Although the kidneys are not responsible for all the toxemias of pregnancy, an analysis of the urine affords the most definite means of determining whether or not such a condition is present. When thus detected, prompt treatment will guarantee to the patient almost certain relief. On the other hand if, as usually happens, the analysis shows conclusively that there is nothing serious the matter, this reassurance fully justifies the trouble taken to secure it.



CHAPTER VIII

MISCARRIAGE

Frequency—Causes and Prevention—Habitual Miscarriage—Warning Symptoms—After-effects—Criminal Abortion—Therapeutic Abortion— Premature Delivery.

We have learned that forty weeks are required for the full development of the human embryo, but this fact carries no assurance that pregnancy will last so long; in reality, it may end abruptly at any time. If growth is interrupted before the twenty-eighth week (the seventh lunar month), the infant will be too immature to live. Even when born alive, it will usually perish within a few hours, or a few days at most. Children born during the seventh month have occasionally survived; but the prevalent belief that they are more likely to do so than if born a month later is erroneous. That superstition originated at a time when great virtue was ascribed to numbers. Since seven was a sacred number, it was considered more auspicious to be born in the seventh month than in the eighth. Universal experience, however, teaches us that the likelihood of rearing a premature child is, by a rapidly increasing proportion, the greater for every week that it remains within the uterus. This is precisely what we should expect, for the period of its existence there measures the perfection of its development; and that, under ordinary conditions, determines how strong and hardy the child will be.

Although during the first six months the outlook for the infant will be equally unfavorable at whatever time pregnancy may be interrupted, physicians prefer to distinguish cases which terminate in the earlier part of this period from those which terminate in the latter part. For technical reasons, the sixteenth week represents a natural point of division. A birth which takes place before that time is called an abortion; one which takes place between the sixteenth and the twenty- eighth week is called a miscarriage. The anatomical reasons which justify such a distinction do not concern us here, and the matter deserves mention merely because the same terms are often employed in a very different sense by the laity. As most of us know, the interruption of pregnancy results sometimes from purely natural causes, and sometimes from the employment of artificial means. As a rule, persons who are unacquainted with medical terminology call a birth of the former kind a miscarriage, and reserve the term abortion for an interruption of pregnancy that is deliberately provoked. Physicians, however, make no such distinction. They use these words, as I have said, simply to indicate how far development has progressed before the termination of pregnancy. Since the term abortion is apt to carry with it the implication of a criminal act, confusion will be avoided if we agree for the time to depart from strictly medical usage and designate as miscarriage the spontaneous termination of pregnancy prior to the twenty-eighth week.

FREQUENCY.—Early interruption of pregnancy is extremely common. Some sociologists declare that it is becoming more and more frequent, and see in it a grave national danger. French statesmen attribute the alarming decline of the birth-rate in their country, in great part, to a rapid increase in the number of pregnancies which end prematurely. Reliable English and German statistics indicate that of the pregnancies which come under the observation of physicians approximately twenty per cent, end in miscarriage. In our own country, though extensive and complete data are not available, it is likely that the incidence is equally high.

The actual frequency of miscarriage is generally underestimated. Patients themselves often do not know what has really happened. When the accident occurs a few days after conception, bleeding may be its only evidence, which will almost certainly be misinterpreted as an irregularity of menstruation; and professional advice will not often be thought necessary. Moreover, in other cases in which the true situation is appreciated the patient does not feel sick enough to seek medical assistance. If it were possible to include in the statistics all these cases as well as those which are concealed because intentionally provoked, the frequency with which pregnancy is interrupted during the early months would be found somewhat greater than is usually supposed.

If we omit the miscarriages which occur within the first few weeks of pregnancy, and which consequently often escape detection, the majority of cases fall within the second and third months. After the fourth month has passed, the probability of such an accident, though not excluded, is greatly diminished. Some statistics recently published by Taussig make this clear. In a series of several hundred cases of miscarriage, one hundred and fifty-seven instances occurred in the second month, two hundred and twenty-two in the third month, seventy-three in the fourth month, thirty-seven in the fifth month, and five in the sixth month. This order of frequency might be anticipated from the anatomical conditions which prevail during the early months of pregnancy, since the attachment of the embryo to the mother is at first relatively insecure, but gradually grows firmer, and becomes as secure as it ever will be by about the fifth month.

It is noteworthy that miscarriage occurs much less commonly in the first than in subsequent pregnancies. Indeed, a somewhat greater liability to the accident with each succeeding pregnancy goes far toward explaining the greater frequency of miscarriage among women who have passed the thirty-fifth year than among those who are younger.

CAUSES AND PREVENTION.—We have seen that the proportion of pregnancies which end in miscarriage is quite formidable. But this should not be true, as the accident is frequently preventable, and many of these accidents could be avoided by the cooperation of patients. As self-denial and personal inconvenience are often essential, it is only fair to explain their value. Furthermore, the, patient who appreciates the reason for certain directions the physician gives becomes responsible to herself, and is much more likely to carry them out than is one who is cautioned without receiving a satisfactory explanation. At best, however, the advice which the physician is able to offer will be imperfect, for it must not be imagined that everything is known concerning the causation and prevention of miscarriage. While our knowledge is so imperfect we must be content to make the most of what we possess. It must be added that no suggestion such as can be given here will enable anyone to dispense with her own medical adviser. On the contrary, if there is reason to fear miscarriage, the prospective mother should be encouraged to seek his counsel as early as possible. Aside from the hygienic measures which she may learn to carry out for herself, various drugs are often of great value in preventing miscarriage. Since these are not applicable to all cases, they should be employed only upon medical advice.

Very early miscarriages may be explained by the loose attachment of the ovum during the first six weeks of pregnancy. This tiny, living sphere, it will be recalled, reaches the womb a few days after conception, and adheres to the uterine mucous membrane. At first, however, its roots are short and delicate, and not so capable of anchoring the ovum as they become later. It is only toward the end of the eighteenth week that the union between the womb and its contents becomes firm.

From what we have learned in Chapter II regarding the anatomical conditions in the early days of pregnancy it is obvious that we need not be greatly surprised at the frequency of miscarriage. On the other hand, it must not be forgotten that there are many natural safeguards against accident: to mention only one, the uterus is ingeniously swung in the abdominal cavity so as to afford a large measure of protection against mechanical shock. Usually, the provisions nature has made are sufficient to resist forces from without which tend to dislodge the ovum. Now and then it happens that the most irrational acts will not interrupt pregnancy; indeed, they often seem particularly inert when practised intentionally.

Fear of loosening the ovum from its uterine attachment prompts experienced women to caution prospective mothers against any kind of sudden or violent effort. Their advice, however, is often needlessly alarming; a great many traditional precautions lack a reasonable basis. Thus, no harm can possibly result from sleeping with the arms above the head; nor from "over-reaching," as when hanging a picture, though a fall under such circumstances might be dangerous.

Patients who have been warned by one experience should always be on their guard if they would avoid repeated miscarriages; others need only lead a sensible, hygienic life, a matter we have already discussed in the chapters dealing with the care of the body and the way to live. For the sake of emphasis, I may here repeat that no prospective mother should become fatigued from any cause; sweeping, moving heavy furniture, lifting heavy articles, and running a sewing machine are not to be attempted. But household duties which do not require strong muscular effort are better assumed than not.

Amusements which may cause jolting, or expose one to the danger of falling, involve some risk of miscarriage. Short rides in a carriage or an automobile over smooth roads are free from objection. Railway- travel and sea-voyages are not advisable in the early months; after the eighteenth week they may be undertaken with a greater degree of safety, provided comfortable accommodations are assured, and the patient has never had a miscarriage.

A few physicians, even at present, attribute the interruption of pregnancy to strong emotions, including intense joy or sorrow, anger, fright, or even jealousy. Without denying altogether the possibility of such an influence, we may be sure that its importance is greatly exaggerated. It is not unusual to see patients who are able to recall a mental shock of some kind shortly before the miscarriage occurred; nevertheless, in such cases diligent search will usually reveal a physical cause for the accident.

Another popular fallacy relates to the effect of drugs upon pregnancy. The use of castor oil and other strong purgatives do not interrupt it. Should the administration of any cathartic be followed by miscarriage, some fault inherent preexisted in the pregnancy, and no amount of precaution would have enabled the patient to reach full term successfully. Quinin in tonic doses may be taken with impunity, and even larger quantities are being constantly used for the cure of malaria without doing the pregnancy any harm. Many other drugs are reputed to have great efficacy in causing the expulsion of the product of conception; unfortunately, they are too well known to require enumeration. They are usually unreliable, and are absolutely inefficient in doses small enough not to endanger the mother's life, provided the pregnancy is a healthy one.

