← catalogue

The Prospective Mother, a Handbook for Women During Pregnancy

by J. Morris Slemons · English · Gutenberg #7129 · 530,793 chars · public domain (US)

The Project Gutenberg eBook of The Prospective Mother, a Handbook for Women During Pregnancy
    
This eBook is for the use of anyone anywhere in the United States and
most other parts of the world at no cost and with almost no restrictions
whatsoever. You may copy it, give it away or re-use it under the terms
of the Project Gutenberg License included with this eBook or online
at www.gutenberg.org. If you are not located in the United States,
you will have to check the laws of the country where you are located
before using this eBook.

Title: The Prospective Mother, a Handbook for Women During Pregnancy

Author: J. Morris Slemons


        
Release date: December 1, 2004 [eBook #7129]
                Most recently updated: December 30, 2020

Language: English

Other information and formats: www.gutenberg.org/ebooks/7129

Credits: Produced by Tricia Gilbert, Tiffany Vergon, Charles Aldarondo, Charles Franks and the Online Distributed Proofreading Team


*** START OF THE PROJECT GUTENBERG EBOOK THE PROSPECTIVE MOTHER, A HANDBOOK FOR WOMEN DURING PREGNANCY ***




Produced by Tricia Gilbert, Tiffany Vergon, Charles Aldarondo,
Charles Franks and the Online Distributed Proofreading Team.





THE PROSPECTIVE MOTHER


A Handbook for Women During Pregnancy



by

J. MORRIS SLEMONS

Associate Professor of Obstetrics,
The Johns Hopkins University.


       *       *       *       *       *


PREFACE


This book, written for women who have no special knowledge of
medicine, aims to answer the questions which occur to them in the
course of pregnancy. Directions for safeguarding their health have
been given in detail, and emphasis has been placed upon such measures
as may serve to prevent serious complications. Treatment of such
conditions has not been discussed, as it can be judiciously carried
out only by a physician who has the opportunity to observe and study
the individual patient. Furthermore, if there is to be notable
improvement in the management of cases of childbirth, the appearance
of untoward symptoms should not be awaited before consulting a
physician; on the contrary, prospective mothers must be taught that
they should be under competent medical supervision throughout
pregnancy.

At present intelligent women demand some knowledge of the anatomical
and physiological changes incident to the development of the embryo
and the birth of the child. These subjects do not readily lend
themselves to popular description, but I have told the story as
simply as possible, following in a general way the text-book of my
teacher and friend, Professor J. Whitridge Williams; indeed, my main
purpose has been to reproduce his book "in words of one syllable."
The use of a number of technical words has been unavoidable, and,
though their meaning has been given in the context, it has not been
feasible to repeat the definition every time an unfamiliar term was
used. On that account a glossary has been provided.

It is with pleasure that I avail myself of this opportunity to
acknowledge the cheerfully given assistance of many friends. In
particular I wish to thank Doctor Henry M. Hurd, until recently
Superintendent of the Johns Hopkins Hospital, for his interest and
advice. I am also under deep obligation to my friend John C. French,
of the English Department of the Johns Hopkins University, for
helpful criticism of the manuscript, and to my colleagues, Doctors
Rupert Norton and Thomas R. Boggs, for valuable assistance. To many
others--doctors, nurses, and patients--I am indebted for numerous
suggestions which have been made either consciously or unconsciously.

J. MORRIS SLEMONS.


       *       *       *       *       *


INTRODUCTION


In all branches of medicine the master word is _prophylaxis_, or
prevention, and its benefits are nowhere more strikingly illustrated
than in the practice of obstetrics. In former times every woman who
gave birth to a child or passed through a miscarriage was exposed to
grave danger of infection or child-bed fever; but at present--thanks
to the recognition of the bacterial origin of the disease and of its
identity with wound infection--this danger can be practically
eliminated by the rigid observance of surgical cleanliness and
aseptic technique. Physicians have also learned that the most
effective method of coping with other serious complications of
pregnancy and labor is by preventing their occurrence, or at least by
subjecting them to treatment in their earliest stages; for, if they
be allowed to go on to full development, the results are little
better than in times past. Furthermore, a careful examination some
weeks before the expected date of confinement enables us to recognize
the existence of abnormal presentations and of disproportion between
the size of the mother's pelvis and that of the child's head. Timely
recognition of such conditions makes appropriate treatment possible
and practically insures a successful outcome; while tardy recognition
is frequently followed by disastrous results.

These few examples give some idea of the benefits of prophylaxis in
the practice of obstetrics. Prospective mothers should understand not
only that there is an advantage in taking such precautions, but that
they may be risking their lives, or at least their future well-being,
unless they insist upon competent medical attention. It is true, of
course, that pregnancy and childbirth are generally normal processes,
but they are not always so. Fortunately, most of the abnormalities
give timely warning of their occurrence, and in most instances may be
relieved by comparatively simple measures; or, if not, they afford
indications for treatment which should lead to a happy termination.
The recognition of the existence of such conditions, however, is not
always easy, and their ideal treatment requires careful training and
sometimes the utmost nicety of judgment. Consequently, if prospective
mothers wish to be assured of the best care, they should be cautious
in the choice of their medical attendant. As the ordinary layman has
no means of determining the real qualifications of a physician, the
choice should not be made upon the advice of casual acquaintances;
but, instead, the family physician should be consulted, who, should
he feel unwilling to assume the responsibility of the case, will be
able to recommend a thoroughly competent substitute.

From my own experience as a teacher and consultant, I state without
hesitation that in no other branch of medicine or surgery are graver
emergencies encountered than in certain obstetrical complications
whose treatment involves the greatest responsibility and requires the
highest order of ability to insure a successful outcome for the
mother and her child. For these reasons a physician should be chosen
only after mature deliberation, and his services should be esteemed
much more highly than is usually the case.

In order that the principles of prevention may receive their fullest
application during pregnancy, labor, and the lying-in period, it is
also advisable that intelligent women should possess some knowledge
of the Reproductive Process in human beings. This information is
imparted by Doctor Slemons' book, which I can thoroughly recommend to
prospective mothers. The subject matter has been carefully chosen,
and the author has wisely refrained from giving advice with regard to
treatment which can be satisfactorily directed only after careful
study by a physician. At the same time he has given a clear account
of the physiology of pregnancy and labor, and has laid down sound
rules for the guidance of the patient.

One of the most important facts emphasized by Doctor Slemons is the
value of medical supervision for several weeks after the child is
born; this precaution contributes greatly toward a rapid and complete
convalescence. During the lying-in period the physician should
supervise the care of the mother and the child, should insist upon
the necessity for maternal nursing, and should keep the mother under
observation until perfectly normal conditions are regained. If the
latter duty is conscientiously fulfilled many years of invalidism may
be saved and thousands of operations rendered unnecessary.

Although there have been notable advances in the science and in the
art of obstetrics since the middle of the eighteenth century, a great
many fundamental facts must yet be learned. For example, we are
almost totally ignorant of the stimulus which causes the mother to
fall into labor approximately 280 days after the last normal
menstruation.

There are two points which I desire to impress especially upon the
readers of this book. Firstly, that the advance of the science of
obstetrics, and consequently improvements in its practice, must
depend greatly upon the cooperation of intelligent women. They must
come to realize that they will secure the best treatment only as they
demand the highest standard of excellence from their attendants; and
they can aid in securing this for their poorer sisters and their
children by interesting themselves in obstetrical charities.

Secondly, they must realize that real progress in the science of
obstetrics can be expected to proceed only from well equipped clinics
connected with strong universities, and in charge of thoroughly
trained and broad-minded men. As yet such institutions scarcely exist
in this country. Women who are anxious to promote the welfare of
their sex can find no better way of doing so than by bringing this
need to the attention of wealthy men interested in philanthropy and
education. Furthermore, they should bear in mind that most of our
important discoveries would not have been made had animal
experimentation not been available, as it is solely by this means
that modern surgical and obstetrical technique has been brought to
its present degree of perfection; and further progress can scarcely
be expected without its aid. They should remember also that whenever
they take such a well-known drug as ergot for the control of
bleeding, or make use of many other apparently simple measures, they
are unconsciously rendering tribute to this type of investigation.

J. WHITRIDGE WILLIAMS.

Johns Hopkins University,
September, 1912.


       *       *       *       *       *


CONTENTS


   I. THE SIGNS OF PREGNANCY AND THE DATE OF CONFINEMENT
  II. THE DEVELOPMENT OF THE OVUM
 III. THE EMBRYO
  IV. THE FOOD REQUIREMENTS DURING PREGNANCY
   V. THE CARE OF THE BODY
  VI. GENERAL HYGIENIC MEASURES
 VII. THE AILMENTS OF PREGNANCY
VIII. MISCARRIAGE
  IX. THE PREPARATIONS FOR CONFINEMENT
   X. THE BIRTH OF THE CHILD
  XI. THE LYING-IN PERIOD
 XII. THE NURSING MOTHER
      GLOSSARY


       *       *       *       *       *


The Prospective Mother




CHAPTER I


THE SIGNS OF PREGNANCY AND THE DATE OF CONFINEMENT

The Positive Signs--The Probable Signs--The Presumptive Signs: The
Cessation of Menstruation; Changes in the Breasts; Morning Sickness;
Disturbances in Urination--The Duration of Pregnancy--The Estimation
of the Date of Confinement--Prolonged Pregnancy.

Many puzzling questions occur to the woman who is about to become a
mother. Most of these questions are reasonable and natural, and
should be frankly answered; but a false conventionality has--until
recently, at least--forbidden any open discussion of facts connected
with childbirth. The inevitable result has been that, without
experience of their own to guide them, prospective mothers have
sought advice from older women, whose experience was at best very
narrow, and whose views were often biased by tradition. Or,
distrusting such sources of information, they have consulted
technical medical works which they could not understand. Either of
these methods is very likely to result in misinformation and to cause
unnecessary anxiety. Yet no one need be alarmed by a plain, accurate
account of Nature's plan to provide successive generations of human
beings. Some trustworthy knowledge of a process so fundamental should
be part of every person's education; it is especially helpful to
women who are pregnant because it affords a rational basis for
hygienic measures which they should adopt. A popular work, however,
no matter how frank and helpful it may be, will not enable one to
dispense with professional advice. For the prospective mother no
counsel is more important than this: _Put yourself at once under
the care of a physician_.

Insistence on the importance of medical advice should not be taken to
imply that pregnancy is to be regarded as other than a normal
process. Its dangers are comparatively slight, as we should expect,
since the property of all living matter to reproduce its kind is both
fundamental and essential; the continuance of living creatures in
this world, plants as well as animals, depends upon the Reproductive
Process. And yet, natural as it is, pregnancy may be attended by
complications. Such complications, though happily rare, are to be
guarded against in every case, and that may be most effectually done
if patients are taught to remain under competent medical supervision
from the time of conception until several weeks after the child is
born. This precaution greatly reduces the frequency of annoyances
during pregnancy and also assists materially toward conducting a
birth to a safe conclusion. Moreover, if this advice is followed,
when complications do arise they will be recognized and dealt with
promptly; they will not be permitted to grow more serious until,
perhaps, they may jeopardize the life of the mother or the child or
both.

The initial symptoms of pregnancy are so widely known that in most
instances the prospective mother herself makes the diagnosis shortly
after conception has taken place; but now and then pregnancy advances
for several months unrecognized and is then detected by a physician
who has been consulted on account of symptoms which the patient has
incorrectly attributed to some other condition. On the other hand,
women sometimes suspect that they are pregnant when they are not; and
such mistakes occur because certain symptoms which are implicitly
trusted by the laity as manifestations of pregnancy are occasionally
associated with conditions quite foreign to it. It is clear that one
interested in the matter must know not only what the manifestations
of pregnancy are and when they appear, but also how far the evidence
that they give is reliable.

The signs of pregnancy may be classified, according to their
reliability, as presumptive, probable, and positive. The doubtful
evidence appears first and the infallible proof last. No one need be
surprised, therefore, if, when her suspicion is first aroused, she is
unable to decide positively whether she is pregnant. Physicians of
broad experience, possessed of facilities for observation which their
patients cannot employ, may find it necessary to make more than one
examination before they commit themselves to a definite opinion; in
some cases, though very rarely, they must wait for two or three
months to be able to do this.

THE POSITIVE SIGNS.--The earliest absolutely trustworthy
manifestation of pregnancy is the motion of the fetus. The perception
by the mother of these movements, which is spoken of as "quickening,"
generally occurs toward the eighteenth week, if she has been told to
watch for them; otherwise they may pass unnoticed until the twentieth
week or later. At first the motion, felt in the lower part of the
abdomen, is very gentle; it has been variously likened to tapping, or
to quivering, or to the fluttering of a bird's wings. As time goes on
the movements grow stronger and occur more frequently; they are,
however, perceived but rarely throughout the day and seldom interfere
with sleep. Occasionally women are annoyed by the sensation and
complain that the child is hardly ever quiet. Even these troublesome
movements are never a cause for anxiety; but prolonged failure to
feel motion after it is once well established should be reported to
the doctor.

In the first pregnancy the passage of gas through the intestines may
be mistaken for quickening long before the movements of the child are
really perceptible; but those who have once experienced quickening
will not be deceived. Whenever women who have borne children are in
doubt the sensation is almost surely not quickening. Furthermore, in
any doubtful case, the motion should be observed by a physician
before being accounted a positive sign of pregnancy. This precaution
will scarcely delay an absolutely positive diagnosis, since the
proper method of examination reveals these movements to the physician
almost as early as the patient feels them.

About the time these movements become perceptible another positive
sign is available. The physician whose ear has been trained to catch
such sounds when he listens over the lower part of the mother's
abdomen will hear the fetal heart-beat. Other sounds may be audible
there, but the character and the rate of the heart-sounds are
distinctive. Since the child's heart beats almost twice as fast as
the mother's, under ordinary conditions it is impossible to confuse
one with the other. The mother never feels the beating of the child's
heart, but occasionally she will mistake for it the throbbing of her
own blood vessels.

Ability to hear the fetal heart not only provides a means of
confirming the existence of pregnancy in doubtful cases, but also
enables the physician to reassure his patient if she fails
temporarily to feel the child move. Sometimes the presence of twins
is recognized in this way. Toward the end of pregnancy the heart
sounds are also of material assistance in determining what position
the child has permanently assumed.

There is a third positive sign of pregnancy to which the physician
has recourse, but generally it is inapplicable as early as those
already mentioned. In the latter months of pregnancy it is possible
to outline the child through the mother's abdominal wall. Although
this procedure adds little or nothing to our resources for making an
early diagnosis, the information it ultimately affords proves one of
the greatest aids in the practice of obstetrics.

THE PROBABLE SIGNS.--Obviously, phenomena for which the child is
responsible--such as have just been described--supply the most
trustworthy evidence of pregnancy; and these phenomena alone are
accepted as positive signs. But there are earlier manifestations
which intimate very strongly that conception has taken place. Shortly
after pregnancy has become established changes begin in the uterus,
as physicians call the womb, and soon reach the point where they may
be recognized by a simple examination which enables the physician to
express an opinion little less than positive. As one result of
pregnancy, for example, the supply of blood is increased to all the
organs concerned with the reproductive process. Partly on account of
this congestion and partly on account of embryonic development, the
uterus becomes altered in a number of ways. Although these changes
occur regularly in pregnancy, they may also occur when the womb is
enlarged from other causes; therefore, if a physician should make the
diagnosis of pregnancy whenever they were found, he would make it
somewhat too frequently. With a little patience, however, he excludes
the chance of being misled; a second examination, approximately four
weeks after the first, will generally place the existence of
pregnancy beyond question, for under normal conditions the degree of
enlargement which takes place in a pregnant womb during a given
interval is absolutely characteristic.

THE PRESUMPTIVE SIGNS.--Although women are most often led to suspect
that they are pregnant by symptoms which are of such doubtful
significance that they must be regarded as merely presumptive
evidence, the practical value of these symptoms is attested by the
fact that subsequent developments rarely fail to confirm the
suspicion. Perhaps they prove misleading once or twice in a hundred
cases; the number of mistakes is small, because the diagnosis is
commonly made not from only one of these doubtful signs but from a
group of them. In order of importance the doubtful or presumptive
signs of pregnancy are these: (1) cessation of menstruation, (2)
changes in the breasts, (3) morning sickness, (4) disturbances in
urination.

_The Cessation of Menstruation_.--The failure of menstruation to
appear when it is expected is nearly always the first symptom of
pregnancy to attract attention, and, as a rule, when this happens to
healthy women during the child-bearing period--which usually extends
from the fifteenth to the forty-fifth year--it may be taken to
indicate that conception has occurred. But there are exceptions to
this very good rule. Besides pregnancy we are acquainted with several
conditions that cause temporary suppression of menstruation; and to
understand its significance we must learn something of the menstrual
process itself.

