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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

An ample supply of Towels, Sheets, and Gowns.

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

Two slop Jars or enamel Buckets with Covers.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Anyone who supposes that patients are more likely to be infected when delivery occurs so quickly that there is not time for the doctor to arrive overlooks the leading factor in the production of this complication. Unless harmful bacteria are introduced into the birth- canal and lodge there, infection is impossible. Bacteria never enter of their own accord; they are usually carried into the vagina by means of an examining finger or some other foreign body. Accordingly, with the exception of those instances in which local inflammation already exists, there is no reason to fear infection when delivery proceeds so rapidly that internal examinations are not required.

PERSONAL PREPARATIONS.--Ordinarily, if the nurse is not already in the house, she will arrive in time to assist the patient in making the final arrangements for delivery. Should the nurse be delayed, the patient herself may make certain preparations to insure personal cleanliness, another very important factor in the prevention of infection.

The presence of hair and the folding of the skin about the outlet to the birth-canal render the disinfection of this area somewhat difficult. It is advisable, therefore, to clip the hair as short as possible and, while bathing the whole body, to scrub the region in question with especial thoroughness. Before the bath an enema of soap-suds should be taken to clear the rectum of material which otherwise might be expelled during the birth and contaminate the field of delivery. The bath-towels and the gown which are used should have been freshly laundered.

Other especial preparation of the delivery-field will be made later by the nurse. But whenever labor progresses so rapidly that neither the nurse nor the doctor arrives before the child is born, such preparations as I have indicated will be sufficient, for more minute precautions are unnecessary unless an internal examination must be made.

THE CARE OF OBSTETRICAL PATIENTS AT THE HOSPITAL.--The majority of obstetrical patients are attended at home, and there is no reason why this should not be. Generally it is unfair to urge a woman to go to a hospital if she has already passed through a normal confinement and there is no reason to anticipate trouble in the approaching one; on the other hand, if any complication whatever is anticipated, the patient should certainly enter a hospital. Furthermore, it frequently proves advantageous to do so where the pregnancy is the first, though no complication is expected and none develops. The average labor with the first child lasts somewhat longer than with subsequent ones, and in consequence there is greater opportunity for the patient's family or friends to interfere with the management of the case, which never benefits a patient, and is sometimes a serious handicap. Then again, the cramped apartments, so common in these days, are poorly adapted to the treatment of sickness of any sort and should induce many obstetrical patients to choose the hospital. There are, besides, other features which favor this course, such as economy, convenience, and safety. From my own experience, which includes the care of patients both at home and at the hospital, I am convinced that, as a rule, the latter is much more satisfactory.

Most cities now have institutions which provide a room and all the essential care, exclusive of the doctor's services, at approximately the cost of a trained nurse at home; luxuries will naturally add to the expense in hospitals as quickly as elsewhere. If one considers the various items connected with attention at home, such as the maintenance of the nurse and of the patient, the cost of the equipment necessary for confinement, the additional household laundry, and the sundry other details, it is clear that hospital treatment becomes distinctly economical. Moreover, the uncertainty of the date of confinement may necessitate paying a nurse for a longer or shorter period before the birth. Expense at the hospital, on the contrary, usually begins when the patient enters; and if she lives in the city it is rarely advisable for her to leave home until the beginning of labor. Even aside from the matter of expense some women prefer the hospital, since in this way they avoid the technical preparations for the birth.

Much more vital, however, is the care patients receive in the hospital, for rigid adherence to surgical cleanliness is exemplified in the hospital as it can be nowhere else. Infections rarely develop there. Formerly these accidents were more common in the hospital than in the home, but conditions are now reversed and fatalities predominate among those delivered in private houses. The modern theory of asepsis has, to be sure, been widely accepted and is practiced so far as possible wherever obstetrical patients are attended, but only in the hospital can the underlying principles be applied with complete thoroughness and persistence. The hospital is constantly alert, whereas in private houses carelessness or ignorance, or both, often lead to lax technique. As a result, statistical evidence indicates that two to three infections occur among those delivered at home for one at the hospital.

In the event of an emergency during labor, the hospital affords another distinct advantage in its staff of trained attendants. Of course they may be brought to one's home, yet not without some delay and extra expense; whereas in the hospital their assistance is instantly available. In institutions charity patients are often delivered under more favorable auspices than are the wealthy at their homes. Convalescence likewise is favored at the hospital, since the rules which control the admission of visitors guard the mother from exhaustion and annoyance. Moreover, isolation such as can only be secured in a hospital is conducive to a well-trained baby.

Patients debating what course to follow often ask when they must leave home, what they should take with them, and how long they ought to remain at the hospital. The attending circumstances will alter the answers to these questions, but in a general way the following directions will serve as a guide.

Ordinarily, the patient may remain at home until the first warning of labor. Departure from this rule is justified if the patient becomes unduly anxious about reaching the hospital in time, especially when she lives some distance from the institution, or if there is any doubt of securing accommodations. In either event, she should go to the hospital at least one week before the confinement is expected. There is no danger in riding to the hospital after labor has begun; frequently, the ride exerts a helpful influence and shortens the labor.

Whatever is to be taken to the hospital should be packed in a bag several weeks before the predicted date of confinement and put in a convenient place so that one may be spared the trouble of gathering it at the last minute. Beside her usual toilet articles, the mother will require several gowns, a dressing-robe, and bedroom slippers. Clothing for the child will also be needed since most institutions stipulate that the infant use its own wearing apparel. If impracticable to transport the entire wardrobe when the mother enters the hospital, so much may be taken as will be needed during the first few days, and other articles may be brought as the need of them arises. The personal laundry of both mother and infant is usually done outside the institution.

Surgical dressings of every description are provided by the hospital. Those who intend to enter a hospital, therefore, may disregard the list of articles necessary for confinement. Similarly, the sterilization, the preparations of the room and of the bed, and personal preparations will be of interest only to the patient who intends to stay at home.

It is not always possible for the physician to say how long a patient should remain at the hospital; the rapidity of the mother's convalescence and the progress of the child, both important factors, cannot be accurately foretold. Frequently, it is a good plan to remain until the infant is four weeks old, but the majority of patients are dismissed at a somewhat earlier date. In no instance, however, should the mother be allowed to leave before the infant is two weeks old. Even when given the privilege of leaving so early she will always understand that competent assistance must be provided at home, for the mother should not resume her routine duties until six weeks after the birth.

