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The document promotes the book 'Keeping Employees Accountable for Results: Quick Tips for Busy Managers' by Brian Cole Miller, which provides practical strategies for managers to enhance employee accountability and productivity. It outlines a SIMPLE approach consisting of setting expectations, inviting commitment, measuring results, providing feedback, linking to consequences, and evaluating effectiveness. Additionally, it includes links to download the book and other related resources.

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100% found this document useful (1 vote)
16 views

Keeping Employees Accountable for Results Quick Tips for Busy Managers 1st Edition Brian Cole Miller - Read the ebook online or download it to own the complete version

The document promotes the book 'Keeping Employees Accountable for Results: Quick Tips for Busy Managers' by Brian Cole Miller, which provides practical strategies for managers to enhance employee accountability and productivity. It outlines a SIMPLE approach consisting of setting expectations, inviting commitment, measuring results, providing feedback, linking to consequences, and evaluating effectiveness. Additionally, it includes links to download the book and other related resources.

Uploaded by

ajijivoinea62
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Keeping Employees Accountable for Results Quick Tips
for Busy Managers 1st Edition Brian Cole Miller Digital
Instant Download
Author(s): Brian Cole Miller
ISBN(s): 9780814473207, 0814473202
Edition: 1
File Details: PDF, 3.55 MB
Year: 2006
Language: english
Keeping Employees
Accountable
for Results

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PAGE ii

Keeping Employees
Accountable
for Results
Quick Tips for Busy Managers

Brian Cole Miller

American Management Association


New York • Atlanta • Brussels • Chicago • Mexico City • San Francisco
Shanghai • Tokyo • Toronto • Washington, D.C.

................. 15602$ $$FM 10-18-05 11:21:28 PS PAGE iii


Special discounts on bulk quantities of AMACOM books are
available to corporations, professional associations, and other
organizations. For details, contact Special Sales Department,
AMACOM, a division of American Management Association,
1601 Broadway, New York, NY 10019.
Tel.: 212-903-8316. Fax: 212-903-8083.
Web site: www.amacombooks.org

This publication is designed to provide accurate and authoritative


information in regard to the subject matter covered. It is sold with the
understanding that the publisher is not engaged in rendering legal,
accounting, or other professional service. If legal advice or other expert
assistance is required, the services of a competent professional person
should be sought.

Library of Congress Cataloging-in-Publication Data


Miller, Brian Cole, 1956–
Keeping employees accountable for results : quick tips for busy managers /
Brian Cole Miller.
p. cm.
Includes index.
ISBN 0-8144-7320-2
1. Performance standards. 2. Goal setting in personnel
management. I. Title.
HF5549.5.P35M55 2006
658.3⬘125—dc22
2005024601

䉷 2006 Brian Cole Miller.


All rights reserved.
Printed in the United States of America.
This publication may not be reproduced,
stored in a retrieval system,
or transmitted in whole or in part,
in any form or by any means, electronic,
mechanical, photocopying, recording, or otherwise,
without the prior written permission of AMACOM,
a division of American Management Association,
1601 Broadway, New York, NY 10019.
Printing number
10 9 8 7 6 5 4 3 2 1

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CONTENTS

Acknowledgments ix
Introduction: The SIMPLE Approach to Accountability 1
Chapter 1. SET EXPECTATIONS 7
Step 1. Determine what your organization wants to
accomplish. 7
Step 2. Determine what part of your organization’s
success is your team’s responsibility. 13
Step 3. Determine what part of your team’s results you
will hold each individual accountable for. 14
Step 4. Determine who should write your employees’
goals. 16
Step 5. Use SMART to define each employee’s
responsibilities with goals that are Specific. 19
Step 6. Use SMART to define each employee’s
responsibilities with goals that are Measurable. 22
Step 7. Use SMART to define each employee’s
responsibilities with goals that are Action-
oriented. 26
Step 8. Use SMART to define each employee’s
responsibilities with goals that are Realistic. 29
Step 9. Use SMART to define each employee’s
responsibilities with goals that are Time-bound. 32
Checklist: Set Expectations 35
Chapter 2. INVITE COMMITMENT 37
Step 1. Be prepared to explain to your employees why
their goals exist. 37