Menstruation is a function of the womb and in all probability is
brought about through the influence of the ovaries. The bleeding,
popularly regarded as the entire menstrual process, is, in fact,
indicative of only one of its stages; the others give rise to no
symptoms whatever. What the stages in the menstrual process are, what
relation they bear to each other, and what the significance of the
whole process is, are problems that have been solved with the aid of
the microscope. In this way the mucous membrane lining the womb has
been studied both at the time of the periods and in the interval
between them, and we have learned that it is constantly undergoing
changes intended to facilitate the reception and the maintenance of
an embryo. Anticipating these duties the mucous membrane receives a
more abundant supply of blood; it also increases in thickness and all
the structures which enter into its composition become more active.
Unless conception takes place these preparations, which represent the
most important phase in the menstrual process, are without value; and
therefore failure to conceive means that the mucous membrane will
return to the same condition as existed before the preparations were
begun. The congestion is relieved by rupture of the smallest blood
vessels, and there follow other retrogressive steps which completely
restore the various structures to their former state. Then there is a
pause, though it is not long, until preparatory changes are again
initiated, or, as we say, another Menstrual Cycle is begun. Each
cycle lasts twenty-eight days, and includes four stages, namely, a
stage of preparation, of bleeding, of restoration, and of rest.

Although pregnancy may become established at any time during the
interval between the periods of bleeding, it is more likely to be
established just before a period is expected or shortly after it has
ceased. Furthermore, whenever conception does take place, the
preliminary preparations for the reception of the embryo are followed
by much more elaborate arrangements for its protection and nutrition.
Under these circumstances the hemorrhagic discharge does not appear.

Were there no other condition to bring about the cessation of
menstruation, the diagnosis of pregnancy would be greatly simplified.
But any one can appreciate the fact that diseases of the womb may
interfere with the menstrual process. Menstruation is influenced,
also, by the ovaries. As a result of age, for example, the ovaries
undergo changes which invariably bring about the permanent cessation
of menstruation, called the menopause. This event occurs prematurely
if both the ovaries are removed by operation. In view of these facts
it is not surprising that sometimes ovarian disorders abolish
menstruation. An impoverished state of the blood, or nervous shock
and strain, or constitutional debility may also interrupt the regular
appearance of the menstrual discharge.

The value of menstrual suppression as an evidence of pregnancy is
not, however, to be discounted to the extent that we might expect.
This is true because the ailments which lead to confusion are
relatively infrequent, and also because they exhibit characteristic
symptoms which are foreign to pregnancy. Often these symptoms are
obvious to the patient herself; if not to her, they will be obvious
to her physician. It is about the doubtful cases, naturally, that a
professional opinion is sought, and on that account physicians are
perhaps inclined to overestimate the difficulty women have in
learning for themselves whether or not they are pregnant. As a matter
of fact, it is unusual for a prospective mother to fail to reach a
correct decision--a decision for which she relies chiefly upon the
suppression of her menstrual periods.

It is doubtful whether menstruation ever continues after conception
has taken place. Instances in which the menstrual function is
believed to persist are not uncommon, and yet in all probability the
discharge regarded as menstrual has a different origin. In most cases
it should be interpreted as meaning that there is some danger of
miscarriage. Since miscarriage often occurs about the time a
menstrual period would ordinarily be expected, there is unusual
opportunity for confusing the symptoms. At all events women err much
more frequently in suspecting that they are pregnant than in
overlooking the condition. Indeed, pregnancy is not likely to be
overlooked unless menstruation has been irregular or suppressed for a
month or more previous to conception. Thus, in the case of nursing
mothers in whom menstruation is already suppressed and who are,
moreover, deprived of certain evidence that the breasts give,
pregnancy may sometimes advance several months before it is
recognized.

_The Changes in the Breasts_.--Various sensations in the breasts
are accepted by women as a reliable sign of pregnancy; thus
throbbing, tingling, pricking, or a feeling of fullness will be
mentioned by one mother or another as having given her the first
intimation that she was pregnant. A few women also find their breasts
become tender immediately after they have conceived; this may be so
marked that they cannot bear pressure. But unless such symptoms are
accompanied by definite, visible changes, they have no value as signs
of pregnancy.

About the end of the second month the nipples become larger and more
erectile, and deepen in color. The pigmented, circular area of skin
which surrounds the nipple, called the areola, also darkens. The
shade that the areola assumes will vary according to the complexion
of the individual, growing darker in brunettes than in blondes.
Ultimately, within this pigmented circle a number of elevated spots
appear about the size of a large shot. These spots betray the
presence of tiny glands always located there which, on account of the
better state of nutrition during pregnancy, grow larger, and
generally become visible.

Usually, after two menstrual periods have been missed the breasts
increase in size and firmness, and often the veins which run just
beneath the skin stand out conspicuously. Before very long it is
possible to squeeze from the breasts a fluid which many persons
believe to be milk, though it is really colostrum, a substance that
resembles milk but very slightly. At first colostrum is a clear,
white fluid, but in the later months of pregnancy it becomes yellow
and cloudy.

None of the changes in the breasts are absolutely characteristic of
pregnancy; even the secretion of colostrum has been noted in
association with various other conditions. Furthermore, as a sign of
pregnancy the presence of colostrum is totally deprived of value in
the case of a woman who has recently nursed an infant, for a small
quantity of milk or colostrum often remains in the breasts for months
after the infant is weaned. In general, however, women who have not
been pregnant before should assume that they have conceived if, after
missing a menstrual period, they note the characteristic changes in
the breasts.

_Morning Sickness_.--Soon after conception many women suffer
from nausea and vomiting, especially on rising in the morning.
"Morning sickness" usually passes off in a few hours, although it may
be more persistent. Perhaps this manifestation occurs more frequently
in the first than in subsequent pregnancies, but certainly one-half,
and probably two-thirds, of all prospective mothers suffer from it.
Usually the nausea begins just after a menstrual period has been
missed, and ceases about the third month or a little later.

But morning sickness is never counted an indication of pregnancy
unless taken in conjunction with other symptoms, for individuals who
are not pregnant may also suffer from nausea in the morning. On the
other hand, a number of prospective mothers escape morning sickness
altogether, and a few experience nausea at other times of day.

_Disturbances in Urination_.--It is not an uncommon belief that
some characteristic change occurs in the urine shortly after
conception. But this is not true; at least no change is revealed by
any method of analysis known at present. Yet there are symptoms
associated with the passage of the urine which appear very promptly
and prevail for several weeks. Chief among these is the desire to
empty the bladder frequently; some patients also have difficulty in
urination, and a few experience discomfort with it. All the bladder
symptoms gradually disappear about the fourth month, but become
prominent again toward the end of pregnancy.

Since the inclination to empty the bladder more often than usual may
be due merely to nervousness or to many other conditions, this
symptom taken alone cannot be regarded as a definite sign of
pregnancy. Indeed, it is mentioned, not because of its importance,
but to point out that it is in no way connected with the kidneys, as
patients are sometimes led to believe. It is a direct and natural
result of pregnancy. Since the womb enlarges and tilts forward at a
more acute angle than formerly, it presses against the bladder,
giving the same sensation as when the bladder is distended with
urine.

Although the presumptive signs which we have considered by no means
exhaust the list, all the others are totally untrustworthy. Each of
the more reliable symptoms, as we have seen, must be accepted
cautiously; but taken altogether, except in very unusual cases, they
may be relied upon. _If, for example, menstruation has previously
been regular and then a period is missed, the patient has good reason
to suspect she is pregnant; if the next period is also missed and
meanwhile the breasts have enlarged, the nipples darkened, and the
secretion of colostrum has begun, it is nearly certain that she is
pregnant; whether morning sickness and the desire to pass the urine
frequently are present is of no importance._ But the most
characteristic evidence, we must remember, is not available until the
eighteenth or twentieth week; then the signs of pregnancy are
unmistakable.

THE DURATION OF PREGNANCY.--After the existence of pregnancy has
become assured, perhaps the greatest interest centers about the date
upon which the birth may be expected. Even to approach accuracy in
this prediction the prospective mother must be familiar with certain
facts which she will always observe, but which, unless she
appreciates their importance early in pregnancy, she may fail to
record or to remember. In a few cases, however, such exceptional
information as knowing the date of conception does not lead to an
absolutely accurate prediction. But the deviation from the rule will
be understood only after we understand the rule itself, which is
based upon what we accept as the average duration of human pregnancy,
technically called the period of gestation.

In a broad sense, the period of gestation for each variety of mammal
is determined by the time required for embryonic development to reach
the point where the young may live independently of the mother. This
point is reached more quickly with small animals than with large. The
mouse, for example, generally brings forth its young in three weeks,
whereas the pregnancy of the elephant lasts two years. In human
beings, counting from the time of conception to the time of delivery,
pregnancy continues approximately 273 days. This number is merely an
estimate calculated from hundreds of cases in which there was no
question as to the underlying facts. Individual cases vary notably,
and indicate that two women may become pregnant on the same day and
yet not necessarily be delivered at the same date.

Irregularities in the duration of pregnancy are not limited to man.
Thus, while the mean period of gestation in the rabbit is thirty-one
days, it may be either shorter or longer by as many as eight days.
Similar variations occur in the pregnancies of all animals, and are,
moreover, notably greater among larger animals, since for such
animals the period of gestation is relatively long. For instance, the
accurate observations of veterinarians indicate that the mean period
of pregnancy in the cow is 285 days from the time of conception. This
fact notwithstanding, a competent observer found that, of 160 cows,
67 were delivered before the 280th day; 68 between the 280th and the
290th day; and 25 after the 290th day. Although nothing unnatural was
observed in any instance, the first animal was delivered 67 days
before the last, and in 5 instances gestation continued 308 days.

In ancient times it was believed that the duration of pregnancy was
of even more uncertain length in man than in the lower animals; but
since the eighteenth century thirty-nine weeks have been accepted as
the average duration of the human pregnancy when reckoned from the
day of conception. As this date is seldom known, it is most
convenient to reckon from the first day of the last menstrual period.
Estimated in this way its average duration is 280 days. As this
period corresponds to ten menstrual cycles, physicians prefer to
describe pregnancy as lasting 10 lunar months of four weeks each.
This is equivalent to 9 calendar months, in terms of which its
duration is popularly stated.

THE ESTIMATION OF THE DATE OF CONFINEMENT.--Since pregnancy is not an
absolutely fixed period, we possess no reliable means of predicting
the exact day when it will end. The most satisfactory method of
prediction consists in counting forward 280 days from the beginning
of the last menstruation or, what gives the same result, counting
backward eighty-five days from this date. _To make the calculation
in the simplest way we count back three months and add seven
days_; this addition is made because seven days generally
represents the difference between three months and eighty-five days.
If the last menstruation, for example, began on October 30th, we
count back three months to July 30th and add seven days, which gives
August 6th as the probable date of confinement.

A prospective mother should remember that this prediction is no more
than approximate. The calculation does not give the exact date of
delivery more than four or five times in a hundred cases. It is
accurate within a week in half the cases and within two weeks in
four-fifths. We also know that delivery is somewhat more likely to
occur after the expected date than before it. But perhaps we shall
get the clearest idea of the accuracy of the rule, or better still
of its inaccuracy, if we imagine twenty patients to have the same
predicted date, all of them giving birth to mature infants. The
chances are that only one of these patients will be confined upon the
day predicted; nine will be confined before and ten after it. In all
probability five of those who pass the predicted day will be
delivered within a week and four others within the second week, while
the twentieth patient will not be delivered until three weeks or more
have elapsed.

Such results clearly indicate our inability to make accurate
predictions even though pregnancy is normal in every way. Whenever
patients pass their expected date uneventfully, if they will bear in
mind that the fault lies with the method of prediction and not with
the pregnancy, they will often be saved anxiety. Frequently such
discrepancies are attributable to a false assumption, for our rule
always assumes that the conception took place immediately after a
menstrual period. While this is generally true, the number of cases
in which it occurs just before the period to be missed is by no means
inconsiderable, and in these we should not expect pregnancy to end
until two or three weeks after the day predicted by the rule.

Occasionally patients know the precise day upon which conception took
place, and prefer to estimate the day of confinement from that rather
than from the beginning of the last menstruation. They may do so by
counting back thirteen weeks from the day of conception; but this
method also is subject to error for, as we have noted, the duration
of pregnancy reckoned in this more exact manner is not constant. Such
a calculation rarely offers any advantage over that made from the
menstrual record.

Another method of estimating the date of confinement is based upon
the assumption that fetal movements are first perceived by the mother
toward the eighteenth week of pregnancy; and in consequence twenty-
two weeks generally elapse between quickening and the day of
delivery. Although such a calculation is far from certain in its
prediction, there are instances in which no other calculation can be
made. A nursing mother, for example, may become pregnant before
menstruation has been reestablished. Under these circumstances,
obviously, the date of confinement cannot be estimated in the
ordinary way, and it is then especially important to know the first
day on which the fetal movements were felt. Furthermore, it is
helpful to note this date in every case, since it serves, if for
nothing more, to confirm the prediction made from the menstrual
record. Besides the two methods just described, which are alike in
that they require the patient herself to make the necessary
observations, there is a third method of estimating how far pregnancy
has advanced, by which the physician is enabled to draw his own
conclusions. This method is based upon the fact that the womb
enlarges from month to month during pregnancy at a constant rate. Up
to the end of the third lunar month it cannot be felt through the
abdominal wall; but in the course of the fourth month, on account of
its size, it must rise into the abdominal cavity. At the beginning of
the sixth month the top of the womb is at the level of the navel, and
at the ninth reaches the ribs. The diaphragm then prevents the womb
from going higher; and two or three weeks before the end of pregnancy
it drops several inches, causing a change in the figure which is
noticeable to the patient, since her skirts hang somewhat lower than
before. From this time on she is more comfortable, because the lungs
are not crowded, and there is less interference with breathing.

These alterations in the position of the womb indicate very
satisfactorily the month to which pregnancy has advanced, but not the
week and much less the day. They do not afford a more accurate means
of predicting the date of confinement than does quickening. The
evidence gained from the position of the womb, like that afforded by
the beginning of quickening, generally confirms the prediction made
from the menstrual history; it serves only occasionally to correct
it.

PROLONGED PREGNANCY.--Since birth does not occur in many cases until
the predicted date has been passed, it will be helpful even at the
cost of repetition to sum up what we know in explanation of such
unfulfilled predictions. They are to be explained sometimes by
uncertainty as to the beginning of pregnancy, as for example by the
supposition that conception took place shortly after the last
menstrual period, whereas it actually occurred two or three weeks
later. In a few instances, however, errors of observation or of
calculation will not account for false predictions.

It is generally admitted that second pregnancies average somewhat
longer than first pregnancies; one series of statistics indicates
that the duration increases slightly with each pregnancy up to the
ninth and decreases after that. Pregnancy is protracted more
frequently in healthy women than in those who are not, and again more
frequently in those who are inactive than in those who work. With
twins, contrary to the popular belief, pregnancy is apt to end
before, not after, the expected date. The sex of the child, in all
probability, has no influence upon the duration of pregnancy.

As we might expect, individuality is also a factor in this problem.
Thus, the period of gestation with some women is regularly longer,
with others habitually shorter than the accepted average. Until
experience has demonstrated their existence, generally, such
peculiarities are overlooked. But occasionally they may be detected
from knowledge of the interval between the menstrual periods; an
unusually long interval between them, for example, would lead us to
anticipate a protracted pregnancy.

Any delay after the expected date of birth has arrived taxes the
patience of the prospective mother. The fact, however, that more than
280 days have passed since the last menstruation, does not
necessarily mean that a patient has gone "over time." Such a question
can be decided solely from the weight and length of the child. Judged
in this way, comprehensive statistics indicate that once in several
hundred cases pregnancy may be fairly called prolonged. Even in these
rare instances an examination about the time of the predicted date
makes it clear whether pregnancy should be artificially ended or be
allowed to proceed to its natural conclusion.




CHAPTER II


THE DEVELOPMENT OF THE OVUM

The Germinal Cells--Fertilization--The First Steps in Development--
The Reaction of the Uterus--The Amniotic Fluid--The Placenta--The
Umbilical Cord.

Pregnancy, besides changing the external form of the body, causes
sensations--as for example those due to fetal movements--which are so
distinctive that they cannot escape notice. These obvious evidences
of approaching motherhood naturally lead thoughtful women to wonder
about the hidden mechanism of development, a mechanism which, of
itself, causes no sensation whatever. It is for this reason, perhaps,
that a prospective mother's imagination is so apt to be unusually
active, often picturing absurd conditions as responsible for one
symptom or another. Those who give free play to the imagination in
regard to the formation and progress of the embryo are pretty certain
to arrive at erroneous if not grotesque conclusions; for example,
they may attribute a protracted pregnancy to the child's having grown
fast to the mother, a situation that cannot arise.

Of course it is not essential that a prospective mother should
understand what is happening within the womb. And upon those who
prefer to be ignorant of the mechanism of development I would not
urge another point of view, for not ignorance but the unchallenged
acceptance of "half-truths" and of totally incorrect explanations is
the chief source of harm. On the other hand, my own experience has
taught me that women who wish to know about development should be
told the truth. In accord with this is the fact that I never have
more satisfactory patients than those who have previously been
trained nurses and who, in preparing for that profession, received
instruction concerning the reproductive function of human beings.