The birth of a child is an act of nature, an act generally performed as satisfactorily as any other bodily function. Birth has, however, so deep a meaning for the mother, as well as for her family and her friends, and is, above all, so vital to the future of the race, that it has naturally become the subject of many impressive superstitions. Primitive peoples have invariably embodied in their religion their views of the origin of life and the phenomena of its inception. With these mysteries Greek and Roman mythology dealt extensively, as did also the myths of the Phoenicians, the Egyptians, the Chinese, and the people of ancient India. No race, indeed, has lacked its own interpretation of childbirth, and no phase of the process has failed to have attributed to it a supernatural significance. A number of these superstitions still distress women on the eve of motherhood. To correct exaggerations and to deny many utterly false impressions of childbirth there is no better way than to give a frank account of what does actually occur. I shall adhere to a purely physiological description of the event, for, although I appreciate fully the fact that its sociological and sentimental aspects are perhaps equally important, these are not, in my opinion, pertinent to a medical discussion.

In a scientific sense the act of birth may be described as a series of muscular contractions which widen the birth-canal and expel the contents of the pregnant womb. Since the process requires an expenditure of energy, it has come to be called labor. Intrinsically, labor does not differ from many other physiological acts. The heart drives blood into the arteries; the bladder empties itself; the intestine moves its contents and finally expels the undigested residue. All these acts strongly resemble that of birth; but they also differ from it, for the head of the fetus is a hard body which resists being molded to the shape of the passageway through which it enters the world. To this resistance the pain which accompanies delivery is largely due. And yet even in this respect the act of birth is not unique; certain circumstances lead to painful contractions of the muscle fibers in the intestine and less frequently of those in other organs.

It is natural to ask what purpose is served by the pain associated with labor; and a moment's reflection will make it clear that one reason for the discomfort is the warning which it gives of the approach of birth. If the mother were not thus cautioned, she might be delivered under very awkward circumstances, and even under such conditions that occasionally the infant would perish the instant it was born. All mammals suffer in giving birth to their young, though with quadrupeds the period of suffering is shorter, for the upright posture of man has changed the shape of the pelvis, rendering birth somewhat more difficult. Anyone who observes the lower animals preparing for delivery will be convinced that they also are responding to pain, the most compelling call of nature.

That the suffering is at all essential to the mother's love for her child I cannot believe. Under certain circumstances, as for example when the Cesarean operation is performed before the onset of labor, the delivery is painless; yet I have never known a mother less devoted to her child on that account. Biology throws no light upon the relation of the "curse of Eve" to present-day confinements.

THE CAUSE OF LABOR.--It is evident that, in a general way, the muscular contractions of the womb cause the birth of the child; but before we thoroughly understand the act, science must discover what stimulates the muscle to contract. Although careful research has thus far failed to disclose the source and character of the stimulus, it has taught many properties of the contractions themselves. Their force has been measured and found to increase as the end of labor is approached; the pressure they exert varies between nine and twenty- seven pounds. We also know that the patient can neither hasten nor delay the contractions voluntarily. Strong emotions are believed to accelerate them at times, and we find a very extraordinary illustration of this effect recorded in I Samuel, IV, 19, where we read: "Phineas' wife was with child, near to be delivered; and when she heard the tidings that the ark of God was taken, and that her father-in-law and her husband were dead, she bowed herself and travailed; for her pains came upon her." On the other hand, and much more familiarly, excitement checks the contractions after they have begun. Every obstetrician has heard patients say that with his arrival the pains died down. Yet such an influence is never permanent; the contractions soon reappear, and labor advances as though no interruption had occurred.

For the artificial induction of labor, the physician has at his disposal means that resemble the method sometimes employed by nature. Suitable appliances introduced into the womb provoke contractions, and labor proceeds step by step as if the stimulus were a normal one. Nature does not, however, ordinarily employ mechanical irritation to start the uterine contractions. The initial factor is more remote and, as I have said, is not yet well understood.

Since, as everyone admits, delivery occurs with conspicuous regularity about the end of the fortieth week of pregnancy, and pregnancy corresponds, therefore, to ten menstrual cycles, some have been led to believe that labor and menstruation have a common basis. The truth of this supposition, however, must be doubtful until we know the cause of menstruation. Yet it is a matter of common observation that the uterus becomes unusually irritable about the time when the tenth menstrual period would be due. Strong purgatives administered with other drugs on or after the calculated date frequently bring about delivery, whereas previous attempts of this kind prove unsuccessful. To account for this peculiar irritability of the uterus about the fortieth-week of pregnancy, microscopical changes in its tissues have been suggested but sought in vain. Nor will the distention of the organ explain it.

A great many theories have been offered to explain the causation of labor, but they have now only an historical interest. To-day we are just beginning to learn the correct methods of studying the problem. The experience of ages has firmly established the fact that the fetus is expelled when ready to enter the world, or as we say, when it has become mature. But how does the fetus assert its maturity? There is the kernel of the matter; that is the real problem, a problem for the solution of which, happily, we possess better facilities than have heretofore existed. One solution that has been suggested assumes that the fetus loses ultimately its power to assimilate the nourishment provided through the mother's blood. In consequence, it is argued, the material which previously enabled the fetus to grow now collects-- in the maternal circulation, stimulating the womb to contract.

A part of this explanation, namely, that the material which stimulates the muscle fibers, whatever it may be, is a chemical substance and that it circulates in the mother's blood, is almost certainly true. There are, however, very weighty reasons for believing that this substance has not the character of food. A more plausible supposition is that the fetus produces this material in the course of its natural living processes, and the substance would accordingly be a waste-product.

THE COURSE OF LABOR.--The current view that labor begins in the early evening and generally ends during the night is incorrect. This impression has grown out of the fact that the whole process frequently consumes twelve hours and must in such an event include some part of the night. Statistical evidence indicates that almost as many births occur at one hour of the twenty-four as another; to be precise, only five per cent. more children are born between 6 P.M. and 6 A.M. than between 6 A.M. and 6 P.M.

As already pointed out, labor commonly begins with transient discomfort in the lower part of the back. At first the uterine contractions are far apart; they last but a moment and cause only twinges of pain. Gradually, the preliminary contractions give place to others of more definite character, which appear at intervals of five to ten minutes. Estimates of the total length of labor will vary according as one counts from the first warning or from the advent of typical contractions which we hear called "pains of the right kind." These generally continue for about four hours, and this period represents the average length of time the physician remains constantly with his patient. Estimates which include the initial symptoms are longer, varying from ten to eighteen hours. Prolonged labors are rare; and extremely short labors are also infrequent, though now and again it will be only an hour or two from the very first pain until the child is born.

To predict absolutely the length of labor for any particular patient is impossible. The averages calculated from large groups of cases have no more than a broad scientific interest; when applied to any individual they are apt to be very misleading. Thus, from statistics we should expect the first labor to be longer than subsequent ones, but we are often surprised by an unusually rapid delivery.

