough for each nursing. Before each nursing the nipples should be carefully washed off with a solution of boric acid. The first secretion of the breasts is laxative; that is, it acts on the bowels, and makes is unnecessary to give the infant anything to take for this purpose. The breasts should be used alternately in feeding the infant, as this allows a longer time for the accumulation of the milk. For the first few days the infant needs very little food, and the mother's milk is generally sufficient.

The infant should be given a teaspoonful of cool water to drink two or three times a day, as the milk does not quench the thirst. The water should be sterilized by boiling, and be kept in an air-tight flask.

At the end of the third month the intervals of nursing for the daytime should be three hours, and the last nursing at night should be at eleven o'clock, and the first nursing in the morning at five o'clock; thus allowing the mother an interval of six hours of unbroken sleep.

The best evidence of the proper nutrition of the child is a progressive gain in weight. The child should be weighed every week. A loss of a few ounces usually takes place during the first few days after birth, so that the child does well if at the end of the first week it weighs as much as it did at birth. After the first week the weekly gain should not fall below five ounces.

The Wet-nurse.— When the mother for any reason whatever is not able to nurse her child, the best substitute is a wet-nurse. Before she is employed the wet-nurse should always be carefully examined by a physician to insure her freedom from disease. The best age is between twenty and thirty years, and the age of the child of the nurse should be at least within a month of that of the child to be nursed. The best sign of the good health of the nurse and of the condition of her milk is furnished by the health of her own child. The breasts should be well formed and the nipple of good shape. It is well, if possible, to get a woman who has borne several children, as she will understand the care of the child better. No woman who is not perfectly healthy is fit to be a wet-nurse; and even after she has been engaged her health and her habits must be watched over.

Artificia1 Feeding.— The first requisite in artificial feeding is that the milk shall be made to correspond as nearly as possible to that of the mother. For this purpose the following formula, prepared by Rotch, of modified cow's milk is considered the best:

Milk 2 ounces Cream 3 ounces Water 10 drams Milk-sugar 6 3/4 drams Lime-water 1 ounce

To make one pint of the mixture for use in the twenty-four hours, take the milk and cream as soon as it comes in the morning, and mix as above directed.

No less important than the correct proportions of the ingredients, is freedom from disease germs and bacteria of putrefaction. Complete sterilization is possible by prolonged boiling; but experience has proved that under prolonged exposure to a temperature near the boiling-point certain changes take place in the albuminoids of the milk which greatly impair its digestibility. Full sterilization of milk for infant feeding has therefore practically been abandoned. It has been found that milk heated to 167 F. for twenty minutes, and promptly chilled by placing on ice, remains practically sterile for twenty-four hours, and it is spared the injurious changes which take place at a higher temperature. This process is known as Pasteurization. The Arnold steam sterilizer affords a convenient method of sterilizing; if used with the cover removed, the steam chamber being open, the temperature of the steam chamber does not exceed 170 F.

It is claimed that in the Arnold steam sterilizer, with the use of a suitable gas stove, the water begins to boil at the end of two minutes after the gas is lighted. A four-ounce bottle of milk at an initial temperature of 70 F. in the open steam chamber attains a temperature of 170 in just one hour. An exposure of about one hour and twenty minutes in the steam chamber is therefore necessary for the Pasteurization.

The rules for sterilizing are as follows:

First, clean the bottles thoroughly; then place them in cold water, which is allowed to come to boil and boiled for ten minutes.

Second, fill each with the milk you wish to use; put in the rubber cork without the glass plug; this leaves a small opening in the rubber cork; set the bottle in the basket, then in the boiler.

Third, set in the refrigerator until needed for use.

Fourth, when wanted for use, place a bottle of the milk so prepared in the tin mug which accompanies the sterilizer; fill the mug with hot water to the height of the milk in the bottle, heat the milk to the temperature of 99 F., remove the rubber cork and put on the nipple, when it is ready for use.

Fifth, cleanse the bottle immediately after using; throw away any milk that has not been used.

Sixth, if the steaming process is preferred, place the basket without the bottles in the boiler, fill the water up to, but not above, the bottom of the basket, place the bottles in the basket, and proceed as before.

It is important that the milk should be sterilized or Pasteurized as soon as it is served in the morning. Each bottle must be thoroughly washed as soon as it is emptied. Milk sterilized in this way will keep for days without spoiling, as it is hermetically sealed and all the unhealthy germs have been removed.

The most exact method for the artificial feeding of infants, and that which most nearly approaches the mother's milk, is that used by the "Walker-Gordon Laboratory," branches of which are to be found in many of the large cities.

Not only is the greatest care taken that the milk used shall be pure and sterilized ready for use, but these laboratories are equipped by special machinery which separates the important elements of the milk— namely, the fat, the milk-sugar, and the proteids. So that the physician can modify the proportions of these various ingredients of the milk to meet the necessity of the age and requirements of the infant.

When the milk contains too little sugar, the infant does not gain as rapidly in weight as it would otherwise do. Too much sugar in the milk is indicated by colic, thin, green, or acid stools, or eructations of gas from the stomach.

An excess of fat in the milk is indicated by vomiting; too little fat causes constipation with dry hard stools. Proteids in excess are a prolific cause of colic and also of diarrhea.

Prescription blanks are furnished the physician, who fills out the percentages of fat, milk-sugar, proteids, and alkalinity, to suit the age, weight, and general condition of the child. He orders also the amount to be given at each feeding, and the number of feedings to be given in the twenty-four hours. Each bottle contains just the amount to be given at one feeding. All that the mother needs to do is to place the bottle in a receptacle containing warm water, until the milk has attained a temperature of 99 F., remove the cotton stopper, and put on the nipple, when it is ready for use.

The Nursing Bottle.— This should be of clear glass, with a rounded bottom, and of such a shape as is easy to clean; so that no particles will cling around a corner which cannot be reached. The graduated bottle is the most convenient, as it enables the quantities of each of the materials used in the preparation of the feeding to be mixed in the bottle, doing away with the trouble of measuring before putting into the bottle.

Rubber Nipples.— Two nipples should be kept for alternate use, and no nipple should be used longer than two weeks. A soft rubber of conical shape is best, with an opening at the top which is not too large, so that the milk will not flow through, as it is desirable that the child should obtain the milk by suction. So soon as the feeding is over, the nipple should be removed from the bottle, and brushed on both sides with a stiff brush. It should then be put in cold water, where it is kept until it is again wanted.

The baby should be fed slowly, from ten to twenty minutes being taken for each feeding. Sucking from an empty bottle or with a nipple in the mouth should never be permitted, as in this way the baby draws air into its stomach, which will result in colic. Each flask should contain only enough for one feeding.