A description of development, in order to be perfectly clear, must
begin with a word about the fundamental structure of the adult body.
Everyone knows that the various parts of the body perform different
functions; but not everyone, perhaps, realizes that, in spite of
their different functions, all the organs of the body are composed of
similar structural units, known as cells. Of course, cells are
definitely arranged according to the use for which the tissue that
they chance to compose may be designed; they have, moreover,
distinctive individual peculiarities which can be easily recognized
under the microscope; but the essential features of the cells remain
the same, wherever they may be located. That is to say, each cell is
a minute portion of living matter, or protoplasm, separated from its
neighbors by a partition, the cell-membrane; each has its own seat of
government, the nucleus, located near its center; and each, to all
intents and purposes, leads an individual existence.

THE GERMINAL CELLS.--Many of the cells in the human body are able to
produce others of their kind. This they do virtually by growing and
splitting in half; cell-division, as this splitting is called, really
represents reproduction reduced to the simplest terms. Most cells can
do no more than produce units like themselves. The bodies of women
contain, however, a type of cell which possesses a far more wonderful
power. Provided the requisite conditions for such development are
met, these cells are capable of developing into human beings. Each of
these remarkable units is called an Ovum, or egg-cell, and represents
one variety of the germinal cells. But the other variety, represented
by the Spermatozoon and developed only in the male sex, is also
required for the production of a human being.

Every ovum originates in the ovaries. These are organs peculiar to
women, having the size and shape of large almonds, and placed in the
lower part of the abdominal cavity. Though the ovaries are two in
number, one alone is sufficient for every requirement of health. It
has been estimated that the ovaries together contain at the time of
birth about 40,000 ova, distributed equally between them. Since less
than 500 ova are required to insure regularity in the menstrual
function, it is clear that, if the surgeon finds it necessary to
remove one of the ovaries, the other will provide abundantly for
menstruation and for the bearing of children. Although every ovum
that will be produced as long as a woman lives has already sprung
into existence by the time she is born, not a single one ripens for
from twelve to fifteen years. The ripening process begins about the
time of puberty, and, unless suspended through the occurrence of
pregnancy, continues until the menopause. During this period, which
is also characterized by the periodical appearance of menstruation,
one ovum ripens each month; sometimes, though rarely, several ripen
at once, and this tendency is partly responsible for twins.

The human ovum is a tiny structure, measuring about 1/125 of an inch
in diameter. With the naked eye it can barely be seen; magnified by
the microscope it appears as a little round bag made of a transparent
membrane. Briefly described, the ovum is a single cell. That is, it
belongs to the simplest class of anatomical structures, and is one of
the millions upon millions of units that make up the body. It
contains a nucleus surrounded by nutritive material, the yolk. Yet
the quantity of yolk is exceedingly small. In this particular the
human ovum differs notably from the egg of birds, as it does also in
that it lacks a shell. Obviously, a shell would not only be useless
to an embryo developing within the body of its parent, but would shut
off the nourishment, which, since the ovum contains so little, must
necessarily be provided by the mother.

When the ovum has ripened, it becomes detached from the ovary, and
enters a fleshy tube about the size of a lead pencil, known as the
oviduct. There are two of these tubes, one running from the
neighborhood of each ovary; both enter the uterus, but on opposite
sides. The ovum travels down the tube which corresponds to the ovary
where it originated. The journey is fraught with momentous
consequences, for it is during this passage through the oviduct that
the fate of the ovum is determined. If it is to develop into a living
creature, a great many conditions must sooner or later be fulfilled;
but there is one which must be promptly satisfied. Shortly after
leaving the ovary the ovum must receive the stimulus to live and
grow; otherwise it will quickly wither and die. This vital stimulus
can be imparted only by the spermatozoon.

The male germinal cell is like the female cell in the possession of a
nucleus; in other respects it is very different. Longer but much
narrower than the ovum, the tiny arrow-shaped spermatozoon is
particularly distinguished by its active motility, for it has a tail
that propels it. The human male cell must travel some distance to
reach the point where it can meet a ripe and vigorous ovum; and since
the journey is not without danger to its life, Nature has provided
that exceedingly large numbers of the male cells shall be deposited
in the vagina at the time of the marital relation. In this way, it is
made sure that some of them will travel up through the uterus and
oviducts, arriving in the neighborhood of the ovaries.

FERTILIZATION.--Convincing observations upon the lower forms of life,
especially upon fishes, have shown that when the germinal cells come
near to each other, the ovum attracts the spermatozoon. The power of
attraction which the ovum exerts may be likened, most simply, to the
influence of a magnet upon iron-filings. While there has been no
opportunity to observe such attraction between the parent cells of
human beings, its existence is not open to doubt. And it is
practically certain that these cells meet in the oviduct, even in
that portion of it which receives the ovum just as it leaves the
ovary. Thither a number of the male cells have traveled by their own
activity; several come in contact with the ovum and one, but only
one, actually enters it. Almost at the moment when they touch, the
two cells unite so intimately that all trace of the spermatozoon is
lost. Fertilization of the ovum, as this event is scientifically
termed, has as its main purpose the uniting of the nucleus of a male
germinal cell with the nucleus of the female germinal cell. This
detail has been carefully studied; we know that the nuclei quickly
blend into one, and that the particles of living matter contributed
by the male animate the female cell with a new and wonderful
activity.

In our every-day way of speaking, fertilization means conception; it
is the instant in which a living being begins its existence. There is
no longer the slightest excuse for confusion regarding the period at
which the life of the unborn child begins. Before the significance of
fertilization was understood, it was perhaps not unreasonable to
believe that life began with quickening or about the time the fetal
heart-sounds could be heard. But now we must acknowledge that both
these ideas were incorrect. The animation of the ovum at the moment
of conception marks the beginning of growth and development which
constitutes its right to be considered as a human being.

Individuality, hereditary traits, sex--all these, we may be sure--are
unalterably determined from the moment of conception. The germinal
cell forms the total contribution of the male parent to pregnancy;
therefore no other opportunity for him to influence his progeny
presents itself, and the substance which enters the ovum at the time
of fertilization must be the basis of inheritance from the father. It
is equally true, as we shall see in the next chapter, that the
nucleus of the ovum and the nucleus alone transmits maternal
qualities. The material which conveys inheritable characters can be
seen and has been identified in both germinal cells; from each of
them the fertilized ovum derives equal amounts. As the parental
nuclei unite, the material which they contain intermingles and
establishes a new being; to attain full development, it requires
nothing further from the father, and nothing save nourishment from
the mother.

THE FIRST STEPS IN DEVELOPMENT.--Although the identity of the
spermatozoon is lost at the moment of fertilization, its influence
just then begins to be asserted. In the fertilized ovum the dawn of
development is shown at first by unusual activity within and later by
alterations upon the surface. Before very long the circumference of
the cell becomes indented as if a knife had been drawn around it, and
shortly two cells appear in place of one. These two cells in turn
divide, yielding four cells which grow and divide into eight. In this
manner division follows division until a multitude of cells have
sprung into existence, all of which cling together in the shape of a
ball. Development always proceeds in the same orderly way; evidently
it is governed by fixed laws which decree that the mass shall remain
for a while in the form of a ball, though the ball, at first solid,
soon becomes hollow.

While these changes are taking place the growing ovum is carried down
the oviduct a distance of four to six inches and finally comes to
rest in the uterus, where it is to dwell during the months necessary
to its complete development. The time consumed by this journey cannot
be measured accurately; it may be as short as a few hours or as long
as several days, but in all probability it is never longer than a
week. Although the element of time is uncertain the method of
transmission is well understood. Of its own accord the ovum can move
after fertilization no better than before; it is never capable of
moving itself. The active agent of transportation is the oviduct,
which has been fitted for this purpose with millions of short, hair-
like structures that project into its interior. These are closely set
upon the inner surface of the oviduct; their outer ends are free and
continually sway to and fro like a wheat field on a windy day; and by
their motion they create a current in the direction in which the ovum
should move, namely, toward the uterus. While passing through the
oviduct, the ovum has no attachment whatever to the mother, yet
development is going on all the time. It is thus made perfectly clear
that development is not directed by the parent. This independence of
the parent, though it continues to be one of the characteristic
features of the development of the ovum, shortly becomes less
evident, for communication is set up between the mother and the ovum
as soon as it reaches the uterus. Unless we were warned, we might
easily misinterpret the significance of this attachment to the
parent. It does not permit the mother, for instance, to influence the
mind or character which the child will have. The purpose of the
attachment is twofold, namely, to anchor the ovum, and to arrange
channels by which, on the one hand, nutriment may reach the embryo,
and, on the other, its waste products may return to the mother. The
mother may influence the nutrition of the fetus; but she cannot
determine the kind of brain or liver her child will have; neither for
that matter can she alter the development of any portion of the
embryo.

After its entrance into the cavity of the uterus prepared to receive
and protect it, the mass of cells sinks into the soft, velvety lining
of the organ. Here it is entirely surrounded by tissue which belongs
to the mother. But just before implantation takes place the
architecture of the ovum is modified in such a way as to indicate the
trend of its subsequent development. We left it, a hollow ball
passing down the oviduct; had we examined the sphere more closely we
should have found its wall composed of a single layer of cells. At
one spot, however, the wall soon thickens. The thickening is due to a
specialized group of cells which gradually grows toward the hollow
center of the ball. A little later, if we study the structure as a
whole, we find it a small, distended sac, from the inner surface of
which hangs a tiny clump of tissue. The clump of cells within and the
inclosing sac as well are both requisite to the ultimate object of
pregnancy; yet they fulfill very different purposes. The clump within
will mold itself into the embryo; the inclosing sac will make
possible the continued existence and growth of the embryo by securing
and conveying to it nourishment according to its needs. These two
structures, which from now on constitute the ovum, can best be
considered separately and in the order of their development. We shall
therefore first study the sac and in the next chapter the embryo.

For a time after this sac, or ball, as you may choose to think of it,
becomes implanted in the uterus, every part of its wall shares in the
responsibility of procuring nourishment for the embryo. On this
account the wall, or capsule, is for several weeks the most
conspicuous part of the ovum. Its position is naturally advantageous,
for, since it forms the outermost region of the structure and comes
into immediate contact with the tissues of the mother, it has the
first opportunity to seize and appropriate nutriment. Consequently,
while there is still relatively little development in the embryo, the
capsule of the ovum gives evidence of rapid extension; the wall
becomes thicker, and the circumference of the sac increases. The
significant thing about this growth, however, is the fact that it
does not progress evenly. At some points cell-division is more active
than at others, with the result that the surface of the ovum speedily
loses its smooth, regular outline. Projections from the capsule
appear; they increase in number and in length; and by the end of four
weeks the ovum, as yet less than an inch in diameter, resembles a
miniature chestnut-burr. To make the comparison more accurate, we
must imagine such a burr covered with limp threads instead of rigid
spines.

These projections, the so-called Villi, push their way into the
mucous membrane of the uterus and serve a two-fold purpose. One of
their functions is to fix the ovum in its new abode; and, though the
attachment is not at first very secure, it becomes stronger in the
course of time and is capable of withstanding whatever tendency the
activity of daily life may have to loosen it. The other, and equally
important, task of the villi, the majority of which dip into the
mother's blood, is to transmit substances to and from the embryo.

We have traced thus far the earliest steps in the development of the
ovum. One portion, we observed, was promptly set apart for the
construction of the future child; this favored portion became
inclosed by all the rest of the ovum, which has a more or less
spherical form and is technically called the fetal sac. The first
duty of the sac is to take root in the womb, and the second, no less
vital, is to draw nourishment from the mother. But neither of these
functions can be performed without the participation of the uterine
mucous membrane, the soil, as it were, in which the ovum is planted.
We must now learn how the maternal tissues assume the responsibility
placed upon them.

THE REACTION OF THE UTERUS.--The womb, which is small before
marriage, is converted by pregnancy into the largest organ of the
body. The virginal uterus, shaped somewhat like a pear, and placed
with apex downward, is carefully protected within the bony basin
between the hips, which is commonly called the Pelvis. The upper and
larger part of the organ, known as the body, lies at the bottom of
the abdominal cavity; the lower part, the neck, projects into the
vagina. The cavity inside the womb communicates above with the two
oviducts and terminates below in a canal which runs through the neck
and opens into the vagina by an orifice known as the mouth of the
womb.

Pregnancy modifies every portion of the womb in one way or another;
but the most profound alterations occur in the body, in the cavity of
which the ovum has come to rest. During the forty weeks of gestation
the organ grows in weight from two ounces to as many pounds; from
three inches in length it increases to fifteen inches; and its
capacity is multiplied 500 times.

The mucous membrane which lines the cavity of the uterus responds to
the stimulus of pregnancy in a characteristic manner and with a
single purpose, namely, to promote the development of the ovum. In
connection with menstruation we noted that this membrane periodically
prepares for the reception of an ovum. And if the expected ovum has
been fertilized, its arrival is followed by arrangements for its
protection and nutrition which are far more elaborate than the
preparations for its reception. Within a few weeks the mucous
membrane becomes half an inch thick, that is, about ten times thicker
than it was; and all the elements entering into its composition,
become unusually active. The blood-vessels are congested; the glands
pour out a more elaborate secretion; and certain cells lay up a
bountiful store of material to be drawn upon in the formation of the
embryo and the building up of the structures that promote its
development.

The ovum is as likely to find a resting place at one spot as another
upon the surface of the uterine mucous membrane. The whole of that
surface has been made ready to receive it; yet the area actually
required to imbed the tiny object is extremely small. As the ovum
escapes from the oviduct and enters the womb, it is smaller, in all
probability, than the head of a pin. For at least a week after its
coming, diligent search is necessary to find the site of
implantation. Insignificant as it is at first, however, the region of
implantation later becomes very prominent, for it undergoes a
transformation that the rest of the mucous membrane does not share.
That is to say, it becomes the point of attachment of the Placenta,
an organ that has the very important function of drawing upon the
resources of the mother's blood. As the ovum sinks into this
especially prepared bed, the villi are formed. They break open the
adjacent capillaries of the mother, thus diverting her blood from its
accustomed course. The blood collects in microscopic lakes in contact
with the capsule of the ovum, and from them flows back into the
mother's veins. Through the veins it returns to her heart, by which
it is distributed through the arteries to the various regions of the
body. The tiny lakes, in which the villi hang, are thus made a part
of the mother's circulation and as such are regularly replenished
with purified blood. By this means the ovum receives a rich supply of
nutriment, and as a natural consequence its growth is rapid.

Before very long the diameter of the ovum is greater than the depth
of the mucous membrane which surrounds it. Consequently that part of
the membrane which covers it is pushed into the uterine cavity, as
the ground is raised by a sprouting seed. Growth continues, the
bulging increases, and extensive alterations are wrought both in the
womb and in the capsule of the ovum. One of these alterations will be
more easily understood if we still think of the ovum as a seed, for
it grows away from its roots just as plants do. Most of the capsule,
therefore, is removed step by step farther from its source of
nourishment, for the maternal blood-vessels do not follow the
expanding sac but retain their original position at its base. Partly
on account of the lack of nutriment thus occasioned and partly on
account of the distention caused by the contents of the sac, atrophy
occurs in the distant portions of the sac's wall. As a final result
of these two factors, the maternal tissue which covers the ovum
becomes thinned and stretched; it is pushed entirely across the
uterine cavity; and by about the twentieth week meets the opposite
side of the cavity, to which it becomes adherent. Subsequently, the
sac which incloses the embryo becomes everywhere fastened to the
inner surface of the uterus and completely fills the uterine cavity.

THE AMNIOTIC FLUID.--The great enlargement of the uterus which is so
marked a characteristic of the latter part of pregnancy is due in a
measure to the luxuriant blood-supply, for better nutrition always
causes growth. In a far larger measure, however, it is due to
distention for which the product of conception is responsible. Beside
the fetus the inclosing sac also contains a considerable quantity of
fluid. This fluid, called "The Waters" by those who have no special
knowledge of anatomy, is technically designated as the Amniotic
Fluid.

In the earlier months of pregnancy the amniotic fluid is not
abundant; later it increases rapidly, so that by the end of the
period it measures about a quart, and frequently even more. The
slightly yellow amniotic fluid is itself clear, but small particles
of dead skin and other material cast off from the surface of the
child's body are floating in it, and may cause turbidity. The absence
of odor supports the view that this fluid is not the child's urine.
The evidence thus far adduced, though not absolutely conclusive,
gives good reason to believe that "the waters" are secreted by the
inner side of the sac which incloses the fetus. Very early in
pregnancy this sac becomes a double-walled structure; and, though its
layers are intimately blended, and together measure not more than
1/16 of an inch in thickness, with a little care they can be
separated. The outer layer, which comes in contact with the inner
surface of the uterus and has to do with the matter of nutrition, is
called the Chorionic Membrane; the inner, the so-called Amniotic
Membrane, is much the stronger and is devoted to the protection of
the embryo, which it completely surrounds with fluid, at the same
time retaining the fluid within set bounds.