Instances in which miscarriage is attributed to the use of some drug are quite common, and we cannot dismiss them without a word of explanation. Such cases generally fall into one of two classes. Often a drug is given credit for efficiency where conception has been erroneously suspected. Shortly after the menstrual date passes, some medicine is resorted to, and the subsequent phenomenon, regarded as the interruption of pregnancy, is really no more than normal menstruation. In another group of cases miscarriage does actually occur, although the medicine employed plays only a minor role in its production. In such instances the irritation which the drug occasions is the last link in a chain of events leading up to the miscarriage, but the main factor lies in some fundamental imperfection in the pregnancy. Physicians recognize a variety of these imperfections, and know that they may be located in the womb, in the embryo, or in the tissues which unite the one with the other. As an intimate knowledge of pathology is often necessary to recognize the underlying, and therefore the actual, cause of the miscarriage, it is not at all surprising that patients frequently err in their interpretations of such accidents, and emphasize unimportant matters.

It would lead us too far afield to attempt to discuss every cause of miscarriage. Nevertheless, there are some very important ones, not yet mentioned, which should be understood by the laity, as appreciation of their significance may avert trouble. In some instances, on the other hand, the accident is unavoidable; to know this should afford the patient a large measure of comfort.

Irregularities in the position of the womb are often responsible for miscarriage. Such a condition may exist in women who have not borne children, but it is far more likely to occur as a result of childbirth. After delivery, the enlarged womb becomes the seat of intricate changes, the purpose of which is the restoration of the organ to the condition which existed before conception. It dwindles in size, and gradually drops to its accustomed location within the pelvic cavity. Six weeks are usually required for these changes.

At the time of birth it is impossible to predict whether the womb will finally resume a satisfactory position. Accordingly, an examination two to four weeks later is essential. In four out of five patients the organ will be found in its proper location, but, even though it is not, suitable measures adopted at once will generally serve to replace and hold it in good position. On the other hand, if the malposition is not recognized until months or years later, simple procedures will prove inefficient, and a surgical operation will become necessary. Were there no other reason for a careful examination at the end of the lying-in period, it would be amply justified by the information which it gives relative to the position of the uterus.

Although there can be no doubt that the routine correction of uterine displacements shortly after labor would go far toward restricting the occurrence of subsequent miscarriage, it would be incorrect to leave the impression that miscarriage will always occur if the uterus is out of its normal position. Not infrequently the changes wrought by pregnancy will cause the uterus to right itself spontaneously.

Another important cause of miscarriage consists in abnormalities in the lining of the uterus. Through inherent defect or acquired disease this tissue may become unsuited for anchoring or nourishing an ovum. In either event, a surgical procedure, known as curettage, affords the most likely means of restoring it to a healthful state. The operation removes the old lining; and a new one quickly develops, which is often more capable of fulfilling the purpose for which it is intended.

An appreciable number of miscarriages depend upon conditions over which medical skill has no control. Under such circumstances, though the accident may be regretted, there is no room for remorse or censure. Often the embryo should bear the blame; if its development is imperfect or if it dies, miscarriage usually occurs very promptly.

We are familiar also with a few maternal conditions which seriously affect the embryo, often seriously enough to cause its expulsion, alive or dead. In this respect, certain constitutional disorders are preeminent. Bright's disease and diabetes are prejudicial to the development of the embryo; women suffering from either of them must be watched with great care. Occasionally, such pregnancies come to a premature end in spite of every precaution. Various infectious diseases, as typhoid fever and pneumonia, also are fatal to the embryo if the causative bacteria pass into it. Fortunately this rarely happens, since the placenta generally affords an effectual barrier to their entrance into the embryo. Organic diseases of the mother's heart also may bring about miscarriage. A patient thus affected should place herself under the supervision of a physician as soon as conception is suspected.

Now and then physicians are completely at a loss to explain cases of miscarriage. Our ignorance is unfortunate, particularly when repeated miscarriages have occurred and their causation cannot be detected.

HABITUAL MISCARRIAGE.—Experience teaches that women who have had one miscarriage must be more careful than other prospective mothers if they would escape a repetition of the accident. Persons who know themselves to be subject to miscarriage should regard no precaution as too burdensome. Not only should they avoid motoring, driving, railroad journeys, sea voyages, and every kind of strenuous exertion, they must accept every opportunity to be quiet and rest. Often such hygienic care yields sufficient protection; but occasionally medicine is also necessary.

A number of causes are at hand to explain habitual miscarriage, but, in fairness, it must be acknowledged that physicians are not able to interpret all cases. With one class of patients the muscle fibers of the womb are peculiarly irritable, whereas in another its lining proves incapable of firmly anchoring the ovum. Moreover, derangements of organs which do not belong to the reproductive group may be responsible for the habit.

It is a curious fact that the accident is most likely to occur when menstruation would be expected were the individual not pregnant. Obviously, extraordinary precaution is advisable at such times, and if the patient would avoid even the slightest risk, she should not leave her bed. The same purpose will not be served by sitting quietly in a chair, nor by reclining on a couch; complete relaxation and composure are secured only when one lies flat on the back, loosely attired in sleeping garments. I have known several persons with a tendency toward miscarriage who overcame it in this way. Recently one of them who had been delivered prematurely on two former occasions, and who was anxious for a successful issue to her third pregnancy, was willing to remain in bed practically the whole period of gestation. She had her reward; a well-developed infant was born at full term, and has continued to thrive.

Prolonged rest in bed, some will say, is debilitating. While that may be true to a degree, untoward effects can always be avoided by systematic massage of the extremities. The abdomen should not be subjected to such manipulations, for they will occasionally provoke painful contractions of the uterus and defeat the purpose of staying in bed.

Patients who are not disposed to undergo a long period of enforced rest, no matter what profit may be promised, should at least consent to keep in bed during that period of pregnancy at which a previous miscarriage took place. We know that the event is particularly apt to recur at such a time. Specifically, it is important to remain in bed one week before and one week after the date in question.

When pregnancies follow one another in rapid succession, the liability to miscarriage is notably increased. A natural interval between births has been provided, an interval which depends upon the mother nursing her child. Ideally, menstruation, and with it the ripening of the ova (egg-cells), does not occur while the breasts are active; but when the infant does not suckle, the ovaries regularly resume their function in a very short time. Since the circumstances attending miscarriage always deprive the mother of the opportunity of nursing, another pregnancy may quickly ensue unless these facts are appreciated.

Those who anticipate the possibility of a premature interruption of pregnancy should realize that the marital relation is inadvisable after conception has taken place. For others, who have no reason to expect irregularity in the course of pregnancy, such a precaution is unnecessary. None the less, women who marry late in life or who first conceive toward the time of the menopause will do well to follow the same rule. The risk of accident may be very slight, but conservative persons will not assume it when the likelihood of subsequent conception is doubtful.

Not infrequently the fundamental reason for habitual miscarriage lies in some anatomical abnormality which a surgical operation alone can correct. As the necessity for interference can be determined only after a careful examination, recommendations of wide application are not possible. Nothing short of painstaking study of each case will afford a basis for advice and action.

SYMPTOMS.—Very definite warning usually precedes a miscarriage, but the threatening symptoms vary greatly in severity and duration. If appropriate measures are taken promptly, these symptoms may disappear with no harmful result Everyone concedes that bleeding and pain are the chief indications of impending miscarriage, although an occasional patient, profiting by former experience, may find other signs prophetic in her own case.

Mature women, accustomed to the regular monthly function of their sex, are prone to treat with indifference a slight discharge of blood occurring during pregnancy. Indeed, it is widely believed that menstruation frequently continues after conception. In point of fact, however, it is very unusual in early pregnancy, and becomes entirely impossible after the fourth month. Accordingly, whenever vaginal bleeding is noticed, some other explanation should be sought; and the patient who would adopt the wisest plan should assume that she is threatened with miscarriage. There are other possibilities, but these are for her doctor to consider.

It is true that small hemorrhages are not necessarily followed by miscarriage. One may even experience slight loss of blood repeatedly, and yet give birth to a healthy child at the natural end of pregnancy. None the less, bleeding, however moderate, should always excite suspicion, as we know it usually denotes the breaking to some degree of the connection between mother and child. The extent of the separation usually determines the degree of the hemorrhage, which in turn indicates the seriousness of the accident. The fate of the fetus will depend upon the area of placenta, which has been incapacitated. Flooding, however, always imperils the fetus, and generally warrants the inference that so much of the placenta has been separated as to render further development impossible. On the other hand, so long as the hemorrhage does not exceed the customary flow at the monthly periods, the life of the child is rarely endangered; while a chocolate-colored discharge, and even the loss of small clots, may continue indefinitely without doing serious harm. Under such circumstances, however, the patient should communicate with her medical adviser, and should save for his inspection whatever may be expelled.