In lieu of the regular sterilizing apparatus, milk may be similarly prepared by placing the milk in an ordinary glass fruit-jar with a screw lid. This is placed in a colander over a pot of boiling water; the milk should be allowed to boil in the open jar for two minutes; the jar-lid is then screwed on, and it should steam for twenty minutes longer.

The capacity of the infant stomach at birth is about one ounce, which is the average quantity of food that should be taken at one meal. The average rate of increase in the amount of food is one and a half drams a week for the first six months; subsequently somewhat less. The intervals of feeding should be two hours at birth, and increased to three hours at the end of the third month. The food should be given at a temperature of 99 F. and fed directly from the sterilizing bottle.

Fresh Air.— In warm weather the baby is taken out-of-doors in from three to four weeks after birth; in cold weather not before two to three months. In the latter case it is prepared for the change by being first dressed as for the street, with wrap and cap; the windows of the room are then opened, and the infant is carried about here. In the winter months when the baby is first taken out, it is better to carry it in the arms, as it will be kept warmer in this way, and if it does become chilled it will be more quickly noticed.

Characteristics of the Healthy Infant.— The average weight of an infant at birth is about seven pounds, and its length is about twenty inches; the extremes are four pounds or a little less up to eleven pounds. The head and trunk of the child are developed out of proportion to the limbs.

The skin of the new-born infant varies from pinkish to red; about the fourth day the color becomes somewhat yellowish; this tinge should disappear about the end of the second week, and at the same time the skin begins to peel off.This process lasts about two weeks longer, when the baby's skin takes on its normal color.

The shape of the head varies greatly, much being due to the amount of pressure during labor; but this disappears in a few days. As a rule, the large bones of the head are felt to be separated by membranous ridges called sutures; there is one on the median line on the top of the head, and at either end of the suture is a large open space, called a fontanel. The largest one is at the front of the head, and is called the anterior fontanel; it is about large enough to be covered by the tips of two fingers, and is of a lozenge shape; this opening does not close till the child is about eighteen months old. In a healthy baby this fontanel should be on a level with the bones of the head; a slight pulsation may be noticed in it, due to the pulsations of the vessels of the brain. There is a much smaller three-cornered fontanel at the back of the suture, and one behind either ear; these soon close up with bone.

A new-born baby cannot probably do any more than distinguish light from darkness. Up to the sixth week there is an inability at coordination of the ocular muscles; after this time the eyes begin to move in an orderly manner, and they will follow a bright object moved slowly in front of them. At about the end of the second month rapid movements are perceived, as is evinced by the child's closing its eyes quickly on an object suddenly approaching it. At three months the child begins to recognize colors; the first recognized are yellow, red, pure white, gray, and black. But the faculty of distinguishing between colors is not perfected till the third year. The mother is recognized about the third month. Hearing and a sense of smell develop rapidly after birth; loud noises in its vicinity will cause a child to start during the first day after birth. By the time the child has reached three months of age it shows signs of having a mind of its own, and is capable of exercising thought. It grasps for objects, and indicates its likes and dislikes. At from eight to ten months it can utter several syllables, and at the age of one year should be able to say mama and papa; at two years it should be able to frame short sentences.

Weight of the Baby.— By the end of the sixth month the child's weight should be double what it was at birth; that is, about fourteen pounds; at the end of the twelfth month be three times as much as at birth, or about twenty pounds.

Muscular Action.— Muscular action in the new-born infant is entirely involuntary, there being no voluntary acts until about the end of the third month. Sucking and licking are largely instinctive. The movements of the arms and legs are impulsive acts, and occur during sleep, just as they did in the intra-uterine life. The act of raising the head, which is attempted about the fourth month in healthy children, is volitional, requiring not so much added strength of muscle as power of coordination. As volition develops the power of coordination gradually increases, and the child learns to perform voluntary or purposeful acts. Voluntary grasping is done after the fourth month. As the child learns to balance its head, it attempts to sit up. This act is not successfully accomplished until about the fortieth week; the child sits firmly alone when ten or eleven months old. Before this time it is necessary to support the head and spine of the child with the hand. By the third or fourth month the infant should be able to grasp things. The child begins to creep about the ninth month. The clothing should be so arranged as to allow entire freedom of motion.

It should be able to stand up by a chair by the tenth month, and be able to walk alone at the end of the first year. It is important that parents should know this, since not knowing what a normal baby ought to be able to do, cases of birth palsy, or even an attack of paralysis due to teething, are not infrequently overlooked, not only by the mother, but even by the doctor, who attributes the inability of the child to do what other children can do at this age simply to weakness, which the child will outgrow; and thus the time passes in which the most could be done to cure the child and to prevent the subsequent deformity.

A baby should not be forced to stand or walk; a very stout baby, on account of its weight, will stand up and walk much later than a slight one, the two being equally healthy. Or if a baby has been sick, it will feel no inclination to stand up. Naturally, a child creeps before it walks, and this develops the muscles of the lower limbs, so that they will support the weight of the child in standing. By prematurely forcing a child to stand up and walk, there is danger of causing bow-legs, as the bones of the legs are still weak; the child should be discouraged from standing up too much rather than encouraged to stand up more.

Sleep.— A large proportion of the time of early infancy is spent in sleep; for the first few weeks the infant only wakens up to be fed. During sleep the eyelids should be tightly closed; a partial opening of the lids, showing the whites of the eyes, is an indication of ill health. Up to the age of six, children require twelve hours of sleep at night, besides an hour or more in the middle of the day; the child should be permitted to sleep as long in the morning as it will.

Respiration.— The healthy infant breathes on an average forty-four times a minute; the only time the respirations can be satisfactorily counted is during sleep. When the child is awake, the respirations are hurried by slight movements of the body, crying, and so forth. The average pulse of a newborn baby is one hundred and forty; this is hurried by the same causes that hastens respirations; the pulse is most easily counted at the anterior fontanel. The average temperature of the infant is 99 F. When the tip of the nose and the extremities are cold, it indicates a lowered vitality.

The nature of the child's cry indicates, variously, hunger, temper, or pain; the mother will soon learn to distinguish these varieties. If the child cries because it is hungry, the cry ceases so soon as it is fed. But a child is never to be fed simply because it cries; it must be fed on the hour by the clock. If this rule is not strictly adhered to, it will suffer all the forms of indigestion and colic that babies are heir to. If it cries because of colic, there is a drawn look on the face, and at the same time the legs are sharply flexed on the thighs and the thighs on the abdomen. If the cries are due to earache, the head will be rolled about from one side to the other. In either case nothing will stop the cries until the pain is relieved. A baby does not shed tears until the third month.