The amniotic fluid performs many important duties. Perhaps the first,
in point of time, is to provide sufficient room for the embryo to
grow in. Later, as the fluid increases, it permits the fetus to move
freely, and yet renders the movements less noticeable to the mother.
Again, the amniotic fluid prevents injuries that might otherwise
befall the child in case the mother wears her clothing too tight.
Harmful as the practice of tight-lacing during pregnancy is, it does
not, thanks to the presence of the amniotic fluid, result in the
disfigurement of the child. For the same reason a blow struck upon
the abdomen, as in a fall forward, is not so serious as might be
thought, since the fluid, not the child, receives the force of the
impact. Some physicians believe that the fetus swallows the amniotic
fluid and thus secures nourishment. The fluid also serves to keep the
fetus warm; or, to be more exact, protects it from sudden changes in
the temperature of the mother's environment. Normally the temperature
of the fetus is thus kept nearly one degree higher than the
temperature of the parent.

Ultimately, the amniotic fluid assists in dilating the mouth of the
womb, which remains closed until the beginning of the process that
terminates with birth. The uterine contractions at the onset of labor
compress the fluid; in turn the fluid attempts to escape but is held
in check by the amniotic membrane, which it drives into the canal
leading from the uterine cavity to the vagina. Acting like a wedge,
the fluid gradually pushes the mouth of the womb wider and wider
open, until it is large enough for the child to pass. The sac usually
ruptures when that point is reached, the fluid escapes, and in due
time the child is born. This is followed within half an hour by the
extrusion of a mass of tissue--in reality the collapsed fetal sac--
which in every language, so far as I know, is named the After-Birth.
An examination of this tissue at the time of delivery repays the
physician, for it is important to ascertain that none of it has been
left in the uterus. Our interest at present, however, is to learn how
the after-birth has assisted toward the growth of the child.

THE PLACENTA.--The after-birth has puzzled scientists as well as the
laity, and not until comparatively recent times have its origin,
structure, and use been satisfactorily explained. Its meaning
profoundly interested primitive men and stimulated their imagination
scarcely less than the mystery of conception. Some uncivilized tribes
believed that the after-birth was animated like the child;
consequently they spoke of it as "the other half," and often saved it
to give to the child in case of sickness. But generally the after-
birth was buried with religious ceremony, and was occasionally
unearthed later to discover whether the woman would have other
children; the prophecy was made according to the manner of
disintegration or some other equally absurd circumstance.

The after-birth consists of a round, fleshy cake, the placenta, to
which two very essential structures are attached. One of these,
running from one surface of the cake, is a rope-like appendage, the
umbilical cord, which links the placenta with the fetus. The other,
attached to the circular edge of the cake, is a thin veil of tissue,
in some part of which a rent will be found. Now, if we lift the
margin of the rent, we shall see that the veil and the cake together
form a sac which we are holding by the opening. This aperture through
which the fetus passed, and it was really made for that purpose, was
formerly placed over the mouth of the womb; the sac itself, distended
by the fetus and the amniotic fluid, was fastened everywhere to the
inner surface of the womb.

It is plain that we have now in our hands the fetal sac, the
development of which we have already traced from the beginning. The
wall of the sac, it will be recalled, was originally of the same
formation throughout; but when the ovum became imbedded in the womb,
that part of its capsule which remained in permanent contact with the
mother's blood underwent special development, whereas the rest of the
capsule gradually pushed away from its primary position and, becoming
stunted in its growth, even lost to some degree the development it
had attained. This latter portion, the veil that passes from the edge
of the placenta, is formed of the two membranes we have mentioned,
namely, the chorion and the amnion.

The placenta is, for the most part, a highly developed portion of the
chorionic membrane, which became specialized simply because it
happened to receive the best supply of blood. At the time of birth
the placenta measures nearly an inch in thickness, is as large around
as a breakfast-plate, and generally weighs a pound and a quarter,
that is, approximately one-sixth of the weight of the child. This
relation between the weight of the placenta and of the child is
regularly maintained; therefore, the larger the child the larger the
placenta associated with it.

The placenta has two surfaces, easily distinguished from each other.
The raw maternal surface was formerly attached to the inside of the
uterus; the fetal surface, covered by the amniotic membrane, was in
contact with the amniotic fluid. Across the fetal surface run a
number of blood-vessels containing the child's blood, converging
toward a central point at which the umbilical cord is inserted. The
point at which the cord is attached affords the simplest means of
distinguishing the two surfaces of the placenta.

Our knowledge as to how the exchange of food and excretory products
between mother and child is carried on by the placenta has been
gained chiefly through the microscope. The oldest medical writings,
as we might suppose, express very fanciful ideas regarding the nature
of embryonic development and the means by which it is made possible;
no rational view of these matters could exist until the circulation
of the blood was described by William Harvey in 1628. After this
epoch-making revelation, it was accepted as true that the mother's
blood entered the unborn child and returned to her own system. But
that view eventually became untenable, for it was proved conclusively
that there is no communicating channel between the two. For years
after that, it was believed that before birth the womb manufactured
milk to sustain the child, just as the breasts do afterwards; but
this theory also was disproved; and, as I have said, only by the use
of the microscope have we learned the truth about fetal nutrition.

When thin slices of the placenta are magnified they are found to
contain countless numbers of tiny, finger-like processes; these are
the villi, and they constitute the major portion of the organ. The
villi seen in a mature placenta are the same as those which projected
from the capsule of the young ovum, but not these alone, for many
branches have sprouted from the original projections. The primary
trunks with all their branches hang from the capsule of the ovum and
extract nutriment from the mother's blood which surrounds them, just
as the roots of a tree extract it from the soil.

The interchange of material between mother and child as carried on in
the placenta can, perhaps, be made clearer if we compare one of the
trunks and its branching villi to a human forearm, hand, and fingers.
The hand, we will imagine, is held in a basin of water, in which, by
turning on a spigot and leaving the outflow unstopped, we have
arranged that the water changes constantly. In terms of this
illustration, the water corresponds to the mother's blood, rich in
oxygen, mineral matter, and all other kinds of essential nutriment;
and the fingers are the villi. The blood-vessels in the fingers, to
go a step farther, represent the blood-vessels which exist within the
villi, connecting with the umbilical cord, and passing by that route
to the body of the child. The blood which thus circulates through the
villi, it is important to emphasize, is the child's blood; it cannot
escape through the coating of the villi, just as our blood cannot
escape through the skin of the fingers. Similarly, the mother's blood
cannot enter the child; the two circulations are absolutely separate
and distinct.

It must be noticed, moreover, that the maternal blood not only brings
to the surface of the villi everything the child needs, but it also
takes away the waste products of fetal life. Let us select one of the
foodstuffs necessary for the unborn child, and follow its course so
far as it relates to fetal nutrition. The mother's blood brings
sugar, for example, from her intestinal tract to the surface of the
villi; through the coating of the villi the sugar passes into the
fetal blood, is carried to the fetal heart, and distributed to the
various fetal organs. They burn it, deriving heat and energy, and in
return give off waste products, namely, carbonic acid gas and water,
which are taken up by the fetal blood, borne back to the placenta,
and pass again through the coating of the villi into the mother's
circulation. These waste products are then transported to the
mother's lungs and to her kidneys, and are finally thrown off from
her body. Before the child is born, therefore, the placenta, which is
an aggregation of villi, acts as its stomach, intestines, lungs, and
kidneys.

In every pregnancy the placenta serves in this way as an organ of
nutrition, arranging for the passage of food from the mother's blood
to the fetal circulation. Occasionally, it is interesting to observe,
the placenta performs a very different function, namely, the
protection of the unborn child from diseases that may attack the
mother. It is able to afford such protection, because the coating of
the villi is not permeable to all sorts of substances. In order to
pass through their walls, material must be in solution; solid bodies,
therefore, are denied admission to the fetal circulation. The most
significant result of this restriction is, perhaps, that so long as
the coating of the villi remains intact and healthful, bacteria
cannot gain access to the unborn child. Since in health there are no
bacteria in the mother's blood, this fact has no bearing upon the
average pregnancy; but in those exceptional cases in which typhoid
fever or some other infectious disease appears during pregnancy, it
is gratifying to know that Nature has provided an unusual defense
against infection of the unborn child.

That we do not know all about the interchange of substances between
mother and child must be admitted; but the essential facts, and they
alone are of interest here, have been established beyond contention.
There is no doubt whatever that the mother's blood surrounds the
placental villi but never enters the child. The fetal blood, on the
other hand, is first in the child's body, then in the villi, and then
returns to the child again. It never enters the blood-vessels of the
mother but passes to and from the placenta as long as pregnancy
lasts.

THE UMBILICAL CORD.--This rope-like structure, familiarly known as
the navel-string, which connects the placenta and the fetus, is
approximately twenty inches long; its length, therefore, is
sufficient to permit the newly born child to lie between the mother's
knees while the placenta remains attached to the womb. The cord is
about the thickness of the thumb and contains three blood-vessels,
all filled with fetal blood; in two of them the current is directed
toward the placenta, the third carries the blood back to the fetus
after it has circulated through the placental villi. In the cord the
vessels lie near together and are encased in a jelly-like substance
that protects them from injury.

So far as is known; the umbilical cord performs no service other than
to link the blood-vessels in the placenta with those in the fetus.
Simple as this may seem, it is of paramount importance in maintaining
the life of the fetus, for compression of the vessels in the cord
would shut off its nutriment. Against such accident, however, perfect
provisions have been made; both the amniotic fluid and the jelly-like
substance which surrounds the vessels are safeguards which
effectually protect the circulation from pressure that might
interrupt it.

Frequently, prospective mothers are told they must not "reach up" for
fear the cord will become entangled. Such a precaution is quite
unnecessary. No matter what the mother does, or does not, the cord
will be found around the child's neck at the time of birth in one of
every three cases. It is not difficult to understand how this
happens. The cord is longer than the uterine cavity and must fall in
coils toward the bottom of it. Now, since the fetus is free to move
it enters and withdraws from these loops, many times, in the course
of pregnancy. Finally, when it takes up a position head downward, as
it nearly always does, the head is the part of the fetus which passes
through the coil, should one happen to lie in its path. After the
head is delivered the physician always feels about the neck to
discover whether a loop of cord is there. If it is, he can release it
easily. This condition, since it occurs so frequently and since it so
rarely produces harmful consequences, should not be considered
unnatural.

After the child is born, the physician cuts the cord, and in due time
the after-birth is expelled through the same passage as was the
child. The expulsion of the after-birth frees the mother of all the
tissue derived from the growth of the ovum, for the intricate
mechanism that served to nourish and protect the embryo was almost
entirely developed from the ovum itself. It is a remarkable provision
of Nature that very little of the mother's tissue is cast off at the
end of pregnancy; and even this small portion is promptly replaced.
By about the sixth week after delivery, the wound which was made by
the separation of the fetal sac has completely healed. Meanwhile the
mucous membrane that underwent elaborate preparations to receive the
ovum, the cavity that was adjusted to its growth, and the muscle
fibers that were strengthened to insure its safe entry into the world
have all regained their original state. Except for the activity of
the breasts, the mother is left in the same physical condition as
before she became pregnant.




CHAPTER III


THE EMBRYO

The Development of Form--The Determination of Sex--Twins--The Rate
of Growth--The Newborn Infant--Heredity--Maternal Impressions.

The new human being begins existence, as I have shown, as soon as the
ovum is fertilized, though at that moment it consists merely of a
solitary cell formed by the union of the two parental cells. From a
beginning relatively simple the human body develops into the most
complex of living structures; and, startling as it may appear to be,
it is demonstrably true that every one of the millions of cells which
compose an adult has descended from the ovum. Furthermore, the
individual himself is not the entire progeny of the ovum; the
placenta and the membranes dealt with in the preceding chapter, we
saw, were also derived from that same source. They possess only a
transitory importance, to be sure, and to most persons they are less
interesting than the embryo, yet we gave them consideration before
discussing its growth because the manner in which the ovum becomes
attached to the womb and draws nutriment from the mother primarily
determines the fate of a pregnancy.

Now that we have become familiar with the arrangements for the
protection of the embryo, we are prepared to learn how it develops,
and may accept the phrase, embryonic development, to cover the whole
period of existence within the womb. In a more technical sense,
however, the use of the term _embryo_ is limited to the first
six weeks of pregnancy and designates the condition of the young
creature before it has acquired the form and the organs of the
infant; after that time the unborn child is called a _fetus_.
Embryonic development, therefore, in the strictest sense of the term,
chiefly involves the shifting of various groups of cells and the
bestowal upon them of different kinds of activity. During this period
comparatively slight growth takes place. By about the twentieth week,
the house, it may be said, is set in order; and there follows a
period marked by the rapid growth of the fetus.

THE DEVELOPMENT OF FORM.--A very old explanation of embryonic
development was that the process consisted altogether in growth.
According to that view the embryo lay curled up in the egg; at the
outset it was equipped with organs, limbs, features, and all the
other bodily structures found in an adult. In order that the ovum
might be transformed into a mature infant, only unfolding and growth
were required. After the microscope came into use, however, so simple
an explanation could no longer be accepted. Scientists soon realized
that the embryo did not exist "ready made" in the ovum, which, even
when magnified, failed to bear the faintest likeness to a human
being.

Although the microscope made impossible this very simple explanation,
it gave in return a truer, if more complex, account of the
transformation from egg to offspring. By this means it has been
definitely proved that the ovum multiplies rapidly after it has been
fertilized, and becomes, as was explained in the preceding chapter, a
sac-like structure within which hangs a tiny clump of tissue. This
inner mass of cells forms the embryo.

It has proved a difficult task to secure very young human embryos,
and many of the ideas we hold relative to the initial stages in the
development of man are based upon what has been found true in certain
mammals, the class of animals to which we belong. The youngest human
ovum known at present has already undergone about two weeks'
development, and there the embryo is represented by a flat disk. From
this stage to the stage of complete development a satisfactory series
of embryos has now been collected, but it is impossible to give here,
even in outline, a description of the evolution of the human embryo.
No one can understand this intricate subject without the aid of
diagrams, models, and other material beyond the reach of all save
laboratory workers.

By the end of the second month the development of the embryo has
advanced so far that anyone could recognize its human shape. About
that time, too, the external sexual organs make their appearance. At
first these are quite similar in both sexes; and, if they are used as
the criterion, it is possible only toward the end of the third month
to say whether the embryo is a male or female.

THE DETERMINATION OF SEX.--The fact that a number of months pass
before the sex can be distinguished by an external examination of the
fetus has led to the erroneous belief that it can be influenced
during the early part of pregnancy or actually determined at will.
Various means to accomplish this have been suggested; many of them
depend upon modifying the mother's mode of living according as a boy
or girl is desired. The most widely known of these doctrines, that of
Schenck, was to the effect that the sex of the offspring is always
that of the weaker parent. He suggested, therefore, that increasing
the vigor of the mother by an appropriate diet would produce a male
child, whereas a decrease in her strength would lead to the opposite
result. His views, however, were incorrect. After studying extensive
statistics Newcomb came to the conclusion that "it is in the highest
degree unlikely that there is any way by which a parent can affect
the sex of his or her offspring."

Moreover, the results of experimental research clearly indicate that
we shall never possess the means by which a mother may control the
sex of her child. In the main laboratory investigations have sought
to answer two questions. First, at what time is the sex of the
offspring determined? and, second, what accounts for the origin of a
male in one instance and of a female in another? The study of these
problems has been carried on chiefly in connection with insects,
worms, and fowl; but as yet insurmountable difficulties have
prevented similar investigations in higher animals. For this reason,
it is not without the greatest caution that results thus far obtained
may be assumed to apply to man.

Sufficient facts, however, have been collected to admit no doubt
regarding the answer to the first question. In most animals it is
definitely known that the sex of the offspring has been fixed when
the male cell enters the female cell, in other words, at the instant
the ovum is fertilized. Excellent reasons exist for believing that
human beings conform to this rule, and that the sex of the child is
unalterably determined at the moment conception occurs. Consequently,
any attempt to influence it after that event must prove futile.

For the present, the second question cannot be answered with equal
assurance. More than five hundred theories have been offered to
explain the relation of sex; nearly all of them have no reasonable
foundation and are only of historical interest. The view that girls
are derived from the right ovary, boys from the left, has long since
been disproven, and deserves mention merely because the laity still
believe it. Happily, during the last few years, observations and
experiments have been made which greatly advance our knowledge of the
subject and give promise of an early solution of the problem. The
controlling factor in sex determination has been narrowed down to
three possibilities; it is inherited either from the single cell
contributed by the father or from the single cell contributed by the
mother, or it is determined by the effect these two cells have upon
each other at the moment when they unite. In most animal species the
weight of authority distinctly favors placing the whole
responsibility upon the male cell.