Pain, the other conspicuous symptom of threatened miscarriage, has not a uniform significance. Since it frequently occurs during the course of pregnancy in association with a number of conditions, it is not a reliable sign of danger. Moreover, the susceptibility to pain varies; thus, of two patients in the same stage of threatened miscarriage one may suffer intensely, while the other remains comparatively comfortable.

Typically, the onset of miscarriage is attended by discomfort in the small of the back, which may be continuous, but more often is intermittent. If preventive measures are instituted at the outset, there is hope of relieving the discomfort and averting the miscarriage; but if the warning goes unheeded, the pain will gradually shift to the lower part of the abdomen and become more severe. It often happens that the cramp-like abdominal pain of threatened miscarriage is confused with that associated with intestinal indigestion. A simple test will sometimes decide the question. If due to the latter cause, the discomfort will usually yield to a teaspoonful of paregoric, whereas it will be without effect if miscarriage is imminent. Exceptions to this rule are not uncommon, yet a better one cannot be given; as a physician, even after considering the technical evidence, may find it impossible to decide at once whether or not miscarriage is threatened.

No confidence can be placed in many so-called signs of miscarriage, though implicitly trusted by the laity. Lassitude, depression of spirits, and general bodily ill-feeling may forecast the interruption of pregnancy; but more frequently they have no such significance. The same estimate holds true of other symptoms, including diarrhea and a persistent inclination to empty the bladder. Nor does fever always lead to the termination of pregnancy. A moderate rise of temperature is without significance; but high fever, persisting for several days, may result in the death of the fetus and subsequent miscarriage. Nevertheless, prolonged febrile affections, such as typhoid fever, frequently leave pregnancy unharmed.

So long as the symptoms are confined to slight bleeding and mild attacks of pain, physicians regard miscarriage merely as threatened. If the bleeding increases, the outlook becomes less favorable, and, as I have said, miscarriage is inevitable when it amounts to flooding. Likewise, rupture of the sack containing the fetus, with escape of the amniotic fluid, indicates that the culmination of events will not long be delayed.

The most favorable outcome is when the entire contents of the womb are spontaneously expelled, which unfortunately does not always occur. There is, to be sure, rarely any difficulty in the natural birth of the fetus, for its meager development prevents serious complications. The separation and extrusion of the placenta, on the contrary, are apt to be imperfect when pregnancy ends in the early months, and medical attention is necessary to determine whether the uterus has been emptied completely. This is particularly important, because the retention of placental tissue affords opportunity for several unpleasant complications; and neglect in this regard accounts in part for the belief that miscarriage is certain to leave women irreparably broken in health.

AFTER-EFFECTS.—No one will deny that invalidism follows the untimely interruption of pregnancy more often than the birth of children at full term. This is not due, as is sometimes said, to the fact that a miscarriage differs from a normal birth in that it is unnatural, for other reasons are apparent. One of them, the retention of placental tissue, has just been mentioned, but serious consequences resulting from it are almost inexcusable, for, although the placenta may separate less readily and be cast off less thoroughly after miscarriage, modern medical skill can successfully cope with such conditions. Another fruitful source of unfortunate after-effects is the imprudence of the patient. Women should remain in bed fully as long after a miscarriage as after the birth of a mature infant; if they would consent to do so, many ill-effects would be averted. But physicians frequently encounter strong opposition to precautionary measures such as this. Many patients argue, illogically, that less precaution is necessary since pregnancy failed to attain its natural conclusion, and infer that the earlier that it ends the more quickly one may leave the bed. In point of fact, even greater precaution is required than if all had gone normally. Still a third cause for ill- health may be found in physical ailments which antedated the miscarriage but were not recognized until after its occurrence.

Invalidism which follows pregnancy and which may be fairly regarded as chargeable to it depends, in most instances, upon an infection acquired at the time of delivery. Infection occurs more frequently when pregnancy ends during the early months, because in this category is included the great majority of criminal abortions, which are usually induced without regard for surgical cleanliness. Fatal complications, or serious consequences which narrowly escape a fatal ending, are common among women who attempt to rid themselves of an unwelcome pregnancy. As they are ignorant of aseptic precautions, their manipulations must necessarily contaminate the site of operation; for this reason and others as well women who attempt to perform an abortion upon themselves imperil their lives. The danger is scarcely less when abortion is induced unlawfully by incompetent operators; for lack of skill, the need of secrecy, and the desire of haste all interfere with necessary aseptic technique. Everyone knows that sad accidents befall those who submit to such operations; but it is not generally recognized that these cases are largely responsible for the ill-repute borne by miscarriage in general. On the other hand, properly supervised miscarriages are attended by no greater danger and probably less than delivery at full term.

CRIMINAL ABORTION.—The destruction of a pregnancy, except when its continuance threatens the life of the patient, is forbidden by law. The important ethical and religious aspects of the act which the law thus stigmatizes as criminal we may properly neglect. Although various religions present a diversity of teaching relative to its moral nature, all agree in regarding it as sinful. Equally important, however, is the fact that no matter what opinion anyone may hold as to the morality of the act he is bound to obey the law. This is apparently not clearly understood by the laity, for many persons think that a physician may terminate pregnancy whenever he is so inclined. If the liability to criminal prosecution which a physician would assume should he comply with a request for the means of destroying pregnancy were clearly realized, patients would not beseech him to incur the risk of heavy find and long imprisonment merely to gratify their own convenience or to save them from disgrace.

The Common Law, an inheritance from England, enriched with authoritative decisions by our own courts, is the groundwork of the law in all the States, and its principles are binding in the absence of express statutes. At Common Law, abortion is punishable as homicide when the woman dies or when the operation results fatally to the infant after it has been born alive. If performed for the purpose of killing the child, the crime is murder; in the absence of such intent, it is manslaughter. The woman who commits an abortion upon herself is likewise guilty of the crime.

The great majority of those who desire the interruption of pregnancy feel they have not assumed an illegal position so long as they avoid instrumental procedures. That is not correct, for even at Common Law it is a misdemeanor to bring about the death of an unborn child by the use of drugs or by any other means.

At Common Law there was a difference of opinion as to whether all induced abortions were illegal. Many courts formerly held that quickening was a necessary prerequisite; but under the modern statutes, practically without exception, the law disregards the period of pregnancy at which the abortion is provoked. Since the time of conception determines the beginning of embryonic development, to prove that the act was committed before fetal movements were perceived is no longer a valid defense. This has been emphatically stated by Judge Coulter, of Pennsylvania, who said: "It is not the murder of a living child which constitutes the offense, but the destruction of gestation by wicked means and against nature. The moment the womb is instinct with embryonic life and gestation has begun, the crime may be perpetrated."

Each commonwealth has enacted its own statutes for the regulation of abortion. In many states, simply to seek the means for destroying pregnancy is a criminal act. Thus, Indiana, perhaps the most progressive of the States in reconstructing its criminal code to accord with modern sociological teaching, has enacted a law which I quote from Burn's Indiana Statutes, Revision of 1908, Vol. I, page 1029. "Every woman who shall solicit of any person any medicine, drug or substance, or thing whatever and shall take the same, or shall submit to any operation or other means whatever with intent thereby to procure a miscarriage, except when done by a physician for the purpose of saving the life of the mother or child, shall, on conviction, be fined not less than ten dollars, and be imprisoned in the county jail not less than thirty days nor more than one year." To include the woman as a party to the crime is a signal mark of progress toward bringing abortion under effective legal control. Heretofore, the perpetrator alone has been responsible, and in most States he remains so, while the woman is regarded as a victim. Clearly, that is unjust, for criminal abortions are rarely, if ever, performed without application by the subject of the operation. According to most of the statutes no distinction is made between the attempt at abortion and its accomplishment. Irrespective of the outcome, those who supply drugs or employ instruments purposing the destruction of pregnancy are guilty of the offense.

An extensive analysis of the various State laws is unnecessary; the mention of a few statutes, selected from different sections of the country, will suffice to indicate the character of prevalent legislation. Massachusetts imprisons those found guilty of abortion for a period of three years or less, and permits a fine of one thousand dollars. In Pennsylvania the same prison sentence is imposed, though the fine may not exceed five hundred dollars. Three years is the minimum imprisonment in Virginia, and a maximum of ten years is allowed. Colorado's law duplicates that of Massachusetts. California imposes no fine, and prescribes a sentence of from two to five years in the State prison. All the statutes make the offense much graver when the woman dies as a result of the practice. Under these circumstances, the crime never takes lower rank than manslaughter; and generally it is murder.

