CARE IN CHILDBIRTH IN THE ABSENCE OF A PHYSICIAN.-The duration of labor averages eighteen hours in the case of the first child and about twelve hours with women who have already borne children. The time is, however, subject to considerable variations in individual instances. Moderate pain in the lower part of the back is usually the first symptom of labor, followed by severe pains, with intervals of rest, in the lower part of the abdomen. Before the child is born" the waters break," that is, the membranes inclosing the child rupture and liberate the fluid in which the infant has been floating.

A full bath should be given the patient before the beginning of labor, and the inside of the thighs, the lower part of the belly, and the parts about the entrance to the "front passage," as well as about the rectum, should be scrubbed with soap and warm water for ten minutes. The bed on which the patient is to be delivered must be supplied with clean sheets and pillow cases. It is well to protect the center of the bed by laying a comforter (or better, a rubber sheet or piece of enamel cloth) folded two feet wide, across the clean sheet, and then covering this with another clean sheet folded over the comforter and tucked in at the sides of the bed. After labor these are to be removed.

The patient should be encouraged to walk about from the first pain till the child's head begins to cause bulging of the parts about the outlet. Labor may be hastened in some cases if the patient does not cry out,

but holds her breath, braces her feet against the foot of the bed, and pulls on a sheet attached to it during the pains. This should not be practiced toward the end of labor. The hands of the attendant must be absolutely clean. After caring for the finger nails, the hands and forearms should be scrubbed with warm water, soap, and a nail brush for ten minutes and rinsed in clean boiled water.

When by frequent inspection it is seen that the child's head is so low down that the parts between the front and back passages bulge, and the head becomes visible during a pain, the patient is to be placed on her left side with her thighs drawn up against her body and a pillow between her knees, and pressure should be made by the attendant's hand against the bulging parts to prevent the expulsion of the child until the parts are properly stretched, so that they will not be torn during delivery. Tell the patient not to strain. Keep up this pressure during the pains for fifteen or, if possible, thirty minutes, when it is best to allow the child's head to escape between the pains.

When the head is born, see that the cord is not wound about the neck; untwist it if it is and support the head. If the rest of the body is not soon expelled, press and knead the lower part of the mother's belly; or, if this does not succeed after ten minutes, extract the child by gentle force, pulling steadily on the head and liberating one arm at a time. As soon as the child is born, an assistant should sit by the side of the mother,

and, pressing on the outside of the lower part of the mother's abdomen, should grasp the womb between the thumb and fingers of one hand and hold it firmly until the escape of the afterbirth.

At the earliest moment after the birth, the child's eyes should be bathed in water (which has been previously boiled and cooled), or, preferably, in a strong solution of boric acid (as much acid as the water will dissolve). Then the infant should be held upside down by the feet for an instant, while the attendant introduces his little finger into the baby's mouth and clears it of mucus or other matter interfering with breathing. The mouth and nostrils should then be gently washed, tongue and all, with warm solution of boric acid. His face should be propped up so as to prevent his inhaling any of the fluid which has escaped from the mother. A folded bunch of old muslin should be used as a temporary pillow for him, as he lies close to the mother's thighs.

The child is still attached to the mother by the cord. There is no hurry about cutting the cord until it ceases to pulsate, after which it must be tied at once at two points; at a point two inches, and at a point four inches from the attachment of the cord on the child's body.

A clean, narrow piece of tape or soft string is wound about the cord tightly and tied securely at each of these two points so as to stop bleeding after the cord is cut. The cord is then severed midway between these two points with a clean pair of boiled, sterilized

scissors. If any bleeding occurs from either cut end of the cord it should be stopped by tying another piece of tape about it.

If the baby does not cry, or breathe easily, spank it gently, and slap it on the soles of the feet. If it does not cry, and breathing is still feeble or has ceased, try immersion. In one of the bowls provided, pour hot water, about 110° F. Into the other bowl, pour cold water. Grasping the infant by the feet and hands, immerse him, all but his head, first in one bowl of water and then in the other, every few seconds. If after he has been dipped thus six times in each bowl he still fails to breathe, lay him on his back on the table, and raise his arms back over his head as far as possible, and after three seconds carry them down, flex them, and make pressure on his chest with them, just as in resuscitating a drowned person. During this process the infant must be surrounded with warm (not hot) bottles, and partially covered with dry flannel or thin, old blanket.

If artificial respiration fails, while he is still kept warm, use" mouth-to-mouth inflation." This is done in the following way: Cleanse the mouth with clean warm water. Put your little finger in the baby's mouth at one side, and hold his tongue down. Place your mouth over his closely, and blow into his lungs with your own breath, steadily and powerfully, over and over, counting six deliberately between the inflations, and compressing the lower part of his chest after

each inflation. Do not abandon this procedure under thirty minutes, unless the baby begins to breathe before this time has passed.

A blue baby is easier to resuscitate than a pallid, relaxed baby, whose heart has evidently been quiet for some time. In either case, if the color changes to a rosy hue there is a good chance of saving his life, and the inflation should be continued indefinitely. A baby who has been thus brought back to life should be examined every ten minutes during the first twelve hours of his life, and if breathing fails again, the same process of inflation should be repeated.

In ordinary cases, as soon as the cord is cut and the child is breathing and crying naturally, he should be immediately put in a warm place by his mother's side, or in a basket in a warm room, and well covered. During the time the infant is being attended to, the assistant has been compressing the mother's womb through the abdomen, and by this method preventing bleeding, and hastening the expulsion of the afterbirth. If the uterus contracts rapidly, and all bleeding ceases, the mother may at once fall asleep for a few minutes while the nurse still grasps the uterus. If over a half hour elapses after the birth of the child, and the afterbirth has not come away, its delivery may be secured by pressing with force upon the lower part of the mother's belly, kneading the womb through the abdominal walls, and squeezing the afterbirth out, but not by pulling upon the cord, which is a dangerous proceed