To facilitate description, labor is divided into stages which are conveniently designated the first, the second, and the third. During the first stage the way is prepared for the expulsion of the child; at the end of the second stage the child is born; the third stage is occupied with the separation and the expulsion of the after-birth. The progress of labor may be ascertained from time to time by means of suitable examinations. Whereas formerly vaginal examination was the only method which served this purpose, we are now acquainted with several. For example much of the information necessary for the proper management of delivery may be gained from examination of the patient's abdomen; and this may be supplemented by observations too technical to consider here.

Occasionally I have heard doctors accused of negligence because they failed to make numerous vaginal examinations. Censure of this kind generally is unjust, for discretion in limiting the number of vaginal examinations provides against infection a guarantee which cannot be overestimated. In many cases, of course, they are still invaluable toward determining what treatment should be pursued, yet they are never employed to the extent once customary. Moreover, physicians have learned to take extraordinary precautions whenever vaginal examinations must be made.

Anyone who practices obstetrics in these days appreciates how careful he must be, especially of the cleanliness of his hands. Energetic scrubbing with soap and water and the free use of antiseptics, as physicians now employ both these measures, appear ridiculous to some women who have witnessed deliveries under a less stringent regime. They may be bold enough to express their disapproval. They may remind us that many women have been successfully delivered without such care. And in this they are correct; we know that nine of every ten mothers passed through childbirth uneventfully before modern precautions were dreamed of. Such precautions as are now taken, however, are necessary to secure the safety of the tenth patient. And it is because they are anxious that all their patients shall enjoy the greatest possible security that physicians dare not omit any precaution.

Disinfection of the physician's hands does not entirely exclude the danger of infection through vaginal examinations. Although he may have been most conscientious, there is some risk of carrying contaminating material into the birth-canal from the region about the opening of the vagina. Unless that region has been satisfactorily disinfected, sterilizing the dressings and cleansing the hands may become a waste of time. Sensible patients, therefore, will never object to the preparations which the nurse is instructed to make.

THE STAGE OF DILATATION.--For reasons which are sufficiently clear, the womb must remain closed while fetal development is in progress; but under normal conditions, when this development is complete, the mouth of the womb dilates and the infant is expelled. The infant never takes an active part in its birth, although physicians once thought it did and attributed tedious labors to stubbornness on its part. The error has been corrected in medical teaching, but many persons unacquainted with the facts cling to the idea that the infant forces its own way out of the womb.

At the end of pregnancy the mouth of the womb is small, too small, often, to admit an instrument as broad as a lead pencil. It is obvious, therefore, that very radical changes must be wrought before the infant can pass. The door, as it were, must be widely opened. This phenomenon, which we call dilatation of the womb, is brought about by involuntary contractions of the muscle fibers in its wall, every point of which they draw upward. Now, the top of the womb is directly opposite its mouth, consequently the contractions inevitably pull its lips wider and wider apart. Ordinarily another factor is concerned in this mechanism. To understand the whole process we must recall that a fluid surrounds the fetus, and that this fluid is contained within elastic membranes. The uterine contractions compress the fluid, drive the membranes, like a wedge, into the mouth of the womb and spread its lips apart. Thus, to the pulling effect just mentioned, a pushing force is added. After full dilatation has been accomplished and the membranes can serve no further purpose, they rupture; as the midwife puts it, "the bag of waters breaks." The quantity of fluid which escapes will vary. Occasionally, a huge gush will drench the patient's clothing; but more often what is lost at first amounts to only a few teaspoonfuls, though small quantities of fluid often dribble away with subsequent contractions.

Although not the rule, it is by no means unusual for the membrane to rupture at the onset of labor, or at least before the mouth of the womb is fully dilated. Exceptionally, rupture occurs a few days before labor begins; and still longer intervals, though extremely rare, have been recorded. Whenever the membranes rupture prematurely, the pushing force of the uterine contractions becomes less effective, though the pulling force is never impaired. Under these circumstances, which occasion what is called a "dry labor," delivery is apt to proceed slowly, yet that does not follow necessarily, for the part of the fetus which happens to lie over the mouth of the womb may act as efficiently as the unruptured membrane would.

During the first stage, the longest of the three, the patient is comfortable between the contractions and generally interests herself in some diverting occupation. The presence of the physician can be of no assistance then, and patients rarely demand it. Usually, they are satisfied to know he is ready to come when called. It is wrong to deceive patients with various recommendations from which they will vainly expect help during this stage; their welfare is best served when they are left alone. Generally the advice of well-meaning friends will be as harmless as it is futile, yet I must emphasize that during the first stage straining to expel the fetus is ill advised. Such effort will surely be ineffective then and may exhaust the patient; in that event it becomes harmful, for she will be fatigued when she most needs strength.

Since, during the first stage, the progress of delivery is not influenced by what the patient may choose to do, she may follow her own inclinations. The average patient will be restless and will keep on her feet most of the time; alternately she will walk or stand still as one or the other happens to make her more comfortable. As a contraction begins she often seeks support, leaning upon a chair or bending over the foot of the bed, and presses with her hands against the lower part of her back. Patients may sit down or lie down whenever they wish; if so inclined they may even go to sleep.

Most patients take no food during the whole course of labor, but, if nourishment is desired, there is no reason for abstaining from it. They may always drink water as freely as they like, and may also have milk, weak tea or coffee, or broth; but alcoholic beverages should never be taken without the specific consent of the physician. This same caution applies to strong coffee and tea. If desired, crackers or toast and rice or other cereals may be eaten in reasonable quantity. For fear of vomiting a patient will occasionally be told not to partake of any food. This advice is given, not because the symptom is alarming, but to save her needless annoyance. Indeed, vomiting frequently indicates that dilatation is well advanced, and, therefore, may generally be regarded as an encouraging sign. Ordinarily a persistent inclination to have the bowels move has the same significance. On the other hand, a constant desire to empty the bladder is more prominent at the onset of labor than later.

To know the moment which marks the transition from the first to the second stage of labor can be of no benefit to the patient; but for the medical attendant the greatest interest centers about this point. Casual observation sometimes enables the physician to recognize it, for characteristically at the close of the first stage the whole picture changes. In a typical case the membranes will rupture at this instant, expulsive efforts will begin, and, as we have just learned, there may be symptoms referable to pressure. Moreover, a blood-tinged discharge, spoken of as the "show," usually makes its appearance about the same time. Since slight bleeding frequently occurs at the beginning of labor, or a little later, this manifestation, like all others, may not be implicitly trusted to indicate the end of the first stage. Such uncertainty, however, is a matter of no great consequence, for in the absence of all these symptoms the physician may, if necessary, accurately determine the degree of dilatation by an internal examination.

