Prolonged hot baths are fatiguing. They draw the blood from the interior to the surface of the body; and during pregnancy they are particularly depressing. Vapor and steam baths have a similar action and should never be taken without the consent of a physician. They serve admirably for the treatment of rare complications of pregnancy; but, like medicine, their use should be limited to cases in which they are clearly indicated.

Unless disagreeable results are noticed, those who have become accustomed to cold baths may continue to take them during pregnancy, but others should not. If, however, the temperature of the water is modified so that it will not produce a shock, no one need omit the morning plunge or shower which most persons find invigorating. Sponging answers the same purpose, for the intent of the morning bath is not to cleanse the body but to arouse the circulation. A thorough rub-down assists in bringing the blood to the surface of the body. Bath and massage together thus constitute a kind of skin gymnastics especially beneficial throughout pregnancy.

Although hot foot-baths have sometimes been thought to cause miscarriage, there is no good reason for believing they ever do. Sea- bathing, on the contrary, may be directly responsible for such a mishap. It is true that pregnant women sometimes indulge in surf- bathing without harmful results; nevertheless the danger of miscarriage they assume is not slight. The shock of the low temperature, the exertion required to keep a firm footing, and the pounding of the surf against the abdomen are all unfavorable influences which more than counterbalance any advantage of such a bath. On the other hand, there is slight risk if any in bathing in a quiet stream or lake.

DOUCHES.—A great many women have the conviction that the vagina is not clean and should, therefore, be regularly cleansed by means of irrigations. This assumption is false and the treatment based upon it is unnecessary. In structure the walls of the vagina closely resemble the skin, but unlike the skin they do not contain glands; the vagina, therefore, has nothing to do with the elimination of waste products from the body. The secretion which issues from the vagina really originates in the glands around the mouth of the womb, and serves to protect the birth-canal against infection from harmful bacteria.

Careful examinations have shown that under normal conditions, which of course include pregnancy, disease-producing bacteria are absent from the vagina; in this respect the vagina is even cleaner than the skin, for disease-producing bacteria are present on the surface of the body. The vaginal secretion becomes more abundant during pregnancy, and the increase is interpreted as an additional guarantee against infection at the time of labor. So far as possible, therefore, this natural antiseptic should not be disturbed.

The advice to abstain from douches will not be adopted by every prospective mother without protest, for, as I have said, many women regard them as necessary to cleanliness. Others who have delicate skins are occasionally annoyed by the irritation of the vaginal secretion, which is not only increased during pregnancy but has a more pronouncedly acid character. Under extraordinary circumstances, it may be permissible to use douches in the early part of pregnancy, but it is practically never advisable to do so during the month preceding the expected date of confinement. Furthermore, at no time should the use of douches be begun without consulting a physician.

A more rational hygienic measure for the relief of itching and smarting about the vaginal orifice consists in removing the secretion as soon as it appears. In other words, the external parts should be kept clean and dry. Great comfort is often derived from the use of a "sitz-bath," which may be easily prepared by placing a small tub upon a low stool and pouring in warm water (about 90 degrees F.) until it is five or six inches deep. Cold sitz-baths are useful in the treatment of hemorrhoids. Whether the bath be hot or cold, the treatment should continue from ten to fifteen minutes, and after it the skin should be thoroughly dried.

A special form of tub, called a "bidet," has been devised to facilitate bathing the parts in question. The device is convenient but expensive, and is certainly not essential. Every purpose will be served by the small tub, provided the desired temperature of the bath is properly maintained by changing the water as may be necessary.

CLOTHING.—In these days at least it is not idle to remark that the first use of clothes is to keep the body warm; all other services they are made to perform are secondary and relatively unimportant. There are very good reasons, to be sure, for dressing neatly and even for dressing in accord with the fashion, so long as the prevailing styles are not harmful. Odd as it may seem, these are matters which are not without significance for the physical well-being of a prospective mother. Neat and comfortable clothing will help her to overcome a natural inclination to become a "stay-at-home," and on this account an inconspicuous way of dressing is often more valuable than medicine. So long as they do not attract attention, most prospective mothers go out in the day time, mingle with their acquaintances, and attend public places of amusement. Deference to fashion, therefore, may contribute substantially to good health.

Yet no prospective mother can afford to forget that first of all her clothing must keep the body warm. Our clothing confines a cushion of air which prevents the escape of the heat that we generate. Now, since dry air conducts heat poorly and moist air conducts it readily, the underclothes should be made of material that absorbs the perspiration; otherwise the heat that the body generates is quickly lost. Woolen garments effectually absorb the perspiration and should be given the preference. Most persons who cannot wear wool next the skin must choose cotton, since silk and linen are much more expensive; there is not in this, however, a serious deprivation. Cotton undergarments are perfectly hygienic; adapting their weight to the season of the year, one will find them equally satisfactory in summer and winter.

Except in summer every inch of the body should be covered with the underclothing; this means that high-neck and long-sleeve shirts and long drawers should be worn, for healthful activity of the skin can thus be best preserved. It is well known to physicians who practice obstetrics that the kidneys fail in their work more frequently during the winter than the summer. To my mind, this is chiefly explained by the way women dress. Even with light clothing the sweat glands respond actively to the heat of summer and thus relieve the kidneys, but in cold weather the sweat glands will not remove their share of the waste products unless the clothing is warm.

Nature generally indicates that the body should be kept warm during pregnancy. Many prospective mothers complain of perspiring freely; others, if reproached because they are not clad warmly enough, reply that they must wear light clothing to keep from perspiring. Thus they discount or render absolutely ineffective a most important natural safeguard against serious complications. It cannot be too strongly emphasized that warm clothing helps to maintain healthful activity of the kidneys quite as much as a proper amount of exercise and the drinking of a suitable quantity of water.

The texture of the outer garments should take into account this same quality of warmth; in other respects in selecting them personal taste is an excellent guide. Outfitters carry a variety of maternity garments; patterns for such garments are also sold by dealers, so that those who cannot afford the ready-made clothes will find it easy to have them made at home. Alterations in the clothing are compulsory as pregnancy advances, and should be timely, made in anticipation of inevitable development rather than in response to it. No prospective mother need go to the extreme of "Reform Clothes"; her apparel should illustrate both her good sense and her personal pride.

It is obviously even more harmful during pregnancy than at other times to cramp the body by the clothing; the chest and the abdomen, the parts most likely to be compressed, are at such times most in need of freedom. To a slight degree natural causes always compress the chest from below upward; and on this account nothing should be allowed to hamper the expansion of the lungs from side to side. On the other hand, if the waist is constricted, not the breathing movements alone but also the growth of the womb will be interfered with. In order to avoid such disagreeable consequences, and at the same time to limit the extent of the maternity wardrobe, skirts may be fitted with practical devices which permit letting out the waistband as occasion demands. So far as possible, however, all the clothing should be hung from the shoulders, and under no circumstances should heavy skirts be worn.

Shoes contribute toward health, or the lack of it, more significantly than the average person realizes. It is particularly advisable that prospective mothers should select foot-wear with care, because their bodies are heavier than usual. The feet are apt to become swollen in the latter months of pregnancy, and consequently the shoes should be roomy, but should always fit. To escape the discomfort of tight shoes, it is generally advisable to wear a shoe an inch longer and broader than the foot at rest.

High heels have been proved a frequent cause of back-ache; half of such cases, in all probability, may be thus explained. High heels tilt the body forward in such a way that the erect posture can be maintained only by an unnatural tenseness of the back-muscles. Some strain of this kind is inevitable during the latter months of pregnancy on account of the enlargement and the position of the womb; it is reasonable, therefore, to minimize it by wearing low, broad heels.

Besides being responsible for many cases of backache, high heels add greatly to the danger of tripping and falling; for this reason alone they should not be worn. Improper foot-gear and not the joints themselves deserve the blame for weak ankles. To prevent "turning the ankle," it is not necessary to restrict oneself to high shoes, but merely to see that the shoes that are worn have low heels and broad soles. Such shoes provide a sure, firm footing, and this the prospective mother particularly needs.