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vi Contents

Step 2. Be prepared to explain to your employees what


is in it for them if they reach their goals
successfully. 39
Step 3. Get ready for your discussion about goals with
your employees. 46
Step 4. Present or discuss the goals with your
employees. 49
Step 5. Seek buy-in or commitment to the goals. 52
Step 6. Document their agreement to meet their goals
in a Performance Plan. 57
Example: Performance Plan 59
Checklist: Invite Commitment 63
Chapter 3. MEASURE RESULTS 65
Step 1. Make sure the measurement tools you use are
efficient. 65
Step 2. Make sure the measurement tools you use are
fair. 67
Step 3. Make sure the measurement tools you use are
simple. 69
Step 4. Use and share the data as soon as it is available. 71
Step 5. Implement the measurement tools and gather
the data. 72
Step 6. Compare the actual results you measured to the
goals. 74
Step 7. Identify the organization’s gain or loss due to
your employees’ actions. 75
Checklist: Measure Results 77
Chapter 4. PROVIDE FEEDBACK 79
Step 1. Motivate yourself to offer feedback. 79
Step 2. Determine when to deliver your feedback. 82

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Contents vii

Step 3. Set the stage for a positive interaction. 83


Step 4. Be specific about what you observed. 84
Step 5. Focus on the behavior or action, not the person
or attitude. 89
Step 6. Never use the word but. 92
Step 7. Explain the impact on the organization. 94
Step 8. Understand your employees’ perspectives. 96
Step 9. Offer a suggestion, if appropriate. 98
Checklist: Provide Feedback 104
Chapter 5. LINK TO CONSEQUENCES 107
Step 1. Determine what consequence(s) should apply. 107
Step 2. Remind your employee of his prior
commitment. 109
Step 3. Spell out what action you will take and why. 111
Step 4. Own the action you are taking. 114
Step 5. Agree on a specific action plan. 116
Step 6. Set a follow-up date and stick to it. 119
Step 7. Offer your support. 121
Step 8. Document the discussion. 123
Example: Link to Consequences Discussion 125
Example: Link to Consequences Documentation 128
Checklist: Link to Consequences 129
Chapter 6. EVALUATE EFFECTIVENESS 131
Step 1. Hold yourself accountable for what you
accomplished. 131
Step 2. Hold yourself accountable for how you
accomplished it. 132

Index 137

About the Author 145

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PAGE viii
ACKNOWLEDGMENTS

Thank you to the busy managers and professionals who took time
to read my manuscript and give me such valuable insight and feed-
back, including Rachel Cope, Lynn Jackson, Chris Kennedy, Dean
Miller, Alex Rodriguez, Wendy Shaw, and Dawn Snyder. Also,
thank you, Adrienne Hickey, for your patience and understanding
through the rough times.
Thank you, Lisa Alexander, for demonstrating to me how to receive
feedback. I’ve never met anyone so addicted to it!
Thank you, Wendy Shaw, for showing me that measurement mani-
acs can be such fun people!
Thank you, Patty Skerritt, for showing me how this stuff works in
the real world. You are one great manager!
Thank you, Garbage. I listened to you constantly while I wrote. I
bet you never imagined your music could inspire someone while
writing a business book!
Thank you, Chris Kennedy, for teaching me several important les-
sons about accountability. And thanks for believing in me, my
friend!
Thank you, Lynn Jackson, for caring enough and having the cour-
age to give me that extremely difficult feedback about the flow of
my third (and what I thought was last) draft. I love you, Sis!
A special thank you goes to my family—Logan, Heidee, Benjamin,
Gail, Wayne, and Dean. Your support, encouragement, and confi-
dence simply overwhelm me!
And most of all, thank you, Tim.

ix

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PAGE x
Keeping Employees
Accountable
for Results

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PAGE xii
INTRODUCTION

This book is written for the busy manager who wants to maximize
employee and team productivity through accountability.
The principles in the book are not exclusively for the busy man-
ager, however. Anyone can use them with a boss, peers, vendors,
consultants, and business partners. You can even apply them out-
side the job. Use them to hold contractors, lawyers, designers, com-
munity leaders, mechanics, your teenagers, and just about anyone
else in your life accountable.
While this book includes a process, several pieces can be used
separately. For example, providing feedback is useful in many other
day-to-day activities. Praise your son’s success in school, recognize
your niece’s efforts in her lacrosse game, or complain to a restaurant
manager about poor service.
What You Can Expect from This Book
Heavy on application, light on theory, this book focuses on how-
tos. It includes steps, tips, and examples throughout. You’ll learn
what to do, when to do it, and how to do it. What you won’t find
is a lot of theory. I’ve included just enough to validate the how-tos
but not enough to make you an expert on the subject. Busy manag-
ers don’t have time for that. ‘‘Just give me what I need to get the
job done!’’ is what I hear most from my clients, whether large or
small, for-profit or not-for-profit.
In each chapter here’s what you’ll see (and not see):
● Lots of examples. Wherever possible I’ve shown one or more
examples of the particular step or point. Most of them are
from real companies or real-life experiences.
● Some theory, but not a lot. I’ve included just enough to help
the steps make sense, and to justify their order.
● Not every possibility is covered. If it were, this book would be
several volumes long. I’ve covered the most common circum-