THE STAGE OF EXPULSION.--The term delivery has been broadly applied to include the whole of labor. More strictly, its use should be limited to the second stage, for this period alone is concerned with the actual birth of the child. Although dilatation has been completed, the uterine contractions continue, devoting their force to emptying the womb. In this they now receive assistance from the voluntary contractions of the abdominal muscles.

The second stage is very much shorter than the first; for this reason and others, too, it proves much less trying. As the child is moved downward through the birth-canal, the mother usually appreciates for herself that she is making headway; whereas in the first stage she may know of progress only through what she is told. Moreover, it is possible in this stage for the physician, by means of inhalations of chloroform, to relieve her of the pain attending the expulsion of the child.

Since the anesthetic properties of chloroform were discovered by an obstetrician who was searching for a drug with which to lessen the pain of childbirth, the facts connected with the discovery have a peculiar interest for mothers. Sir James Y. Simpson had always been anxious for some means to prevent the suffering endured during surgical operations "without interfering with the free and healthy play of the natural functions." He, therefore, welcomed the introduction of ether anesthesia from America; and in January, 1847, at the Edinburgh Medical School, administered ether to an obstetrical patient. This was the first instance in which an anesthetic was employed at the time of childbirth. Since ether, to his mind, had certain shortcomings, Simpson set about finding another anesthetic, and devoted all his spare time to testing the effect of numerous drugs upon himself. How he came to try chloroform has been vividly told by one of his neighbors. [Footnote: "Late one evening, it was the 4th of November, 1847, Dr. Simpson, with his two friends and assistants, Drs. Keith and Duncan, sat down to their somewhat hazardous work in Dr. Simpson's dining room. Having inhaled several substances, but without much effect, it occurred to Dr. Simpson to try a ponderous material which he had formerly set aside on a lumber- table, and which, on account of its great weight, he had hitherto regarded as of no likelihood whatever; that happened to be a small bottle of chloroform. It was searched for and recovered from beneath a heap of waste paper. And with each tumbler newly changed, the inhalers resumed their vocation. Immediately an unwonted hilarity seized the party--they became bright-eyed, very happy, and very loquacious--expatiating upon the delicious aroma of the new fluid. But suddenly there was talk of sounds being heard like those of a cotton mill, louder and louder; a moment more, and then all was quiet--and then a crash! On awakening, Dr. Simpson's first perception was mental--'This is far stronger and better than ether,' said he to himself. Hearing a noise, he turned round and saw Dr. Duncan beneath a chair, quite unconscious, and snoring in a most determined manner. More noise still and much motion. And then his eyes overtook Dr. Keith's feet and legs making valorous attempts to overturn the supper table. By and by Dr. Simpson having regained his seat, Dr. Duncan having finished his uncomfortable and unrefreshing slumber, Dr. Keith having come to an arrangement with the table and its contents, the sederunt was resumed. Each expressed himself delighted with this new agent, and its inhalation was repeated many times that night. Miss Petrie, a niece of Mrs. Simpson, gallantly took her place and turn at the table, and fell asleep, crying: 'I'm an angel! Oh, I'm an angel!'"--Quoted from "The Life of Sir James Young Simpson," by H. Laing Gordon; Masters of Medicine Series.]

The introduction of chloroform met with violent opposition, not upon medical grounds alone, but also for moral and religious reasons. "To check the sensation of pain in connection with the visitations of God," zealous theologians announced, "was to contravene the decrees of an all-wise Creator." Simpson reminded them "that the Creator, during the process of extracting the rib from Adam, must necessarily have adopted a somewhat similar artifice--for did not God throw Adam in a deep sleep?" Nevertheless, a number of years passed before the prejudice against artificial sleep was overcome. Chloroform only became popular after Queen Victoria consented to its use at the birth of her seventh child, Prince Leopold, in 1853.

There is still some difference of opinion regarding the routine employment of chloroform in obstetrical practice, though the weight of authority favors its use during the contractions at the end of the second stage, providing always that no preexisting organic derangement renders the drug dangerous. Under no circumstances, however, should chloroform be given in the first stage, and seldom at the beginning of the second. Prolonged administration will exert an injurious influence upon both mother and child; under these conditions it ultimately weakens the uterine contractions and delays the delivery. Such an effect must be avoided, since it would endanger the life of the child by asphyxiation as well as exhaust the mother. On the other hand, a few drops of chloroform inhaled with each pain toward the end of the second stage will dull sensibility, although consciousness remains unaffected. When the drug is thus administered, the uterine contractions are scarcely, if at all, altered, and the assistance which the patient is willing to give herself generally becomes more powerful. Should the anesthetic have the opposite effect, it must be withheld; but that is seldom necessary. As the head advances the anesthesia is deepened, and the mother sleeps soundly while the child is being born.

As long as dilatation is in progress, the patient may sit up or walk about; but with the advent of the second stage she should go to bed, for there she will be able to make the best use of the expulsive pains. The appropriate posture for delivery is still the subject of dispute, though modern views in no instance advocate the unnatural absurdities formerly supported by custom or superstition. Students of ethnology relate that among savage tribes almost every conceivable position was advocated for women in labor. Subsequently it became customary to have delivery take place in specially constructed chairs which are still used in semi-enlightened countries. With civilized nations at present women are always delivered in bed; yet national peculiarities still prevail. Some physicians favor what is known as the English position, in which the patient lies on her left side with her face inclined toward the chest, the trunk bent toward the knees, and the legs drawn up toward the abdomen. The majority of obstetricians, however, prefer that the patient should lie flat on her back. With the average case, and from the standpoint of facility in delivery, which of these postures happens to be chosen is a matter of indifference. But it is so much less awkward for the physician when the patient is on her back that this position has been widely adopted in America.

During the expulsion of the child the mother intuitively desires to help herself; generally she cannot resist straining, and rarely needs encouragement. Assisting the uterine contractions with voluntary muscular effort, the act commonly described as "bearing down," may be performed most effectively when the patient is lying on her back. The knees are drawn up and spread apart; the feet are braced against some firm object; the hands grasp straps fastened at the foot of the bed; and the head is slightly raised so as to bring the chin near the chest. When the contraction begins the patient takes a deep breath and holds it while she strains vigorously, as if to make her bowels move. All voluntary effort should cease as the contraction wears away, for straining between the contractions can accomplish nothing. Her own inclination to "bear down" will clearly indicate to the patient when she ought to act.