According to recent evidence, there are two kinds of male germinal
cells; one kind giving rise to female offspring and the other to
male. In all probability, at the time of the marital relation, these
varieties are deposited in the vagina in equal numbers; and,
moreover, the mode of their production is such as to place absolutely
beyond human control the possibility of changing this ratio. Since
only one spermatozoon enters the ovum, whether or not the child will
be a boy or a girl depends entirely upon which type gains entrance.
If this explanation is correct, and it is in accord with careful
biological observations, it removes from the mother all
responsibility for the sex of her child. Furthermore, since the facts
indicate that male-producing and female-producing spermatozoa are
present in equal numbers, it follows that practically there is an
even chance that an embryo will develop into a boy or a girl.

Birth statistics bear out this conclusion, as data gathered from many
countries indicate that when long periods of time are studied 105
boys are born with a surprising regularity for every 100 girls. Thus,
the records of Berlin, Germany, for a hundred years show that the
maximum difference occurred in 1820, when the males outnumbered the
females by 4.79 per cent.; the minimum difference, which was noted in
1835, was .64 per cent. in favor of boys.

No inquiry is more often submitted to the physician by prospective
mothers than this, "Can you tell me if my baby will be a boy or a
girl?" He cannot. Many rules, to be sure, have been advocated as safe
guides toward reaching the correct answer; every midwife possesses
her individual formula which she has "never known to fail." But the
boastful success depends upon the application of some such method as
the following, which I have heard my teacher, Dr. J. Whitridge
Williams, expose to his classes. The patient is asked if a boy or
girl is desired. She confesses, and is then informed that the sex of
her child will be the opposite of her wish. When this guess proves to
be correct, there is no doubt of the prophet's wisdom; when it is
not, his honor is protected, for the parents have had their hope
fulfilled. Their happiness makes them forgetful that the guess was
wrong, or, for that matter, that it was ever made.

It was once believed that the sexes might be distinguished before
birth by the number of heart beats occurring within a minute. In a
general way, the action of this organ in females is somewhat more
rapid than in males; and so it was thought that a rate of 144 or more
indicated the female and a rate of 124 or less the male sex. But
experience has taught that this rule leads to accurate prophecy in no
more than half of the cases. As a matter of fact, no means of
definitely foretelling the sex of the child has been discovered, and
I doubt if it ever can be.

TWINS.--As every one knows, pregnancy commonly terminates with the
birth of a single child. Twins appear in approximately only one of
ninety pregnancies, while triplets are extremely rare. It is true
that even quintuplets may occur, though up to 1904 only 29 authentic
instances could be collected from the whole range of medical
literature.

Twins are most frequently born to parents whose ancestors have
established this tendency; the trait is usually inherited from the
mother's family, though occasionally it is passed on through the
father. Of course, that does not explain the cause of twins, which in
reality may result from either of two circumstances. More commonly
their genesis depends upon the ripening of two eggs at about the same
time and the fertilization of both by two different spermatozoa. The
children, in this instance known as double ovum twins, may be of the
same sex or not. On the other hand, single ovum, or identical, twins
are always of the same sex; this follows, since but one egg and but
one spermatozoon are here concerned. The incident permitting twins to
develop from a solitary ovum must occur soon after conception has
taken place. It will be remembered that the first step in the
development of the fertilized ovum consists in its dividing into two
cells. Ordinarily, both these take part in the development of one
embryo, but occasionally they separate and give rise to two.
Frequently, the presence of twins can be recognized during the latter
months of pregnancy, and accurate means are known of determining
after they are born to which variety any given pair belongs.

THE RATE OF GROWTH.--When we recall the definite and often marked
differences in the physical character of women, such as weight and
height, it is surprising to learn that the prenatal development of
their children proceeds with uniform speed. One very practical result
is that the physician is thus enabled, at the birth of a premature
infant, to estimate accurately the period of its development. Various
criteria, some of which are easy of application, aid in this
determination. For example, the length of the child is practically
constant for each of the ten lunar months into which the whole
gestation period is divided; if, therefore, the length of the newborn
infant is known, the stage of its development can always be inferred.
From the fifth month the calculation is especially simple, since the
length measured in centimeters divided by the figure 5 gives the
month to which pregnancy has advanced. Similarly, we can infer the
period of development from the weight, though the calculation is more
intricate and the method less reliable, inasmuch as the size of the
child in the latter months varies somewhat according to the weight of
its mother.

At the end of the fifth month, the weight of the fetus is from nine
to ten ounces; whereas an average infant when born at the expiration
of the full term of pregnancy, that is, with the completion of the
tenth month, weighs about seven pounds. The fetus, therefore,
acquires roundly ninety per cent, of its weight during the second
half of pregnancy, which clearly indicates that Nature reserves this
period of gestation for the fetus to increase in size, a phenomenon
less mysterious but no less important than the evolution of the
embryo.

Nothing is more valuable than the weight in affording an indication
as to whether a prematurely born infant may be reared. It is unusual
to raise a child weighing less than four pounds, which corresponds
approximately to the end of the eighth lunar month of development (a
trifle more than the seventh calendar month). After this time, the
prospect of living becomes greater in proportion to the nearness with
which the infant has approached maturity. No truth exists in the
widespread belief that the seventh-month child is favored above that
born later but before the natural end of pregnancy. Experience has
taught that the probability of success in rearing the child increases
rapidly after the seventh month. This is reasonable on the following
somewhat theoretical grounds. The digestive organs later attain a
higher state of perfection, and are better prepared to carry on their
work satisfactorily. Moreover, the gradual deposition of fat beneath
the skin during the last two months of pregnancy materially assists
in fitting the child for the conditions met with in the external
world, since the fat affords a barrier against the escape of heat
generated within the body, making it much easier to keep the child's
temperature at the normal point. Even other more technical reasons
could be given to demonstrate the error of the superstition regarding
the seventh-month child--a conviction endorsed by medical men
hundreds of years ago and as yet not discarded by the laity.

When pregnancy has reached "term," the child, having completed its
prenatal development, is ready to cope with conditions as they exist
in the external world. At term the average child is twenty inches
long and weighs 7 1/7 pounds (3,250 grams). The length is remarkably
constant; but the weight, as is well known, is often somewhat above
or below the average figure. In a general way, smaller children occur
in the first than in subsequent pregnancies, and, moreover, may be
expected when the mother is a small woman, or poorly nourished, or
has worked hard during her pregnancy. On the other hand, a tendency
to bear large children is present when the opposite conditions
prevail. It is not unusual to see infants weighing eight or nine
pounds at birth, but babies of more than ten pounds are rare, and the
fabulous, though not infrequent, reports of fifteen and twenty-pound
infants are probably not based upon actual weighings, but upon the
impression of someone who has merely seen the child or perhaps
guessed the weight from lifting it.

Although the fetus frequently changes its position during the earlier
months of pregnancy, generally by the beginning of the tenth lunar
month it has assumed a permanent posture. It has then reached such a
size that it can best be accommodated in the cavity of the uterus if
its various parts are folded together so as to give the fetus an
ovoid shape. To secure this form its back is arched forward, and its
head bent so that its chin touches its chest; its arms are crossed
just below the head, its legs raised in front of the abdomen, and its
knees doubled up. In this form the fetus occupies the smallest
possible space.

With relation to the mother the position of the child, for several
weeks before birth, is one in which its long axis is parallel to the
long axis of her body. This remains true no matter whether the head
or the buttocks are to precede at the time of birth. In ninety-seven
out of a hundred cases, however, the head lies lowermost and
consequently is the first portion of the child to be born. The
opposite position, in which the head is the last portion born, is,
even with the most skillful treatment, somewhat more serious for the
infant, though not for the mother.

THE NEWBORN INFANT.--The baby at birth is not a miniature man. As
compared with an adult its head and abdomen are relatively large, its
chest relatively small; its limbs are short in proportion to the
body; and at first glance it appears to have no neck at all. The
middle point of a baby's length is situated about the level of the
navel, whereas in a man the legs alone represent approximately half
his height. The changes after birth consist chiefly in growth; but
not altogether, since at least one organ, the thymus gland, becomes
smaller and completely disappears during childhood, and other organs,
especially the liver, are proportionately smaller in the adult than
in the infant.

The body of the infant also differs from that of the man in
possessing greater softness and flexibility. These qualities depend
upon the nature of its skeleton, which is composed of more bones than
later in life, when several have fused together to form one to give
the mature body a more rigid frame. Furthermore, the individual bones
are not so firm, consisting of an elastic material called cartilage,
so that some movements which in an adult would cause such serious
injuries as fractures and dislocations are perfectly harmless to a
newborn child.

The legs are not only short in proportion to the body but are always
curved, and the feet are held with the soles directed toward one
another, a position clearly abnormal in the adult. But every mother
should know that these are natural conditions in the infant, and are
the result of the posture of the child before birth. They soon
straighten out. The bowed legs of an adult are of an entirely
different origin, resulting from a disturbance of nutrition in
infancy called rickets.

A small amount of short wooly hair is usually found over the back of
a newborn infant. More conspicuous, however, is the presence there of
a gray, fatty substance which, though always more abundant over the
back, is at times distributed over the whole body; rarely is it
entirely absent. The material, technically named the vernix, is the
product of the glands in the skin and is a perfectly normal
secretion. After its removal, which is readily accomplished by
greasing the infant with lard or vaselin before giving the initial
bath, it never reappears.

A varying amount of hair covers the head of the infant. No
significance should be attached to the quantity, for the conviction
that exists, especially among negroes, that a heavy suit of hair for
the child occasions "heart-burn" in the mother during pregnancy is
without foundation. The color of the hair at birth does not indicate
its ultimate shade; changes are often noted during infancy. Similarly
the permanent color of the eyes is not assumed until later; at the
time of birth the eyes are generally, if not always, blue in color.

A baby's head is a matter of great concern to the family.
Occasionally, the skull is round and well shaped from the moment of
birth, but more often it is long and narrow; sometimes the form is
even startling to the inexperienced. The peculiar shape of the head
results, of course, from its passage through the birth-canal and is
not a sign of any disease. In a few weeks, or even less, the strange
appearance passes away. It is unwise to attempt to alter the shape of
the head by bandaging or massaging since the growth of the brain will
spontaneously accomplish what is desired; interference can do no
good, and may do serious harm.

Nature facilitates an appropriate molding of the head during birth so
as to permit its easy passage through the bony pelvic cavity of the
mother, and gains that end in two ways. The bones of the head remain
pliable until after the infant is born, and, further, their edges are
not welded together as in an adult, but are separated from one
another by an appreciable distance. During the act of birth the edges
are brought into contact or even overlap, materially reducing the
size of the head. Within a few hours after birth the bones again
spread apart, and some months elapse before they begin to unite; the
union is not completed until some time during the second year of
infancy.

Many mothers are anxious to know how far the senses of the infant
have developed when it enters the world. This problem has stimulated
some scientific investigation, though hardly so much as its interest
would justify. Two lines of inquiry have been pursued toward its
solution. The objective point of one of these has been to determine
how nearly the sense organs of the newborn correspond anatomically to
those of an adult; that is how perfectly has their organization been
completed. The other has been to learn how the infant reacts when the
various senses are stimulated; the interpretation of these reactions
is, however, particularly liable to error and sometimes amounts only
to guesswork.

The organization of the nerves and muscles in the eye is far from
perfect at the time of birth. The muscles act irregularly; indeed,
the lack of muscular adjustment is such that movements of the eye
likely to alarm the parents are regularly observed in very young
infants. Furthermore they cannot focus images which fall upon their
eyes. The retina, which receives visual impressions, has reached such
development at birth, however, that sensations of light can be
perceived. For example, if a lamp is suddenly flashed before the face
of a newly born baby it cries. From this and similar evidence,
indicating that strong light irritates the delicate structures of the
eye, we have learned that a nursery should not be illuminated, during
the day or night, so brightly as the rooms adults occupy. Certainly
several weeks, and probably several months, pass before an infant can
see anything save as blurs of light and darkness. Objects, such as a
hand, probably appear as shadows, which are not correctly interpreted
until late in infancy.

In regard to color vision we have as yet no reliable information
concerning children under two years of age. Infants of less than a
year have been known to distinguish certain colored papers. But such
discrimination is probably due to a difference in brightness of the
colors.

Although the organ of hearing is well developed at birth, the drum of
the ear in very young infants cannot transmit sounds, as in the
adult. For the latter kind of transmission it is necessary that the
pressure on both sides of the drum-membrane should be equal, and this
is arranged by the admission of air to the middle ear through a
passage from the throat. At the time of birth, on account of the
swollen condition of the mucous membrane which lines this passage, it
is blocked, and the middle ear is filled with fluid; these conditions
interfere with the transmission of sound, and consequently its
perception is dulled. But even in the absence of a drum-membrane an
adult can hear; the vibrations in such cases are transmitted through
the bones of the skull, and this very likely also occurs in newly
born infants. In most instances, at least, they react to a
disagreeable noise within the first twenty-four hours, and their
sensitiveness in this direction explains why the nursery should be
kept quiet.

Investigators have not come to uniform conclusions concerning the
sense of smell and of taste. In all likelihood, smell is not acute at
the time of birth. Taste probably is better perceived, yet some
newborn babies are said to suck a two per cent solution of quinin as
eagerly as milk, though stronger solutions are distasteful. According
to the best available information a young infant can detect the
difference between a sweet, bitter, sour, or salty taste only when
the tests are made with a solution possessing the quality in question
to a marked degree. It is common knowledge that babies cheerfully
suck the most tasteless objects, and it is not improbable that at
first the reaction depends upon the temperature of the object and the
feeling it creates in the mouth.

The moment it is born, a baby perceives pressure if its skin is
touched. To this sensation, however, some parts of the body are much
more sensitive than others; the tongue and lips are most sensitive of
all. Heat and cold are probably perceived more acutely by infants
than by adults; to pain, on the other hand, babies are less
sensitive. An infant is aware of the movements of its own muscles,
and also appreciates a change from one position to another, as
experienced nurses know very well, and on that account carefully
avoid keeping a baby on one side continuously.

The vast majority of movements performed by young infants are reflex
acts, that is, the cerebrum, the part of the brain with which
thinking is done, is not concerned with their performance. Of these
reflexes the most notable are sucking and swallowing, but sneezing,
coughing, choking, and hiccoughing may also be observed; stretching
and yawning have been recorded in several instances, even during the
first days of infant life. None of these movements, we must remember,
are produced consciously; the baby cannot reason and does not
recognize anyone, even its mother.

HEREDITY.--The transmission of bodily resemblance and of traits of
character from parent to child is a broad and complicated subject,
whose fundamental principles biologists are just beginning to grasp.
The facts thus far established regarding heredity relate chiefly to
plants and to the lower animals. There is no doubt whatever that the
meager knowledge we possess of heredity in man will be amplified and
will ultimately indicate on the one hand the marriages which are
advisable and, on the other hand, those which are not. Indeed, the
foundations for a science called Eugenics, which purposes to improve
the human race in this way, have already been laid. It is barely a
decade, however, since our knowledge of heredity has approached that
order and system which entitle it to be ranked as a science; and in
this brief period great strides could hardly be expected in its most
intricate field, that of human inheritance.

The modern teachings of heredity are of interest to us, nevertheless,
since they intimate the time when a child's inheritance is fixed and
the means by which hereditary characters are conveyed. To understand
these fundamental points we must recall that at the moment of
conception a male germinal cell combines with a female cell, and that
this act, which is named fertilization, brings together vital
elements from the two parents. We have seen that the spermatozoon
represents the solitary contribution of the father toward the
development of the child, and the spermatozoon, therefore, must
convey the material basis of paternal inheritance. Similarly we might
expect the ovum to be the bearer of the maternal qualities inherited
by the child. This is actually true; but much of the evidence is of a
technical character and must be omitted. Yet an experiment
successfully conducted by Castle and Phillips will indicate, even to
those who have no special knowledge of the mechanism of heredity, the
important role the ovum plays. These investigators removed the
ovaries from an albino guinea-pig, and in their place substituted the
ovaries of a black guinea-pig. "From numerous experiments it may be
emphatically stated that normal albinos mated together produce only
albinos." But in this experiment the result was otherwise, for the
albino into which the ovaries of a black guinea-pig were grafted
produced only black offspring. The color-coat of her young,
therefore, was not influenced by her own white hair, but was
determined by the eggs really belonging to the black animal from
which the ovaries were taken; in no other way can the result be
interpreted. It is certain, moreover, that the mode of transmission
of material qualities here exemplified is not exceptional; on the
contrary there is no doubt that the ovum always conveys the sum total
of the qualities the offspring inherits from the mother.

The germinal cells then contain the material basis of inheritance,
and in all probability the substance is located within the nucleus of
the cells. This substance had been seen and studied long before its
relation to the problem of heredity was suspected. Because it takes a
deeper stain than the rest of the nucleus, it stands out prominently
when the cell is treated with certain dyes, and this property
accounts for its name--chromatin. Under such conditions as prevail
just before a cell divides, the chromatic substance is broken up and
reassembled in the form of rods called chromosomes. Curiously enough
the number of rods is uniform for each species of animal, though
different numbers are characteristic of different species; the
characteristic number for man is twenty-four.