The Stools.— The stools of a very young baby fed on breast-milk should be of a yellow or orange color. There should be three or four evacuations daily; they should contain no curds. Stools of bottle-fed babies are lighter in color and more offensive.

Constipation.— Constipation is not uncommon in infancy; it may be overcome by the use of a soap suppository, or by an injection of warm soap-suds into the bowel, or by an injection of oil and water, or by gentle friction over the bowel, following the course of the large intestine.

To make the soap suppository, take a piece of castile soap about an inch long, give it the shape of a cone not any larger than the end of the little finger, and make it perfectly smooth. This is inserted to about half of its length into the rectum and held there until it causes the bowels to move.

The bowel injection is best given by means of the single-bulb syringe, known as the eye and ear syringe; the bulb holds about two tablespoonfuls of liquid. This may be warm cotton-seed oil, sweet oil, or glycerin one teaspoonful to warm water two tablespoonfuls. The nozle should be small, smooth, and well oiled. It should be very carefully introduced into the bowel, being directed a little to the left side, and the bulb gently squeezed to force the contents into the bowel. The injection is more effective if it is retained for a little while; this is accomplished by making slight pressure on the anus with a towel.

Rubbing the abdomen for about ten minutes in the direction of the large bowel is sometimes very effective in overcoming constipation; begin in the right groin and rub up as far as the border of the ribs, then across to the left, then down on the left side.

Vomiting.— Vomiting means often only that the stomach has been overfilled, and may be relieved by withholding all food for a few hours.

Urination.— The frequency of urination in a newborn baby will vary greatly with the weather and other conditions; in cool weather it is not unusual for the napkin to need changing almost every hour. Healthy urine should not stain the napkin. The new-born infant secretes very little urine until it begins to take nourishment freely. The bladder is usually emptied during birth, and very often the bowels also, so that if the child seems well and there is no malformation of the parts, the family may be assured that the apparent retention of urine is only temporary.

The use of hot fomentations over the kidneys and bladder will often hasten the evacuation of urine if it has been unduly delayed. If the secretion seems highly concentrated, a drop of sweet spirits of niter in a teaspoonful of water may be given every two hours.

Teething.— The first tooth generally appears about the end of the fourth month; in delicate children they come later. As a rule, the lower front teeth come first, coming in pairs, one tooth coming on each side of the mouth; followed in about a month by the corresponding teeth in the upper jaw. Preceding their appearance the gums become swollen, hot, and painful, and the saliva forms in excess and runs from the mouth. The child is irritable, flushed and restless; and there usually occurs some disturbance of the bowels, commonly diarrhea. This all indicates a nervous derangement, and calls for a judicious diet and general careful oversight. The symptoms subside when the teeth are through. During teething the child manifests a desire to bite on something, and a soft rubber ring will give it great comfort.

The first set of teeth are twenty in number, and are usually cut in groups, starting about the fourth month and continuing until between the twentieth and thirtieth month, when the first dentition should be complete. As a rule there is an interval of rest between the eruption of the various groups. During dentition children are generally more peevish and fretful than usual, but there should be no general constitutional disturbance. During dentition it is of especial importance to keep the bowels well opened; it is better to have them too loose than costive; constipation at this time greatly increases the tendency to convulsions.

Bottle-fed babies are apt to cut their teeth later than those nursed at the breast. The lack of appearance of any teeth before the end of the first year indicates that the nutrition of the child is below par, or, in other words, that the child has rickets. The permanent teeth begin to appear about the sixth or seventh year.

PART IV.— THE MENOPAUSE.

CHAPTER XIV.

THE MENOPAUSE.

Average Duration of the Menstrual Function; Duration of Menopause; the Menopause; General Phenomena of the Menopause; Prominent Symptoms of Menopause; Pathologic Conditions of the Menopause; Hemorrhage at the Menopause a Significant Symptom of Cancer; Causes of Suffering at Menopause.

"Yet I doubt not through the ages one increasing purpose runs, And the thoughts of men are widened with the process of the suns. Knowledge comes, but wisdom lingers, and I linger on the shore, And the individual withers, and the world is more and more. Knowledge comes, but wisdom lingers, and he bears a laden breast, Full of sad experience, moving toward the stillness of his rest."

— "Locksley Hall."

Average Duration of Menstrual Function.— The average duration of the menstrual function is from thirty to thirty-two years. Raciborski estimated the duration of menstrual life at about thirty-one years and nine months. According to him, the mean age of puberty at Paris was fourteen years and seven months; therefore, the average age of the menopause was forty-six and one-half years. Tilt gives the average age of the cessation of menstruation in 1082 cases as forty-five years and nine months. The average age is between forty-five and fifty years. It has been shown by Krieger, Kisch, and others, that the earlier the menses appear, the later they cease, and vice versa. However, when the first period is unusually early or late, the menopause comes very early. Also that the sexual function is usually abolished earlier in the laboring classes, who are compelled to work hard and who have many cares, than in the well-to-do and rich.

Race does unquestionably influence the duration, but given a sound healthy race, which is not too much enervated with civilization, and the menstrual process will, equally with the total physical vigor and the vitality, be increased. At the present day there is an increased sexual vitality, which shows itself in the fact that the duration of menstrual life has been increased three to four years during the past generation. The inference can be fairly deduced that vigorous vitality causes prolongation of the menstrual process and the actual age.

Duration of Menopause.— By the menopause or climacteric is understood the whole period from the beginning irregularities in the time of appearance of the menstrual flow until its actual cessation. The average duration of the menopause is from two and a half to three years.

The Menopause.— The menopause is a physiologic and conservative process. It occurs at a time of life when all the tissues are most stable and the nutrition of the body is at its best. Other physiologic changes which occur at the same time are decrease in the size of the spleen and lymphatic glands, the muscular coats of the intestine atrophy, and lessened peristalsis ensues; hence the increased tendency to constipation. These are not the degenerations of age, but the blood-supplying, blood-making, and blood-elaborating organs of the body have completed the growth of the organism, done their work, and are striking a balance with the needs of the economy.

The object of each metamorphic or developmental epoch is a critical readjustment of the organism, in order to insure the greatest possible amount of health for each subsequent period of life. In the vast majority of cases this object is quietly effected, but sometimes the constitution only rallies after having been severely shaken for a varying period.

General Phenomena of the Menopause.— Borner states that while many women pass this period without noting any change in their former condition, and are conscious of the occurrence of the change of life only by reason of the absence of the menstrual flow, others suffer for years with a host of troubles.