In the second stage patients regularly experience a feeling of pressure against the rectum, and this sensation, since it depends upon a low position of the child's head, is a welcome sign. Cramps in the legs also indicate progress, for they result from similar pressure against nerves adjacent to the lower part of the birth- canal. The cramps disappear immediately after the child is born, and are consequently never dangerous. Straightening out the legs or rubbing them usually gives relief. Most women, however, complain during the expulsive period only of pain in the back, and find nothing so grateful as firm pressure over this region.

Energetic efforts quickly bring the head to the outlet of the birth- canal, where it may be seen, at first only during the contractions, but later during the pauses as well. The crown of the child's head is generally directed upward and becomes fixed against the pubic bones of the mother, which lie just in front of the bladder. Around this firm pivot the child's head rotates upward, and, as a result of the movement, forehead, eyes, nose, mouth, and chin successively emerge from the birth-canal. Following the birth of the head, natural forces turn the body upon one side, the better to accommodate the shoulders to the passageway. After these are born, the rest of the body slips easily into the world, and the second stage ends.

THE PLACENTAL STAGE.--Although the third stage is chiefly concerned with the separation and the delivery of the after-birth, on which account it is known as the placental period, the description of other no less remarkable events belongs here. Even after the infant is born the umbilical cord extends from its navel to the placenta, just as it has done throughout pregnancy. Among larger mammals separation of the new-born from the mother is brought about in one of two ways; sometimes the activity of the young breaks the navel-string, though more frequently the mother bites it in two. Both these methods, we are told, have been employed by savages; but at the beginning of civilization it became customary to sever the cord with a cutting tool, and the tie thrown round it represents the first attempt of man to ligate blood-vessels. Ordinarily there is no need for haste in this operation. On the contrary, some delay is often of advantage, since an appreciable quantity of blood that otherwise would remain in the placenta is thus given opportunity to enter the infant's body. According to present ideas, as long as the heart-beat can be felt in the cord it should not be tied.

The sleep induced toward the close of the previous stage lasts for a few minutes, so that most patients are unconscious through the greater part of the brief placental stage. Before the influence of the anesthetic has worn off, the physician has an excellent opportunity to sew up any laceration which may have occurred in the course of delivery. Slight injuries are not uncommon, especially if the confinement be the first, for the most skillful treatment often fails to prevent them. Since superficial tears are never serious if promptly closed, it is not their occurrence, but the failure to recognize them, or to sew them up when they are recognized, that deserves condemnation.

After the birth of the child the womb becomes smaller, its walls grow thicker, and the cavity within is narrowed. This series of changes partly detaches the placenta, but the separation depends chiefly upon the uterine contractions. These contractions also force the after- birth into the vagina, whence it may ultimately be dislodged by the patient if she bears down again. Usually, however, it is preferable to save her further efforts of this kind, and, as a routine, the physician places one hand upon the abdominal wall, grasps the womb, and, during the contraction, makes firm pressure downward. The maneuver expels the after-birth, which consists of the placenta, the membranes, and the umbilical cord. Then the empty womb will form a hard, spherical mass about the size of the child's head, lying just above or to one side of the bladder.

Slight bleeding also occurs during the third stage, and further loss of blood follows the removal of the after-birth. The total loss varies between a half pint and a pint, though larger amounts may be noted occasionally without appreciable effect upon the mother. Naturally, large, robust women can spare much more blood than those who are anemic. And yet pregnancy invariably prepares the mother for a loss of blood that would alarm anyone unfamiliar with obstetrical practice. Often the woman just delivered is not harmed by a hemorrhage that would endanger the life of a healthy man. This may seem paradoxical, but it is not; for the surplus blood, which formerly performed important duties in connection with the nutrition of the fetus, must now be removed to readjust the mother's circulation.

In a very small number of cases an unduly large loss of blood follows the expulsion of the placenta. Fortunately, by treatment which consists usually in spurring Nature to more vigorous action we are well equipped to deal with this emergency. A wonderful mechanism has been provided by Nature to control excessive bleeding after delivery. If the forces upon which this mechanism depends are sluggish, the physician stimulates them. As in the preceding stages, the muscle fibers of the uterus supply the power in question, and because of this role an observant obstetrician once called them, "living ligatures." Certain of these fibers encircle the mouths of the blood- vessels which have been left open through the detachment of the placenta. When they contract the vessels are squeezed, impeding the escape of blood. The necessity of this action explains the contractions which continue even after the placenta has been expelled, when they are vigorous enough to cause discomfort they are spoken of as "after-pains." After-pains seldom follow the birth of the first child, but they regularly follow later confinements. In any case, such contractions do not persist very long, for tiny clots form within the blood vessels and effectually close them. As soon as the lining of the womb has been restored the clots are absorbed, leaving the organ in much the same condition as before conception took place.

THE EFFECT OF LABOR UPON THE CHILD.--Unless the experience of countless generations had taught us otherwise, we should fear the child would be injured by its passage through the birth-canal. Immediately after the birth evidence of the journey is seldom wanting, but it quickly disappears.

The unusual size of the infant's brain requires the head to be large, and bestows upon it a contour which differs from that of the mother's pelvic cavity. Since the bones of the pelvis are rigid, while those of the fetal skull are malleable, the head is molded as it descends into the pelvic cavity, so that its passage may be made the easier. As the result of this process of accommodation the skull becomes relatively longer from crown to chin than in adults. Within a few weeks, however, the modification vanishes. If an infant is born with the buttocks first, the head does not linger in the birth-canal, a fact which in such cases explains the pleasing shape of the skull, which emerges with the contour determined by fetal growth.

Whenever a soft swelling appears over that portion of the scalp which was foremost during the birth, the curiosity of the family is aroused; but the swelling is harmless and subsides quickly. It originates for the same reason that a finger swells if too tight a ring is worn, which, as everyone knows, is because of interference with the circulation. Just as the swelling of the finger disappears when the constriction is removed, so the swelling of the scalp subsides shortly after the child is born. Usually no trace of it can be found the next day; but even when more persistent it will always vanish after a short time.

For the child the most notable result of labor relates to the revolutionary changes in its mode of existence. Up to the time of birth the fetus received nourishment by way of the placenta, but after separation from the mother another source of food must be found. The health of the tissues, perpetually in need of oxygen, requires that the lungs act very promptly. Contact with the air, which is cooler than the previous environment of the child, irritates the nerve-endings in the skin; in response to the sensation thus produced breathing is established automatically. Whenever the temperature stimulus proves insufficient, physicians employ a stronger one, spanking the child until it cries lustily. Crying not only expands the lungs, but also has a favorable influence upon needful alterations in the fetal circulation.