CORSETS.—No question connected with women's dress has provoked so much discussion as the use of corsets. "Are corsets necessary to health?" has been differently answered by those who would appear to be equally competent authorities. In the time of our savage ancestors we may safely conclude that they were not used; and, therefore, it is really a question as to whether their continued use for generation after generation has finally made some support of this kind indispensable to the average woman. While that matter has not as yet been settled, it is obvious that custom is really responsible for the conviction of many women that they appear slovenly without corsets. On the other hand, not a few women, unmindful of fashion, never wear them; they testify that they are healthier for doing so. Whether this be true or not, no one can honestly believe that corsets will soon be banished; and the practical problem is to distinguish between those that may do good and those certain to do harm.

During pregnancy the abdomen tends to fall forward and slightly downward, and though it is in pregnancies after the first that this tendency is most marked, every prospective mother will be more comfortable if she wears some sort of support to counteract what physicians term a "pendulous abdomen." Such a condition can be prevented by the use of several appliances, and the device best suited to the case should be chosen. Those who have never become accustomed to corsets will probably find a corset-waist or an abdominal supporter the most comfortable and useful. But the average young woman who has previously employed a sensible, well made, and loosely fitting corset need make no change until the third or fourth month of pregnancy. From then on she should wear a corset especially designed to conform with the changes that naturally occur in the figure.

There is a plan, wrong in principle, which many adopt. Reasoning that it will be necessary to change the corset from time to time, and desiring to practice economy, a number of women purchase the cheapest corset at hand. This they replace with a larger one of the same style from time to time. The result is that an improperly fitting garment is worn continuously; and, in the end, this plan proves almost as expensive as, and far less suitable than, a proper corset, which would remain serviceable throughout pregnancy, or at least until a few weeks before confinement.

Most, and probably all, of the injuries for which corsets are responsible result from their misuse. Naturally serious consequences may be expected if they are worn with the design of compressing the abdomen so as to render pregnancy less noticeable or perhaps to conceal it altogether. Thus worn, the corset becomes not only an instrument of torture but a source of danger both to the mother and to the child. Fortunately there are very few women who fail to appreciate the risk of thus striving to disguise their condition; and generally it is the needless discomfort, the trifling ills thoughtlessly inflicted upon themselves, that prospective mothers must be taught to avoid.

At present there are manufactured a number of excellent maternity corsets; but there are also worthless types, and some likely to do harm. To judge them fairly they must be examined with regard to several requirements. In the first place the corset should not be stiff and should always be capable of easy adjustment; it must never interfere with the activity of any organ. As enceinte, the French word meaning pregnant, signifies, the prospective mother should be unbound. Tight clothing, as we have already remarked, hinders the breathing movements; it also interferes with the action of the heart, and occasionally causes the child to assume an unfavorable position within the uterus. The adjustment of the maternity corset to the progressive development of the body is generally provided for by means of extra lacings down the sides, and by the insertion of elastic material.

The maternity corset, in the next place, must support the enlarged uterus. Correctly shaped and worn, it extends well down in front, fits snugly around the hips, and arches forward so as to conform to the curve of the abdomen. In place of the arching, or "cupping" as manufacturers call it, some maternity corsets have attached to their lower edge limp flaps of a strong fabric which lace together. The maternity corset-waist also should extend well under the abdomen and fit snugly around the hips.

Finally, the corset should support the bust; the unpleasant sensations due to congestion of the breasts can be relieved most successfully by elevating them. It is exceedingly important, however, that the upper part of the corset should fit loosely, for otherwise the development of the breasts may be hindered, and the nipples depressed. As a further precaution against pressure above and also to secure the proper amount of support below, it is generally advisable to begin putting on the corset while lying down. In every case the corset should be laced from below upward; if laced in the opposite direction it fails to lift the womb and tends to push all the abdominal organs downward.

Any kind of corset is likely to become uncomfortable toward the end of pregnancy; and of course should then be discarded. An abdominal supporter made of woven linen or rubber is frequently used to advantage during the last three or four weeks. With the first pregnancy the supporter is rarely necessary, but with subsequent ones it is frequently useful as early as the sixth month and is indispensable later. A substitute for the manufactured supporter can be made at home. Some such device often facilitates turning in bed, and on that account may be found even more useful at night than during the day.

THE BREASTS.—Personal hygiene during pregnancy includes the preparation of the breasts with a view to success in nursing. All measures which promote the health of a prospective mother also serve to equip her for the nursing period; and in that sense the directions just given for the care of the body, as well as the rules to follow in the next chapter regarding a wholesome way of living, bear directly upon lactation. But there are also local measures to be adopted, some of which, such as supporting the breasts and avoiding constriction by the clothing, have already been mentioned. Finally, the nipples must be toughened and, if short or flat, they must be drawn out, for the best supply of milk will count for nothing if the infant cannot nurse comfortably.

Some approved method of toughening the nipples so that they will not be injured by the sucking efforts of the infant, no matter how vigorous, should be begun eight weeks before the expected date of confinement; to start earlier will do no harm, but it is quite unnecessary. A number of procedures have been advocated, but in my own experience the following simple method is the best. The nipples are scrubbed for five minutes, night and morning, with soap and warm water. Generally, a soft brush, such as a complexion-brush, is satisfactory; but if this is too harsh, at first a wash cloth may be used. After having been thoroughly scrubbed the nipples are anointed with lanolin and covered with a small square of clean, old linen to prevent soiling of the clothing.

Another method widely used, but somewhat less trustworthy, consists in bathing the nipples and applying a dilute solution of alcohol. Formerly brandy, whiskey, or cologne were recommended, but at present the following solution is commonly used. A tablespoonful of powdered boric acid is added to three ounces of water and thoroughly mixed. This is poured into a six-ounce bottle, which is then filled with grain alcohol (95 per cent). The solution is applied twice a day with a small piece of absorbent cotton.

Well-formed nipples need only be toughened, but depressed nipples require additional treatment; and this should be begun about the middle of pregnancy. The old-fashioned way of making the nipple more prominent was to cover it with the mouth of a bottle which had previously been warmed. The vacuum created, as the bottle cooled, drew the nipple out. Similarly, the bowl of a clay pipe was sometimes placed over the nipple; the patient sucked the stem, the nipple was drawn into the bowl, and with persistence day after day success was often attained. A similar and somewhat more aesthetic procedure is now employed. The nipple is seized between the thumb and finger and alternately pulled out and allowed to retract. These manipulations, if faithfully practiced for several months, generally make the nipple prominent enough for the infant to grasp. Occasionally patients need to wear a contrivance sold at instrument stores which consists of a circular piece of wood modeled to fit the breast and perforated in the middle to accommodate the nipple. The appliance should not be used unless a physician thinks it necessary.

Directions regarding the care of the breasts are sometimes taken lightly, yet such care is not a minor duty. Now and then a patient will pass through pregnancy uneventfully, will be delivered without difficulty, and will enter upon what promises to be a rapid convalescence when her recovery is interrupted by the development of inflammation of the breast. Because such a complication may be prevented, its appearance is the more to be regretted. Furthermore, the responsibility for its prevention usually rests with the patient herself. If she has been conscientious in preparing the nipples and continues to watch them throughout the nursing period, the annoyance of an abscess will almost certainly be prevented.



CHAPTER VI

GENERAL HYGIENIC MEASURES

The Need of Fresh Air—Outdoor Exercise—Massage and Gymnastics—The Influence of Work upon Pregnancy—Relaxation and Rest—Is Traveling Harmful?—Mental Diversion.

Besides the hygienic measures described in the preceding chapter, whose observance should be recognized as more or less obligatory, there are more general questions of conduct, such as exercise, relaxation, mental occupation, and amusement, which are also important. These measures, although frequently determined merely by personal inclination or by the force of circumstances, nevertheless exert a tremendous influence upon health. This fact a prospective mother is likely to realize, for she is certain to consider not only her own welfare but also that of the expected child; and she is consequently concerned about details of conduct that most persons would regard as trivial. She may, indeed, be too conscientious. Well- meaning friends, sometimes in reply to her questions and sometimes without solicitation, offer her a great deal of advice. Their counsel, aside from the fact that some of it may be misleading, may have the effect of prescribing so many rules that, if she followed them all, she would never lose sight of the fact that she is pregnant. Such a degree of self-consciousness is certain to make her unduly apprehensive. The proper attitude of mind is quite the opposite; so far as possible the prospective mother should forget that she is pregnant. This state of mind is really the more rational, for if a woman's daily life has previously been in accord with such simple rules of health as everyone should adopt, the existence of pregnancy calls for very slight changes.