One of the most essential changes is that of the woman s psychic condition— from slight vagaries, loss of interest in the daily affairs of life, to melancholia and insanity.

"Two factors are generally taken into account: first, the sudden cessation of the menses; second, the reflections of the patient caused by her condition, meditations on the loss of youth and sexual power, and anxiety in view of the dangers of the climacteric. It cannot be denied that there is some truth in the supposed sad thoughts about the beginning of old age, and the depression caused by them can scarcely be considered abnormal" (Borner).

Napier believes that it is extremely rare for the cessation to occur without some physical discomfort or some disturbance of the nervous system, but adds that: "Some women, however, cease menstruating with very slight inconvenience." As a rule, the woman misses one, two, or more periods, then a menstruation of almost normal quantity and duration; and this is again repeated at gradually longer intervals, and with a diminished flow, until actual cessation occurs.

The periods cease owing to the degeneration and disappearance of the glandular tissues of the uterus, and secondarily to similar changes in the ovaries and other glands. This is followed by an atrophy of all the structures of the genitalia.

An increase in the size of the uterus, from increase in the amount of blood, is frequently noticed at the beginning of the menopause; later it becomes smaller in all its dimensions. The wall becomes thinner; the cervix becomes shorter and thinner, sometimes hard, sometimes flabby as a membrane. But the distinguishing feature of the menopastic uterus is atrophy of its lining membrane.

The changes in the uterus and Fallopian tubes are earlier than those in the ovaries, so that ovulation, though lessened in activity, may persist for a considerable time after menstruation has ceased. Ovarian atrophy has been referred to senile rather than menopastic changes.

Atrophy of the ovaries occurs very gradually. Peuch found that in one case the ovaries were of normal size three years after the establishment of the menopause. Kiwisch describes the structural change in this gland as consisting, on the one hand, of an increase of the connective-tissue stroma; and, on the other hand, the Graafian vesicles themselves undergo retrograde change. In consequence of these microscopic changes, which take place very slowly, the entire organ becomes harder and smaller.

Napier believes that the ovaries secrete specialized substances which aid in determining menstruation; and that in a less degree the utricular glands and the glands of the Fallopian tubes share in this action. He considers that this is probably secondary to the chain of peripheral irritation from the uterine glands, but that this secretion is none the less an essential feature of the menstrual process.

In support of this view he calls attention to the pigmentation of the skin which occurs during pregnancy and chlorosis, showing that the absence of the catamenia results in the retention in the blood of some substance which would normally be excreted at this time.

Other atrophic changes in the genitalia are shriveling of the vulva, with prolapse of the vagina or uterus from relaxation of the ligaments and loss of the natural support afforded by the changed perineal body.

Uterine catarrh occurs almost invariably, and only ceases in advanced years. Displacements of all kinds are frequent, but on account of the now greatly diminished weight of the uterus, these are insignificant.

The vagina is at first almost always hyperemic, but this disappears as the vessels successively atrophy. The vagina gradually becomes narrower and shorter. The mucous membrane loses its rugae and presents a pale, grayish, blanched hue.

The researches of Byron Robinson, made by the dissection of a number of old women, show that after the menopause not only is there an atrophy of the genital organs, but that the hypogastric plexus of the great sympathetic nervous system also shrinks away. "It becomes smaller and firmer, and no doubt some strands disappear. On this fact must he based the pathologic symptoms accompanying the cessation of the menstrual function."

The importance of the genital organs is shown by the vast nerve-supply sent to them. When this great nerve-tract becomes atrophic, so that it can no longer transmit the higher physiologic orders, all parts of the sympathetic system must be unbalanced, until a new line, the next line of least resistance is established. And Robinson believes that this is the explanation of the many pathologic manifestations of every viscus at the menopause; that is, "the irritation which arises by trying to pass more nervous impulses over plexuses than normal gives origin to what is unfortunately known as functional disease. It is just as organic as any disease, only we are unable to detect it."

Chemical changes in the blood and tissues are constant vital phenomena; increased oxidation causes increased activity of the circulation, increase of temperature, increase of urea and carbonic acid in the economy from retrograde changes, and, finally, during menstrual life the flow of blood from the uterus carried off the effete materials from the highly charged system.

The elimination of albuminoids, as shown by the altered condition of the blood after menstruation, is greater than can be accounted for by the blood discharged. When the menopause is attained suddenly, the retention of such albuminoid substances must act toxically. Hence the resulting clinical fact that sudden cessation of the menses is, in the majority of cases, attended with pronounced symptoms of discomfort, and it is in these cases that untoward results are most likely.

James Oliver believes that the catamenial flow eliminates from the body substances whose presence in the blood would exert a deleterious influence on the animal economy.

The Prominent Symptoms of the Menopause.— Christopher Martin holds that the symptoms of the change of life are produced largely by a condition of instability and increased excitability of certain other cerebrospinal centers directly brought about by failure of the menstrual center, and adds: "It is probable that the ovaries, like the liver and thyroid gland, modify the blood circulating through them, and add to the blood some peculiar product of their metabolism. It may be that some of the climacteric symptoms are due to the loss of this substance from the system."

Arthur Johnstone's theory of the symptoms of the menopause is that the lining membrane of the uterus atrophies and becomes old cicatricial tissue, and sinks into quiet decay. The nervous system begins to readjust itself; but no longer having free outlet through the soft, lymphoid tissues of the uterus, the wave pressure meets with resistance and a choppy sea results. Vertigos, bilious attacks, and so forth are nothing more than reflex waves. The weakest organ of the individual is the one that generally suffers. And that the kidneys, which all along have borne the brunt of life, should now show positive signs of disease is natural.

The etiology and pathology of the menopause lie in the sympathetic nervous system. And it is by the breaking up of the harmony of previous processes that nervous disturbances are produced.

After the cessation of the flow, over 8% of women suffer from "flashes"; this symptom is caused by irritation of the heart and vasomotor centers. The blood-vessels of the head and neck seem to be most affected, yet the skin of the whole body shares in the disturbance. Besides the vasomotor and heat center being disturbed, the sweat center is irritated. The flushes and flashes are followed by various degrees of sweating, which varies from a slight moisture to great drops.

Nervous irritability is a prominent symptom in 8% of women at the time of the menopause. Most of the pain arises around the stomach; that is, the solar plexus. Digestive disturbances are very common at this time; they may be in the shape of fermentation, diarrhea, or constipation, accompanied by congestion of the liver.