The lungs, since they must from this time on provide oxygen for the infant, need to receive more blood than formerly. The vessels leading toward them must be widely opened, and structures which previously diverted the blood-stream to the navel must be closed. The intricate shifting of forces which produces the change cannot be understood without a knowledge of anatomy; it will suffice for us to know that the blood is drawn into the vessels of the lungs with each inspiration. Other changes also occur. On account of some of these, namely, certain alterations in the blood current through the heart, physicians once taught that newly born infants should always be laid upon the right side. Except in very unusual cases, that precaution is now regarded as unnecessary.

Of all the elements essential to nutrition, oxygen is the only one required immediately after birth; as the child enters the world well stocked with all the others. Babies are not born hungry, as many people seem to think. Neither is their crying a proof of it, for, as we have observed, they have other very good reasons for crying; nor is their readiness to suck anything that comes in contact with the mouth, for they will behave in the same way while they are receiving an abundance of nourishment through the umbilical cord. Many hours pass before a newly born infant can possibly need food. Indeed, it could survive a week or longer without taking anything, by mouth, except water. The ability to suckle at birth merely indicates that the infant is prepared to utilize the mechanism which nature will now employ to sustain it.

After the umbilical cord has been severed the blood vessels within it can serve no further purpose. Consequently the remnant of this structure attached to the child's abdomen begins to shrivel. Formerly the care of the stump was considered a trivial matter; when cleanliness was neglected decomposition caused more rapid separation than takes place under the treatment which it now receives. No annoyance should be felt because the cord hangs on a long time; indeed, such an experience means it has been given exceptionally good care. Separation rarely occurs before the end of a week. It may be deferred for two weeks, or even longer, if the stump has been kept perfectly clean. After the shriveled cord drops off, the skin around the navel contracts, leaving a small raw area which discharges a yellow fluid for two or three days before the healing is complete.

MEDDLING.--In selecting a physician the patient will almost certainly have been guided by her confidence in his ability. It may seem strange, therefore, to insist that he be allowed to conduct the delivery as he thinks best. Nevertheless, suggestions from outsiders are so common, especially if the labor be at all prolonged, that it seems appropriate to warn patients to pay no attention to such advice. In the heat of excitement well-meaning relatives are sometimes inclined to interfere, and women who are not members of the family occasionally wish to discuss their experiences, irrelevant as they may be.

The patient's intimate friends, quite naturally, have the keenest personal interest in the event, an interest that of itself disqualifies them from reasoning calmly at the time. Their influence may be positively harmful if they persuade the physician to undertake procedures which his judgment convinces him are inadvisable. Should he turn a deaf ear, they will think him lacking in sympathy; but should he adopt their suggestions he would assume the full responsibility, and would perhaps be censured later by the very persons whom he sought to please. There can be no question of the proper course for him to pursue. Any influence which such entreaties may have will always be in the direction of too early interference, which is fraught with danger to mother and child alike. The master- word is patience, and it applies alike to the mother herself, to the doctor, and to her friends.

Almost always the whole duty of the doctor consists in watching the progress of labor, so that he may be ready to render assistance should it be needed. Until the second stage begins there is no real necessity for him to remain in the room. Indeed, it is better for him not to do so after he has made sure that satisfactory conditions prevail, for his judgment will be less biased if the patient is not continuously under his observation.

JUSTIFIABLE INTERVENTION.--It is quite true that in the progress of the birth difficulties now and then arise; yet they are far less common than rumor would lead us to believe. The unusual always attracts attention, often receiving greater emphasis than it merits. The particulars of confinement provide no exception to this rule; a delivery which requires artificial aid will be talked about, while hundreds that terminate naturally pass without comment. In this way the public gets an exaggerated notion of the frequency of difficult labors. Moreover, the nature of the trouble is usually distorted, for reports of medical events are apt to be incorrect, and errors multiply with each rehearsal. Obstetrical patients who wish, so far as possible, to escape the depressing influence of such inaccurate reports will be most likely to succeed if they follow the advice to select a physician at the beginning of pregnancy. When this is done the physician will have opportunity to explain or discredit alarming rumors, a task which it is usually necessary for him to perform, for there are always some persons who feel that a prospective mother should listen to everything that they have heard of childbirth.

The most frequent cause for intervention during labor is insufficiency of the muscular contractions to overcome the resistance of the birth-canal. Unusual resistance of this kind explains the longer labors of women who have passed middle life before becoming pregnant. They may need to exercise more patience than younger women, though they have no greater reason to apprehend serious difficulties. Whenever rigidity of the muscles adjacent to the birth-canal arrests delivery the physician may employ the obstetrical forceps, which have been in use since the seventeenth century.

Although it is widely known that physicians sometimes terminate labor in this way, the public estimate of the merits and of the limitations of the instrument is so inexact that the truth about it should be understood. Obstetrical forceps were devised by one of the Chamberlens, a family of French Huguenots who fled to England in 1569. The invention was long kept a secret; therefore its date cannot be fixed, nor even the inventor clearly identified, though everyone agrees that he was a member of this family. Clearly the instrument had been in use for some generations prior to Hugh Chamberlen, who translated from French into English the foremost obstetrical textbook of his time. The book, published in 1672, does not contain a description of the forceps, but in his preface Hugh Chamberlen refers to delay in delivery, saying, "My father, my brothers, and myself (though none else in Europe as I know) have by God's blessing and our own industry attained to and long practiced a way to deliver women without prejudice to them or their infants in this case." It is not questioned that the forceps was the secret that his ancestors and he himself employed so long and so profitably. About a century ago what are probably the original models of the instrument were discovered in a country home of Essex which once belonged to the Chamberlens; there they had been hidden in a trunk in the garret. The box in which they were concealed contained four pairs of forceps, representing different stages in their development, besides other instruments and a number of letters which established their ownership.

After an unsuccessful attempt to sell the family secret in Paris, Hugh Chamberlen found a purchaser in Amsterdam. The privilege of using it in Holland was then granted physicians for a monetary consideration, and that practice continued until two philanthropists purchased the secret to make it public. It was ultimately learned, however, that the sale was a swindle, for the device which the purchasers obtained consisted of only half the genuine instrument. The real secret was revealed by a son of Hugh Chamberlen, who bore the same name as his father; but probably the first accurate printed description of the forceps was made by Samuel Chapman, in his treatise on obstetrics which appeared in 1733. Subsequently they came into general use, and, with many modifications, remain the most important instrument in the obstetrician's equipment. There can be no exaggeration in the claim that the instrument has done more to save human life than any other surgical appliance.