It does not, for example, condemn her to inactivity and seclusion, for it is advisable to lead a moderately active life during pregnancy. Of course, such obvious indiscretions as prolonged exertion, violent exercise, and fatiguing journeys should be avoided, for transgression of the laws of health brings its own punishment, generally in the form of discomfort, more quickly, and often more severely, during pregnancy than at other times. Yet, on the whole, it is more frequently necessary to emphasize to prospective mothers what they should do than what they should avoid. This happens to be the case because, as a rule, they are inclined to become recluses. For fear of attracting attention they often wish to give up outdoor exercise during the day; they stay away from public places of amusement, and deny themselves other pleasures to which they have been accustomed. Against this tendency they must be warned, for if they yield to it they will surely be the worse off both physically and mentally. Every prospective mother should make up her mind to enjoy recreation out of doors regardless of comments.

THE NEED OF PURE AIR.—Outdoor life has been so urgently advocated of late that the public has come to appreciate its benefits almost as fully as do physicians. The existence of pregnancy does not lessen, but rather enhances, the value of fresh air; in order to enjoy the best health during this period one should spend at least two hours out of doors every day. Neither the season of the year nor the state of weather should modify this obligation. If the sun is shining the "airing" is more delightful, but it should be taken in bad weather also, on a protected porch or in a room with the windows wide open.

Even when the injunction to be regularly out of doors is observed women are accustomed to spend the greater portion of the day in the house, and on that account special attention must be given to keeping the air of the house pure. Ventilation takes care of itself in summer, when the windows are open, but in cold weather, when in our anxiety to keep the temperature comfortable we may overlook the need of fresh air, it demands close attention. The necessity of ventilation at all times is due, of course, to the composition of the atmosphere and to the changes produced in it as we breathe.

The air about us is a mixture of gases, of which oxygen and nitrogen are the most important. Although nitrogen, which constitutes four- fifths of the atmosphere, is taken into our lungs in breathing, we make no use of it, but breathe it out in precisely the same condition as we take it in. As chemically combined in the food-stuff known as protein, nitrogen is indispensable to animal life; but our bodies make no use of the gaseous form of nitrogen. Oxygen, on the other hand, supports life; and though it forms less than one-fifth of the atmospheric air, it is present in ample amount for our needs. After we draw air into our lungs, the oxygen it contains is absorbed by the blood and used by the tissues. In return our tissues give up a waste product, carbonic acid gas, which is thrown off by the lungs. It is interesting to observe that the carbonic acid gas which animals exhale supports the life of plants, and that the plants, under the influence of sunlight, give back pure oxygen to the atmosphere. Obviously, the complementary relation exhibited here is of mutual benefit.

The average person uses about four bushels of air a minute. Consequently, rooms that are occupied must be constantly replenished with fresh air; otherwise the point is quickly reached where the occupants are breathing an atmosphere that is not only poor in oxygen but saturated with carbonic acid gas and other impurities conveyed by the breath. Foul air such as this causes headache, dizziness, faintness, nausea, and occasionally even more serious disturbances. Those who live in "close" rooms day after day grow pale and languid; their appetite fails and some of their natural power of resistance against illness is lost. Many people are unhealthy simply because they neglect to supply their living quarters with a steady stream of air from the outside.

While it is impossible to keep the air in any room as pure as the outside atmosphere, perfectly satisfactory ventilation can be easily arranged. Some of the impure air in a house is always escaping of its own accord and its place is taken by air from the outside. Thus, the cracks around the windows and doors let bad air out and good air in; and, besides, most building materials are porous. These natural paths, however, must be supplemented. The simplest device for ventilation, which is also the best, consists in opening a window at the top and bottom. The width of the opening may be regulated so as to permit the air in the room to change without occasioning disagreeable drafts; if necessary the current may be broken by a screen of some pervious material placed in the opening.

The bed-room should always be supplied with plenty, of fresh air, which "quiets the nerves" and helps one to sleep soundly. Furthermore, the temperature of the bed-room should be lower than the temperature of rooms occupied during the day. Both these requisites will be properly met by leaving a window open at night, which may be done throughout the year in most climates, if one puts on enough covering. There is no danger of catching cold from sleeping with the window open; on the contrary, breathing fresh air day and night is one of the best ways to prevent colds.

OUTDOOR EXERCISE.—Outdoor exercise is indispensable to good health. It benefits not only the muscles, but the whole body. By this means the action of the heart is strengthened, and consequently all the tissues receive a rich supply of oxygen. Exercise also promotes the digestion and the assimilation of the food. It stimulates the sweat glands to become more active; and, for that matter, the other excretory organs as well. It invigorates the muscles, strengthens the nerves, and clears the brain. There is, indeed, no part of the human machine that does not run more smoothly if its owner exercises systematically in the open air; and during normal pregnancy there is no exception to this rule. Only in extremely rare cases—those, namely, in which extraordinary precautions must be taken to prevent miscarriage—will physicians prohibit outdoor recreation and, perhaps, every other kind of exertion. Under such circumstances the good effects that most persons secure from exercise should be sought from the use of massage.

The amount of exercise which the prospective mother should take cannot be stated precisely, but what can be definitely said is this— she should stop the moment she begins to feel tired. Fatigue is only one step short of exhaustion—and, since exhaustion must always be carefully guarded against, the safest rule will be to leave off exercising at a point where one still feels capable of doing more without becoming tired. Women who have laborious household duties to perform do not require as much exercise as those who lead sedentary lives; but they do require just as much fresh air, and should make it a rule to sit quietly out of doors two or three hours every day. It will be found, furthermore, that the limit of endurance is reached more quickly toward the end of pregnancy than at the beginning; a few patients will find it necessary to stop exercise altogether for a week or two before they are delivered.

Walking is the best kind of exercise, but long tramps are inadvisable during pregnancy, except for those who have previously been accustomed to them. Most women who are pregnant find that a two or three-mile walk daily is all they enjoy, and very few are inclined to indulge in six miles, which is generally accepted as the upper limit. Perhaps the best way to measure a walk is by the length of time it consumes. Accordingly, a very sensible plan is to begin with a walk just long enough not to be fatiguing and to increase it by five minutes each day until able to walk an hour without becoming overtired. It is always advisable not to crowd the exercise of a day into a single period but rather to take it in several installments, for example, an hour in the morning, and another in the afternoon. Under all circumstances, it must never be forgotten that the feeling of fatigue is a peremptory signal to stop, no matter how short the walk has been.

Very few outdoor sports can be unconditionally recommended to a prospective mother. Because athletic exercise is either too violent or else jolts or jars the body a great deal, it is especially dangerous in the early months of pregnancy—the only time when it is likely to be at all attractive. Croquet, alone, perhaps, is free from these objections. Although golf and tennis are by no means certain to bring on miscarriage, they involve a risk which, slight though it may perhaps be, will not be assumed by cautious women.

Horseback riding during pregnancy is injurious. We occasionally hear of women who have ridden horseback without immediate harmful consequences, but they have nevertheless exposed themselves to danger unnecessarily. It is better to give up skating and dancing also than to run the risk of accident, especially since these diversions are attended with some danger of falling. In a general way, whenever the question of entering into any kind of recreation must be decided, it is wise to err on the conservative side rather than risk overstepping the limit of endurance and having to pay a penalty more or less severe.

Carriage riding cannot take the place of walking and can scarcely be classed as exercise; it is wholesome, nevertheless, because it takes the participant out of doors and provides a change of scene. Certain details, however, should be carefully observed; thus, a safe horse, a carriage that rides easily, and smooth roads should be selected. Similar advice pertains to motoring; with smooth roads, a cautious driver, and a comfortable machine, short rides in an automobile are not harmful. Carriage riding and motoring are particularly serviceable as a means of getting outdoor diversion during the last few weeks of pregnancy.