Unless some arrangement was made to prevent it, the act of
fertilization would cause the number of chromosomes in the fertilized
ovum to be double the number characteristic of the species. In man,
for example, the addition of twenty-four chromosomes from the
spermatozoon to an ovum that already contained twenty-four
chromosomes of its own would mean that after fertilization the ovum
contained forty-eight. Such a result is prevented through the process
to which we have referred in the preceding chapter as the ripening of
the ovum, and also through a similar process in the case of the
spermatozoon. These two processes lead to a reduction in the number
of chromosomes, so that finally every human germinal cell contains
twelve, and therefore when the ovum is fertilized the characteristic
number twenty-four is restored. While we know nothing of the forces
which determine, on the one hand, what elements shall be discarded by
the germinal cells and, on the other hand, what elements shall
remain, it is definitely proved that a selective process always takes
place. This fact admirably explains the variation in the
characteristics inherited by children of the same family. So far as
is known, the traits which will be passed on from either parent are a
matter of chance. Whatever these hereditary traits happen to be, the
best evidence we have indicates that the problem of a child's
inheritance is settled once for all the moment conception takes
place.

MATERNAL IMPRESSIONS.--Contrary to all that we know of heredity, the
conviction prevails among the laity that the character of a child
depends greatly upon the mother's surroundings during pregnancy: this
is the doctrine of maternal impressions. As is usual with
superstitions, this one emphasizes the unfavorable possibilities and
holds that the unborn child may be affected by the mother's unhappy
thoughts or maimed by her mental distress if she is exposed to
unpleasant sights. For this belief there is no foundation; the cases
often cited in its support may be fully explained on the grounds of
coincidence.

With the possible exception of such individuals as are spending their
lives in solitary confinement, there is scarcely a human being who
has not in the course of nine consecutive months some untoward
physical or mental experience which engraves itself upon the memory.
Prospective mothers are not apt to be exempt from a rule so general
in its application, but if by good chance one happens so to be she
will hardly fail to hear of the misfortune of others, which,
according to the doctrine of maternal impressions, may be equally
effective in interfering with the proper development of the child. We
should then rightly expect most, if not all, babies to be "marked"--
clearly a situation which does not prevail.

In order to learn how frequently prospective mothers may have
disagreeable experiences which they fear will affect the formation of
the child, I have lately asked the patients whom I have attended,
"Was there any incident during your pregnancy to which you could have
attributed the infant's condition, had it been marked?" The babies of
all those to whom the question was submitted were normal; yet without
exception those whose pregnancies just completed were their first
answered in the affirmative. It is also pertinent that one of these
patients had lost her brother by a violent and accidental death when
she was four months pregnant; a similar bereavement was suffered by
another at the eighth month; each was, however, delivered of a
perfectly healthy child. Among those with whom the recently ended
pregnancy was not the first I found some who could remember incidents
popularly believed to have an influence over the development of the
embryo; most of them, however, had given the matter so little thought
that they could not definitely recall whether such incidents had
occurred or not. From a similar series of observations covering two
thousand cases, William Hunter came to the conclusion, nearly two
hundred years ago, that there was no support for the belief in
maternal impressions.

Whenever a child does happen to develop abnormally, it must be clear
that, from the very nature of our existence, some incident can be
recalled which will satisfactorily, yet unjustly, bear the blame. It
may be confidently said, however, that, for every mother whose fears
are realized, hundreds are agreeably disappointed in finding their
babies perfectly normal. In the face of so many negative instances it
is amazing that any person, even though ignorant of medical teaching,
should be inclined to attribute abnormal development to something the
mother has seen or heard, thought or dreamt, or otherwise experienced
while she was pregnant. Yet unfortunately many do believe this. It is
worth while, therefore, to supply further evidence, and thus escape
any suspicion of unfairness in argument, to prove that maternal
impressions are unable to affect the formation of the embryo.

It is found, as a matter of experience, that the superstition
regarding maternal impressions generally begins to cause anxiety
during the second half of pregnancy; and then such an influence is
entirely out of the question. By the end of the second month the form
of the embryo has been definitely determined, and subsequently cannot
be altered. It is even true that errors in development are most apt
to occur within the two or three weeks that immediately follow
conception, and therefore occur at a time when pregnancy is not often
clearly recognized. Thus it happens that women begin to worry about
the influence their minds will have upon the formation of the child
long after its form has been established.

Incidents in the life of a prospective mother are in point of fact
equally inert so far as their influence upon development is
concerned, no matter whether they occur during the earlier or later
part of pregnancy. There is never any anatomical means by which
maternal impressions could be conveyed to the embryo. Such an
influence would have to be exerted through the placenta; and that is
impossible. There are no nerves in the placenta to carry impulses
from the mother to the child. Even the blood streams of the two
beings are kept apart; and though it is unheard of that the blood
should carry nerve impulses, if that happened to be the case, it
could not prove effective here, for the blood of the mother does not
enter the child. It is nourished by food which passes from the
mother's blood, to be sure, but there is no more reason to expect
this nutriment to exert an hereditary influence than there is to
expect an infant to grow to resemble the cow with the milk of which
it is fed. With these two possibilities eliminated, no path can be
imagined by which impulses might travel from the mother to the
embryo.

Scientific investigation has brought to light these facts, as it has
also taught the real causation of the disfigurement once attributed
to the mother's mind. Departures from the usual form of the body
occur during the earliest days of pregnancy and arise in consequence
of some irregularity in the process which molds the body-form from a
simple spherical mass of cells. Why irregularities sometimes occur is
not altogether clear; except in so far as it has been determined that
the fault lies within the embryo itself. Whenever these defects are
associated with events which have disturbed the mother's mind, it
cannot be other than a simple coincidence.




CHAPTER IV


THE FOOD REQUIREMENTS DURING PREGNANCY

The Food-stuffs: Water; Mineral Material; Protein; Carbohydrate; Fat--
What We Do to Our Food--How Much Food Is Needed During Pregnancy?--
The Importance of Liquid Nourishment--The Choice of Food--Cravings--
The Relation Between the Mother's Diet and the Size of the Child.

There is a gain in weight during pregnancy amounting finally to about
thirty pounds; exceptionally, it is as little as ten or fifteen
pounds, and, at the other extreme, as much as forty or fifty. With
individuals inclined to be stout the increase is greater, and it is
relatively greater in later pregnancies than in the first. During the
early months of pregnancy the weight generally remains stationary or
suffers a slight loss; even in those rare instances in which the
weight begins to increase shortly after conception the gain is less
marked in the earlier months than later. For the last three months
the average monthly gain has been found to be between three and a
half and five and a half pounds.

The weight gained during pregnancy is not, as can be readily
understood, permanently retained. At the time of birth, in
consequence of the expulsion of the child, the after-birth, the
amniotic fluid, and a varying amount of blood, there is necessarily a
loss of from ten to fifteen pounds. Later, as the maternal tissues,
whose growth has been stimulated during pregnancy, return to their
original condition, a further loss in weight takes place. It is not
unusual, however, for women to remain permanently better nourished
than before they became pregnant. Under ordinary conditions the food
of the prospective mother provides not only for her own wants but
also for those of the embryo. Between the two organisms there exists
a relation which resembles that existing between a house in course of
construction and the contractor who supplies the building material.
The mother furnishes what is needed to construct the "living
edifice," as Huxley called the growing embryo, but she is not
responsible for the lines of the building. The embryo is both
architect and mechanic, designing the structure and arranging the
"organic bricks" in their proper places. The work of construction
necessitates the expenditure of an appreciable amount of energy and
the creation of waste products that must be removed, lest they
accumulate and interfere with the growing structure. These waste
products leave the embryo by way of the umbilical cord and the
placenta and return thus into the mother's circulation; ultimately
they leave the mother through the same channels that carry off her
own waste. First and last, then, the nutrition of the mother and of
the child are so bound together that it has been impossible to study
them separately. Our knowledge of food requirements during pregnancy
has been obtained by measuring the food requirements of the mother
alone; and as nutrition during gestation is fundamentally the same as
nutrition at other times, it is necessary for us first to consider in
general the food needed by the human body.

THE FOOD-STUFFS.--The waste products we throw off indicate that the
substances which compose our bodies are being constantly broken down
and reduced to a condition such that they are useless to us. In
normal persons hunger signifies that they need material to replace
what has been used up. The substances thus required, if the wants of
the body are to be satisfied correctly, are called the food-stuffs;
and they are the same during pregnancy as at other times. The
foodstuffs are usually classified according to their chemical
properties; on this basis they are placed in five groups: (1) Water,
(2) Mineral Materials, (3) Proteins, (4) Carbohydrates, (5) Fats.

In view of the different purposes which the foodstuffs serve, it is
convenient to group them in another way. Thus, the carbohydrates and
the fats may be placed together because they are the body fuel; their
value consists in the heat and energy which they yield when acted
upon in the tissues. Water and mineral matter, on the other hand, are
never a source of energy; they assist in building new tissue or in
repairing tissue that already exists. The proteins are unique, in
that they may serve either purpose. Primarily the proteins are
tissue-builders, but in the absence of sufficient fat or carbohydrate
the body burns protein to secure heat and energy.

Each food-stuff, therefore, serves a distinct purpose, and some of
them render services which the others cannot perform. A man will die
if either water or mineral matter or protein is completely withdrawn
from his diet. Fat or carbohydrate, on the other hand, or even both
of them, may be excluded for some time without causing serious
inconvenience. It is true, nevertheless, that each food-stuff
performs some task better than any of the others can perform it, and
for that reason all of them should be included in the diet of an
healthy individual.

Some of the food-stuffs, such as water and table salt, come to the
body separate from the others; but generally the different types
reach us intimately mingled in the various articles of food in common
use. Foods vary greatly, however, in the amount of the different
food-stuffs they contain. The meats, for example, have a relatively
large protein content; in the vegetables starch, which is one of the
carbohydrates, predominates. As to the choice of food and the amount
that is necessary for the average person, generally the appetite is a
safe guide; but the accurate observations of physiologists have gone
so far as to determine the exact requirements of the body. Not the
least important principle taught by these investigations is to avoid
dietary fads, for in arranging a satisfactory diet the problem to be
solved is not, What is it possible to live on? but, What serves best
as nourishment? The experience of countless generations has taught us
that we thrive best on a diet which includes all five food-stuffs.

_Water_ constitutes nearly two-thirds of the weight of the body.
As water is constantly being given up in the life process, health
demands an abundant supply of liquids to replace the waste. The
average daily loss has been found to be between two and three quarts.
Of this amount the urine constitutes nearly two-thirds; and the
remaining third is eliminated through the skin, the lungs, and the
bowels. Although the deficiency thus created is met in part by the
water in our solid food, the greater part of the loss is made up by
the liquids we drink, and we are warned, in a measure, by the
sensation of thirst that they are needed.

_Mineral material_ is of the greatest importance as a
constituent of our food. It contributes to the welfare of the body in
at least three ways; (1) it gives rigidity to the bones, (2) it
supplies an essential ingredient of the living substance in all the
tissues, (3) it is present in the blood and in the other body fluids,
where it is of service in such vital processes as the beating of the
heart, the transportation of oxygen to every portion of the body, and
the maintenance of an acid or alkaline condition of the digestive
juices according as the one or the other is necessary for the
assimilation of the food.

An animal deprived of mineral food will die as surely as one deprived
of water. In arranging our diets, however, we are not compelled to
take the minerals into account, for, with the exception of table salt
(sodium chlorid), the meat and vegetables that we eat provide the
mineral material the body requires. Iron, for example, which imparts
to the blood one of its most essential qualities, occurs in
relatively large amounts in apples, spinach, lettuce, potatoes, peas,
carrots, and meats. Only now and then does it become advisable to add
iron deliberately to the diet. Similarly lime (calcium) the material
that makes the bones hard, is present in quantities ample for the
needs of the body in the bread, milk, eggs and vegetables that we
eat. The remaining mineral constituents of the body, among which the
most conspicuous are magnesium, potassium, sulphur, and phosphorus,
occur in foods which we are naturally inclined to take, so that we
secure an abundance of them unconsciously.

_Protein_, the third food-stuff which we must eat to keep alive,
contains the chemical element nitrogen in such form that it can be
incorporated in our tissues. Although most persons derive their
protein in part from meat, milk, and eggs, it is possible to satisfy
the requirements of the body on a purely vegetarian diet. Experience
has shown, however, that it is both natural and advantageous that we
employ a mixed diet.

The property of protein to build living tissue and replace tissue
waste probably depends upon several factors; but certainly one of
them is the presence of nitrogen. So intimately associated are the
consumption of the tissue substance and the elimination of nitrogen
that we have no better way of judging the amount of tissue substance
used in the body than by determining the quantity of nitrogen that
appears in its various waste products. From such investigations it
has been found that the quantity of protein required to repair the
breaking down of the tissues is not great. The average man consumes
approximately a quarter of a pound (100 to 120 grams) of protein
daily; but this quantity is in excess of his real needs. Indeed,
Chittenden has shown that for various classes of individuals, namely,
students, athletes and soldiers, half as much is sufficient. Other
physiologists, though admitting that this is true, contend that it is
inadvisable to regulate one's diet on such a slender basis. Very good
reasons are assigned for the view that more protein is needed than
just enough to counterbalance the tissue waste. Thus, in the case of
animals, it has been found that a diet low in protein finally causes
digestive disturbances and other ailments.

Although it does not seem advisable to practise rigid economy in
arranging the protein content of the diet, it is equally important
that we should not go to the other extreme. The consumption of over-
large quantities of protein, as would be the case if we lived
exclusively upon meat, increases putrefaction in the intestines and
throws unnecessary work upon the kidneys, which are the organs
chiefly concerned in getting rid of the waste products of protein.

_Carbohydrate_ is the name given the group of foodstuffs to
which the sugars belong. The food value of cane sugar, the most
familiar member of the group, was recognized even in prehistoric days
by the natives of India. By boiling the plant we call sugar-cane they
obtained a substance to which they gave the name Sakkara, and from
this our word sugar evidently originated. The roots of this plant
were carried into Europe and cultivated during the Middle Ages.
Obviously, its value was and is appreciated, since the cultivation of
the sugar-cane and the sugar-beet has become the foundation of a
great modern industry.

There are some persons, perhaps, who do not realize that beside cane
sugar many kinds of carbohydrate occur in our food. Glucose or grape
sugar, for example, occurs not only in the fruit indicated by its
name, but also in other fruits, in corn, in onions, and in the common
vegetables. Glucose is especially suited to act as nourishing food.
In keeping with that fact our digestive juices convert most of the
sugars we eat, if not all of them, into glucose, which is regularly
present in our blood. It is unnecessary to enumerate all or even the
more important compounds included in the carbohydrate group; but
everyone should know that starch is its chief member, and that after
being thoroughly digested starch enters the body as glucose and
therefore serves the same purpose as sugar.

The value of carbohydrates as a source of heat and energy may be
accurately measured, and is technically expressed in terms of a unit,
called the calorie. As the energy which our bodies require may be
estimated in the same terms, it is possible to determine whether or
not our food is equal to our wants. Very naturally the energy
requirements of any individual are influenced by his weight and by
the work he does. But we may take as a standard the results of an
extensive study of American families which indicate that women
require four-fifths as much energy-yielding food as men. It also
seems safe to conclude that a woman weighing 130 pounds who does her
own housework requires food every day having an energy-value of 2,500
calories; smaller women and those who do no work require somewhat
less. In a mixed diet the chief source of this energy--and the source
from which it is most economically obtained--is the carbohydrates.

_Fat_ yields more energy and heat than does carbohydrate, bulk
for bulk; but fat is burned by our tissues less readily. We
instinctively avoid eating a great deal of this food-stuff; in the
course of a day the average person consumes no more than one or two
ounces. The natural aversion which many feel toward fat may possibly
depend upon the difficulty with which they assimilate it. In colder
climates, however, we know fat to be a staple article of diet; and it
is not unlikely that the very conditions which make it necessary
there explain the unusual tolerance for it.

Fat is more than fuel. Deposited in our bodies, beneath the skin for
example, it prevents the escape of heat that we generate and protects
us against the penetration of cold. This food-stuff, therefore,
contributes in several ways toward maintaining the temperature of the
body at a constant level.

Our source of fat is chiefly animal food and in a smaller measure
vegetables; but the fat our food contains is not altogether
responsible for the fat in our bodies. Carbohydrates, if in excess of
momentary needs, are partly converted into fat and stored as such. A
reserve supply of nourishment is thus provided, and is drawn upon
only when the food that we consume does not contain as much energy as
we expend.