Tilt holds the very plausible view that the too strong reaction of the sexual organs on the central ganglia of the sympathetic nervous system is their principal cause of disease. Puberty, menstruation, pregnancy, lactation, or the menopause almost always entail some derangement of this system which is sometimes sufficiently severe to lead to insanity and suicide. Debility underlies all affections of the sympathetic nervous system, in the same way as nervous irritability underlies all cerebral diseases. Sometimes there is an overpowering sense of exhaustion pervading the whole system.

Forms of climacteric insanity are delirium, mania, hypochondriasis, melancholia, irresponsible impulses, and the perversion of moral instincts.

"If the reproductive apparatus does not act on the brain by the instrumentality of the circulating organs of the blood, it must do so by means of the nerves. The genital apparatus is richly endowed with nerves from the sympathetic system, and I have shown how frequently evident signs of disturbance in these centers coincided or alternated with headaches, nervousness, hysteria, and epilepsy. What wonder, then, if the same powerful influence of the sexual organs, through the instrumentality of the sympathetic system, should at times produce a permanent derangement of the mental and moral faculties. I am thus led to look on the sympathetic nervous center as a source of vital power producing reflex morbid phenomena, in accordance with variable cerebral predisposition" (Tilt).

Another very frequent symptom of the menopause is distress in the region of the heart, with palpitation and shortness of breath. It may be caused by the condition of the blood, whether it be impoverished— anemia— or too rich in red globules; by reflex irritation of the pneumogastric or sympathetic nerves; by overexertion; or by alcoholism. It may also be due to general debility; the woman resists fatigue less easily, and she experiences a general malaise. To the palpitations are rapidly added faintness and shortness of breath. The sleep is troubled with distress in the region of the heart. It is said that women in whom the menopause occurs early are more liable to tachycardia than those who menstruate later in life; and that it occurs with especial frequency when the menopause has been prematurely induced by surgical operation or by disease. It is believed that this functional heart trouble is caused by the increased connective-tissue fibers of the sexual organs acting in some unknown way on the terminal fibers of the sympathetic; and it is not infrequently due to the formation of scar tissue at the seat of a cervical laceration, and has often been promptly and permanently relieved by removing the cicatricial tissue and suturing the wound. The cause acts by producing a transitory paralysis of the inhibitory fibers of the pneumogastric nerve.

Pathologic Conditions of the Menopause.— Perhaps the most alarming symptom of the menopause is hemorrhage. It may be due to general or local causes. Among the general causes are diseases of the heart, lungs, spleen, and kidneys. Local causes of hemorrhage are: inflammation of the lining membrane of the uterus, chronic pelvic inflammations, faulty uterine positions, erosions and ulcerations of the mouth of the uterus, fibroid tumors, and cancer. All competent observers agree that cancer in women is much commoner from forty to fifty years than at any other age.

Hemorrhages occupy the foremost place among the pathologic phenomena of the genital tract during the menopause. Hemorrhage has been attributed in many instances to the senile rigidity and friability of the uterine vessels, which are not in a condition to offer sufficient resistance to the blood-pressure which is brought to bear on their walls; there is also softening and relaxation of the uterine tissue. Additional causes are found in the circulatory disturbances in the pelvic organs, whereby the outflow of blood from the pelvic vessels is hindered a chronic congestion in the uterine vessels is produced. It has also been attributed to early and profuse menstruation, frequent and difficult labors, frequent abortions, and excess in drinking.

The third and last variety includes those cases which may be referred to some disease of the pelvic organs themselves. Anatomic changes may lead up to pathologic conditions. A chief feature characteristic of uterine disease is malnutrition from atrophy— a sudden curtailing of the blood-supply from the degeneration of the genital-nerve apparatus and consequent impaired vitality of tissue from defective nourishment. The anatomic changes in the glands and substance of the uterus also favor the irritation, and the development of new growths, which may be malignant or benign— as cancers, fibroid growths, and so forth.

Hemorrhage at the Menopause a Significant Symptom of Cancer.— Not only should any excessive and prolonged bleeding at the time of the menopause be a source of great anxiety to the woman, but even the irregular appearance of a slight show of blood just sufficient to keep the clothing stained, or a slight bleeding following coition; since all of these are symptoms of very great gravity, and demand an immediate local examination and appropriate treatment.

The widespread belief among the laity that hemorrhage at the time of the menopause is a normal condition, and that if left alone it will stop in the course of a few years, is most erroneous and fatal. On this altar of ignorance thousands of women sacrifice their lives every year. The case-book of any gynecologist will testify to the truth of this statement. The following three cases will serve to illustrate different types of hemorrhage in cancer patients, in no one of which did the patient even suspect that she was suffering from anything more serious than the "vagaries of the menopause."

Case I.— Woman aged seventy years; came on account of incontinence of urine, which had been troublesome for two years. The menopause occurred at fifty. She stated that three or four years previous to her visit, she had had a return of the flow of blood, perhaps twice in the first year, and that during the past year there had been a flow every month— about the same that there used to be. This she took to be a return of the menstrual period. She said, further, that there was a constant bleeding— enough to necessitate the wearing of a napkin— and an occasional severe hemorrhage; that she could not take long walks or drives because of the excessive flow which followed.

The case was one of cancer of the uterus which had spread to all the pelvic viscera; and in addition to this, the patient's general condition was such that any operation was out of the question. Yet the patient had never thought of the possibility of any uterine trouble sufficiently serious to make a local examination necessary. It was only the loss of control over the bladder that drove her to seek a physician's advice.

Case II.— Woman aged fifty-three years came to consult me because of pain, hemorrhage, and loss of weight. There had never been any cessation of the menstrual period. She said that she began to have irregular hemorrhages three years previously, and that they were constantly becoming more frequent and more alarming, and that, in addition to this, there was a constant discharge of blood, which necessitated her wearing a napkin all the time. She also stated that for the preceding six months the pain had been so severe that she had not had one solid night's sleep, and that in that time she had lost forty pounds in weight.

This patient was in the very last stages of cancer of the uterus, and all that could be done for her was to make her comfortable. She had given birth to one child which caused a deep tear of the neck of the womb; and it is probable that this neglected tear was the primary cause of the cancer, which began in the neck of the womb.

Case III.— Woman aged forty-five years; married, but had never had any children. She said that the periods were normal as to duration and amount, but that for the past two years they had two days ahead of time, and that for the past four months she had been having just enough irregular bleeding between the periods to keep her clothing stained.

On examination a diagnosis of cancer of the uterus was made. The pathological examination proved this to be a most malignant type of cancer of the neck of the womb. The entire uterus and appendages were at once removed. And although the patient made an excellent recovery from the operation, she succumbed to the disease one year after the operation was performed.