Evidently we possess sufficiently stringent laws regarding criminal abortion; yet, as everyone knows, they do not prevent perpetration of the crime. On good authority, we are informed that eighty thousand unlawful abortions are performed annually in New York, in spite of a possible penalty of four years in the State prison. This is due in part to difficulty in securing evidence and failure to prosecute when evidence could be gathered, but more particularly to the fact that the general public does not appreciate the gravity of the offense. The same feeling is illustrated in the advertising of abortifacients. Newspapers and magazines unhesitatingly carry, under the guise of remedies to regulate the health of women, notices of drugs and equipment intended to destroy pregnancy. This is expressly forbidden by many statutes. [Footnote: Thus, the Maryland law provides that "any person who shall knowingly advertise, print, publish, distribute or circulate any pamphlet, printed paper, book, newspaper notice, advertisement or reference containing words or language or conveying any notice, hint, or reference to any person or to the name of any person, real or fictitious, from whom, or to any place, house, shop, or office, where any poison, drug, mixture, preparation, medicine, or noxious thing or any instrument or means whatever; or from whom advice, direction, information or knowledge may be obtained for the purpose of causing the miscarriage or abortion of any woman pregnant with child, at any period of pregnancy, shall be punished by imprisonment in the penitentiary for not less than three years, by a fine of not less than five hundred dollars, nor more than one thousand dollars, or by both, in the discretion of the court."]

The knowledge that prohibitory laws exist is sufficient to deter reputable physicians from illegal practice; whereas known laxity in the enforcement of the law continually tempts unscrupulous persons to provoke abortion. Among the poorer classes the procedure is undertaken by ignorant women, while persons in more comfortable circumstances avail themselves of the services of medical men who are usually incompetent and value money above professional honor. The net result is an unpardonable death-rate and a large proportion of invalids. Aside from the legal aspect of the act, the element of personal danger would seem a warning to be heeded by women who contemplate becoming a party to this crime.

THERAPEUTIC ABORTION.—If a woman is suffering from tuberculosis or some organic affection, pregnancy may add a serious strain upon the already crippled machinery of her body. Occasionally gestation itself may cause changes which threaten life. In either event the duty of the physician is plain. The law is acquainted with such emergencies, and explicitly permits the termination of pregnancy when undertaken to relieve or cure such conditions. When performed to restore health the operation is called therapeutic abortion.

The Maryland law, for example, grants the right to induce abortion whenever two or more physicians see the patient and agree that "no other method will secure the safety of the mother." Similar rules are prescribed by the statutes of other States, but none concedes the right of abortion as a means of keeping the woman from suicide.

Since therapeutic abortions are legal, they may be done openly; hence the operation is performed in appropriate surroundings and with every refinement of surgical technique. These fortunate conditions materially alter the outlook; serious consequences of the operation itself need not be feared. Competent surgeons, employing modern methods, may perform hundreds of abortions without the loss of a single patient. Moreover, pregnancy may be terminated safely and expeditiously at any time; the lay view which regards abortion as more serious after the second month than before it is a relic of days gone by.

PREMATURE DELIVERY.—In the introduction to this chapter we noted that the infant becomes viable after the twenty-eighth week, which marks in a practical sense, the transition of the fetus from an immature to a premature stage of development. In point of frequency, premature delivery ranks far below either abortion or miscarriage.

Unlawful interference with pregnancy generally proceeds from a desire to avoid offspring, and lacks incentive after the infant becomes capable of living independently. Criminal operations, therefore, are not a conspicuous cause of premature delivery. Occasionally physicians resort to artificial means to end gestation during the later months in order that organic complications may be relieved; but most premature births occur spontaneously. Sometimes they are due to ill-health, while in other instances no evidence of disease is found in either mother or child. Careful study of the individual patient, however, is generally helpful toward the prevention of repeated premature delivery.

The course of premature labor closely resembles delivery at full term. But it is shorter because the infant is small; and the subsequent loss of blood is not so great. The recovery of the mother is never retarded by the fact of earlier delivery, though the conditions which caused it may prevent rapid convalescence.

The outlook for the infant depends upon a great many factors. Most important among them is the perfection of its development, which may be estimated most satisfactorily from its weight and length. Occasionally children have been reared when they weighed as little as three pounds, but hope that they will survive should not be entertained unless they weigh four pounds or more. This is attained about eight weeks before maturity, and corresponds to a length of forty centimeters (16 inches), measured from the crown of the head to the heel. Premature children perish, most frequently, either from incomplete development of their heat-regulating apparatus, which predisposes them to pneumonia, or from imperfections in the digestive functions, which increase the liability to malnutrition. To overcome the first danger, incubators have been devised and have become familiar to everyone through public exhibitions. A basket or box supplied with hot-water bottles answers the same purpose, and has the advantage of better ventilation. The second danger can be overcome only by proper feeding. Breast-milk provides the most reliable nourishment for premature infants. If the mother cannot supply it, a wet-nurse should be procured, and, if the infant has not the strength to suckle, the milk should be drawn from the breast and fed with a medicine-dropper or a spoon.

In addition to providing proper food and maintaining an even body- temperature, care must also be taken to protect these infants from various harmful influences such as too much handling, strong light, and loud noises. Although every precaution be observed, frequently all counts for nothing; but if the child does thrive, there is no reason for worry about its ultimate development. When a premature infant lives, the same chances for adult health await it as it would have had if born in its due time.



CHAPTER IX

THE PREPARATIONS FOR CONFINEMENT

Engaging the Nurse—Desirable Qualities in the Nurse—Preliminary Visits of the Nurse—The Necessary Supplies for Confinement—The Baby's Outfit—Sterilization—The Choice and Arrangement of a Room— The Bed—The Preliminary Visit of the Doctor—When to Call the Doctor—Personal Preparations—The Care of Obstetrical Patients at the Hospital.

Prospective mothers are anxious to learn how they shall prepare for the approaching confinement. They desire their preparations to be thorough, reliable, and in accord with the most approved methods of treatment, for they realize that preparations along these lines will not only prevent haste and confusion at the time of birth, but will also promote a satisfactory convalescence. Apparently trivial details often safeguard confinement against serious accident. Indeed, measures which aim at the prevention of illness form the chief asset of modern obstetrics, and of these none takes higher rank than the maintenance of strict cleanliness during and after childbirth. This fact fortunately is widely appreciated at present, and not a few women inquire voluntarily the means of observing the proper precautions. It is true, of course, that even today many women are delivered in filthy rooms and upon dirty beds, and that in spite of such surroundings some of them make a good recovery. Yet grave complications develop much more frequently among those who have not paid attention to the preparations for confinement.

The surgical dressings and other supplies do not require attention in the early months of pregnancy. A number of articles, invaluable when delivery occurs at full term, are useless if the fetus is immature and cannot live, and therefore it is unnecessary to provide them until two or three months before the confinement is expected. In the event of a miscarriage what is needed can be procured upon very short notice. But, on the other hand, delivery subsequent to the twenty- eighth week may require all the equipment useful at full term so that everything should be in readiness by that time.

ENGAGING THE NURSE.—As soon as the existence of pregnancy is clearly recognized the patient should select the doctor and the nurse who will attend her. Prompt selection of a nurse will assure the widest choice, for proficient nurses are in demand and book engagements far in advance of the date they will be needed. Furthermore, it is a relief to the patient to have her attendants selected. The possibility of premature delivery never interferes with engaging the nurse very early in pregnancy, for that accident releases both patient and nurse from their contract.

Nurses demand that the date be specified upon which an engagement shall begin, as, unless their calendar is definitely arranged, they are unable to earn a livelihood. This leads to a question which is difficult to answer, for the precise day of delivery is uncertain; consequently to fix the beginning of the engagement may prove a troublesome matter. On the one hand, there is risk of having to pay the nurse for a time before her services are actually needed; on the other, a false economy may result in the absence of the chosen nurse at the critical moment. In finding a way out of this dilemma a patient must be guided by her means and the location of her home. Those who can afford it will not hesitate to employ a nurse from one to two weeks in advance of the expected date of confinement; and for those who live where nurses cannot be procured quickly, a similar course is recommended. But persons of only moderate resources, living in a city where, in an emergency, a substitute can be gotten from the local "Nurses' Directory," will find it convenient to engage the nurse from the calculated date. The substitute will remain with the patient until the arrival of the nurse originally engaged.

Occasionally, it may happen that a patient will prefer to keep the substitute. Such a course, however, would be unjust to the nurse who was first selected, unless she could immediately secure other work. She has reserved a definite period of her time for the patient, and probably has declined work which seemed likely to conflict with the engagement already made. She is fairly entitled, therefore, to assume charge of the case, and the patient who refuses to make the change is obligated to pay her according to the terms of the agreement.

