CHAPTER IX

HYGIENE OF INFANTS IN GENERAL

BY WALTER REEVE RAMSEY, M.D.

ST. PAUL, MINN.

Prenatal Care. Protection of Mother and Fetus During the Period of Gestation. The old idea that the life of the child begins at birth and that its physical and mental development dates from that period is no longer tenable.

The relation between mother and fetus is so intimate during intrauterine life that the future of the infant, is often decided during the first months of pregnancy. This interdependent relation continues not only until the birth of the child, but in a measure during the period of lactation.

It is a question, therefore, of great moment how far improper nutrition, illness, body defects, occupation, etc., of the mother are capable of influencing the proper development of the fetus.

It is difficult, in most cases impossible, to determine with any degree of accuracy the effects of these influences. The most that can be done is to take certain influences, the effects of which can be accurately measured, and then base our opinion upon them by analogy.

A consideration of the hygiene of the infant should extend far ahead of the beginning of fetal life and might properly include the life history of the parents and grandparents.

It should be apparent that the least that can be taken for granted, is that both the father and the mother be healthy individuals in the broadest sense of the term in order to have a fetus develop normally and that after conception, the health of the mother be maintained at as high a point as possible.

So many factors enter into the question of what is normal and what abnormal, particularly as concerns the environment, food, occupation, mental attitude, etc., of the mother that it is difficult to be arbitrary in deciding them, as it not infrequently happens that what would be normal for one woman would, under other conditions, be abnormal for another. We shall, therefore, discuss the known conditions relative to the mother, which directly affect the fetus, and in as far as possible in the order of their frequency and importance.

Improper Nutrition. By this is meant a condition in which, without any definite pathological entity, the general physical status is below par. The woman is pale; hemoglobin below normal; the muscles flabby. She is easily fatigued, and not infrequently there is also an accompanying mental depression.

This condition of malnutrition not infrequently exists before conception and naturally with the added demand upon the system will, if not corrected, grow progressively worse.

The causes of malnutrition in the mother are usually not difficult to determine.

One of the most common causes of malnutrition in the young married woman may be found in the festivities of the prenuptial period. Excitement, over fatigue, loss of sleep, improper and excessive food frequently lay a proper foundation for a period of invalidism throughout the gestation period.

Food.-Improper and insufficient food is one of the most common causes of malnutrition. This is true particularly among the working classes, where the girls work in factories up to the time of their marriage and where there is lack of knowledge of food values and food preparation.

That a course in food values and food preparation should be given to the girls of every upper grade school there is not the faintest doubt.

During the entire period of gestation, proper food and proper elimination go hand in hand. It is not only necessary that proper food and sufficient food should be eaten, but the proportion and character of the food must vary in the individual case.

Sufficient amounts of coarse food, such as vegetables and coarse bread, should be eaten to keep the bowels regular and free. Constipation, and the consequent autointoxication attending it, are undoubtedly fertile causes of malnutrition in the pregnant woman. Further elimination of waste products should be increased by proper amounts of water, drunk preferably between meals.

Excessive meat should be avoided as it tends to derange the digestion and greatly increases the elimination of nitrogen.

Alcohol should be excluded from the diet of pregnant women and coffee and even strong tea should be drunk sparingly.

Housing.-Bad housing conditions is another fertile field for the production of malnutrition. The home of the prospective mother should be comfortable, sunny and well ventilated. Sleeping in small rooms with the windows and doors closed, resulting in improper areation of the blood from bad air, cannot fail to have a deleterious effect upon the fetus.

Occupation.-Occupation is an important factor in the nutrition of the mother and fetus.

In my work in France among the women and children I found that when the women worked in factories up to, or nearly up to, the time of their confinement, the mortality among the infants often reached 50 per cent. in the first weeks. It was found that when the women lived in the country and worked in the homes, or on the farms, the mortality among the infants during the first weeks was scarcely above 85 per 1,000 births, although the work was perhaps quite as hard, and the sanitary conditions under which they lived were quite on a par with those in the city.

If these women were taken out of the factories a month before their confinement and given proper rest and good food, their physical condition improved rapidly, with the result that the babies were born vigorous, the mothers were able to nurse them, and the mortality was reduced to a minimum.

The most ideal occupation for a pregnant woman is the ordinary duties of the household. She should perform her duties leisurely and should not be on her feet but a limited part of the time. She should spend an hour or two during the middle of the day in the recumbent position, and during the last weeks it may be necessary, if there is much disturbance of the venous circulation in the lower extremities (varicose veins), to spend much of the day in a sitting posture with the feet elevated.

Occupations which necessitate long periods being passed in standing or even sitting in cramped positions or where the air is charged with foreign substances which act as an irritant to the respiratory tract should absolutely be prohibited.

On general principles the state should prohibit pregnant women from working in factories except under the most favorable conditions. It would be much better to give women, where they are dependent, sufficient pension to keep them in the home and proper employment should be furnished for them there.

Exercise. Exercise is, however, of vital importance to the health of both the prospective mother and fetus and should be maintained up to the last days, whenever possible. Riding about in an automobile does not take the place of walking.

Mental Condition.-The mental condition of the pregnant woman probably exercises some influence upon the well being of the fetus. Just how much there is, if anything, in Maternal Impressions it is impossible to say. It would seem logical, however, that in the interest of both, the mental condition of the prospective mother should be tranquil and happy. She should avoid exciting plays and literature, and coitus should be avoided during the first and last months of pregnancy.