MASSAGE AND GYMNASTICS.—If a prospective mother is obliged to stay in bed several weeks, massage may be useful; otherwise there is no necessity for this treatment. Whenever required, massage should if possible be given by an experienced masseuse. If this is out of the question and the patient must rely upon one of her friends, it should be understood that "general massage" is needed; in other words, one part of the body after another should be gone over systematically. With an inexperienced masseuse, however, it will be safer not to massage the abdomen, since awkward, vigorous, or prolonged manipulations in that locality may provoke painful uterine contractions. Rubbing the breasts also can do no good; on the contrary, it may do harm by bruising them.

The best time of day to have massage is in the morning, at least an hour after breakfast. The duration of the treatment will depend upon the patient; it should always cease as soon as she begins to feel tired. After one has become accustomed to it, massage may generally be continued for an hour. The room in which it is given should be cool, and after the treatment has been completed the patient should be wrapped warmly and left undisturbed for half an hour.

Gymnastics, like massage, are useless to those who can enjoy outdoor exercise. Walking more perfectly strengthens the muscles which take part in the act of birth than any system of "home calisthenics" that has been suggested. In some conditions which make walking inadvisable the use of calisthenics will be helpful. These exercises generally consist in breathing movements and in movements of the extremities, especially the legs, which bring into play the same abdominal muscles that are used at the time of delivery. A detailed description of the exercises is here purposely omitted, since gymnastics should not be used unless advised by a physician, who should watch their effect and thus be guided as to whether the patient should continue them.

THE INFLUENCE OF WORK UPON PREGNANCY.—No single influence is more unfavorable to comfort and health during pregnancy than is idleness, so that every prospective should occupy herself with congenial work and fitting diversions. The kind of occupation makes no essential difference, so long as it does not overtire either the body or the mind. Since most women are absorbed in the affairs of the home, it may be well to begin by saying that the existence of pregnancy by no means requires the abandonment of domestic duties. On the contrary, when it is convenient, the prospective mother should have a share in the housework. She should not undertake everything that is to be done about the house, for no matter how small the household there are certain duties too laborious for her to attempt; these will be easily recognized and turned over to someone else. Even with regard to those tasks which lie within her strength she should use a little forethought to prevent unnecessary steps.

All kinds of violent exertion should be avoided—a rule which at once excludes sweeping, scrubbing, laundry work, lifting anything that is heavy, and going up and down stairs hurriedly or frequently. The use of a sewing machine is also emphatically forbidden. Treadle work is known to be one cause of swollen feet, of varicose veins, and of aches and pains in the legs or the abdomen. If a prospective mother has to do her own sewing, the machine should be fitted with a hand attachment or motor. Except for the possibility of straining the eyes, there is no objection to sewing by hand.

Besides the activities that should be excluded because they may be harmful, every housekeeper will find enough to keep her busy. It is generally not a small task to suggest what others shall do and to see that orders are properly carried out; consequently those who take no part in the actual work may retain an absorbing interest in their domestic affairs by directing them. Such direction, indeed, should, toward the end of pregnancy, constitute the mother's sole participation in the housework.

In a general way the amount and the kind of work that a woman may be permitted to undertake during pregnancy depend upon what she has been used to. It is not unlikely that anyone who is unaccustomed to manual labor may injure her health and cause the pregnancy to end prematurely if she undertakes hard work. On the other hand, women of the working classes sometimes continue at their occupations to the natural end of pregnancy without harmful consequences. It is undeniable, however, that among this class miscarriages are more frequent than among the well-to-do. Furthermore, the average birth- weight of mature infants whose mothers have remained at work during the last three months of pregnancy is ten per cent. less than the average birth-weight of infants among the leisure class. This matter of the baby's weight is not always serious in itself, but indicates in the case of working women who are pregnant the existence of a strain that sometimes leads to serious accidents.

The employment of women during pregnancy and immediately thereafter is regulated by law in many countries. For example, the laws of Holland, Belgium, England, Portugal, and Austria prohibit the employment of women in factories during the last four weeks of pregnancy or the four weeks following childbirth. Such employment is unlawful in Switzerland for two weeks before and six weeks after childbirth. There is no legal regulation of the employment of pregnant women in either Germany or Norway, but the laws of both countries forbid them to return to work until six weeks after they have been delivered. Among civilized nations Turkey, Russia, Spain, Italy, France, and the United States make no attempt to regulate employment either before or after childbirth.

Of course there are strong sentimental reasons for relieving prospective mothers of the necessity of earning a living, but there are also excellent hygienic reasons against many kinds of employment. For example, it should be unlawful to employ them in chemical industries where, owing to their condition, they are especially liable to be injured by the materials which they handle. Jacobi states that the worst occupation for pregnant women is working with metals, in particular lead; more than half of them suffer miscarriage or premature confinement. Furthermore, the health of the child may be endangered if the prospective mother does hard work of any kind. This is true chiefly because she does not have appropriate intervals of relaxation, for it is a firmly established principle that a prospective mother must be free to rest the moment she begins to feel tired. The least, therefore, that can be done to better prevalent conditions among women who must work during pregnancy is to require by law a reduction in the number of their working hours, and to protect them from the necessity of earning a living for two months after they have been delivered.

RELAXATION AND REST.—During the early months of pregnancy many women complain that they feel enervated, and tire quickly even when they do things which were formerly done with ease; this experience is so common that it can scarcely be considered other than natural. Curiously enough this is also the period during which the attachment of the ovum to the womb is relatively insecure, and therefore the inclination to be quiet is justified by the prevailing anatomical conditions. No prospective mother should struggle against the inclination to rest; she should yield to it in spite of the advice to the contrary which older women are apt to give. Furthermore, it is especially important about the time when a menstrual period would ordinarily be expected to be guided by this impulse not to be active, since overexertion then, more than at other times, is apt to be followed by miscarriage. Except in rare cases the observance of this precaution is less urgent after the fourth month, when the ovum has become more securely attached to the womb. But again, toward the end of pregnancy the development of the mother's body necessitates a comparatively large amount of rest; patients who continue to exert themselves may expect to suffer from shortness of breath and a number of other annoyances.

In order to save needless steps and to avoid confusion and worry, it is always helpful to map out beforehand what must be done in the course of the day. Ideally, such a schedule should set apart intervals for relaxation and rest. In the morning, for example, while the housework is in progress, it is important to stop occasionally, if only for a few moments, and lie down on a couch. After the midday meal it is advisable to undress and go to bed. Even though one does not fall asleep, an hour or two of complete relaxation will be beneficial. A nap in the afternoon does not interfere with sleeping at night provided plenty of exercise has been taken during the day. In this way walking in the late afternoon or early evening helps to secure a good night's rest.

During the first six or seven months, pregnancy, in itself, does not cause sleeplessness, but later, as a natural result of the enlargement of the womb, there are several disagreeable symptoms which may cause broken rest at night. In the later months the weight of the womb requires women to sleep on the side, and for some of them this position is awkward at first. Frequently the pressure makes it necessary to get up several times during the night to empty the bladder. In a few cases also the compression of the chest interferes somewhat with breathing. When insomnia is due to the pressure of the womb against neighboring parts of the body, it can be partially counteracted by getting into a comfortable position; but it is also necessary to have the surroundings as conducive to sleep as possible. Thus anyone will be much more likely to rest well if the bed-room is large and well ventilated, if the mattress is comfortable, and if the coverings are warm without being heavy. Finally, not the least important detail is to occupy a single bed, so that it is possible to turn over without fear of disturbing someone else.

In most instances, however, the inability to sleep during pregnancy— and indeed at any time—is due to a faulty frame of mind. With reference to the average man or woman, in his very helpful book "Why Worry," Walton says, "it is futile to expect that a fretful, impatient, and overanxious frame of mind, continuing through the day and every day, will be suddenly replaced at night by the placid and comfortable mental state which shall insure a restful sleep." Like everyone else, the prospective mother must stop thinking when she retires, otherwise the blood will not be diverted from the brain as it must be to fall asleep. To aid in bringing about this condition a number of expedients may be employed. For example, a warm bath, warm sheets, or a hot-water bottle placed against the feet all help to draw the blood from the brain to other parts of the body. Similarly, a warm glass of milk or a small portion of easily digestible solid food taken just before retiring will help to make one drowsy; on the other hand, over-eating at the evening meal or later is not an infrequent cause of wakefulness.