How long will a nurse be needed after the child is born? The answer to this question may be altered by so many circumstances that a hard and fast rule cannot be given. Before the advent of "Trained Nurses," obstetrical patients were cared for by "Monthly Nurses," so called because they remained one month with their patients. It is, likewise, customary to keep the trained nurse four weeks after the birth; but whenever possible it would be well to retain her six weeks, since this period elapses before the mother has entirely regained her normal physical condition. Those who can afford to keep a trained nurse six months or a year are exceptional, but very fortunate.

Someone may feel that the suggestions I have made are not suitable to her case. Very likely they may not be; to cover all the possibilities could scarcely be expected, for every case has its problems and peculiarities. After consultation with her physician each patient will decide what is particularly advisable for her. Nevertheless, I would emphasize the importance of securing a competent nurse and retaining her for at least four weeks. Even with those who must guard their expense account the truest economy will lie in such a course. Whenever lack of resources seems likely to prevent this arrangement, the patient who is looking to her best interests should enter a hospital where excellent care can be provided at a cost within her means.

DESIRABLE QUALITIES IN THE NURSE.—It is rarely advisable to select as nurse a member of the family or an intimate friend. Some of the motives governing such a course—sentiment, mutual devotion, and the desire to be humored—are inconsistent with the best kind of nursing. If the nurse knows the patient intimately, undue anxiety may interfere with her judgment; thoroughness in routine duties may be hindered by mistaken consideration for the patient; and in an emergency sympathy rather than reason may guide her. A successful nurse must satisfy at least two requirements; she must be capable professionally and also personally agreeable to her patient. Some regard advanced years as essential to the first of these qualifications, but this does not necessarily hold good.

The personal qualities generally welcome in a nurse are neatness, thoughtfulness, a sympathetic nature, an even disposition, and a cheerful view of life. Since a short interview is insufficient for taking the measure of a nurse, patients usually rely upon the opinion of someone else in selecting her. The judgment of her former patients is frequently prejudiced in one direction or the other, and such an estimate must always be accepted with caution. Much the most trustworthy method is to allow the physician to select her. He will know nurses who possess the requisite qualities, and certainly he is most competent to judge their professional attainments. If the choice of a nurse be left to the doctor, the two are sure to work harmoniously, and the patient will benefit by their cooperation. Otherwise she may suffer because of their dissensions, for, if the doctor is accustomed to one procedure and the nurse to another, misunderstandings may occur, although both methods yield equally good results. Whenever he does not select her, she should be asked to confer with him long before the case is due. Obviously, a physician cannot be held responsible for a nurse's ability unless he is acquainted with her training and methods of work.

In an effort to economize, many are inclined to employ "half-trained" or "practical nurses." When the confinement is not the first and there is no reason to anticipate any irregularity during labor or thereafter, I can see no vital objection to such an arrangement. It is of the first importance, however, to be assured that the "practical nurse" is neat and appreciates the necessity of keeping everything about the patient scrupulously clean. But competent nurses who charge less than the customary fee will be hard to find. The recommendations which these women receive are apt to be even more misleading than in the case of trained nurses, because more is expected of the latter. My experience has taught me that patients form particularly unreliable opinions of practical nurses, and I have frequently witnessed incompetence in such women which was overlooked by the patient.

A low-priced nurse is seldom a cheap one, as her shortcomings may be reflected in the health of the mother or the infant long after she has left the case. Especially when the baby is the first, the mother will depend upon the nurse for instruction which should be both sound and thorough. The principles taught her will be put into practice and utilized for many months, playing a vital part in the training of the infant. It becomes essential, therefore, to secure a nurse who will give the baby a good start, and instruct the mother along right lines. Perhaps this is less needful if the mother has learned her lesson from previous experiences. But even then a good nurse relieves her of responsibility and materially assists her to a quick and lasting convalescence. In the end the most proficient nurses are the least expensive.

THE PRELIMINARY VISITS OF THE NURSE.—Many of the precautions which safeguard a confinement should be considered by the patient and the nurse together. The character and quantity of the supplies, the choice of a room for delivery and subsequent convalescence, the proper clothing for the infant—all these are problems which may be solved most satisfactorily in the light of the nurse's experience and the resources at hand. Two visits are usually sufficient to arrange these details. An interview early in pregnancy, soon after the nurse has been selected, provides an opportunity to lay plans and especially to review the list of articles needed at delivery. Such articles as are already in the house may be checked off; the others may be procured at leisure. Eight to ten weeks before the expected date of the confinement the nurse should pay a second visit and should inspect the supplies to see that they are complete. Certain articles which I shall indicate must be sterilized. As this procedure is more reliable when carried out by an experienced person it will be convenient to have all the dressings finished by the time of the nurse's second visit, in order that she may sterilize them.

The question may arise as to whether the nurse shall come to the patient upon the date for which she has been engaged or shall wait until summoned. From the physician's standpoint it is often more acceptable to have the nurse in the house a few days before the confinement, though some patients strongly object to this. Provided the nurse may be got quickly at any time of day or night, there can be no objection to leaving the decision to the patient herself.

THE NECESSARY SUPPLIES FOR CONFINEMENT.—As to just what a confinement outfit should contain physicians differ to some extent; but this disagreement pertains rather to luxuries than essentials. In the lists here suggested nothing essential has been omitted, although economy, as far as is consistent with good judgment, has been kept in mind. Any article not included in my list which the doctor or nurse in attendance recommends may be noted in the space for memoranda.

Some patients prefer to take no part in preparing the supplies for confinement. Indeed, the demand for a ready-made confinement outfit has become large enough to lead several firms to put them upon the market. These outfits differ in completeness and vary in price from a few dollars up to fifty. The majority of patients, however, still attend to such details themselves, and will find a list of the needful supplies convenient.

Make-up and Sterilize: 7 Dozen Sanitary Pads. 2 Sanitary Belts. 2 Delivery Pads. 5 Dozen Gauze Sponges. 2 Dozen Gauze Squares. 4 Dozen Cotton Pledgets. 2 Sheets. Bobbin for tying the Cord. A Pair of Obstetrical Leggins. A Dozen and a Half Towels (Diapers).

Obtain from the Druggist: 100 Bichlorid of Mercury Tablets. 100 grams Chloroform. 4 ounces Powdered Boric Acid. 4 ounces Tincture Green Soap. 1 pint Grain Alcohol. A small jar of White Vaselin. A cake of Castile Soap. A two-ounce Medicine Glass. A Medicine Dropper. A bent glass Drinking Tube.

The following articles should be in the house, ready for use.

An ample supply of Towels, Sheets, and Gowns.

A new Hand-Brush; the cheap variety with wooden back and stiff bristles is preferable.

Two slop Jars or enamel Buckets with Covers.

A two-quart Fountain Syringe; an old one may be substituted provided it has been thoroughly boiled.

Three Basins and a one-quart Pitcher of agate or enamel-ware.

A Douche-Pan; the "perfection Bed-Pan" is preferable.

Two pieces of Rubber-Sheeting are required, one large enough to cover the mattress of a single bed (2 x 1-1/2 yds.), the other smaller (1 x 3/4 yd.). Should this be too expensive, the best substitute is white table oil-cloth.

The nurse will explain how the various surgical dressings are made, but, as the patient may forget some of the directions, all the details will be given here. At least three to four pounds of absorbent cotton will be used in the dressings. To make the pads entirely of absorbent cotton is very expensive. The cheaper cotton- batting is therefore employed to give them body, and they are faced only upon one side with the absorbent material. Furthermore, the rolls of absorbent cotton, as purchased, may be separated into three or four layers, one of which is thick enough for the facing. About six rolls of the batting should be purchased.

Surgical gauze, which tradespeople sometimes call dairy-cloth, is the most suitable material for covering the pads. Bleached cheese cloth will answer the same purpose, but it is more expensive and rather heavy. Approximately thirty-five yards of the gauze, which comes in a thirty-six-inch width, will be needed. When the supplies are finished, they are wrapped in separate bundles and sterilized. Old muslin or some of the diapers are generally used for covers.

The sanitary pads, also called vulval or perineal pads, absorb the discharge which always occurs after delivery. They are made of absorbent cotton and cotton-batting covered with gauze; a convenient size is ten inches long and three to four inches wide. Their thickness is approximately an inch, one-third of which is composed of absorbent cotton.

The sanitary belt is used to hold these pads in place. Very satisfactory ones are made of two strips of unbleached muslin, three inches wide. The first of these must be long enough to reach around the waist; the second, which passes over the pad, is somewhat shorter and has two parallel slits in one end; through which the waist-band passes at the back; the three free ends are pinned together in front.