WHAT WE DO TO OUR FOOD.--With the exception of water and mineral
substances, the food-stuffs must undergo chemical alterations before
they are capable of being absorbed into the body; this is the work of
digestion. The digestive processes, the main purpose of which is to
break up the carbohydrates, proteins, and fats into substances of
much simpler chemical structure, begin in the mouth and are not
completed until some time after the food has entered the intestine.
As the food moves through the alimentary canal, it is mixed with the
various digestive juices containing ferments, such as pepsin, which
are the active agents of digestion. Although digestive processes go
on automatically, they are, in a degree that is far from negligible,
influenced by the mind. Thus, cheerfulness promotes digestion, and
not infrequently mental depression may be the direct cause of
indigestion. Indeed, it is chiefly in regard to the state of the mind
of the prospective mother that the existence of pregnancy may be said
to have a bearing, whether favorable or unfavorable, upon her
digestion.

The digestive juices are prepared in glands which lie either within
the lining of the alimentary canal or adjacent to it. In the latter
event the glands are connected with the canal by means of tubes.
These glands must be warned when to pour out their secretion, and
their very first warning usually comes from the agreeable sensations
experienced when we see, smell, or taste inviting food. If we are
hungry, our viands attractive, and our surroundings congenial, the
stimulus excites a plentiful secretion of the digestive juices;
conversely, the opposite conditions, to some extent, check their
flow.

The sight of attractive food, as we all know, "makes the mouth
water," that is, it calls forth the saliva which contains one of the
digestive ferments. Thus, at the beginning of a meal, favorable
conditions for digestion are established. The saliva, however, acts
only upon starch; and, moreover, its action upon this carbohydrate is
weak unless the food is thoroughly chewed and mixed in the mouth.
Most of us, perhaps, overlook the importance of mastication, which
not only crushes all the food-stuffs, preparing them for efficient
digestion, but also stimulates the flow of the digestive juices.
Furthermore, by thoroughly masticating our food, we know intuitively
when we have had enough, and thus avoid overeating.

In the stomach the digestion of starch is continued for a time, but
the chief work of gastric digestion concerns the proteins. They alone
are attacked by pepsin, a ferment secreted by the mucous membrane of
the stomach. Moreover, since pepsin is able to act only when an acid
is present, the gastric mucous membrane also secretes hydrochloric
acid.

Just as the digestive glands in the neighborhood of the mouth become
more active when we are conscious that desirable food is at hand, so
do the glands in the stomach. Mastication also stimulates the flow of
the gastric juice, and this flow is greater if we enjoy what we eat.
Furthermore, it has been shown that, after entrance into the stomach,
the food itself increases the flow of the digestive juices. All
articles of food are not, however, equally efficient in producing
this effect: thus meat requires more pepsin for satisfactory
digestion than bread, and consequently meat calls forth a larger
quantity of gastric juice.

Fat in all probability is not digested in the stomach; even starch
and protein are not broken down sufficiently by the time gastric
digestion is complete to permit them to be absorbed into the body.
"The value of digestion in the stomach," as Howell says, "is not so
much in its own action as in its combined action with that which
takes place in the intestine." It is even possible for satisfactory
digestion to take place without the assistance of the stomach. This
fact has been substantiated by several cases in which men have lived
for years after the stomach was removed to eradicate a disease. It is
true, nevertheless, that intestinal digestion can be performed more
economically if it begins where gastric digestion normally leaves
off.

Of the changes wrought in the food by the various digestive
processes, those which are the most profound take place in the
intestine. While the food is being moved through this organ--some
thirty feet in length--it is reduced to simple chemical fragments,
which are absorbed by the intestinal wall. Digestion in the intestine
is carried on through the agency of a number of ferments, the more
important of which are supplied in the juice manufactured by the
pancreas. The pancreatic secretion contains three separate and
distinct ferments, which act respectively upon carbohydrate, protein,
and fat. The absorption of fat, however, is materially assisted also
by the action of the bile.

A part of what we eat always escapes digestion; the unused portion,
it has been estimated, is somewhat less than one-tenth of an ordinary
mixed diet. The residue from vegetables is notably larger than the
residue from meat. The _undigested_ portions of all the food-
stuffs collect in the lowermost portion of the intestine and form a
part of the feces. Here also are gathered the _indigestible_
material we have eaten, the products of bacterial decomposition in
the intestine, and other waste substances that the body should throw
off.

HOW MUCH FOOD IS NEEDED DURING PREGNANCY?--In connection with the
development of the child we have already referred to the difference
in the purpose of the constructive processes which go on in the
earlier months of gestation and those which take place in the later
months. In a general way the first half of pregnancy is occupied with
the formation of the embryo from relatively simple structural
elements, the second half with its growth into an infant, which
acquires ninety per cent. of its substance and weight at birth after
the fifth month of embryonic development. A similar contrast may be
observed in the nutritional processes of the mother. Often, at the
beginning of pregnancy, the appetite is poor and there is
indisposition of one kind or another, with the natural result that
there is slight if any change in the mother's weight; whereas later a
period ensues when her appetite increases, her health improves, and
she gains in weight.

Since it is natural that the weight of the mother should remain
practically stationary during the early months of pregnancy, it is
clear that a diet which has previously been ample will likewise be
sufficient for some time after conception has taken place. To most
persons, however, it is not clear that the quantity of food
ordinarily eaten will suffice also during the later months of
pregnancy. On the contrary, popular opinion holds that the
prospective mother "should eat for two." It is not unimportant to
point out the erroneous character of this superstition, because
overeating during pregnancy is much more likely to provoke discomfort
than insufficient nourishment.

In order to comprehend the nutritional needs of the prospective
mother, one must keep in mind the fact that our food always serves
two purposes. These are, as we have seen, to build or to repair
tissue and to furnish heat and energy. Since these needs of the body
during pregnancy--as at all other times--are best understood when
considered in their relation to the food-stuffs which supply them, we
shall take up these various ingredients separately.

Protein, which repairs tissue and also furnishes the substance from
which new tissue is made, is used more economically during pregnancy
than when the maternal functions are inactive. As a result of this
economy the same allowance of protein which is sufficient before
conception is sufficient also during pregnancy. This fact has been
put in the clearest light by extensive observations made upon
animals. Dogs which were not pregnant, for example, have been
carefully fed so that their food should contain just enough protein
to cover the needs of the body and keep their weight constant.
Subsequently, when these animals became pregnant precisely the same
amount of protein was fed to them. The result was that they gained in
weight, and at the same time the waste products of protein they threw
off were notably diminished. Such observations, of which there have
been a large number yielding concordant results, may be safely taken
to mean that an amount of protein previously satisfactory for the
animal is also sufficient for her during pregnancy. We are forced to
conclude that protein was used more sparingly in the latter
condition--a view which has been repeatedly confirmed with regard to
human beings as well as animals. It is found, for example, that an
amount of protein competent to meet the needs of a man of a given
weight will not only provide for the wants of a woman of equal weight
while she is pregnant, but will also leave a surplus sufficient for
the growth of the fetus.

With regard to the mineral substances, likewise investigations
indicate that the "housekeeping" of the body during pregnancy
proceeds along unusually economic lines. It is not advisable,
therefore, to make any change in the diet with regard to these
substances. Attempts have been made to cut down the amount of
minerals in the food for the purpose of softening the fetal skeleton.
The success sometimes attributed to these efforts is, however, very
doubtful, for we know that the mother's tissues will be robbed of
minerals for the embryo whenever her food fails to contain them in
sufficient amount for her own needs and those of the child.
Practically speaking, the mineral content of diet during pregnancy
requires no thought, for so long as meat and vegetables are eaten in
satisfactory quantity the mineral nutrition will take care of itself.

The food-stuffs which supply heat and energy, since the amount of
energy utilized by the body during the latter months of pregnancy is
somewhat in excess of that previously required, do not follow the
same rule as the protein and the mineral matter. It has been found
that just before the fetus becomes mature the energy requirements of
the mother are approximately one-fifth greater than in the non-
pregnant condition. It is certain, however, that no extra demand for
energy exists until the fifth or sixth month of pregnancy, and that
the excessive requirement is extremely small until the last three or
four weeks. Even then the prospective mother requires less energy-
giving food than the average man.

Since the body handles carbohydrate more readily than fat, it is
preferable that whatever additional energy pregnancy necessitates
should be supplied by carbohydrates. An increase in the daily
consumption of fatty food, over and above that previously found
agreeable, is not only unnecessary but undesirable. Every-day
experience teaches that less fat taken with the meals promotes the
comfort of the prospective mother. A glass of rich milk a little
before meal time, however, not only makes up for this omission but
also prevents "heart-burn," a very common ailment of pregnancy.

Although there is an appreciable increase in the quantity of starch
and sugar utilized toward the end of pregnancy, it is generally quite
unnecessary to increase these materials correspondingly in the diet.
Nearly everyone eats more of all the food-stuffs than the body needs.
In the case of the prospective mother the surplus ordinarily taken
meets every need incident to her additional energy requirements.
Because we eat more than we need, someone has said, with as much
truth as humor, that prospective mothers "neither want nor need to
eat for two. The fact is more likely that enough for one is too much
for two." For the average woman it is wiser to take less during
pregnancy rather than more, for over-indulgence is apt to lead to
indigestion. The moment when the appetite is satisfied should be
accepted as the stopping point, and that will be instinctively
recognized if one eats deliberately, and thoroughly masticates the
food.

Regularity in the hour of eating is always healthful, and for some
prospective mothers three meals a day prove quite satisfactory. Not a
few, however, who adhere to this habit make the mistake of eating
more than is wise; and large meals are particularly inappropriate to
pregnancy. On this account most prospective mothers will be more
comfortable if they take some simple and wholesome nourishment at
fixed times between meals. Such an arrangement modifies a ravenous
appetite, and it is, at the same time, beneficial to those who are
not inclined to eat enough at the regular meals. If small amounts of
food are taken five or six times a day, a tendency to be nauseated,
which is not uncommon in the early months of pregnancy, can often be
averted. In the latter months, too, because the capacity of the
stomach is diminished through the encroachment of the enlarged womb,
frequent meals generally contribute toward comfort and health. While
the inevitable consequences of overloading the stomach are to be
avoided at all times of the day, it is especially important to
remember the disagreeable results of a hearty meal at night. The
evening meal should be a light one and should be eaten three or four
hours before going to bed.

THE IMPORTANCE OF LIQUID NOURISHMENT.--Every prospective mother
should have brought to her attention the great importance of drinking
water at regular times and in larger quantities than was formerly her
custom. Since water constitutes two-thirds of the substance of our
bodies, it is necessary, of course, for everyone; but during
pregnancy it is especially necessary for the building of new tissue
and for safeguarding the mother's kidneys. Prospective mothers would
protect themselves against a number of ailments if they were more
careful to drink a sufficient amount of liquids. They may easily
determine whether they are doing so, for whenever the urine passed
during twenty-four hours measures less than a quart, they are not
drinking enough. Generally the daily elimination of urine fluctuates
between two and three pints; a larger amount, however, is rather a
favorable indication than the reverse.

The variations in the quantity of liquids that healthy persons drink
make it impossible to say just how much anyone should take. It may be
said with confidence, however, that women who are pregnant should
consume at least three quarts of fluid every day, and by far the
greater portion of this should be water. The rest may be taken in the
form of milk, soup, cocoa, and chocolate. Against the moderate use of
tea and coffee no valid objection can be raised; the tradition that
they may cause miscarriage is incorrect. For well-known reasons the
habitual use of strong tea or coffee is always harmful, and it is,
therefore, equally as objectionable during pregnancy as at other
times. Beverages which contain a small percentage of alcohol, such as
malt and beer, may or may not be helpful; they should be regarded as
medicine, not to be taken without consulting a physician.

THE CHOICE OF FOOD.--There is no diet specifically adapted to the
state of pregnancy; the prospective mother may usually exercise the
same freedom as anyone else in the selection of food. She should,
however, choose what will agree with her and avoid that which she
cannot digest and assimilate. Personal experience in the main must
guide everyone as to what to eat, and most women may follow the
dictates of appetite after they become pregnant as safely as they did
before.

It is true, of course, that careful scientific observations have
taught not only what the nutritional requirements of the body are,
but also how the diet may be arranged to satisfy these requirements
most conscientiously and economically. "Caloric Feeding" is the name
given the method which aims to furnish an individual the exact amount
of food, and usually to furnish it at a minimum cost. Its principles
are of great practical importance to the commissary of an army or to
the purveyor of an institution which provides for large numbers of
people; but it is neither necessary nor advisable that the diet of
any healthy individual be regulated solely with a view to satisfying
the actual requirements of his or her body. Food should possess other
qualities than fuel value: first of all it must be appetizing, for
appetizing food receives the most thorough digestion.

We all know how variable are our appetites. What appeals to one will
not appeal to another, and frequently the same person has no appetite
to-day for food that she will eat with relish to-morrow. Precise
rules, therefore, to guide healthy persons in the selection of their
food are not obtainable; neither are they desirable, for the exercise
of individual preference possesses notable advantages. In order,
however, that there may not also be disadvantages, the prospective
mother, like anyone else, must be content to choose food that is
simple, wholesome, and of such a character that it will not throw an
undue burden upon the digestive organs.

During pregnancy some uncooked food should be eaten every day. Ripe
fruit answers the purpose admirably. At all seasons of the year fruit
of one variety or another, such as apples, peaches, apricots, pears,
oranges, figs, cherries, pineapples, grapes, plums, strawberries,
raspberries, and blackberries may be obtained and should have a place
in the diet. In making a choice personal taste alone need be
consulted.

Fruit contains a large proportion of water as compared with other
articles of diet; and, therefore, is especially capable of quenching
thirst. Fruit also lessens the desire for sweets, acts as a laxative,
and furnishes mineral material which the body needs. Its laxative
effect is most pronounced when it is eaten alone, as, for example, in
the morning before breakfast or at night upon going to bed; cooked
fruit taken with the meals acts much less effectively. Fruit and
vegetable salads are wholesome, but cannot be recommended
indiscriminately during pregnancy, for not infrequently the dressing
used with them causes discomfort. Under these circumstances it is
obvious that one should do without salads.

The cereals wheat, corn, rye, oats, and barley are the most prominent
source of starch in an ordinary diet. Breakfast foods manufactured
from grain are not only nutritious in themselves, but their value is
increased by the milk or cream used with them. Bread is the staple
starch-containing food in this country, and starch is our main source
of energy, but it is necessary to eat only a small quantity of bread,
if the diet includes a relatively large amount of vegetables. It is
advantageous to use bread made from unbolted flour (Graham bread) or
from corn meal, because the coarse undigested residue which they
leave stimulates the movements of the intestine and assists in
overcoming the constipation which is generally associated with
pregnancy. Pastry must be avoided by those who suffer from
indigestion; and every prospective mother should eat pastry only
occasionally, and not very much of it at any time. The best desserts
are raw and freshly cooked fruit, preserves, gelatin, custard, ice
cream, and light puddings, such as rice and tapioca.

Vegetables should be abundant in the diet of every prospective
mother. Some of them, however, are digested with difficulty, and on
this account cabbage, cauliflower, corn, egg-plant, cucumbers, and
radishes should be eaten sparingly. Occasionally it will be necessary
to exclude them from the diet altogether. Other vegetables produce
flatulence, and for that reason parsnips and beans may cause
discomfort. The prejudice, however, which exists against onions,
asparagus, and celery should not be heeded; all of them are harmless,
and celery thoroughly cooked with milk is very wholesome. Besides
these, moreover, there are many highly nutritious and easily
digestible vegetables which can be freely recommended, such as both
sweet and white potatoes, rice, peas, lima beans, tomatoes, beets,
carrots, string beans, spinach, Brussels sprouts, and lettuce.

Vegetable food contains all the material necessary to sustain life,
and some persons prefer to adhere strictly to a vegetarian diet. Most
prospective mothers, however, find a mixed diet more agreeable, and
this is sufficient reason for using it. Furthermore, no fair
objection can be raised against the use of animal food, provided the
pregnancy is normal. It is important, nevertheless, to remember that
meat contains protein in concentrated amounts, and that meat once a
day answers every need not only of the mother but also of the growing
fetus.

The ideal animal foods are milk and eggs; they contain every
ingredient necessary to repair old and to form new tissues. But
usually the prospective mother may have any animal food she wishes:
beef, veal, lamb, poultry, game, fish, oysters, and clams. The
relatively large fat-content of pork, goose, and duck renders them
indigestible for some persons, who, of course, should not eat them.

From what we have learned about foods in general and their relation
to pregnancy it is clear that the question so often asked by
prospective mothers, "Are there any special directions regarding my
diet?" may be briefly answered as follows: Under no circumstances is
the need of food increased in the first half of pregnancy. During the
last two or three months, while the most notable growth of the fetus
is in progress, there is a perceptible increase in the amount of
energy expended by the mother, and this may be readily supplied by a
glass of milk or some equally simple nourishment between meals.
Furthermore, throughout pregnancy, most women are made most
comfortable by frequent small meals; they will almost certainly
suffer discomfort if heavy meals are eaten three times a day.