The use of narcotics is rarely necessary in the early months of pregnancy, and the simple measures just mentioned will also generally be found sufficient in the later months. But these procedures, or any other except the use of strong drugs, will be ineffective unless the individual knows how to get into the proper state of mind. This means not only that she must be able to banish worries, regrets, and forebodings; she must also have acquired confidence in whatever method she employs. She must convince herself that she can sleep, or at least that it makes no difference if she cannot. This independent spirit, which is very essential, can be confidently assumed, for if she does not sleep well it can be made up during the next day or at least the next night. Having adopted this attitude, and having assumed a comfortable position, which should be retained as long as possible, the attention should be concentrated upon the thought, "I am getting sleepy, I am going to sleep." Under these circumstances she can hypnotize herself and "produce the desired result more often than by watching the proverbial sheep follow one another over the wall."

IS TRAVELING HARMFUL?—Traveling has been made so easy and alluring that nowadays long journeys are undertaken with scarcely more concern than was once felt when the people of neighboring towns exchanged visits. Thus modern facilities have introduced a new factor into the problem of the way to live during pregnancy. It is a well-known fact that traveling is sometimes attended with risk to the prospective mother, though the danger is exaggerated in the popular estimation. For this the newspapers are chiefly to blame. They inform the public of the cases in which embarrassing situations have arisen, but there is no record of the thousands of pregnant women who travel without any mishap.

What the effect of traveling is likely to be is very difficult to predict under any circumstances, and the question cannot be answered at all unless the specific conditions presented by each case are taken into account. In a general way the points to be considered are the vigor of the patient, the period of pregnancy at which she has arrived, and the character of the journey she wishes to undertake. Prudent women will never attempt to decide this question for themselves, but will always obtain professional advice. The disapproval of the physician, no doubt, will sometimes cause keen disappointment; but conservative advice is the best and should always be followed.

To be on the safe side a prospective mother who has previously had a miscarriage should not travel at any time during pregnancy; others are not obliged to follow this stringent rule except during the first sixteen and the last four weeks of pregnancy. In the former period there is some danger of miscarriage because traveling may cause separation of the relatively loose attachment of the ovum. In the latter period the muscle-fibers of the womb are usually irritable and therefore the rolling of a ship or the jolting of a car may set up painful contractions which in some instances expel the fetus. Generally there is the least risk of accident between the eighteenth and the thirty-second weeks, though patients should be careful even during this interval not to travel at the time when a menstrual period would ordinarily be expected.

The length of the journey and the ease with which it can be made are also important features to be considered. Obviously there will be less danger of mishap from a short trip than from a long one; if possible, therefore, long journeys by rail should be broken so as to afford opportunity for rest. Railroad trips which do not exceed two or three hours are generally not so fatiguing that they must be prohibited, provided the individual is perfectly well. Traveling by boat is less tiresome than traveling by rail and, if equally convenient, the boat should be given the preference. Long automobile tours are attended with considerable risk of miscarriage and, therefore, are forbidden.

MENTAL DIVERSION.—As a rule good health prevails throughout pregnancy; it would be enjoyed even more frequently if many prospective mothers did not think so much about the fact that they are pregnant. For this deplorable self-consciousness the spirit of the age is in part to blame; there never was a time, in all probability, when people took such a keen interest in all matters pertaining to health. It is also true, however, that fuller instruction is needed now because the temptations to depart from a regular, temperate way of living have notably increased.

At all events the point has now been reached where the average man or woman knows something of anatomy, physiology, and the laws of hygiene. Such knowledge should be helpful, and generally is, but if it causes anyone to think incessantly about the workings of the body, to that person it is detrimental. We all know such individuals. They are made miserable because they scrutinize functions, like the beating of the heart, that go on automatically and should be left unobserved, or they minutely analyze their feelings and misinterpret normal sensations as the evidence of disease.

The tendency to be introspective is especially pronounced in women who are pregnant, and this is readily explained by the reciprocal relations between the mind and the body. If the prospective mother correctly interpreted the changes which occur in her body, as well as the sensations for which these changes are responsible, she would escape the uneasiness of mind that causes many sorts of discomfort. It is unfortunately true, however, that her lack of familiarity with the facts about pregnancy and her belief in unfounded traditions frequently lead to the misinterpretation of natural conditions. An anxious frame of mind also causes real ailments to assume an importance out of all proportion to their actual significance.

Patients who have followed my advice to place themselves in the care of a physician as soon as they clearly recognize the existence of pregnancy will receive his assistance in properly estimating the significance of what they notice. This service is by no means the least the obstetrician renders his patients. His opinion should always be sought when symptoms are not understood; but it is not unusual for patients to bring to the doctor's attention many complaints that would pass unnoticed if they taught themselves to restrain the imagination, to refrain from pessimistic reflections, and to divert their thoughts from themselves to outside affairs.

Generally it is during the early months of pregnancy that patients are most likely to be self-centered, and consequently suffer from many annoyances that either proceed from or are exaggerated by this faulty frame of mind. During this period a prospective mother is not fully aware of the meaning of pregnancy. Toward the twentieth week, however, she perceives the movements of the child and her thoughts are turned to it instinctively. About this time many of the discomforts of pregnancy disappear and there ensues a period of unusually good health. Perhaps it would be going too far to give this more wholesome altruistic mental attitude the entire credit for the relatively better health of the second half of pregnancy, but without doubt it is a most important factor.

Such then is the influence of the mind over the body that anyone who wishes to cultivate good health must correct the faulty habit of always thinking of herself. The most suitable form of diversion will depend upon personal taste. Domestic duties absorb the attention of most prospective mothers, but domestic duties should not occupy them exclusively. Outdoor recreation is necessary and serves the double purpose of strengthening mind and body. Public amusements should also be patronized; no prospective mother has the right to sacrifice herself to pride. Music, the various arts, a systematic course of reading, the acquisition of a foreign language—all these are commendable forms of diversion, and others will occur to anyone. Obviously the avocation will be most happily chosen if it directs the attention into channels likely to lead to the greatest pleasure.



CHAPTER VII

THE AILMENTS OF PREGNANCY

Nausea and Vomiting—Heartburn—Flatulence—Defective Teeth—Pressure Symptoms: Swelling of the Feet; Varicose Veins; Hemorrhoids; Shortness of Breath—Leucorrhea—Toxemias.

Most of the ailments to which prospective mothers are liable are merely the natural manifestations of pregnancy, exaggerated to such an extent as to cause inconvenience and discomfort. In the early months, for example, persistent nausea and vomiting may become the source of great annoyance, and later the pressure of the womb against neighboring structures may cause a variety of symptoms. It does not follow, however, that any of these ailments will necessarily appear. On the contrary, many women are more healthy during pregnancy than at any other time.

Occasionally illness is charged to pregnancy with which in reality pregnancy has nothing to do. While awaiting the birth of a child, just as at other times, women may suffer from coughs or colds, from aches or pains, from malaria, pneumonia, typhoid fever, or in fact from any disease. It is evident that such complications are accidental; and, though pregnancy confers no immunity against them, it does not, on the other hand, render women more susceptible to all kinds of ailment.

And yet there are diseases for which pregnancy is directly responsible. These are, to a very large extent, preventable; and, though they occur rarely, precautions for their prevention should be taken in every case of pregnancy. By far the most important members of this group are the toxemias of pregnancy. These, as will be explained later, cause symptoms which the patient herself may recognize, and her physician may often detect their presence still earlier by alterations in the composition of the urine. For this reason routine examination of the urine during pregnancy is a means of prevention indispensable for safeguarding the health of the prospective mother.

A number of ailments of which prospective mothers may complain do not require treatment with medicine. This, however, will not be taken to imply that there is no need to consult a physician. On the contrary, and it cannot be emphasized too strongly, the prospective mother should seek professional service whenever there is anything about her condition she does not understand. Sometimes, when she thus consults the physician, he will explain to her that what she has noticed is merely one of the natural manifestations of pregnancy and that she can have no control over it; at other times he will suggest changes in her mode of life which will very likely afford her relief. The frequency with which physicians find that ailments may be corrected by the adoption of hygienic measures indicates that such ailments are more often due to ignorance or carelessness than to the existence of disease.