The delivery pads are made of the same materials as the sanitary pads; preferably a yard square and four inches thick. A rather heavy top-layer of absorbent cotton must be used in them, and they should be quilted or tacked at several points to prevent slipping. A rubber pad is ill adapted for use during delivery. Some absorbent material made into proper shape proves much more satisfactory since it can be thoroughly sterilized and can be thrown away after it has been used.

I am told that cotton-waste is a good substitute for absorbent cotton in the delivery pads. It is inexpensive, and will be rendered capable of absorbing fluids after it has been boiled in washing soda and dried in the sun. Each delivery pad should be separately wrapped and sterilized.

Gauze sponges will be needed by the doctor; about five dozen should be prepared. The gauze is cut in eighteen-inch squares. Opposite edges are folded toward one another, about two inches being lapped each time; this finally yields a seven or eight-ply strip, which is wrapped into appropriate shape about two fingers. The ravelled ends are then tucked into the roll. It is most satisfactory to divide the sponges and sterilize them in two bundles.

Small pieces of gauze about two inches square will also be needed in caring for the baby's eyes and mouth. Several dozen should be cut, and they may all be sterilized together.

Cotton pledgets are simply bits of absorbent cotton the size of a hen's egg, the rough edges of which have been twisted together. A small pillow-case full of them ought to be made up and sterilized.

Obstetrical leggins are preferably made of canton flannel; they are cut to fit loosely and should reach the hip. If they are prepared so as to extend to the waist at the sides, they may be held in place by a waistband, and in this way will prevent unnecessary exposure without interfering with the doctor. They should be sterilized.

Towels, if used at all, should be without fringe. It is economical not to employ them, but to use diapers in their place. Three packages, each containing six diapers, should be sterilized.

Sterilized sheets are often useful at the delivery; more than two are never needed. They should be wrapped separately for the sterilization.

Sterilized bobbin is generally used for tying the cord. Several pieces are cut in nine-inch lengths and sterilized in a single package.

A dressing for the cord will be required, but there is no necessity for preparing a special one. It is generally satisfactory to wrap the cord in one of the sterile gauze sponges which has been previously soaked in alcohol.

Several methods of drying up the cord give equally good results, and it is usually a good plan to allow the nurse to dress it as she wishes, since the employment of a method with which she is familiar will more likely insure a satisfactory result in her hands. A dressing popular with many nurses is prepared as follows: In a piece of muslin four inches square cut a small circular opening; double the linen and dust boric acid between the folds. If this method is preferred, several of the dressings should be prepared and sterilized together.

THE BABY'S OUTFIT.—Preparations for the infant may be thorough without being elaborate. Instinctively, the prospective mother leans toward extravagance in fitting out her baby's wardrobe, and easily slips into the error of providing too much. Time and energy are frequently devoted to an extensive wardrobe which the infant quickly outgrows; in consequence many articles must be made over before they are used. Even with modest resources a prospective mother can acquire everything the baby really needs.

A very sensible plan, in my judgment, is to prepare what will be wanted during the first two months; subsequently, articles may be made or bought as they are needed. Accordingly, the quantity of wearing apparel and the nursery supplies I have suggested pertain only to the early weeks of infant life. Although no essential has been omitted, the outline is plain and economical.

At present, outfitters supply a variety of ready-made, garments for the infant and conveniences for the nursery; in many of them notable ingenuity is displayed which aims at the child's comfort or the saving of labor to the mother. Catalogs of these articles, which are often expensive, are furnished by dealers.

In preparing clothing for the new-born, several principles must be kept in mind. The first is that the garments must be warm without being unduly heavy; and another that they should be roomy, permitting perfect freedom of motion. A third no less important principle is simplicity. Adornment of the clothing gratifies the mother, but does not serve a single useful purpose. The lists which follow include all that is necessary for the young infant; they will also serve as a basis for elaboration if a more lavish outfit is desired.

Necessary Clothing. 4 Abdominal Flannel Bands. 3 Undershirts. 4 flannel Skirts. 4 Night Gowns. 12 White Slips. 3 Knit Bands. 4 Dozen Diapers. Cloak and Cap.

Nursery Equipment. An old Blanket. Assorted Safety Pins. Soft Damask Towels. Wash Cloths. Hot-Water Bag with Canton Flannel Covers. Talcum Powder. Olive Oil. Bassinet.

Additional Articles; Convenient but Not Essential. Rubber Bathtub. Rubber Bath-Apron. Flannel Apron. Bath Thermometer. Bath Hamper. Quilted Mattress Covering. Baby Scales. Screen. Low Chair without Arms. Drying Frames.

STERILIZATION.—Now and again, those who follow very rigid rules to avoid infection during childbirth are criticized for their pains. The general public has not yet grasped the true relation of bacteria to this condition; a relation which, indeed, first became clear to medical men within comparatively recent years. The development of our knowledge of the nature of infection forms one of the most entertaining chapters in obstetrics, and provides a simple way of showing the genuine need of preventive measures. Several observant physicians had previously suspected the character of "child-bed fever" (as infection of the mother was once called), but convincing proof of its contagious nature was not forthcoming until the middle of the nineteenth century, when signal facts were pointed out by three men, each working independently, though all came to similar conclusions. The evidence they gathered should have left no one doubtful that the disease is contagious, and largely preventable. On the contrary, bitter opposition was encountered for the time, and only within the last two decades has their teaching found wide practical application.

In 1843 Oliver Wendell Holmes published the paper on "The Contagiousness of Puerperal Fever," which is now preserved in his volume of "Medical Essays." Physicians were startled to be frankly told the responsibility they assumed if they neglected the truth taught by epidemics of this disease. "The dark obituary calendar" which marked the progress of these epidemics clearly indicated that "the disease is so far contagious as to be frequently carried from patient to patient by physicians and nurses." A violent controversy followed this arraignment, and, consequently, the preventive measures which Holmes so convincingly urged were not adopted as promptly as they should have been. The full justice of his conclusions has since been universally admitted, and medical men now find it difficult to understand how anyone could have taken issue with the sentiment which he expressed. "For my part," Holmes said, "I had rather rescue one mother from being poisoned by her attendant than claim to have saved forty out of fifty patients to whom I had carried the disease."

But the most important early observations upon child-bed fever were made in 1847 by a young Hungarian, Semmelweiss, while he was an assistant in the large Lying-in Hospital in Vienna. In thoroughness, power of conviction, and practical value his work was masterful. It is no exaggeration to regard his observations as the rock upon which antiseptic surgery, the glory of the nineteenth century, was built.

Semmelweiss had been seeking an explanation of the dreadful scourge, and his mind was ready for the reception of the truth when it was revealed through the death of one of his colleagues. This physician injured his finger accidentally in performing an autopsy upon a patient who had died from child-bed fever. And the condition disclosed by examination of his body after death was identical with that found in cases of child-bed fever. Here then was the clew; the disease was contagious. Semmelweiss was ignorant of Holmes' views; what had happened before his eyes suggested to him that the disease was due to a poison which could be conveyed from one person to another. Moreover, his interest and his power of insight led to further comparison. Clearly, the open wound on the physician's finger had been the portal through which the poison entered; but where was there a similar portal in obstetrical patients? The answer was plain. The birth-canal at the time of delivery is always an open wound. There the poison entered, and child-bed fever was a wound infection!

Several years later Tarnier, who was to become an eminent obstetrician, but was then a student in Paris, chose the diseases of the lying-in period as the subject for his graduating thesis. He was unacquainted with the work either of Holmes or of Semmelweiss, and approached the problem from still another standpoint, drawing attention to the much higher deathrate among women delivered amid unsanitary surroundings. Tarnier also considered that the disease was a form of poisoning, that it was contagious, and that measures should be instituted to protect patients against it.

Of these pioneers, by far the greatest credit is due Semmelweiss, who devoted his life to the problem, although his opinions continually met with scepticism and even ridicule. More convincing proof than he could furnish was demanded before his contemporaries would believe that child-bed fever was due to lack of precaution. Fortunately the evidence was soon produced. In 1880, Pasteur obtained bacteria from the organs which had been infected, and was able to grow the bacteria in his laboratory; thus the ultimate cause of the disease became firmly established. With the harmful agents in their hands, Pasteur and his followers were enabled to study their characteristics and to recommend means of destroying them.