These cases have been cited at length because they are all typical and because of the variety of symptoms and the great difference of age. Only in one of the cases was there any very severe pain, and it was really the pain, which had become unendurable, which caused the patient to seek relief.

It is the concensus of opinion of the medical profession that cancer of the uterus is one of the common causes of death among women; that the cancer rate of mortality has increased during the last four decades; that it is most common near the time of the menopause; and that there is a direct causal relation between cancer of the neck of the womb and the traumatisms which occur during childbirth.

The symptoms of cancer of the uterus are hemorrhage, a more or less offensive discharge, and pain. The quantity of blood may vary from a slight amount which occasionally stains the clothing to a profuse hemorrhage. In the married, bleeding following coition is always a suggestive symptom. During the menopause any irregular or profuse bleeding should excite suspicion. After the cessation of the menopause any bleeding whatsoever, whether slight or profuse, should always be regarded as a danger signal which demands an immediate and thorough local examination. The same is true of any offensive vaginal discharge. Pain is frequently so late a symptom that to wait for its appearance means that the favorable time to perform an operation has passed by. Emaciation is also a symptom of advanced disease.

Cancer is chiefly a disease of the climacteric; when there is a diminished power on the part of the tissues to resist adverse influence. It affects the debilitated and overworked, but it is also found in the well nourished and in the comparatively young.

Cancer always begins as a local disease, and when it occurs in the uterus, it is easily accessible and eradicable in its earliest stages; that is, if the disease is discovered in its incipiency, an operation will remove all the diseased tissue. If, on the contrary, the disease is left to nature, the growth spreads out into the surrounding viscera like the roots of a tree in the earth, and the cancer may be literally said to eat into the tissues which it invades. At the same time the germs of the disease begin to be carried all through the body, and the entire constitution is affected.

Prophylaxis, or the Prevention of Cancer.— All pelvic inflammations should be promptly treated, and not allowed to become chronic. Leucorrhea is a symptom of inflammation, the true cause of which can be determined only by local examination. Women who have given birth to children— and this is more especially necessary as they near the age of forty years— should be carefully examined for tears of the neck of the womb. If these tears are extensive they should be repaired, as it is certain that malignant growths frequently do follow local injuries and traumatisms.

Any irregular or profuse bleeding demands an immediate investigation by means of a local examination.

A stormy, irregular, or delayed menopause should excite in the woman a suspicion of some abnormal condition.

The importance of women being carefully watched by gynecologists at this period of their lives cannot be too emphatically stated, for upon the early recognition of cancer depends the only hope of radical cure of the disease. It is estimated that at the present time not less than 95 per cent. of all cases of cancer of the uterus come under the observation of the profession at a stage of the disease when all prospect of permanent relief is out of the question.

It is a deplorable state of affairs that women, not knowing what a normal climacteric is, attribute all hemorrhages, no matter how severe, to the change of life. Therefore, regarding the hemorrhage as a necessary evil, they fail to consult a specialist until the favorable time for eradicating the disease by means of an operation has passed. And whatever knowledge science may bring in the future as to the cure of cancer, at present it is a fact universally agreed upon that early operation, while the cancer is still local, is the only radical cure for the disease.

Pruritus Vulvae. Perhaps one of the most annoying and obstinate symptoms of the menopause is pruritus vulvae. This is sometimes caused by sugar in the urine; there is a congestion of the liver which results in sugar being thrown into the system and this is eliminated by the kidneys. It is quite possible that this is due to the altered circulatory conditions of the menopause.

Kidney Disease.— The last pathologic condition which we will mention is kidney disease. Le Gendre believes that the menopause exerts a deleterious effect on the kidneys, whether this be a congestion, followed by a diminution in the quantity of urine, or a sort of auto-intoxication due to the retention of a poison in the system that has been prevented from leaving by the ordinary path.

Armstrong says that in almost all cases at the time of the menopause the amount of urine passed is below normal, the specific gravity is increased, and that the urine contains urates and almost always uric acid in excess. Further, that the functions of digestion and assimilation and the various metabolic changes are so largely under the control of the nerve-centers that nothing seems more likely than that so great a disturbance of that system as takes place at the menopause should cause secondary derangements of these most important functions. That being so, the blood becomes loaded with waste products, and the usual symptoms follow— gout and so forth.

It has been a grave question in the mind of the medical profession whether the dangers that certainly do attend the menopause are natural or acquired; that is, could these dangers be averted by any precautions or hygienic measures on the part of women, or are these dangers a necessary accompaniment of this period of life?

Tilt has reached the conclusion that: "The best way to avoid the dangers of this critical time is to meet its approach with a healthy constitution. A marked want of strength prevents the regular succession of the vital phenomena by which all critical periods are carried on. And as the change of life is marked by debility, when this is grafted on constitutional weakness, loss of power will be of long duration. All complaints remain chronic because there is not stamina enough to carry them through their stages."

Causes of Suffering at Menopause.— Dusourd, whose practice lay in an agricultural district in the south of France, as well as Tilt, believes that peasant women suffer little at this time. Their health is generally good when the menopause comes on and they are little liable to nervous disorders. The poor of large towns suffer much at this epoch— the necessity of working hard, the anxieties of poverty and their unhygienic surroundings. But by a fortunate compensation the necessity for working hard prevents or cures the nervous affections which so often assail the rich at this period.

Tilt's cases showed that women who suffered much at the menopause had previously suffered at puberty and at the menstrual periods. And among thirty-nine cases where there was no suffering at the menopause, there was the same immunity from suffering at puberty and at the menstrual epochs.

Tilt's statistics were, or course, taken from English women. In forty-four cases of my own, all women past the menopause, the average age of the first menstruation was fourteen years and four months; and the average age of the actual cessation of the menstrual flow was forty-eight years and five and two-thirds months. Subtracting from this the average age of the first menstruation, we have as the mean age of menstrual life thirty-four years one and two-thirds months; that is, the average duration of the menstrual function was from two to four years longer than that usually given.

A further investigation in order to ascertain any possible relation between the age of marriage and the number of pregnancies and the sufferings of the menopause elicited the following statistics. The average age of marriage was twenty-five years and ten months. Of the four women who were married after thirty-eight years, all were sterile; among the remaining there was an average of slightly above three children each. Forty per cent. of all these cases had one or more miscarriages. Nine had habitually suffered from severe dysmenorrhea, eleven had slight dysmenorrhea, and twenty-two had never felt the slightest inconvenience.