NAUSEA AND VOMITING.—We have already learned that nausea, especially in the morning on rising from bed, frequently corroborates the suspicion of a woman that she has become pregnant. So commonly, indeed, is this symptom expected that most women take no account of it other than as an evidence that they have conceived, and consequently do not complain of it. A few who have heard the old adage, "a sick pregnancy means a safe one," which incidentally is not correct, actually accept nausea as a favorable sign. In other cases the nausea is not to be dismissed so lightly; and a relatively small group of patients suffer from persistent vomiting. When prospective mothers are questioned systematically, it appears that at least one- half and perhaps two-thirds of them experience more or less discomfort from sick stomach. Generally this begins shortly after a menstrual period has been missed and ceases six or eight weeks later; it persists occasionally until the movements of the child have been perceived.

Nausea and vomiting are limited, in the vast majority of cases, to the early morning, but some patients are annoyed only after meals, and a few at irregular intervals during the day. The fact that the attacks do not always appear at the same time, and that they differ in severity, indicates that different causes may be concerned in their production. And it is true that there are several kinds of vomiting that occur during pregnancy, although the classification interests only physicians. The laity, however, should understand that the treatment of any given case will vary according to the class to which it belongs, and therefore the occurrence of troublesome vomiting should be promptly reported to the physician.

Most frequently it will be found that there is nothing serious the matter. The vomiting ceases or, at least, it becomes less troublesome as soon as the diet has been more carefully arranged, constipation has been corrected, or other hygienic details, such as outdoor recreation and mental diversion, have received the attention requisite for good health. In a much smaller group of cases the restoration of the womb to a proper position or the treatment of some other local condition, which can generally be remedied without difficulty, is all that is necessary. But finally, in extremely rare instances, the vomiting of pregnancy is due to a definite disease whose existence may be recognized by special methods of analyzing the urine. In any case, if the physician is given an opportunity to make the necessary observations and thus determine the variety of the vomiting, no time will be lost in beginning effective treatment. In an overwhelming majority of the cases, as I have said, nothing serious will be found; and then the control of the vomiting will lie within the power of the patient herself.

Since nausea is usually experienced in the morning on rising from the recumbent to the upright posture, measures to prevent an attack should be begun even before the patient raises her head from the pillow. In the first place something to eat should be taken as soon as she awakens. The most satisfactory results follow eating two or three pieces of crisp toast or a Bent's cracker (sold by grocers), either of which should be thoroughly chewed and swallowed without taking anything to drink. Good results are also obtained, though less uniformly, from eating other food, such as fruit, oatmeal, or eggs. The benefit secured from this procedure is explained, perhaps, by the activity of the digestive organs and the effect of that activity upon the circulation of the blood. The food eaten before rising is not intended to take the place of breakfast, which ordinarily will be eaten later. Furthermore, it is essential to remain in bed until half an hour after the food was taken; and not to rise then unless perfectly comfortable. Anyone who is inclined to be nauseated should get up slowly and dress leisurely, sitting down as much as possible while putting on the clothes. If breakfast is not desired at once, it should not be forced, but some food should be eaten between early morning and noon.

It is an exceedingly good rule to bend every effort toward escaping the initial attack of nausea, for in this way one soon gains confidence, and overcomes the depressing habit of being continually on the watch for the symptom, lest she be taken unawares. Exceptionally, however, patients feel more comfortable if they vomit in the morning; this may be helpful, for example, if a large meal has been eaten just before retiring the previous night.

Next to morning sickness in point of frequency comes the disposition to be nauseated about meal time. Those who vomit after the meal is finished are frequently inclined to eat soon again; and there is no reason why they should not. Sick stomach after meals may be due to several causes, such as eating hurriedly, eating too much, or selecting food that is difficult to digest. If a meal is bolted the stomach may be overloaded before the appetite is appeased; and consequently those who eat too much are fortunate when the stomach rejects the excess. Eating slowly and masticating the food thoroughly, we know, is the proper way to insure taking no more than is needed.

One of the most valuable precautions against persistent nausea consists in taking small amounts of food five or six times during the day. Directions regarding the frequency of meals and the choice of food have been given in Chapter IV, to which the reader may refer. It may be repeated, however, that a prospective mother should naturally avoid anything which she knows is likely not to agree with her. On the other hand, she is almost certain not to be nauseated by any article of food for which she has an appetite.

Lying down for a short while after meals frequently serves to prevent an attack of vomiting. It is a good rule, furthermore, at whatever time of day the sensation of nausea may occur, to lie down immediately. An ice bag or cloths wrung out of cold water, if applied to the abdomen, often give relief; warm applications occasionally serve the same purpose better. Some patients prevent nausea by constantly wearing a flannel bandage about the abdomen.

Many instances of the vomiting of pregnancy cannot be explained by errors in diet, for the attacks come on repeatedly whether the stomach contains food or not. Under these circumstances mental influences frequently have to be reckoned with. Indeed, in most cases of vomiting of pregnancy dietetic and other hygienic measures are of no avail unless the patient learns to divert her attention from troublesome thoughts.

That the brain can exert an influence over the stomach is a fact well substantiated both by physiological experiment and by medical observation. In all probability there is a definite spot in the brain, called the "vomiting center," the irritation of which causes retching and the upheaval of the contents of the stomach. As this nervous mechanism is possessed by everyone, it is not called into existence by the advent of pregnancy. Nevertheless, it seems likely that pregnancy renders it more sensitive, and it is certain that pregnancy establishes new means by which the center may be stimulated. This admission does not imply, however, that the prospective mother must submit to inevitable discomfort, for she can and should muster the strength to resist it.

Time and again an unhappy frame of mind exaggerates or prolongs the vomiting of pregnancy. Thus, disappointment, anxiety, grief, fright, and other types of mental uneasiness not only magnify the discomfort but sometimes are its sole cause. The curious cases in which the husband suffers from nausea while his wife is pregnant are explained by mental influences. As a result of the same kind of influence, women who imagine themselves to be pregnant often suffer from violent vomiting, which ceases as soon as they discover their error. On the other hand, women who for several months remain ignorant of the fact that they are pregnant rarely suffer from sick stomach.

Any kind of worry may be and often is the direct cause of the vomiting of pregnancy, though patients are often unwilling to confess it; and occasionally do not seem to know what it is that troubles them. In any event, having received the assurance of her physician that there is nothing serious the matter, the prospective mother who is annoyed by nausea should make every effort not to become self- centered. She should have congenial companionship and should interest herself in pursuits outside of, as well as within, her home. Of all the measures that may be employed to overcome this manifestation of pregnancy the most fundamental and essential is mental diversion.

HEARTBURN.—Obviously, it would not be fair to consider indigestion as one of the ailments peculiar to pregnancy, for anyone is liable to suffer from indigestion. Yet dyspeptic symptoms, more especially heartburn and flatulence, occur so frequently at this time that something should be said regarding their causation and treatment.

A burning sensation rising from the stomach into the throat, familiarly called heartburn, is generally due to an overabundant secretion of hydrochloric acid, which is, as we have learned, a normal constituent of the gastric juice. Of late, the conditions which influence its secretion have been the subject of laboratory investigation, which has disclosed, among other interesting facts, the way to prevent heartburn. These experiments have taught that the introduction of fat into the stomach shortly before a meal decreases the amount of acid secreted during digestion. Consequently, anyone who is troubled by heartburn and wishes to avoid it should take a tablespoonful of olive oil, a cup of cream, or a glass of rich milk fifteen or twenty minutes before meal-time.

On the other hand, fatty food eaten with the meals prolongs the stay of food in the stomach and causes an increase in the secretion of hydrochloric acid. An excess of the acid, as we have just learned, is favorable to the development of heartburn. Therefore, as a further precaution against this source of discomfort, it is advisable not to use a large amount of butter or of salad oil, and to refrain from fried food, rich desserts, or any other article of diet known to contain a relatively large amount of fat.

Once it has developed, heartburn will be aggravated by taking cream or olive oil. The most rational curative measures then consist in diluting the acid by drinking a couple of glasses of water and in counteracting (neutralizing) the acid by taking a teaspoonful of baking soda (bicarbonate of soda) or a tablespoonful of limewater; and, if necessary, either of these doses may be repeated. Patients often adopt the very sensible habit of carrying with them a block of magnesium carbonate, which they nibble whenever the symptom appears.

