it should be turned round and round so that the membranes attached to it may be twisted in a cord and thus brought out of the womb. If the mother shows no signs of faintness no effort should be made to squeeze the afterbirth from the womb for at least half an hour, as pains frequently return within that time and the afterbirth is expelled without assistance from the nurse. In either case the nurse should not forget to twist the membranes into a cord, for if they are not removed in this way infection of the womb may occur. The soiled sheets should now be removed from the bed and clean ones substituted, care being taken not to raise the mother's head, after which a binder should be placed on the mother's abdomen, using a stout pillowcase for this purpose held tightly in place with safety pins. A pad of clean towels should be placed under the mother to catch the discharge and she should be allowed to go to sleep. The birth canal should not be washed out with water or any other liquid after the child is born or during the mother's convalescence. The baby should be rubbed with olive oil and given a warm bath. Its eyes should be washed with boric acid solution and a drop of a 1 per cent solution of nitrate of silver placed in each eye in accordance with the directions given on page 178. The stump of the cord should be well powdered with boracic acid covered with a pad of sterile absorbent cotton which should be held in place by small strips of adhesive plaster. THE CARE OF THE BABY.1 I. Some Important Truths. 1. It is easier, better, and cheaper to prevent than to cure disease. 2. Everything that protects the mother before her baby is born improves the health of the baby after its birth. 3. Many of the diseases observed in older children and adults begin in infancy. 4. Healthy babies make strong men and women. 5. The baby's food, home, and surroundings play an important part in keeping it well or making it sick. 6. Mother's milk is the best food for babies. 7. Cow's milk which has become infected with disease germs kills many babies. 8. Extreme heat and impure air kills many babies in the summer, especially bottle-fed babies. 9. The health and happiness of the whole househould are improved by everything done to protect the baby. 1 Prepared by a committee of the American Association for the Study and Prevention of Infant Mortality, except paragraphs on "Home Modification of Milk," ""Constipation," "Colic," and "Condensed Milk." II. General Suggestions for the Care and Feeding of Infants. MOTHER'S MILK-NATURE'S FOOD. 1. The most loving act a mother can do is to nurse her baby. When the baby nurses, it not only gets the best food, but it is less liable to many diseases, such as "summer complaint," convulsions, and tuberculosis. Out of every 100 bottle-fed babies an average of 30 die in the first year, while of the breast-fed babies only about 7 out of every 100 die in the first year. 2. Nearly every mother can nurse her baby during the first 3 or 4 months of its life, and if she can nurse it for 10 months, so much the better. 3. There may be an abundant supply of milk after the first few weeks, even if there is but little at first; the act of suckling causes the milk to come into the breasts, and increases the supply. It is very important that the baby nurse regularly. 4. If the baby is too weak to nurse, a healthy infant can be used to excite the flow of milk until the baby has grown strong enough to nurse. This should not be done without a physician's advice. 5. The only way to tell how much food the baby is getting is to weigh it before and after each nursing; for at least 24 hours. The clothes need not be removed, but the baby should be dressed in exactly the same way when weighed after nursing as before. (If the baby should soil its diaper after the first weighing do not change it until after the second weighing.) In case the baby is not getting enough breast milk, the quantity lacking should be made up by properly prepared cow's milk. Let a physician decide this. This may be only a temporary shortage on the mother's part, and with suitable care the milk will probably increase so that the baby will eventually be satisfied with the breast only. 6. The following things influence the milk supply: Peace of mind is necessary for the mother; she must not worry; she should not get overtired. She should eat freely of her customary diet. The total quantity of fluids taken by her in 24 hours should not be less than 2 quarts; in hot weather more. Stuffing, however, is unnecessary and undesirable. 7. Consumption in the mother is practically the only disease that always forbids nursing. Paleness, nervousness, fatigue, pains in the back and chest, or the return of the monthly sickness are not sufficient reasons for weaning, but when these symptoms are present or pregnancy ensues a physician should be consulted at once. 8. Shortly after birth, boiled water, without sugar, may be given. to the baby at regular intervals until the mother's milk supply is established. The baby, however, should be put to the breast at stated times, as often as the mother's condition permits. IMPORTANT POINTS TO BE REMEMBERED IN NURSING THE BABY. It is always wise to make nursing as easy as possible for the mother and to give her opportunities for rest. Therefore, the sooner the baby is satisfied and gaining on three-hour or even four-hour intervals the better. Convenient hours for nursing the baby are as follows: (1) Seven nursings in 24 hours: 6 a. m., 9 a. m., 12 noon, 3 p. m., 6 p. m., 9 or 10 p. m., and once during the night. (2) Six nursings in 24 hours: 6 a. m., 9 a. m., 12 noon, 3 p. m., 6 p. m., and at the mother's bedtime; or at 6 a. m., 10 a. m., 2 p. m.. 6 p. m., 10 p. m., and once during the night. (3) Five nursings in 24 hours: 6 a. m., 10 a. m., p. m., or later. 