In a list of fifty-two cases, eight were added to the list already given, all of whom had passed the menopause. Five were perfectly healthy and had never suffered the slightest inconvenience. Of these, one was single and only one had one miscarriage. Ten had suffered at the time of the menopause from slight malaise, but not sufficiently to call in a medical attendant. Thirty-seven were more or less seriously ill; thirty of these needed local as well as constitutional treatment, and seven constitutional treatment only.

The prominent symptoms of the climacteric were as follows: Marked debility, 24; intense nervousness, 31; nervous prostration, 9; melancholia, 10; headache, 14; neuralgia, 6; hysteria, 7; irritable heart, 11; tachycardia, 8; insomnia, 19; indigestion, 32; constipation, 28; diarrhea, 3; leucorrhea, 38; rheumatism, 21; gout, 1; Bright's disease, 12; hemorrhage, 6; alcoholism, 2; corpulency, 2.

As a result of the study of these cases, the most striking feature was the relation of miscarriages to the sufferings and ill health at the time of the menopause. Of the nineteen women who had miscarriages, only one did not suffer in some way at the time of the menopause. Four suffered only slightly, and fourteen suffered extremely, not only during the menopause, but in the post-climacteric period as well. And the next most striking feature was that the prominent symptoms of the menopause are preeminently reflex or the functional diseases of the nervous system.

Tilt believes that single women suffer less than other women at the time of the menopause. He further writes: "As at puberty, from the ignorance in which it is still thought right to leave young women, so at the change of life, women often suffer from ignorance of what may occur, or from exaggerated notions of the perils which await them. It would be well if they were made to understand that if in tolerable health, provided that they will conform to judicious rules, they have only blessings to expect from the change of life. Most unfortunately, the individual not cognizant of the invisible changes going on in the economy does not adapt the mode of life to the new conditions of the organism, and the weakened and lessened amount of the digestive fluids is unable to master the large quantities of food. The absorbents refuse to take more than is needed to repair the tissues. The atrophying muscles of the digestive tube, unable to hurry on the mixed products of indigestion; fermentation; and micro-organisms inciting fermentations and elaborating toxic alkaloids, poison and disorder the functions of life. Man's outdoor life enables him to escape many of these evils.

"Woman's enervating mode of life, the continued introspection, coupled with the peculiar changes in the nutrition of the body at this time, render the nervous system peculiarly impressionable and liable to the manifold forms of diseases. 'The woman is told that she must be calm and patient, and in time the tomb-builder will alleviate all her sufferings.' This critical period may be dangerous to those who are always ailing, for habitiual sufferers at the menstrual periods, and for those affected with uterine diseases. If, on the first indication of the change of life, women who are in fair health carefully followed a regimen and pursued a line of life in harmony with the physiologic processes on which this change depends, disease would be prevented. But as the change concerns a natural function, it is left to nature; no additional precautions are taken, and advice is sought only when the mischief is done."

It is not wise to marry during this period. On the first appearance of the irregularities of the menopause the amount of food and stimulants to which women have been accustomed should be curtailed rather than augmented. The system requires supporting by medicine and regimen— as, baths, mental and moral hygiene, and occupation— rather than stimulating by spirits.

We have seen that, in accordance with the plethric theory, which prevailed until 1835, and with the nerve theory, which is based on the latest anatomic and physiologic researches, menstruation is a physiologic process to get rid of effete material, and is therefore an excretion.

At the end of perhaps thirty years, by a conservative process of nature, the child-bearing period ceases and the organism is readjusted to the end that the woman's vitality may all be conserved for her own individual life.

Each metamorphic or developmental period of life— dentition, puberty, and the menopause— throws a special strain on the nervous system, and the recent studies of the sympathetic nervous system at the time of the menopause show that very extensive anatomic changes occur at this time. That being the case, the woman must lead such a life as will insure her having on hand a large reserve force necessary to meet these heavy demands. Tilt's observations show that women who have experienced no suffering at puberty or, at the menstrual periods do not suffer at the menopause. It is therefore evident that the time to begin this preparation is in childhood.

That single women suffer less than married women would suggest that excessive coitus and the occurrence of abortions, frequent child-bearing, and lesions as the result of pregnancies, many of which lesions could have been prevented or cured by the timely aid of the physician, are the combined sources of much of the suffering at the time of the menopause.

That the most frequent and serious disturbances are those of the nervous system, and that from their mode of life and habits of introspection the rich suffer more from these ailments than the poor, must cause serious consideration of the physiologic necessity for a definite occupation for the daughters as well as for the sons of the rich.

The frequency with which Bright's disease is found at the time of the menopause is dependent not so much on the local physiologic changes which are taking place as on the time of life. Loomis says that it was not until life-insurance examinations became so common that the frequency with which kidney disease existed in persons who believed themselves well was even imagined. And as a result of his observations in these cases, and of a large number of autopsies conducted at the Bellevue, he stated that it was his belief that 90% of men and women over forty years of age suffer from some form of Bright's disease. That being the case, it would seem that after this period of life at least as much attention should be directed to the kidneys as to the teeth, and that a semi-annual examination of the urine should be made.

Although the menopause is a physiologic occurrence, yet, owing to the many pathologic changes which are liable to take place at this time, the woman should be as carefully watched during the menopause by the gynecologist as the pregnant woman now is by the obstetrician. If the same care were taken, in the majority of cases, the dangers attending the menopause would be avoided, and the woman would be prepared to enjoy a healthy and useful post-climacteric period of life.

CHAPTER XV.

HYGIENE OF THE MENOPAUSE.

Diet; Constipation; Stimulants; the Kidneys; the Skin; Turkish Baths; Massage; Exercise; Profuse Menstruation; Hemorrhage; Mental Therapeutics.

"'Tis the breathing time of day."

— "Hamlet."

Hygiene of the Menopause.— The changes which occur in all the organs of the body at the time of the menopause are retrograde, and therefore just the opposite of those which occur at the time of puberty. This fact should be borne in mind in the matter of alimentation. All that is now needed is to make the repair equal to the waste.

Diet.— Unless the woman is taking a great deal of active exercise, it is better to diminish the amount of meat eaten, and to increase the vegetable food and take more fluids. Unless the effect of the meat eaten is counterbalanced by active outdoor exercise, it produces an excess of waste matter, which accumulates and causes biliousness, and sometimes rheumatism and gout. A vegetable diet is less taxing to the excretory organs than an animal diet.

Indigestion is at this time of life apt to appear in the form of fermentation, which may assume the gastric or intestinal type. The chief causes of the formation of gases are the lessened peristaltic action of the intestines, the increased tendency to congestion of the liver and to obstinate constipation.