Much as we must regret that the warnings of Holmes and of Tarnier passed unheeded; lamentable as may be the blindness of the generation of Semmelweiss to the truths revealed by his research, it is not surprising that such radical teaching met with a hostile reception. As we measure time in retrospect from the vantage ground of to-day, the three to four decades required for full acceptance of their revolutionary doctrines seem a brief span. Antiseptic methods would not have prevailed so quickly as they did, had not the same epoch which gave us a Pasteur also given a surgeon with a receptive mind, ready to seize and apply the discoveries of the French genius. This was the great service of Joseph Lister. Impressed with Pasteur's studies on fermentation, Lister saw an analogy between this process and the putrefaction of wounds, a condition which he was eager to prevent. He had reason to believe that carbolic acid would check decomposition, and he employed a weak solution of it in the treatment of wounds; later he devised a "carbolic spray," by means of which when his operations were performed the atmosphere round about might be sterilized.

It is but a short step from antiseptic operations to our own era of aseptic surgery, and that a step in the direction of simplicity. Now we know that the sterilization of the air is rarely necessary and have dispensed with Lister's elaborate apparatus. Furthermore, and of far greater moment, experience has taught that the destruction of bacteria before they have opportunity to come in contact with the wound is more effective than efforts to kill them as they approach or after they have invaded the tissues. Initial freedom from bacteria is the ideal of asepsis; to secure it, the modern surgeon is ever watchful of the cleanliness of his hands, his instruments, his dressings, and of the site of operation or whatever may come near it.

The importance of the changes wrought by the adoption of aseptic methods requires no emphasis, for the marvels of modern surgery are even more impressive to laymen than to the medical profession. Everybody now understands that strict cleanliness is indispensable to the success of a surgical operation. But the general public has not fully awakened to the same profound necessity in connection with childbirth, although it was child-bed fever that called forth the observations and experiments upon which modern surgical technique rests.

Although most obstetrical patients appreciate the fact that there is an advantage in sterilized dressings and sanitary surroundings, few realize the risk they run without them. One must know the mournful history of the past to be adequately impressed with that danger, for we no longer see the epidemics of childbed fever which formerly swept over communities, sacrificing ten of every hundred women as they became mothers. Precaution is no less necessary on that account; the scourge would be rampant again if the reins were loosened.

Most instances of puerperal infection are, it is true, referable to lack of care. Nevertheless, the complication develops now and then where all precautions have been conscientiously observed. Under such conditions the infection will in all likelihood be a mild one, and a tedious convalescence usually proves its most disagreeable feature. Such stringent preventive measures as are now practiced in many hospitals have reduced the frequency of infections to the point where only one fatal case, or even less, occurs in a thousand deliveries. These rare cases remind us that vigilance must never be relaxed, and that patients who are confined at home require just as much care as those in hospitals, where conditions are the best to prevent infection and the complications, which follow.

The first essential toward the avoidance of infection in obstetrical cases is clean dressings. Naturally, these should be clean to the sight, but it is in invisible dirt that serious danger lurks; bacteria are the causative agents of this disease. Experiments have taught the bacteriologist that disease-producing organisms are killed in half an hour when subjected to a high atmospheric pressure and the temperature of steam. Special apparatus has been constructed for carrying out the procedure. It is unnecessary for our purposes, however, since the essential conditions may be secured, though with less convenience, in any kitchen. If a prospective mother finds it awkward to do the sterilizing at home, and her nurse is unable to take charge of the matter, she may arrange with a local hospital or the nearest nurses' directory to sterilize her dressings. Yet a very little ingenuity suffices to do the work at home with perfect satisfaction. Installments of the smaller bundles may be sterilized in a galvanized bucket. To do this place an inverted bowl, with a depth of three to four inches, at the bottom, and pour in water until the bowl is almost covered. A breakfast plate rests on the bowl, and upon this the dressings are stacked; a second larger plate which fits the top of the bucket is utilized as a lid to close in the sterilizing chamber. This will not accommodate the larger packages; a more satisfactory method for all of them is to use a wash-boiler in which has been swung a muslin hammock.

To arrange the latter form of home sterilizer, cut an oblong piece of unbleached muslin large enough to sink far down into the boiler and run a drawing-string of stout cord about the edge. Cover the bottom of the boiler with several inches of water; tie the hammock in place, passing the cord beneath the handles of the boiler to hold the muslin securely. Pack in the dressings, which have been wrapped in appropriate bundles; put the lid in place, thus closing the sterilizing chamber, and leave the dressings exposed to the steam for at least half an hour. After the operation has been completed, the bundles are taken out of the boiler and allowed to dry in the air. They must not be opened until the occasion for which the supplies were prepared arrives; awaiting this event, they are laid away in a convenient closet or drawer.

A word of caution may be added concerning a method of sterilization employed at home more frequently, perhaps, than any other. According to this procedure, the supplies are wrapped in paper, thrust into a hot oven, and left there until the paper is scorched. From the standpoint of economy as well as of thoroughness, this method is likely to prove unsatisfactory. Frequently, the dressings themselves are scorched; I have known patients to ruin several installments of their supplies in this way. Moreover, dry heat is not so trustworthy as steam for sterilizing purposes.

Judicious management means the preparation of the supplies necessary for confinement before turning to the selection of the infant's outfit. Ordinarily, both these tasks should be finished by the end of the eighth month, and final arrangements for the approaching delivery will then claim attention. If the patient expects to remain at home, she must decide which is the best room to occupy; she will wonder how it ought to be equipped, and she will be anxious to learn what personal preparations are advisable at the beginning of labor.

Intelligent answers to these questions are important. A patient should request the physician to criticize her plans when he pays the preliminary visit four to five weeks prior to the expected date of confinement. If she has acted unwisely in any respect, he will point it out, and may suggest changes which will enable her to employ to the best advantage the resources at hand.

THE CHOICE AND ARRANGEMENT OF A ROOM.—An old-fashioned custom, which relegated obstetrical patients to the most secluded part of the house, with little regard for comfort and still less for hygiene, has now few, if any, adherents. There is an advantage, to be sure, in having a quiet room; but this qualification may be secured in a room well located with regard to other essentials. Selection of a suitable room is not a trivial point. In most cases, since patients ordinarily remain for convalescence in the same room in which the infant is born, the chamber must serve a two-fold purpose. A number of requirements, therefore, must be met, and they must all be kept in mind when the room is chosen.

We have seen that the act of birth, natural as it is, may have a very unnatural sequel if precautions against infection are treated lightly. It is proper, therefore, that the delivery-room should be as clean as care can make it. Such radical measures as may be employed in sterilizing the dressings are here out of the question; if possible, they would be absurd. Infection usually develops because harmful bacteria come in contact with the patient. For that reason, an infection is more likely to be communicated by the dressings than by articles about the room, which only become a source of danger when the dirt upon them is transferred by an attendant.

An acceptable delivery-room may be arranged in any home; it is by no means necessary to duplicate the equipment of a modern hospital. To choose a room convenient to the bathroom will be found advantageous not only at the time of birth but throughout the lying-in period. The furnishing should be simple and scrupulously clean; indeed, it is improbable that one of these good points can be secured without the other. Furthermore, the preparation of the room should be completed well in advance of the date of confinement.

A large collection of furniture interferes with the nursing, and also increases the difficulty of keeping the room free of dust. It is sound advice, therefore, to remove everything which will not serve some good purpose during the delivery. Should any article be wanted later, it can be brought back to its accustomed place. The furniture may be conveniently limited to a bed, a bureau, a washstand, a table, and several chairs, one of them a large, comfortable rocker, which will prove invaluable during the early part of labor.

To approach perfect conditions, bric-a-brac, needless hangings, and everything that might collect dust should be temporarily removed. A profusion of pictures does not accord with the best sanitation of a room devoted to the treatment of obstetrical patients; those which are to be left upon the wall ought to be taken down and wiped carefully with a damp cloth. Other desirable preparations would be instinctively undertaken by the modern housekeeper, and it may seem presumption to mention that the room itself ought to be subjected to most thorough cleaning. It is well to leave the floor bare or merely covered with freshly cleaned rugs. Carpeting is difficult to protect against soiling and is not sanitary. If left down, the carpet should be covered with some suitable material, firmly stretched and tacked in place.

We know that the air in most households does not contain disease- producing bacteria; but the presence of any contagious disease materially alters the situation, and may imperil the convalescence of an obstetrical patient. Preferably, one should never select a room in which there has lately been sickness, and under no circumstances may such a room be used until carefully fumigated. The more conspicuous diseases which for at least several months absolutely disqualify an apartment for obstetrical purposes are diphtheria, pneumonia, pleurisy, erysipelas, scarlet fever, typhoid fever, tuberculosis of all varieties, and every sort of discharging sore.

When possible, two adjoining rooms should be given over to the mother and the infant; if this is impracticable, the single room should be large, easily ventilated, well lighted, and heated in such a way as to permit a change of temperature without difficulty. All these features help to make convalescence comfortable and free from petty annoyances. A room which has a southern or eastern exposure proves grateful for those who must remain indoors; frequently, this will be beyond reach, but a room getting the sun's rays directly during part of the day will always be available, and the selection should be made with that requirement in mind. At the time of birth and for the first few days which follow, a patient may not appreciate this feature; ultimately she will understand the need of sunlight better than the need for the more technical, and therefore the more impressive, preparations.