2 p. m., 6 p. m., 10 The baby should be offered cooled boiled water between feedings, especially during hot weather. The length of time for nursing varies with the individual and the breast. The average infant rarely nurses longer than 15 minutes. The important point is to satisfy the baby. If there is any doubt, let it nurse longer, but not more than 20 minutes. If it is not satisfied after 20 minutes, consult a physician. It is customary to nurse only one breast at each feeding, and to use them alternately. If, however, the baby does not get enough from one breast, give it both. It is important to keep the nipples clean; they should be washed before each nursing. Caked breasts or cracked nipples are the usual causes of breast abscesses, and although they may be harmful to the mother, they do not make the milk poisonous for the baby. In both instances consult a physician. In order to avoid abscess, a caked breast should be gently rubbed with olive oil. Caked nipples should be washed before and after each nursing with boric-acid solution (one teaspoonful of boric acid to a glass of hot water). III. Weaning. The baby should be completely weaned at the end of the first year. Up to this time breast milk should be given to the baby as long as it thrives. It is better, when possible, to continue nursing through the summer and to wean in the fall. It is better to wean in the summer than in the spring, if by doing so the baby can have breast milk longer. Do not wean the baby suddenly; it should be done gradually by replacing one breast feeding at a time with a bottle feeding. Several weeks are required for weaning. It is dangerous to wean a young baby. It should not be done for the convenience of the mother and should never be done without the advice of a physician. Contagious disease in the mother does not mean that it is necessary to wean the baby. In case of severe illness, contagious or otherwise, a temporary weaning may be necessary for the mother's sake. A physician should decide this. As soon as the mother's condition permits, the baby should be put back on the breast. The supply of breast milk can sometimes be brought back by putting the baby regularly to the breast for several days, even when nursing has been stopped for several weeks. IV. Mixed Feeding. When the mother's milk is diminishing it is advisable to make up the lack with properly prepared cow's milk. This may be done either by following one or more breast feedings with enough modified milk to satisfy the baby or by giving one or more full-bottle feedings in place of a like number of breast feedings. The flow of breast milk tends to diminish when the baby nurses less than five times in 24 hours. When the baby is being nursed once every 4 hours and is not satisfied, it is better to give him after nursing enough modified milk to satisfy him, rather than to replace a nursing with the bottle. If, on the other hand, shorter intervals and more feedings are being used, a bottle feeding may take the place of a nursing without so much danger of decreasing the milk supply. Most babies need additional food after the seventh month. V. Bottle Feeding. Cow's milk is the most satisfactory substitute for mother's milk. The best milk (this does not mean the richest milk) is none too good. Get "certified" milk if possible. If you can not obtain certified milk, get the cleanest and purest bottled milk you can find. Milk sold in bulk, or bottled from the can in stores, or by milkmen in their wagons, is likely to be stale and contaminated and not a proper food for the baby, even though it looks and tastes good. "Baby foods" and condensed milks and the like are not satisfactory substitutes for good cow's milk and often harm the baby. Raw milk may carry the germs of tuberculosis, scarlet fever, tonsillitis, diphtheria, typhoid, and other communicable diseases. Unless the milk is above suspicion, danger should be prevented by proper pasteurization of the milk or by boiling or by sterilization. Pasteurization.-Pasteurization means heating the milk to about 150° F. for 30 minutes and then rapidly cooling it. Milk for the baby should always be pasteurized in the feeding bottle. It may be done as follows: The milk should be mixed and poured into the clean feeding bottles, which should then be stopped with clean nonabsorbent cotton. It is then ready for pasteurization. While a number of satisfactory pasteurizers may be bought in the shops, a home-made pasteurizer can be easily constructed. Take a wire basket that will hold all the nursing bottles for 24 hours and place this basket containing the bottles in a vessel of cold water filled to a point a little above the level of the milk. Heat the water and allow it to boil for five minutes. Then run cold water into the vessel until the milk is cooled to the temperature of the running water. The milk is then put into the ice chest, which should be not warmer than 50° F. Sterilization.-By sterilization of milk is meant the process of rendering it germ free by boiling it on 3 successive days or by keeping it for 15 minutes under pressure at a temperature of 242° F. Boiling.-Milk is boiled for one or two minutes in a large vessel and poured immediately into the sterilized bottles, stoppered with cotton, FIG. 78.-Pasteurizer for infant feeding bottles that can be rapidly cooled in running water, and put on the ice. This destroys all living bacteria, but not spores or eggs, which will not do harm unless the milk is kept too long after boiling. It should be used within 24 hours. If the baby's milk is to be mixed with other ingredients, such as oatmeal, barley water, rice water, sugar, etc., these should be added to the milk before pasteurization, boiling, or sterilization. When the milk is once prepared the bottle should not be opened until it is given to the baby. Home modification of milk.-A mother should nurse her baby whenever it is possible, but in case of her death or severe illness it becomes necessary to provide other food for the baby. Some mothers are unable to supply enough breast milk and the nursing has to be |