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2 Keeping Employees Accountable for Results

stances. If yours are different, either ask someone for help


(you can call me at Working Solutions) or get one of those
long, drawn-out books.
● An easy-to-read format. It highlights the basics so that you
can easily skim past stuff you already know.
● Details when you need them. You can delve deeper when you
want more specifics and go right back to a higher level when
you’ve had enough.
● A conversational style. It’s simple and makes for a quick read.
The SIMPLE Approach to Accountability
Accountability is a process that consists of six principles. Each prin-
ciple builds on the previous one.
S ⳱ Set Expectations. Your employees need to know what is ex-
pected of them before you can hold them accountable for anything.
You can’t assume they know what is supposed to be done, when, or
to what quality level. The more clearly you set expectations and
goals up front, the less time you will waste later clarifying—or
worse, arguing—about what was really expected.
I ⳱ Invite Commitment. Just because your employees know what
to do doesn’t mean they will do it. After they understand what the
goals and expectations are, they need to commit to achieving them.
They are more likely to do this when they buy in to two things:
how the goals will benefit them personally, and how the goals will
help move the organization forward. When this connection is
made, they will commit to the goals. They will welcome your hold-
ing them accountable for their results.
M ⳱ Measure Results. You need information to hold your employ-
ees accountable. You will measure their performance so that you
can gauge whether they’ve met the goals and expectations that they
committed to. Goals aren’t measurable unless they are quantifiable,
and all goals can be made quantifiable. Measure the results and
compare them to your employees’ goals to find the gaps that require
further attention.

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Introduction 3

P ⳱ Provide Feedback. Share the information you’ve gathered


with your employees. Feedback doesn’t solve problems by itself. It
opens the door for problem-solving discussions and follow-up ac-
tions. Your employees cannot do a good job without feedback, and
they certainly can’t improve without it. Most of the time, giving
feedback is all it takes. Setting expectations followed by quality
feedback is the backbone of holding someone accountable for re-
sults.
L ⳱ Link to Consequences. Sometimes your employees will need
a little more help to live up to their commitments. When they
struggle to reach their goals, you can help them by administering
appropriate consequences. Don’t confuse consequences with pun-
ishments, though. Punishments are inflicted on employees to make
them pay for their shortcomings. They do not contribute to a solu-
tion. Consequences, however, will guide and focus employees’ be-
havior and encourage them to take their commitments more
seriously.
E ⳱ Evaluate Effectiveness. After you have worked with the princi-
ples of accountability for a while, you need to evaluate how your
efforts have paid off. Determine if you were successful at holding
your employees accountable to reach the goals that were set. And
in the spirit of continuous improvement, review how you handled
the process. Find ways to be more effective at applying the princi-
ples of accountability. Hold yourself accountable for holding others
accountable!
Each chapter covers one principle of SIMPLE. Each principle is
divided into several how-to steps. Each step is presented in the same
easy-to-read (and even easier-to-skim) format:
THE STEP describes what the step is in one sentence.

THE REASONS section explains why the step is important.

THE BASICS section covers the highlights of how to do the step or


the essentials to keep in mind while doing it.

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4 Keeping Employees Accountable for Results

THE DETAILS section delivers all the background information about


the step, substeps, examples, variations of the step, and things to be
cautious about.
At the end of each chapter is a CHECKLIST that will give you the
highlights of what is covered in that chapter. Use this to make sure
you understand all the main points before moving on.
How to Use This Book

◆ This book is organized so that you can readily get as much or


as little information as you want. You can skim at a high level
without missing the essentials. Just read the Steps, Reasons, and
Basics in each chapter. When something grabs your attention, it is
easy to dive deep into the Details right there.
◆ Examples are spread throughout the book. They are displayed
in a way that makes it easy to pick them out quickly. Generally,
they illustrate the point being made in the text preceding them.
There is a long example at the end of Chapter 2. It shows the
conclusion of all the work done in chapters 1 and 2. The other long
example is at the end of Chapter 5. This one demonstrates how
several steps in chapters 4 and 5 might be used together in a real-
life situation.
◆ This book is written as a process, but several pieces of that
process can stand alone. For example, you can apply the principles
of SMART goals to business planning, project management, em-
ployee development planning, personal goal setting, succession
planning, and more.
◆ This book will not help you much with your superstars. If you
want to manage your superstars better, get a book about rewards
and recognition. That said, is this book all about problem employ-
ees? Not really. Sure, you will learn how to deal with those problem
employees. But more important, this book is about helping you set
your employees up for success so that none of them ever becomes a
problem employee!