FLATULENCE.—The distention of stomach and intestines with gas, technically called flatulence, may be associated with heartburn or appear independently. The gas arises from the action of bacteria upon the food. There can be little doubt that flatulence occurs so regularly during pregnancy because the pressure of the enlarged womb prevents the contents of the intestine from moving along as rapidly as they have done previously.

To be relieved from this source of discomfort, it is necessary, in the first place, that the bowels should be regularly evacuated; very often nothing further is required than to overcome the habit of constipation. Occasionally, however, the diet must be arranged so as to exclude food which is likely to form gas. For example, parsnips, beans, corn, fried food, candy, cake, and sweet desserts, all of which are known to cause flatulence, should be avoided; in aggravated cases the allowance of starchy food of every kind should be cut down to small portions.

Since the production of gas in the intestine is due to the action of bacteria sometimes relief from flatulence is secured only after the administration of intestinal antiseptics. Drugs, however, will be prescribed by the physician, and will not be employed until the simpler hygienic measures have failed. Similarly, the physician should decide whether it is advisable for the patient to drink milk inoculated with harmless bacteria (The Bulgarian Bacillus) which has lately been placed on the market. The bacteria thus administered in the milk are antagonistic to the intestinal bacteria that produce gas, and consequently have been recommended for the treatment of flatulence. If this commercial product cannot be conveniently obtained, one may use instead tablets containing the bacteria, which can be supplied by druggists.

DEFECTIVE TEETH.—Unless suitable precautions are observed, the digestive disturbances of pregnancy have a tendency to injure the teeth. The regurgitation of the acid contents of the stomach, for example, may cause cavities to develop or may enlarge those that already exist. In all probability the damage done in this way—and not the removal of lime from the teeth for the formation of the child's skeleton, as some have thought—is responsible for the origin of the saying that "every child costs a tooth." This notion is of course absurd, yet it is quite true that toothache and the decay or loosening of the teeth are not infrequently associated with pregnancy. On this account, throughout the period of pregnancy particular care should be given the teeth.

One of the very first duties of a prospective mother, after she knows that conception has taken place, is to visit her dentist. This step is very important as a means of insuring the teeth against such harmful influence as pregnancy may have upon them. If the dentist finds the teeth in poor condition, the patient should consent to have them treated immediately. That this is the reasonable course seems sufficiently obvious, yet the majority of women have been slow to adopt such a view.

For a long time dental work of every description was incorrectly believed to have an untoward effect upon the development of the child; and the extraction of a tooth, it was thought, would surely be followed by miscarriage. Although the extraction of teeth is not frequently undertaken nowadays, I have known several prospective mothers who required the operation, and who had it performed without experiencing a single untoward symptom. Very naturally dental work should be restricted during pregnancy to that which is absolutely necessary, and temporary fillings generally suffice; but whatever is needed should be done without delay.

Brushing the teeth after meals and removing particles of food that may have been caught between them—important enough at all times—are of even greater importance during pregnancy. If the gums are sore and the teeth show a tendency to loosen, the best tooth-paste is one containing potassium chlorate.

An alkaline mouth-wash should be used several times a day; after an attack of vomiting it is always advisable to rinse the mouth with such a solution. As a wash either lime water or milk of magnesia, or a solution of bicarbonate of soda may be used; they are equally good. Lime water may be prepared at home inexpensively in the following way: Place a teacupful of builders' lime in a large bowl and add two quarts of water; thoroughly mix and allow to settle. Pour off and throw the water away, since it often contains impurities. Add two quarts of water again and allow the mixture to stand three or four hours, stirring occasionally. Strain through a piece of muslin into bottles and keep well corked. One tablespoonful of this solution should be added to a glass of water to obtain the proper strength for a mouth-wash.

PRESSURE SYMPTOMS.—Because human beings walk erect, and not on all fours, they are liable to suffer from various ailments of pregnancy that quadrupeds escape. Thus the upright posture is the chief factor, at least, in causing such complaints as swollen feet, varicose veins, hemorrhoids, and cramps in the legs. The attention of patients should be called to the source of these troubles, for in most instances they can be prevented by forethought and prudence.

During the last two or three months of pregnancy every prospective mother should carefully avoid being too much on her feet; she should lie down, as has already been emphasized, at regular times of day and frequently sit down to rest. Proper support for the abdomen, such as is afforded by a correct corset or a maternity supporter, lifts the pregnant uterus, and to a notable extent relieves of pressure the structures beneath it. On the other hand, incorrectly made corsets, the use of circular garters, and running a sewing machine by foot- power all aggravate the pressure symptoms of pregnancy.

Swelling of the Feet.—So long as the swelling is confined to the feet and legs it does not mean that there is trouble with the kidneys; the swelling is satisfactorily explained by the pressure of the enlarged uterus upon the veins which pass through the lower part of the abdomen and conduct the blood from the legs on its way back to the heart. The womb is rarely heavy enough during the first half of pregnancy to interfere with the flow of blood through these vessels, but in the last few months such interference is very common.

Generally the limbs are equally affected, yet occasionally the swelling is more marked on one side or the other. The characteristic changes begin in the feet. The skin covering the back of the foot becomes tense and has a waxen appearance; it is easily indented, bearing for a moment the imprint of anything that is pressed against it. Often the swelling extends no higher than the ankles, but it may involve the calves, the thighs, or even the vulva, which is the region between the thighs.

If the swelling remains slight, no attention need be paid to it. But if it becomes extensive or painful, nothing will give relief except going to bed. Patients observe for themselves that the swelling lessens during the night, and from this usually learn that the proper treatment is rest. When it is absolutely impossible to remain in bed long enough for the swelling to disappear, the next best plan is to accept every opportunity, during the day, to sit down and prop up the feet.

Varicose Veins.—The distention of the surface veins of the legs, the condition known as varicose veins, is not a peculiarity of pregnancy. Anyone who must be on his feet a great deal is liable to suffer from this ailment. It is true, nevertheless, that pregnancy increases the likelihood of the development of varicose veins. The walls of the vessel are generally able to withstand whatever strain is placed upon them during the first pregnancy, and usually the varicosed condition does not develop until after there have been several pregnancies.

As a rule, both legs are similarly affected, but if only one, it is more likely to be the right. This is explained by the fact that the position of the child within the womb is ordinarily such as to cause greater pressure on the vessels of the right side. For the same reason when the legs are unequally affected, generally the veins of the right side are the larger. In any case, however, the birth of the child removes the source of the interference, and during the lying-in period, provided that the patient remains quiet for a sufficient length of time, the vessels regain their normal caliber. Once they have been distended, however, the veins remain more susceptible to engorgement. Consequently, in order not to increase the strain these vessels naturally bear during the latter months of pregnancy, the precautions just mentioned for the avoidance of all the pressure symptoms should be strictly observed. Upon the first intimation that the veins are becoming dilated, a patient should be unusually careful to keep off her feet all that she can. Only in extreme cases will it be compulsory to go to bed. But, if the veins are large and painful, she should stay in bed until material improvement has taken place. Subsequently she should wear a flannel bandage, snugly applied, about the leg from the toes to a point somewhat above the knee; the bandage should extend higher whenever the veins of the thigh also are dilated. In putting on the bandage the heel may be left uncovered; after leaving the foot a turn of the bandage will be taken around the ankle and thence applied upward. A flannel bandage may be easily made at home. Bias strips are cut about three inches in width and sewed together end to end so that the joining will lie flat. Unless the bandage must extend far above the knee, eight yards will be a sufficient length.

Elastic stockings, which may be purchased from a druggist, serve the same purpose as the bandage, but are very much less durable. Even if worn during the day they should be taken off at night; and when protection of the veins is required after going to bed, the bandage is the most sanitary way of securing it.

The danger that one of the vessels will break may be disregarded, if they are constantly protected by the measures that have been mentioned. In the event of accident, however, make firm pressure over the bleeding point with a freshly laundered handkerchief, and apply an ice bag outside the dressing until the doctor arrives.

Hemorrhoids.—Hemorrhoids are caused in the same way as varicose veins of the legs. The two conditions differ merely in point of location; but hemorrhoids, on account of their location, are much more exposed to irritation.