The obstetrical forceps have been of such great service in diminishing the number of still-born infants that they were once called the child's instrument. The need of its employment in behalf of the child may be determined by careful observation of the fetal heart-sounds, which are heard over the mother's abdomen, and by means of which one may learn the condition of the child. Signs of danger are extremely uncommon so long as dilatation of the womb is not complete, for any strain which labor may impose upon the child will usually occur during its passage through the pelvis. Most often, therefore, the head has reached the outermost part of the birth canal before extraction becomes advisable.

The forceps are used also on behalf of the mother, if the continuation of labor seems likely to throw undue stress upon her. On this account the physician frequently resorts to them if his patient is suffering from pneumonia, typhoid fever, or any acute illness at the time of labor. Other maternal indications for their use include various chronic derangements, well exemplified by certain diseases of the heart. Furthermore, even when there are no preexisting complications forceps are employed on account of exhaustion or other conditions which may develop during the course of labor. It must be clearly understood, however, that the physician alone can determine when intervention is justified, as well as what operative procedure is most appropriate; for even though good reasons for terminating labor exist, forceps cannot be properly used unless nature has already fulfilled very definite requirements. By no chance can the patient, much less her friends, decide this matter. And besides, none but a trained observer can detect the symptoms which clearly indicate Nature's incompetence to effect delivery. Disregard of these truths by the family with consequent urging that something be done must be held partly responsible for the reckless use of the instrument. It will be a step in the right direction, therefore, when the laity comes to understand that the value of the instrument generally pertains to the welfare of the child, and that, in any event, its use will be harmful if employed before the womb has been completely dilated.

Although forceps can be employed only in cases of head presentation, intervention may be warranted when some part of the fetus other than the head will be born first. Two or three times in every hundred patients we meet with breech presentations, that is, cases in which the buttocks precede; after their expulsion, the body, the arms, and the head follow. Breech presentations occur more frequently among women delivered prematurely, as might be expected since an examination eight to ten weeks before the calculated date reveals a larger percentage of breech presentations than a similar examination about the normal end of pregnancy. In explanation of these results we accept the view that the size of the fetus at the earlier date does not require nicety of adaptation to the cavity of the womb, whereas at term, unless the child is small, the best accommodation is secured when the head lies downward.

Most breech cases are delivered spontaneously; if not, the outlook for the mother is no less favorable on that account. Assistance, when undertaken, is usually prompted in the interest of the child, which will be seized by the legs and extracted if there are indications to terminate labor. Purely as a precautionary measure, a second physician will often be called about the time the stage of expulsion begins. Foresight of this kind must give the patient confidence rather than alarm her. Indeed, should operative intervention of any kind become necessary in the practice of obstetrics, the inclination of the doctor to call an assistant must be regarded as an evidence of superior judgment.

MANAGEMENT OF BIRTH WITHOUT A DOCTOR.--A prospective mother should not be left alone during the four weeks prior to the expected date of delivery, for it is important that during this period aid may be quickly summoned in the event of an emergency. However, if the confinement be the first, ample warning of delivery will always be given. Even in a later confinement several hours will probably elapse between the preliminary signs and the birth itself. It is extremely rare to have labor progress so rapidly that the child is born before the doctor arrives. Under such circumstances, if the nurse be present she will be master of the situation; whenever she has been unable to reach the patient, someone near by should be called to render what assistance may be needed. A labor which advances so rapidly that skilled assistance cannot be procured is proof in itself that everything is going in an ideal manner, and that interference is not necessary. Although the doctor may not arrive until after the child is born, he frequently renders valuable service in expelling the placenta or in sewing up lacerations. No one should presume then that there is never need for a physician after the second stage is over.

If the suggestions made in the preceding chapter are heeded, immediately after labor begins the room will be set in order and the bed will be properly protected; the patient will take a tub-bath and will put on a freshly laundered nightgown. The sterilized dressings are then placed where they can be easily reached, but are not opened until needed. Antiseptic tablets have been procured, and, following the directions on the bottle, it will be simple to make up a solution of bichlorid of mercury of a strength of 1-1,000.

After the contractions become strong and return at intervals of five minutes, or if the waters have broken, the patient should go to bed; the knees should be drawn up and spread apart, but bearing down with the pains should not begin until the inclination is irresistible, since this forbearance will make the delivery slower and thus afford protection against lacerations which physicians ordinarily seek to prevent by the use of chloroform. In the absence of a doctor it is never permissible to administer this or any other anesthetic. As long as a physician familiar with its action gives the chloroform untoward results need not be feared in obstetrical cases; but the risk would be too great to allow anyone to give it who was unacquainted with the early signs of an over-dose. Again, fear of accident should prevent patients from using the closet when labor is progressing rapidly, for an inclination to empty the bladder or the rectum often signifies that birth is about to take place. Even though this is true, if there is need, patients may try to use the bed-pan.

About the time when the patient goes to bed the attendant prepares to render such assistance as may be required. First she should scrub her hands thoroughly with soap and water and subsequently soak them in the bichlorid solution for five minutes, or longer if there be no need for haste. A large delivery-pad is then placed under the patient, the leggins put on, and, from this moment, the outlet of the birth-canal should be exposed to view. After the scalp of the child comes into sight, the attendant is not to leave the bed-side, though she must keep "hands off" until the head has been completely expelled.

A pause occurs between the birth of the head and of the rest of the body. It is usually safe to await further expulsive contractions, but should the child's face turn a dusky blue, which indicates that it needs to breathe, the patient is to be advised to strain vigorously and to make firm pressure over the womb with both her hands. At the same time the attendant must pull the child downward, having seized its chin with one hand and the back of its head with the other. The straining of the mother combined with traction by the attendant will be certain to effect delivery quickly. As soon as the child is born, it should take a breath and begin to cry. If it does not cry of its own accord, it can usually be made to do so by holding it up by the feet and slapping it on the back several times. Subsequently the child is placed between the patient's legs in such a way as to prevent stretching of the cord. Usually the nurse will leave it in this position and turn her attention to the mother.

After the birth of the child it is easy to feel through the mother's abdominal wall, which has now become lax and flabby, the organs which lie beneath it. The top of the womb, once just below the edge of the ribs, may now be found about the level of the uppermost part of the hip bones, a position which it keeps until detachment of the after- birth begins. As the after-birth peels off, the firmly contracted womb gradually rises in the abdominal cavity, and by the time when the separation has been completed reaches the region of the navel.