The most nearly ideal diet consists of very little meat and a
comparatively rich allowance of vegetables and fruit. The food should
be chosen with regard to individual appetite and should be varied
frequently. Thorough mastication always increases the efficiency of a
diet. Thus the food will be most perfectly mixed with saliva and
broken into fragments which can be readily attacked by the digestive
juices of the stomach and the intestines.

CRAVINGS.--There is a well-known tradition that women who are
pregnant are subject to longings for one article of diet or another,
and that unless the desire be promptly gratified the child will be
"marked." In the light of what has already been said regarding
maternal impressions, this evidently is nonsense. A prospective
mother, like anyone else, does frequently desire one article of food
more than another. So long as the object of her wish is not obviously
harmful, it should be granted; but if it is not granted no harm will
come to the child.

Remarkable instances in which disgusting substances have been craved
and eaten are often talked about and have even found their way into
popular novels. The unfortunate victims of these unnatural cravings
are not of sound mind. With reference to them a physician of
unusually broad experience wrote fifty years ago, "I have never met
with any example of this sort; which leads me to infer that these
longings are more frequent in books than in the practice of our art."
This conclusion is even more fully justified to-day than when
originally expressed.

THE RELATION BETWEEN THE MOTHER'S DIET AND THE SIZE OF THE CHILD.--
With the beginning of careful, scientific study of the nutritional
problems of pregnancy, investigators were interested to learn the
source of the material which was used to build up the child's body.
Two possibilities suggested themselves: one that the material came
from the mother's food and the other that it was derived from her own
flesh. In order to determine which of these methods was the natural
one, animal experimentation was resorted to and gave identical
results in the hands of independent observers. It was found, as I
have already stated, that the same diet which had previously kept an
animal's weight constant was sufficient to meet her requirements
during pregnancy and also to provide for the growth of her offspring.
The mother animal was actually found somewhat heavier at the
termination of pregnancy than at the beginning. It seemed fair to
conclude, therefore, that nutrition had proceeded along more economic
lines, and that under these conditions the customary diet had
furnished the material for the formation of the young. Still other
observations indicated that, if the food is not sufficient for both
mother and offspring, it is Nature's plan to protect the young and
leave the mother's wants incompletely satisfied. On the other hand,
when an unnecessarily large amount of nourishment is taken, the
excess is stored partly in the young, and partly in the mother's
body.

There can be no doubt that the results of such observations upon
animals are applicable to human beings. Everyone familiar with the
practice of obstetrics knows that women who gratify enormous
appetites during pregnancy, especially if they also fail to take
exercise, give birth to large children. On the other hand, it is said
that children born during times of famine are frequently delivered
prematurely, or, if mature, they are small and puny. A similar though
much less marked contrast exists between the babies of the working
classes and the well-to-do, and clearly indicates that the weight of
the baby varies directly with the food of the mother.

The quantity of the food is more influential than its quality, though
the latter is also a factor in determining the size of the child. An
excessive amount of starch or sugar in the mother's diet is stored as
fat in the child. On this account it is reasonable to eat sparingly
of candy, cake, and other sweets; but further attempts to reduce the
weight of the fetus by discrimination against different articles of
food are not advisable.

The various theories that have been advanced with a view to reducing
the size of the child are impracticable; some of them, rigidly
carried out, would actually jeopardize the health of both beings. All
of them are designed to make the infant's bones soft and to diminish
the fat in its body. To this end, generally about two months before
the expected date of birth, the mother's diet is arranged to consist
chiefly of meat; and as far as possible she is denied candy, sweet
desserts, soup, bread, cereals, vegetables, and water. Such a diet
overlooks, among other things, the tremendous importance of liquids
to the woman who is pregnant. Certainly its indiscriminate use would
result in far more harm than good; and no one should adopt it without
minute directions from a physician.

Attempts to make the infant's bones soft by limiting the mother to
food containing extremely small amounts of lime and other minerals
are also unnatural, for we have learned that whenever the mother's
food fails to contain the material the fetus requires the mother's
tissues are called upon to supply it. Under these conditions,
therefore, her bones will give up their lime.

It is of the very first importance that the mother's nourishment be
correct from the standpoint of her own requirements, and such
treatment will also redound most beneficially to the child. She
should never fall, however, into the error of over-eating, which will
not benefit her and will cause unnecessary growth of the fetus. On
the other hand, there can be no justification for measures that tend
to weaken her. She may be careful, in other words, to avoid over-
growth of the fetus, but should not adopt a diet so restricted as to
interfere with normal development. So long as her health is
successfully maintained, she may give herself no concern as to what
the size of the child is likely to be. That is a detail which
concerns her physician, and which will be observed by him several
weeks before the expected date of birth.




CHAPTER V


THE CARE OF THE BODY

The Bowels--The Kidneys--The Skin--Bathing--Douches--Clothing--
Corsets--The Breasts.

If we stop to think it is only too apparent that the human body is a
machine. We seize energy in one form and convert it into another,
just as truly as do the windmill, the locomotive, and the dynamo. In
the case of the human machine, the latent energy of the food is
turned into the various activities of everyday life. Our bodies
utilize their fuel more perfectly than any machine that man has
invented; but they fail, nevertheless, to do so completely. And just
as the efficiency of an engine cannot be maintained unless the smoke
escapes and the ashes are raked away, so no human being can enjoy
health unless his waste products are promptly removed. The task of
removal, as most of us know, is assumed by our excretory organs,
which include the bowels, the kidneys, the skin, and the lungs.

During pregnancy the mother must get rid not only of her own waste
products, but also of those of the child. The waste products of the
child, if weighed, would not amount to a great deal; but they are by
no means negligible. So far as we can tell, it is chiefly on account
of their peculiar character that they increase the work of the
mother's excretory organs. Whatever the cause, they do increase it,
and experience has taught us that these organs must always be kept in
a healthful condition to protect both the mother and the child from
harm. Consequently a prospective mother who wishes to take proper
care of her body must, in the first place, direct her attention
toward keeping up the normal activity of all the excretory functions.

THE BOWELS.--While pregnant, nine out of ten women suffer from mild
constipation. Those who have been previously troubled with this
complaint may find it aggravated from the outset, but in most
instances it does not appear until after several months have passed.
Constipation is explained by the fact that the enlarged womb presses
against the intestines; and, as the enlargement increases,
constipation generally becomes more pronounced. No doubt there was a
time when women, perhaps unconsciously, counteracted this natural
result of pregnancy by the use of a diet consisting largely of fruit
and vegetables and also by outdoor exercise. Such measures, indeed,
still afford the simplest means of overcoming constipation.

Throughout pregnancy the bowels should move at least once every day.
When they do not, some of the waste material that should be removed
is absorbed by the body and seeks to leave it through the organs that
are already doing their full share of work. For example, under such
conditions, the kidneys, instead of exerting themselves more
vigorously, may become less active than they were.

It is everyone's duty to form the habit of having the bowels move
regularly. Now the most favorable opportunity for assisting the
intestines to empty themselves occurs shortly after meal-time, since
the involuntary movements of the intestines are most active while
digestion is in progress. It should be regarded as an imperative
duty, therefore, to grant Nature such an opportunity every morning
just after breakfast. This should be done at a definite hour, day
after day, even though the inclination is absent; and in many
instances the desired habit will be formed.

A glass of water on going to bed or on getting up has a laxative
effect; and there are other dietary measures which may be employed
with advantage. Thus, coarseness of the food, as we know, stimulates
intestinal activity, and this fact explains the peculiar value of
Graham bread, bran bread, and corn bread. Fresh fruit and vegetables
counteract constipation for two reasons, namely, because they leave
in the bowels a relatively large amount of undigested substance, and
because they contain ingredients that have a specific purgative
action. Such ingredients are especially noteworthy in rhubarb,
tomatoes, apples, peaches, pears, figs, prunes, and berries.

Enemas used as a routine measure are mischievous. They interfere with
the "tone" of the bowel-muscle so that it acts sluggishly and bring
about a condition in which the bowels will not move without
artificial stimulation. At best these irrigations remove no more than
the contents of the lower bowel, and should be employed only when
there is acute and urgent need of clearing out the rectum.

Obstinate constipation is uncommon, and strong purgatives are seldom
needed. If they become necessary, a physician should be consulted as
to what to take. Whenever dietary measures and exercise, which is
discussed in the next chapter, fail to counteract the natural
tendency toward constipation, the prospective mother may generally
resort to "senna prunes" or some equally simple and harmless
household remedy. Senna prunes are prepared as follows: Place an
ounce of dried senna leaves in a jar and pour a quart of boiling
water on them. Allow to stand two or three hours; strain off the
leaves and throw them away. To the liquor add a pound of prunes.
Cover and place on the back of the stove, allowing to simmer until
half the liquor has boiled away. Add a pint of water and sweeten to
taste, preferably with brown sugar. The prunes should be eaten with
the evening meal. The number required must be learned from
experience. Begin with half a dozen, and increase or decrease the
number, as required. The syrup is an even stronger laxative than the
prunes.

THE KIDNEYS.--Any one may judge for herself whether or not the bowels
are doing their work satisfactorily, but not so with the kidneys. For
this purpose the urine must be examined by a physician. In spite of
this fact, considerable responsibility rests upon the prospective
mother, whose duty it is to collect the specimens properly--a detail
that is apt to be neglected. It is impossible to urge too strongly
the importance of saving, at regular intervals, all the urine passed
in twenty-four hours, of protecting it from decomposition, and of
sending a sample to the physician. The intervals may be longer at
first, for the kidneys have very little extra work to do until the
sixth month. Usually, therefore, it is a satisfactory plan to send a
sample for analysis the first of each month during the early half of
pregnancy; but during the latter half one should be sent the first
and the fifteenth of each month.

To estimate the exact amount of urine passed in twenty-four hours and
to protect it properly, in the first place, the vessel in which it
will be collected should be carefully scalded out. As a further
precaution against decomposition, add a teaspoonful of chloroform to
the vessel, which should be kept covered, and not allowed to stand in
a warm room. Unless these details are conscientiously observed,
putrefaction may take place and vitiate the analysis the physician
wishes to make. The precise amount of urine which the kidneys excrete
in twenty-four hours will be determined as follows: At a convenient
time, for example at 8 A.M., empty the bladder and throw the urine
away; this marks the beginning of the observation. Subsequently, save
all the urine passed during the day and night, and finally at 8
o'clock the next morning empty the bladder and add this urine to that
previously collected. The total amount, thus collected, should be
measured.

It is unnecessary to send all the urine to the physician; six ounces,
somewhat less than half a pint, will be enough. But the physician
should know what the total amount was found to be; therefore, a
record of the measurement, the date, and the patient's name should
accompany the sample. If limited to a single fact about the urine, it
would be most helpful to know the amount passed during the twenty-
four hours. In this way, as I have already pointed out, the patient
herself may derive valuable information, for if the urine is scanty
in amount--that is, less than a quart--she should drink more water.

Unscrupulous newspaper advertisements alarm people through incorrect
statements about trouble with the kidneys. For example, they declare
that a sediment in the urine is a sign of disease; but that is false.
The mere act of cooling sometimes causes substances to crystallize
out of perfectly normal urine. Or, putrefactive changes which
frequently take place after the urine has stood for a time may cause
some of its normal constituents to be precipitated. A sediment,
either white, pink, or yellow, may indicate that the urine is too
concentrated, and consequently means that the individual should drink
water more freely; but it generally means nothing more serious. The
really important abnormal constituents of the urine, namely, albumin
and sugar, never form a sediment.

"Pain in the back" is a complaint frequently used to defraud the
public. This symptom does not indicate Bright's disease. It is
generally due to the muscles far away from the kidneys, with which,
usually, the pain has nothing whatever to do. Similarly a desire to
pass the urine frequently does not indicate any disturbance of kidney
function, but is explained by the pressure of the enlarged womb
against the bladder; it is a very annoying, yet a natural, result of
pregnancy.

THE SKIN.--The functions of the skin are at the very foundation of
health. It protects the delicate structures which it covers, assists
in the regulation of the temperature of the body, and excretes waste
products. The excretory function of the skin is always active, but we
are unconscious of this activity except on warm days and at times
when we perspire freely. In the coldest weather, however, the body
throws off what physiologists call the "insensible perspiration." The
most important measures for the care of the skin are those intended
to insure the activity of the sweat glands, namely, bathing and
proper clothing. But before considering these measures, we will
describe certain alterations in the skin which cannot escape the
notice of the prospective mother, and which she is likely to
misinterpret.

On account of the growth of the uterus the abdominal wall is
stretched during pregnancy. To a certain degree the skin yields to
the distention, but it finally cracks, and lines appear which are
commonly called "pregnancy streaks." At first they are delicate and
pink or blue in color; later they become white and more extensive.

The streaks indicate the situation of small breaks in the deeper
layer of the skin, which is less elastic than the upper layer. They
are not painful, and should never cause anxiety. Their size and
number vary with the degree of abdominal distention, which in turn
depends upon various factors, such as the size of the child and the
quantity of amniotic fluid. Although these streaks are most
frequently located upon the lower part of the abdomen, they may
extend to the outer sides of the thighs; and occasionally appear over
the breasts, since they too enlarge during pregnancy. Stretching of
the skin, of course, is not confined to pregnancy; consequently, the
same kind of streaks often appear in people who are growing stout.

Attempts to prevent or limit the pregnancy streaks prove futile.
There is a common belief that they may be prevented by the use of
vaselin, goose-grease, mutton-fat, or some one of a variety of
lotions; but this teaching is not borne out by experience. None of
these applications, however, are harmful, and there can be no
objection to using them except that they cause needless soiling of
the clothing. After the child is born the streaks fade of their own
accord, though they rarely disappear entirely.

In certain localities the skin grows darker during pregnancy. We have
already referred to the deepening of the color around the nipple as
one of the signs of pregnancy; a similar but much less pronounced
discoloration occurs about the navel, which also becomes shallow and
may begin to pout in the latter months of pregnancy. About this time,
with very few exceptions, there appears a more or less intense brown
line which runs downward from the navel in the middle of the abdomen.
Sometimes, though not very often, small dark areas, which have been
called "liver spots," appear elsewhere over the body. The name is
unfortunate, for the spots do not indicate a disorder of the liver.

At present it is generally admitted that alterations in the color of
the skin during pregnancy are due to deposits of iron. This mineral
substance, among others, as we have learned, is required for the
development of the embryo. The child is born with a supply of iron
calculated to meet its needs for about a year. Such a reserve is
necessary, as Bunge has pointed out, because human milk does not
contain enough iron to satisfy the infant's requirements. During
pregnancy, therefore, the mother's blood transports iron to the
placenta, where it can be absorbed into the child's system; and while
being thus transported some of it is deposited in the maternal
tissues. The deposits are especially frequent, as I have mentioned,
in the middle line of the abdomen, on account of the arrangement of
the blood vessels there. Deposits elsewhere may depend upon other
conditions; but whatever their cause the pigmentation vanishes a
short time after the birth.

Alterations in the color of the skin have no effect upon its
excretory function, which, indeed, generally becomes more active
during pregnancy. According to one estimate, the average person
possesses twenty-eight miles of sweat glands. If these figures are
not sufficient to demonstrate the importance of the skin as an
excretory organ, surely no one will fail to be impressed by the
tragic result which in one case followed throwing all the sweat
glands out of action. This was brought about in the case of a young
boy whose body was covered with gold leaf to provide entertainment at
a Parisian festival. The living statue was not exhibited, however,
for shortly after the youth was gilded he became ill and died.

In health more than a pint of water is eliminated through the skin
every day, and along with it waste products are removed from the
body. Exercise, hot drinks, warm weather, and heavy clothing promote
the activity of the sweat glands. Under certain circumstances
physicians endeavor to relieve the kidneys by stimulating their
patients to perspire freely. It should be clear, therefore, that when
a prospective mother naturally perspires it is a good indication.
Attempts to stop the perspiration are always ill advised; rather
should this function be encouraged by keeping the skin in good
condition with baths and warm clothing.

BATHING.--The accumulation of dead skin, grease, dust, and dried
perspiration on the surface of the body hinders the actions of the
sweat glands. Some of this material is wiped off by the clothing, and
more of it is removed by washing with plain water; but the most
effectual cleansing results from a liberal use of warm water and
soap.

Since the prospective mother must throw off the waste products of the
embryo as well as those of her own body, it is obvious that
cleanliness is never more important than during pregnancy. For this
reason she should take a tepid tub bath or shower every day. It is
not necessary that the temperature of the bath be determined with
accuracy or that it be always the same; but generally a temperature
between 80 and 90 degrees F. is found most agreeable. At this
temperature a bath is termed "indifferent," because it is neither
stimulating nor depressing; it is employed purely for cleansing the
body. Every part of the body should be well soaped, and from ten to
fifteen minutes should be given to washing all the exposed surfaces.
The best time for such a bath is just before going to bed, though
there is no objection to taking it during the day, provided that two
hours have passed since the last meal, and that another hour is
permitted to elapse before one goes out of doors or undertakes anything
that requires exertion.

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
ha

Showing first 200,000 characters. Full text: gutenberg.org/ebooks/7129