THE BED.—Now that housekeepers recognize how easily such furniture can be kept clean, few homes are without a brass or an iron bedstead; they are equally sanitary. Undoubtedly, this kind of bedstead fulfills the needs of an obstetrical patient much better than any other; and, if at hand, it should be used. The single bedstead is the most acceptable, and the mattress ought to be at least twenty inches above the floor. A low, wide bed interferes with proper management of the delivery and later handicaps the nurse in taking care of the patient. Wooden blocks may be used to raise a bed which otherwise would be too low. It is well worth while to provide them if one desires good nursing, for no attendant can do her best when she must continuously bend over a very low bed.

The location of the bed at the time of delivery is not an unimportant matter; it must always be placed so that the brightest possible light will shine over the foot. Since birth often occurs at night, one should make certain that the artificial lighting of the room is good, and place the bed most advantageously in reference to it; at the same time the necessity of a good light from the windows, when delivery occurs during the day, should not be forgotten. The head of the bed may be placed against the wall, but both sides must remain freely accessible not only at the time of delivery but also throughout the lying-in period.

A smooth, firm mattress, made in one piece, should be provided. One which has been used several years and possibly worn in a hollow will require renovation to be made comfortable. A feather bed should not be used under any circumstances. The mattress must be protected; and protection is best secured by means of a large piece of rubber sheeting. The regulation household sheet covering the rubber should be tucked well under the mattress at the ends and sides; in that way the rubber sheeting will be held firmly. Since the part of the bed where the hips rest will be most exposed to soiling, the protection of this area is usually reinforced by a "draw sheet." To arrange this, a cotton sheet is doubled so as to make a strip about one yard wide and two yards long; the smaller piece of rubber sheeting is laid between the folds. The draw sheet will reach from the middle of the back to the knees; its ends should be tucked under the sides of the mattress, to which it is fastened by means of large safety pins. After delivery, the draw sheet may be removed without disturbing the mother, who will thus be assured a clean, dry, and comfortable bed.

The bed-clothes covering the patient during labor will vary with the season of the year, but should always be light; in summer a single sheet will suffice, and in winter a blanket will likely be needed. For sanitary reasons, a freshly laundered sheet should also be placed outside the blanket until the delivery has been completed; later, it may be replaced with a light spread. Two pillows will be needed, and it is very convenient to have one of hair, the other of feathers. While there is no necessity for sterilizing the bed-clothes, it is advisable to use linen which has been recently laundered and kept well protected from dust. Among the poor, infection from soiled bed- linen is not uncommon.

THE PRELIMINARY VISIT OF THE DOCTOR.—No teaching of medical science has been given greater prominence of late than the principle of prevention. In obstetrics it finds a particularly wide field of application, and its practice is responsible for removing many of the former terrors of childbirth. We have just learned that preventive measures effectually reduce the frequency of puerperal infection, and in an earlier chapter we saw the value of routine examination of the urine as a means of anticipating other complications. Moreover, the benefit of promptly reporting to the physician anything that does not seem to be as it should has been urged constantly, for in this way is afforded the earliest opportunity to treat complications. Similarly a visit from the doctor about four weeks before the expected date of confinement is indispensable to skillful management of the delivery; neglect of this precaution is sometimes responsible for bad results.

At this visit the physician not only becomes familiar with the general health of his patient, but he also notes certain facts which will have a direct bearing upon the course of labor. By means of a few simple measurements he may accurately determine the character of the pelvis, the bony structure through which the fetus passes. When they are compared with what we know as the normal measurements, a very good idea is gained as to whether the birth-canal will present any obstacle to the passage of the child; and, if it will, there is opportunity to deliberate what treatment may be necessary. Since another factor in the problem, namely, the size of the child, cannot be accurately predicted, occasionally the physician may hesitate to express as definite an opinion as the patient may wish. Nevertheless, though it may be impossible to learn every detail, the available information well repays the time and trouble expended. In nine out of ten cases nothing whatever is found out of the way; the result is an assurance which always justifies the examination.

During this examination the position of the child is also ascertained. By means of a series of painless manipulations through the abdominal wall of the mother, the head, the body, and the extremities of the child may be mapped out, and the conclusions verified by locating the fetal heart-sounds. In this regard, also, the physician usually finds normal conditions. The most favorable presentation, that in which the head is the part to be born first, occurs in ninety-seven of every hundred cases. When less favorable conditions are recognized, they may frequently be corrected at once; but should that prove impossible, with foreknowledge of the presentation, the physician will be more competent to conduct the delivery.

With a clear understanding of the character and value of the information gathered at the preliminary examination, patients are not likely to refuse it. If they do, the risks should be fully explained to them. Some physicians decline to assume the responsibility of a patient who will not permit these observations. Such a decision is rarely necessary, for in my experience the patient's consent has never been difficult to obtain. Many women now regard the visit as part of the routine attention, and inquire when it will be made.

The appropriate time for this examination, as I have indicated, is approximately one month prior to the calculated date of confinement. Before this period, we have no assurance that the presentation which is found will continue until the time of birth. The fetus frequently alters its position as long as it is not large enough to fill out the cavity of the womb, consequently it is only during the last month of pregnancy that the final presentation can be determined. But to defer the examination after the period I have specified is unsafe since we lack an exact method of fixing the day of confinement, and too long a delay might render a preliminary examination impossible.

Aside from its relation to the observations just outlined, the preliminary visit provides an opportunity for the physician to criticize the preparations which have been made, and for the patient to inquire about the personal preparation advisable at the beginning of labor. She will also learn the signs which indicate that labor has begun and will be told what to do when they appear. Although physicians may not agree in all these directions, there can be no difference of opinion relative to the essential points. At least, the rules given here will serve to bring the patient and the doctor to a definite understanding as to the course he desires her to follow.

WHEN TO CALL THE DOCTOR.—During the last two or three weeks of pregnancy not a few patients are more comfortable than they have been for several months. About this time the womb usually drops somewhat and relieves the pressure which has interfered with breathing. These changes, however, do not promote comfort in every direction; more freedom for the organs of the chest means compression of the structures below the womb; consequently, the inclination to empty the bladder and for the bowels to move becomes more frequent. Patients complain also of cramps in the legs and experience difficulty on walking. This order of events enables some women to recognize the approach of delivery. Of course there is other evidence when labor actually begins. Its onset may be indicated in one of three ways, namely, by periodic pains, by a gush of water from the vagina, or by a discharge of blood as though the patient were taken unwell. Each of these unmistakable signs is a sufficient reason for notifying the doctor.

At the onset of labor, dragging pains are usually felt at the back, but sometimes in the lower part of the abdomen. The rhythm with which they come and go identifies them more certainly than any other feature, though this indication is not entirely reliable, for intestinal colic also causes rhythmical pain. At first the uterine contractions which occasion the discomfort are weak and appear at long intervals. Gradually they become stronger and closer together. When the interval between them has been shortened to half an hour or less their significance is fairly certain, provided the abdomen becomes tense and hard with each pain, remaining comparatively soft between them.

When contractions begin during the day or early evening, the physician will be glad to have immediate notification in order that he may arrange his appointments and thus be free to attend the patient when she needs his services. On the other hand, if they begin between 11 P.M. and 7 A.M. the nurse, who will always be summoned with the very first warning, should be allowed to decide when the doctor is to be called. Unless other instructions have been given, she will usually wait until the interval between the contractions is five to ten minutes.

Usually the symptoms make it clear that labor has begun, but occasionally the greatest difficulty will be experienced in deciding whether the discomfort has not some other origin. Uncertainty may prevail not only because of the similar effects of colic, but also from the fact that uterine contractions do not always have the same value. Preliminary pains may appear several days, or even weeks, before the actual onset of labor. Now and then the "false" pains cease, and after a period of comfort efficient contractions are established. There is never difficulty in recognizing the latter; doubt always relates to the preliminary pains, which may subside or may pass into the efficient type. We lack a method of foretelling which turn they will take; developments may be calmly awaited, with the assurance that ample warning will precede the birth.

A slight mucous discharge from the vagina is frequently seen toward the end of pregnancy and may be disregarded, but a gush of watery fluid always means that the sac which contains the fetus has ruptured. Uterine contractions generally follow within a few hours, though in a few instances they will not appear for a number of days. Under any circumstances the event ought to be promptly reported to the doctor. Similarly, he should be notified whenever bleeding from the vagina occurs, since it is important to have him determine its significance.