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Introduction 5

◆ This book outlines an ideal process that may not always jibe
with the real world you live in. I recognize this and realize that you
may not be able to follow every step presented here. I considered
trying to anticipate every possible contingency and addressing it.
Rather, I chose to trust that you wouldn’t have the title ‘‘manager’’
if you didn’t already know how to adapt or go with something that
was less than a perfect fit.
Use the steps as a model or a pattern to follow when they make
sense for you. Adjust your approach when they don’t pertain. I have
confidence that you, Busy Manager, can take what is relevant and
use that to become an even better manager.

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PAGE 6
CHAPTER 1

✓Set Expectations

The success of any organization comes down to one thing: how


well it organizes its members to focus on and work toward the same
purpose. Assuming an organization knows what that thing is, and
communicates it well, your staff members should be focused on
doing their part in that effort. If your staff members don’t contrib-
ute to that aim, they’re probably not doing the right work!

Step 1. Determine what your organization wants


to accomplish.
The Reasons
Everything done anywhere in the organization should link back to
what it has declared is its most important work. So start at the
top. Organizations use different methods to identify what’s most
important—missions, visions, strategies, objectives, goals, and val-
ues are the most common. Each has a slightly different meaning
and a slightly different emphasis that will help you get clear about
the focus of your organization. Your organization’s focus doesn’t
merely set the context for holding your employees accountable; it
should drive it!

The Basics
1. Review all of your organization’s mission statements, vision
statements, values, strategies, goals, and objectives.