All dishes rich in sugar, as cake, candy, preserves, and jelly, should be indulged in with moderation; or where there is a tendency to fermentative indigestion, they should be wholly avoided.

All dishes known to be difficult of digestion, as hot breads, pastry, cheese, fried dishes, and rich salads, should be cut off the menu, since these readily overtax an already weakened digestive system.

If there is a hereditary tendency to rheumatism or gout, the disease is most apt to take on an active form at this time. In either case the manifestation of the disease indicates an excess of uric acid in the system, and a diet becomes a necessity. Pickles, all highly spiced articles of food, and vinegar must be omitted from the bill of fare. The vinegar may be replaced in salad-dressings by lemon juice. Tomatoes, rhubarb, strawberries and grapefruit are contra-indicated; also all articles of food rich in sugar.

In chronic cases animal food cannot, as a rule, be excluded from the dietary, but must be limited in quantity. Fish, eggs, and fowl may be eaten, also a moderate amount of lean meat in the form of beef, lamb, and mutton. Milk may be indulged in freely. The diet should consist principally of easily digested fresh green vegetables. The amount of tea and coffee should be limited. All malt liquors, sweet wines, and champagne must be absolutely prohibited.

Constipation.— A daily free evacuation of the bowels is essential to good health. Where constipation exists, and the woman is full-blooded, with a tendency to a rush of blood to the head, saline laxatives are indicated. But if the woman is constipated and anemic, cascara sagrada is a better laxative; while cod-liver oil acts as a laxative and at the same time improves the quality of the blood.

Stimulants.— Women resort to alcoholic stimulants as an analgesic to relieve pain, whether physical or mental; as a narcotic to produce sleep; and as a spur to a failing appetite or bodily powers.

The majority of women patients say that they first used alcohol in the shape of whisky, brandy or gin to relieve pain at the time of the menstrual period. The pain that is caused at this time by a chilling of the body would be as effectually relieved by drinking a cup of hot tea; while if the pain is intense and constant, recurring every month, it is doubtless caused by some local inflammation, and the use of alcohol only veils the real trouble, and the woman loses valuable time by not consulting a physician at once.

As to the use of alcohol to blunt the nervous sensibility due to mental suffering, it is the testimony of the entire medical profession that this is the greatest cause of inebriety or drunkenness among women of all classes of society.

Sleeplessness generally arises from some well-defined physical cause— very frequently from inaction of the liver— and the proper remedial agents should be used to remove the cause.

While at first the use of alcoholic beverages increases the appetite, as the amount taken is increased, distaste for food is created, the system languishes under an insufficient food-supply, and the original aim of increasing the appetite is defeated.

As to taking stimulants to do more work than one could otherwise accomplish, it is by means of stimulants that woman can accomplish her physiological ruin more quickly than is possible in any other way. And the early symptoms of chronic alcoholism show themselves in the form of neuralgia, insomnia, palpitation of the heart, and muscular tremors.

The Kidneys.— On account of the prevalence of some form of Bright's disease after forty years of life, the kidneys should be carefully watched at this time. And in order to keep them in good condition they must be well flushed with water every day. Three pints of urine should be excreted daily, and three pints of water as such must be taken into the system daily. The urine should be examined by the physician every six months. In this way kidney disease is often discovered in its incipiency, which otherwise might run into a serious form of Bright's disease.

The Skin.— It must be remembered that the skin is one of the excretory organs of the body, and the pores should be kept well open by the various forms of baths.

The Turkish bath or some modification of it will often be found to be particularly useful. Massage with alcohol after the bath lessens the tendency to take cold. For a woman who is anemic or run down, it is well to follow the Turkish with the Roman bath, which is an inunction with almond oil or cocoa-butter. A much more thorough massage is given with the Roman bath than with the "alcohol rub." It is often necessary to modify the Turkish bath by omitting the steam-room and shortening the time spent in the hot dry air. In ordinary cases the time spent in the hot dry-room should be only that necessary for producing a free perspiration. This time varies in different individuals from ten to twenty minutes. No woman should go to a Turkish bath without first consulting her physician, since if the woman has a weak heart, the bath may be the source of positive danger. Comparatively few women are strong enough to take the cold plunge.

Massage.— Massage, well given by a skilful masseuse twice a week, will greatly tone up the nervous and circulatory systems. Women who are very stout and who have sluggish livers with obstinate constipation will find massage particularly beneficial.

Exercise.— Daily exercise in the open air is absolutely essential to every woman's good health. The minimum amount of outdoor exercise compatible with health is an hour's walk, at the rate of three miles an hour. If the woman has never taken any exercise, she must begin with a very short walk and stop on the first sign of fatigue. Gradually increase the distance and the speed until the three miles is reached.

Profuse Menstruation.— If the menstrual flow is unusually profuse or lasts beyond the regular time, the woman should stay quietly in bed until the flow ceases. All exercise increases the flow.

The flow now becomes less in quantity, and the periods more infrequent than formerly. Hemorrhage must always be regarded as a danger-signal the significance of which can scarcely be overestimated. To immediately consult a specialist on the appearance of any irregularities of the flow would, in the opinion of the most eminent gynecologists of the day, be the means of saving thousands of women's lives every year.

Mental Therapeutics.— It is particularly necessary at this time of life that the mind should be pleasantly occupied. Her children have passed the age when they need her constant supervision, and the mother must take some relaxation from her home cares, in the form of social diversions, amusements, outdoor life, and change of scene. Any mental occupation that will take the woman out of herself is the best possible safeguard against a state of introspection which conjures up a host of evil fantasies, and which is the first step in the downward road to a fixed and permanent melancholia.

"Hang sorrow, care will kill a cat; And therefore let 's be merry."

CHAPTER XVI.

HINTS FOR HOME TREATMENT

Indigestion; Constipation; Diarrhea; Enemas; Vaginal Douche; Baths; Headache; Fainting; Hemorrhage.

"Woman is woman's natural ally."

— EURIPIDES.

Indigestion.— The chief causes of indigestion are: eating rapidly, eating at irregular hours, eating indigestible foods, constipation, and lack of exercise. No one who values her good health will allow herself to be hurried through a meal, nor will she allow the perplexities of life to be thrust upon her at the table for solution. The first requisite for the digestion of foods is that they should be well masticated, so that the digestive fluids may act on the finely divided particles to the greatest possible advantage. And while digestion is going on all mental labor should be held in abeyance, in order to avoid drawing the blood away from the stomach to the brain. Furthermore, it is a well-known fact that digestion is best performed when the meals are served at regular hours.