Physical Defects.-Many of the conditions which result in injury and death to the fetus are frequently directly dependent upon physical defects in the mother. Of these perhaps the most common are those of malformations and malpositions of the uterus. Malposition of the uterus, particularly retroversion, is a common cause of abortion in the early months of pregnancy.

Malformations of the uterus, such as bifurcation, are not rare and often result in the expulsion of the fetus before term.

Deformities of the pelvis as the result of rachitis and tuberculosis are perhaps the most common causes of injury and death to the fetus during parturition.

Changes in the normal diameter of the pelvic ring are not so necessarily fatal to the fetus since the technique of Cesarean section has been perfected, together with other surgical technique now prac

ticed by skilled obstetricians. These operations result in the saving of a majority of infants who were formerly sacrificed.

Tight lacing, thereby deforming the chest wall and crowding the abdominal organs out of their proper positions is still a source of danger to the fetus, but certainly whatever other delusions women may have regarding dress this one fortunately seems to have passed, at least for the time being, and we hope for ever.

Illness. All forms of illness, both acute and chronic, react more or less directly upon the fetus. Many of the acute contagious diseases such as Diphtheria, Scarlet Fever, and Measles, may run their course and recovery of the mother take place without any apparent injury to the fetus. Abortion, however, is common and if the disease is at all severe the fetus is liable to show the results later even if it is not apparent at birth.

Such diseases as whooping cough are particularly liable to produce abortion and the experience with the recent epidemic of Influenza (Flu) has demonstrated it to be most fatal both to mother and fetus.

Exposure to all contagious diseases should, therefore, be carefully avoided by pregnant women. They are particularly liable to infection and if infected, they run great chances of paying the penalty with their lives, or at least with the life or normal development of the unborn child.

Any inflammation of the uterus or tubes (metritis, endometritis, salpingitis, ovaritis) is apt to injure the fetus in some manner and expulsion is liable to occur before term. The one disease, however, which is responsible for more injury to the fetus and for more still births and abortions, as well as constitutional defects following birth at full term, than any other is syphilis.

Another common condition often interfering seriously with the nutrition, and sometimes the life of the fetus, is the persistent vomiting of pregnancy. It is not an infrequent occurrence that this condition is allowed to go on for months without treatment, the family believing that there is nothing to be done.

Uremia is another frequent source of injury or loss of life to both mother and fetus. The uremia may result from over taxation of the kidneys which are already diseased, or perhaps more frequently from an acute nephritis resulting from an over-taxation of the kidneys by toxic substances.

The urine of pregnant women should be examined regularly at least once monthly during the entire period of gestation and should continue to be examined daily for a considerable period after confinement as uremia not infrequently follows some days, or even weeks, after delivery.

Abortion. There are certain conditions which definitely predispose to abortion. There are, however, many other conditions which are responsible, directly or indirectly, for the death or expulsion of the fetus before term which are impossible to determine.

Ohlfield assumes that 20 per cent. of all pregnancies end in a pre

mature expulsion of the fetus. It is probable that in a large number of cases the fetus is expelled in from one to three weeks or during the following menstruation, and this without the knowledge of anyone. This may occur with, or without, the intervention of anyone in a criminal manner. As to the frequency of abortion the following table

has been prepared by Agnes Bluhm, in 100 cases:

3.34 during the first month 25.94 during the second month. 43.51 during the third month 14.64 during the fourth month

6.69 during the fifth month

From this it would seem, as has been generally believed, that the third month is particularly favorable for abortion. It is the general experience among physicians that after the third month the pregnancy is more liable to continue to term.

Of all illnesses which affect the mother, syphilis is by far the most frequent cause of abortion. With the Wassermann reaction and the early possibility of treatment the record for miscarriages becomes less and less, with a fair chance of a normal and apparently healthy fetus. Other illnesses which frequently produce abortion are Malaria pneumonia, colitis, etc.

Many abortions are produced by mechanical means, hard muscular work, in which there is much body motion and jarring.

In 100 confinements in workers, Hirchberg found 9 premature births in sewing women, 12 in stone cutters and 16 in washerwomen.

Cohabitation should be interdicted, especially around the second and third months, and more particularly among neurotic women. Psychic disturbances are common causes of abortion. Sudden fear and sometimes great excitement may produce sudden contraction of the uterus and dislodgment of the fetus and placenta.

Malpositions of the uterus, especially retro-flexion, is spoken of by many authors as a common cause. The shaking incident to automobile riding (not spoken of) is undoubtedly a common cause. The jarring from severe cough in bronchitis and especially in whooping-cough. In all such cases codeine or other opiate should be used at once.

The frequency of criminal abortion is unfortunately very frequent in this country where statistics are often undependable and there is often no way of reaching an accurate estimate. According to Doleris 50 per cent. of all abortion cases coming to the gynecological clinic are criminal.

The means employed and the necessity for secrecy result in a large proportion of women doing the abortion themselves, or in having it done by professional abortionists who are themselves incompetent persons. This results in a large number of deaths from sepsis.

Eclampsia is of course a frequent cause of abortion, resulting in a large mortality to both mother and child. In cases of eclampsia, the best treatment for the mother (narcosis) is frequently fatal to the