Although the development of hemorrhoids cannot always be prevented, it is a well-known fact that constipation renders the chance of their appearance much greater. In a measure, therefore, regular, daily evacuation of the bowels serves to prevent the ailment, and also to cure it, once it has developed. But walking and even standing aggravate hemorrhoids. The recumbent posture, as might be expected, is of itself frequently enough to give relief. It is much more likely to do so, however, if the hips are elevated by placing a pillow under them.

In severe cases it is helpful to restrict the diet for a few days until the congestion and acute suffering have subsided. If the hemorrhoids protrude, they should be replaced (which the patient may generally do for herself), and an ice bag should be applied to the seat of pain. Various ointments and suppositories of different composition are valuable in the treatment of this ailment, but, as not all cases are relieved by the same medicine, a physician should be consulted to learn what is most suitable in any given instance.

Hemorrhoids often grow progressively worse as pregnancy advances, and are frequently aggravated immediately after the birth of the child; but they generally disappear within a few weeks. Whenever a natural cure is not thus effected, it may become necessary to resort to surgical treatment. Operative procedures, however, should not be undertaken during pregnancy, since the condition is likely to reappear before the child is born.

Cramps in the Legs.—There are nerves as well as blood vessels that the pregnant uterus may press upon, and pressure of this kind may cause pain. At times the pain is definitely localized at the point where the nerve is pressed upon; under these circumstances the discomfort is felt in the lower part of the back. On the other hand, the pain may be referred to the point where the nerve ends. In this way is explained not only pain in the leg but also those sensations of numbness and tingling which prospective mothers not infrequently complain of. The presence of these pressure symptoms is usually limited to the last few weeks of pregnancy. They often begin about the time the child's head enters the bony canal through which it is ultimately born; engagement of the head, as this is called, occurs simultaneously with the dropping of the waist-line, that is, about two or three weeks before delivery. From the time the head is engaged all the pressure symptoms become somewhat more intense.

From the very nature of their causation, it is clear that cramps in the legs are difficult to treat. The recumbent posture lessens the discomfort, and, if in addition the hips are elevated, absolute comfort will occasionally be secured. Whether or not the administration of medicine is advisable must be determined by the physician who has the opportunity to see the patient. The birth of the child, of course, removes the cause of the pressure and permanently relieves this discomfort.

Shortness of Breath.—Besides the ailments caused by the downward pressure of the pregnant uterus, there are also symptoms due to its upward growth. Thus shortness of breath is regularly noted toward the end of pregnancy, and, as has already been mentioned, it is one of the reasons for exercising leisurely.

Unlike the other pressure symptoms, shortness of breath is ordinarily aggravated by the recumbent posture, for lying flat on the back increases the compression of the chest. At night, which is frequently the time when difficulty in breathing is most pronounced, the patient may, if necessary, sleep propped up in bed. For this purpose an appliance called a back-rest may be used, but an extra pillow under the head and shoulders is usually sufficient.

LEUCORRHEA.—The meaning of the white discharge from the vagina known as leucorrhea is variable: at times it indicates the existence of an ailment requiring treatment, and at other times it does not. To be on the safe side, therefore, anyone who is troubled by leucorrhea should obtain her physician's opinion as to its significance.

Normally, as we learned in Chapter V, there is an increase in the vaginal secretion during pregnancy; but this fact is rarely noticeable until the latter months. Usually it is pronounced only during the last few weeks. At that time, owing to its antiseptic qualities, this pale white fluid should not be disturbed by the use of douches. In the early months of pregnancy, however, leucorrhea may cause such inconvenience as to demand medical treatment.

While itching is the most disagreeable effect of such a vaginal discharge, it should be known that itching is not always due to leucorrhea. Thus it may be caused by a highly concentrated urine, and in that event will be relieved by drinking a larger amount of water; or it may be due to the presence of unusual constituents in the urine. Skin diseases also cause itching; and light haired people, since they have more delicate skins that brunettes, are especially susceptible to these ailments. To such skin affections soap and water may be very irritating; so that when they exist it is often advisable to cleanse the parts with olive oil. In other cases, ointments are required and will be prescribed by the physician.

Itching of the skin over the extremities or over the whole body, it is clear, cannot be attributed to leucorrhea, but in these very rare cases the irritation would seem to be caused by some waste product which is being eliminated through the sweat glands. We do not know what the substance is, but, as the symptom appears so seldom, it must be due to an unusual kind of waste product or else to one whose elimination normally occurs through other channels. The affection of the skin thus brought about is really a very mild kind of poisoning, and since the offending substance arises in the body of the patient herself the condition is called an autointoxication. Effective treatment consists in drinking water freely and taking a cathartic, for the one stimulates the kidneys and the other the bowels to assist in getting rid of the cause of the trouble.

TOXEMIAS.—In order to understand what are known as the toxemias of pregnancy, we must remember that the nutrition of our bodies involves three separate and distinct sets of processes. What we eat is, in the first place, digested and absorbed into the body; secondly, the products of digestion are utilized by the tissues; and, finally, the waste material is thrown off from the body. Any one of these processes may be carried out in a way that is not consistent with health. Most of us realize that disturbances may occur in the course of digestion, and we are also aware that the excretory organs occasionally fail to do their work in a satisfactory way. But what laymen, perhaps, do not appreciate is that the intermediary steps— between the time when the food is absorbed and the time when the waste material is finally eliminated—may not be taken precisely as health requires. Of course, any person may be the subject of one or another of these nutritional disorders, but unquestionably such disorders are somewhat more frequent during pregnancy than at other times. Nor is this difficult to understand, for the nutritional processes of two beings are here linked together. They generally proceed harmoniously, but if they do not there results an autointoxication of the mother which is called a toxemia.

Such toxemias, with extremely rare exceptions, do not occur in the early months, but are associated with the period of the active growth of the fetus, namely, the second half of pregnancy. For this reason, and for some others which do not concern us here, it seems probable that the nutritional processes of the child are primarily responsible for these ailments. This view, however, must be somewhat modified, for experience has clearly taught that the efficiency with which the maternal excretory organs do their work has a great deal to do with the effect that the fetal waste products have upon the mother. On this account she has been urged to pay attention to personal hygiene. It is also necessary, however, that she should become acquainted with the symptoms which give warning that the excretory organs are acting imperfectly.

Autointoxication can almost always be prevented. The means of prevention are neither mysterious nor difficult to carry out; they lie within the power of every prospective mother, for they consist merely of what has already been discussed, namely, the intelligent regulation of the diet, the care of the body, and a correct ordering of the daily life. To the chapters dealing with these subjects reference should be made and particular attention should be paid to what has been said concerning:

(1) Wearing suitably warm clothes, (2) Bathing regularly, (3) Taking a proper amount of exercise, (4) Drinking water liberally, (5) Avoiding an excessive quantity of meat, (6) Guarding against constipation.

At present the value of prevention in the treatment of the toxemias of pregnancy is so clearly recognized that charitable organizations employ nurses to visit women of the poorer classes during pregnancy in order to instruct them about the measures that I have just indicated. Remarkable results have already been obtained. In one clinic where this method has been adopted the frequency of all kinds of toxemia, I am told, has notably diminished, and serious types are not permitted to develop. Similar results should be obtained in private practice when patients place themselves under medical supervision at the beginning of pregnancy. Under these favorable circumstances symptoms of autointoxication probably occur not oftener than once in every hundred pregnancies, but nine out of ten of them, being promptly recognized, yield readily to relatively simple treatment.

The early detection of such complications depends largely upon the patient herself. As has been emphasized—and it cannot be said too frequently—she should not fail to submit, at appropriate intervals, a specimen of urine for examination. It is by such an examination generally that the development of a toxemia is first detected. Occasionally, however, significant signs will attract the patient's attention before there is any change in the urine. For that reason, it is important to notify the physician if any of the following symptoms appear:

(1) Serious vomiting. (2) Persistent headache. (3) Dizziness. (4) Puffiness about the face. (5) Blurring of vision, or the appearance of black spots before the eyes. (6) Neuralgic pains, especially in the pit of the stomach.

It must be clearly understood, however, that any of these symptoms may be present without indicating that a toxemia is developing. Nevertheless, they should be brought to the physician's attention without delay, and, at the same time, a specimen of urine should be given him for examination.