While these changes, which naturally require from ten to thirty minutes and occasionally longer, are taking place, the attendant must wait patiently; attempts to hurry the separation of the placenta are never wise, for they may lead to excessive bleeding. No effort should be made to bring away the after-birth by pulling upon the cord. It is equally unwise for inexperienced persons to press upon the womb in the hope of pushing out the placenta. To encourage the mother to strain just as she did in assisting the birth of the child would always be a safer plan. And if that is ineffective, further delay is necessary; in several instances a natural separation of the placenta has repaid me for waiting as long as two hours. Prolonged delay may be annoying, yet, provided that the doctor arrives within a reasonable time, it can scarcely lead to anything more serious than annoyance. Rather than authorize frantic efforts to remove the afterbirth, I should much prefer to have a patient of my own call another doctor.

If the after-birth comes away of its own accord, as will generally happen when due patience has been exercised, it may be severed from the child and put aside for the inspection of the doctor, for he should learn by examining it whether everything has come away properly. The cord must be securely tied in two places with the sterilized bobbin mentioned in the list of articles for confinement. One ligature is applied about two inches from the child's abdomen, the other an inch nearer the placenta; the cord is then cut between them with a pair of sterile scissors. Anyone fearful of injuring the infant may prevent accident by spreading a diaper under the part of the cord to be severed. This precaution also protects the bed from soiling, for there will be a single spurt of blood the instant the cord is cut. So long as the child is in good condition there is no urgent need of this operation. If the child is breathing satisfactorily it may generally be deferred until the doctor arrives. When this course is chosen the attendant will wrap the infant in a warm blanket, place it along with the after-birth in a safe spot, and subsequently devote herself to making the mother comfortable.

The vulva and neighboring parts are bathed with a 1-1000 bichlorid solution. Soiled dressings are removed, the gown changed, and, if necessary, clean sheets put on the bed. A sterile sanitary pad is placed over the vulva and a fresh one substituted as often as necessary, but none of the pads should be destroyed. All the dressings must be saved so that the doctor may see how much blood has been lost. As we have learned, bleeding regularly occurs while the placenta is separating and thereafter; excessive bleeding will rarely follow a normal delivery if the attendant has heeded the precaution to leave everything to nature. If ever the loss of blood should become alarming before the doctor arrives, it is advisable to raise the foot of the bed, to keep the patient quietly on her back, to grasp the womb through the abdominal wall, and to massage it constantly until the nearest physician can be gotten.

Of these directions the most important is that which relates to the management of the womb, for in cases in which labor has been normal in other respects the relaxation of its muscle is most often responsible for flooding. What to do in this event must therefore be made plain. First the patient should try to empty her bladder, and, if she cannot, pressure made above the organ will usually expel the urine. The attendant will then take her seat on the edge of the bed, facing the patient's feet, and will locate the womb. When there is flooding one may expect to recognize the womb as a large, rather soft mass lying in the mid-line of the abdomen with its upper margin somewhat above the navel. With one hand, or with both if necessary, the mass is grasped in such a way that the fingers cover the top of it and pass backward toward the spinal column; the thumb remains in contact with the front of the organ. The womb is stroked and squeezed much as one kneads dough, and for this reason the procedure is technically called kneading. Such manipulations cause the muscle fibers to contract firmly, and in consequence the blood vessels are tightly closed and bleeding ceases. Similarly, cold applications to the abdominal wall tend to provoke uterine contractions; placing over the womb an ice-cap or towels wrung out of cold water and doubled several times often have a beneficial influence when there is a tendency toward relaxation. Some physicians also recommend that the child be placed at the breast, since suckling is known to cause uterine contractions. There are other measures which are occasionally employed, but they should be used only by physicians, for in the hands of an inexperienced person they may do more harm than good.

Very often a slight chill follows labor. It has a nervous origin and need never give uneasiness; a drink of warm milk, hot-water bags to the feet, and extra blankets will be sure to make the mother comfortable. On the other hand, excitement of any kind aggravates this condition. In general, recently delivered patients must be kept quiet no matter how well they feel. A few hours of sleep, or, at least, of repose, are justified by the fatigue incident to labor, and nothing should be permitted to interfere with it.

METHODS OF REVIVING THE CHILD.--Complications which interfere with the child's vitality rarely occur when labor proceeds so rapidly that there is not time to get a doctor. Nevertheless a description of child-birth would be incomplete without reference to the measures intended to revive asphyxiated infants.

Such measures aim, first of all, to make the infant breathe for itself, and if breathing does not begin promptly we resort to artificial respiration. Mucus in the mouth or in the lower air- passages hinders the entrance of air into the lungs; consequently it is the duty of the attendant to remove this mucus by means of gauze or some light fabric wrapped about a finger and passed backward over the tongue. In most cases nothing else will be necessary. But if breathing is not immediately established, the child should be grasped by the feet with one hand and held downward while its back is vigorously slapped with the other. Usually, it gasps at once; when it does not, the attendant may stroke its face and chest with her hand, which has been previously held in cold water for a moment; or she may dash a handful of cold water upon its body. With very rare exceptions these procedures make the child cry.

One must always be alert to see the very first attempt at breathing, for unduly prolonged manipulations may defeat their own object; the natural inclination always is to do too much rather than not enough. In some instances, however, the measures thus far indicated will not prove successful, and, if not, the cord must be tied and cut through, for subsequent treatment cannot be conveniently carried out while the child remains attached to the placenta. As soon as the cord is severed the child is placed in a tub of warm water, about the normal temperature of the body, and is moved about in the bath for a few moments, the attendant watching closely all the while, for the breathing is often very superficial. Should signs of beginning respiration not appear, the attendant should grasp the child by the shoulders, dip it up to the neck in a basin of cold water and quickly return it to the warm tub. This operation may be repeated five or six times; generally the instant the child touches the cold water it draws up its feet, opens its eyes, and cries. One must take care that the plunge lasts but a moment; if the child becomes chilled efforts to revive it will likely be unsuccessful. Indeed, the necessity for keeping it warm must be constantly borne in mind.

With the very exceptional cases in which hot and cold tubs are ineffective, the following method becomes valuable. Wrap the child in a blanket and lay it face downward upon a table or chair, allowing the head to hang over the edge. Roll the body on one side or a little beyond; then slowly roll it back upon its face and onward to the other side. This maneuver is repeated fourteen times to the minute, but not more frequently. When properly performed it secures a flow of air to and from the lungs with the same rapidity as in the normal respiration of an infant. Efforts to revive the child must not be quickly given up, as a successful outcome occasionally requires half an hour of work or even longer. One method after another should be tried in the order which I have indicated. A physician always perseveres so long as the heart-sounds can be heard; but, since an inexperienced person might be unable to decide upon this point, the most reliable course for the layman is to persist in the resuscitation until the physician arrives.