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circulation through it, returns by the umbilical vein directly to the
heart. The circulation continues until respiration is established,
when it ceases spontaneously, and any interruption of it, before the
latter process has commenced, is immediately fatal. From these facts
we are warranted in inferring that a change necessary to life
(probably oxygenation) is produced in the placenta, although the
nature of that change is obscure, and the relative properties of the
blood in the umbilical arteries and veins not at all known. That the
organ in question not only revivifies the blood, but also elaborates
new vital fluid, thus performing a function analogous to that of the
stomach, can only be inferred from the absence of any other source
from whence the fetus could obtain materials for growth and
support.”
THE MEMBRANES.
These are expanded from the edge of the placenta, in connection
with which they form a complete involucrum of the fetus and waters,
and at the same time a lining for the uterus. The membranes grow
and expand in the same proportion as the fetus, and when expelled
after the birth has taken place, are, in connection with the placenta,
termed the secundines.
There are three of these membranes, which are found surrounding
the fetus. “There is first the outer, or connecting membrane, which is
flocculent, spongy, and extremely vascular, completely investing the
whole ovum, and lining the uterus; secondly, the middle membrane,
which is nearly pellucid, with a very few small blood-vessels
scattered over it, and which form a covering to the placenta and
funis, but does not pass between the placenta and uterus; thirdly, the
inner membrane, which is transparent, of a firmer texture than the
others, and lines the whole ovum, making, like the middle
membrane, a covering for the placenta and funis. With the two last
the ovum is clothed when it passes from the ovarium into the uterus,
where the first is provided for its reception. These membranes, in the
advanced state of pregnancy, cohere slightly to each other, though in
some ova there is a considerable quantity of fluid collected between
them, which being discharged when one of the outer membranes is
broken, forms one of the circumstances which has been
distinguished by the name of by, or false waters.”
It seemed necessary that I should make these preliminary remarks
concerning the physiology of the placenta and the membranes, in
order that you might the better understand the third process of
labor, or that which consists in the expulsion of these growths, the
secundines, as they are called.
I have now some practical remarks to make, which I hope you will
study faithfully, for it not unfrequently happens that a child is born
before you can obtain the assistance of a physician; and after the
child has been expelled, what to do in reference to the after-birth;
that is a question which, under such circumstances, puzzles your sex
more a great deal than it need or ought to do.
Suppose, then, that a child is born suddenly, or at least before the
medical man or woman whom you would employ, comes to your aid,
and the placenta remains undelivered.
I shall tell you, in another place, not to be in such a flurry, as
women too often are, in regard to separating the umbilical cord. So,
too, I say in regard to the after-birth; be in no hurry.
Have you not often heard people say that the after-birth has grown
fast and sticks? Women sometimes say this, and so do the doctors,
some of them; such, for example, as are not honest enough to tell the
truth, if they know it, and would make you believe that they are
doing a great thing when they get away the after-birth, if it sticks.
Now please remember that it is right that the placenta should grow
fast to the womb; that is, to its inner surface. It is always grown fast,
and should be; but it is possible for it to adhere more firmly in some
cases than in others; and in some cases, too, the uterus seems to be
so weak that it has not power sufficient to expel it.
In cases when the womb is very active after the birth of the child,
the placenta may be expelled very quickly.
But it is more commonly the case that after the uterine
contractions have forced the child into the world, the womb reposes
itself for a half hour, less or more. After this, periodical pains begin
to occur, so that the after-birth may be completely thrown forth into
the world; but far oftener it is either wholly, or in part only, into the
vagina, where it remains for a time at least.
At what time, and under what rules, should manual aid be
administered in helping away the after-birth? By different
practitioners different rules have been instituted. A rule of Dr.
Hunter’s was to wait till four hours after the birth of the child. If the
placenta come away of itself, before this time have elapsed, it is well;
but if, on the other hand, it still remain in the cavity of the uterus,
manual aid may become necessary.
Another rule is, to judge by the pains, without any regard to the
length of time that has elapsed since the delivery of the child; pains,
it is said, accompany the contractions; the contractions expel the
placenta; the pains, therefore, indicate the time at which artificial
assistance should be interposed.
Another rule is, first to determine the situation of the womb before
any manual attempt is made for helping away the after-birth. If, on
examination, the placenta is found lying in the upper part of the
vagina, and through the os uteri, and more especially if the union of
the umbilical cord with the placenta can be felt, it is considered
proper to remove it. But if the umbilical cord ascend high into the
womb, and no part of the placenta can be felt, it is considered best to
wait.
Still another rule is, to act according to the feeling and condition of
the uterus, without any regard to the length of time after the birth,
the pains, or the situation of the placenta. If, on examination
externally, it is found that the womb is yet large, uncontracted, and
pulpy, the placenta should not, according to this rule, be interfered
with. But if, on the other hand, there is an opposite state of things—
that is, if the uterus is found hard and contracted, feeling like a
child’s head in the abdomen, and if it remain so for some time
permanently, it is considered safe and best at once, in a proper
manner, to remove the viscus. A skillful practitioner will bear in
mind all these circumstances, and form a rule out of all of them, as it
were, to guide him in each individual case; and I wish you to
remember, that although you may consider the principal part of
delivery is accomplished at the time when the child comes into the
world, it is to be remembered that its real danger has not yet
commenced, and that the birth of the placenta is a most important
part of the process.
Into all the niceties and difficulties of this part of the accoucheur’s
art, I do not, you will remember, attempt to induct you. It is my
object to give you some general ideas of the matter, such as may be of
use to you in an emergency, and prevent a great deal of unnecessary
anxiety and alarm in some cases. My remarks will also, I trust, go to
impress upon your minds how very necessary it is, under such
circumstances, to have the aid of a physician—a man or woman, I
care not which—who understands well the art. You may say that
nature is sufficient in most cases to perform her own tasks unaided
and alone. That, I admit, may all be true, especially with those who
have good constitutions, and who observe well the laws of life. But
remember that these circumstances do not always exist. Any one of
you would rather incur the expense of having a physician a thousand
times, when he is not needed, than to suffer danger for his want in a
single instance.
OF FLOODING AFTER DELIVERY.
Hemorrhage is one of the most dangerous of all circumstances
connected with labor. Fortunately, however, this does not often
happen; and in those cases when it does occur, it may generally be
very soon arrested, provided the proper means are adopted.
This form of uterine hemorrhage not unfrequently occurs when
the physician is absent. For this reason, it is necessary that I should
make some remarks on the subject.
Flooding may be either external or internal. When the blood
passes from the vagina, we call it external; when it does not thus pass
off, but remains within the cavity of the uterus, causing the abdomen
to swell and the patient to faint, we call it internal.
Here is a remarkable fact in nature. Women, in consequence of
possessing the menstrual function, and being exposed to the
accidents of childbirth, are more subject to hemorrhage than men. In
striking accordance with this fact, it appears to have been a
benevolent intention of the Creator to form the female system in
such a manner that it more readily recovers from profuse loss of
blood than that of the opposite sex. Under the effects of severe loss of
blood, the system of a man remains pale and enfeebled for months,
perhaps, while that of a woman regains its strength and color in half
the time. Many a time, before I was aware of these facts, I have been
fearful, and sometimes greatly alarmed at the amount of blood lost at
the birth of a child, and when, to my great surprise, in a day or two
the patient was up, and apparently almost as well as ever. This, then,
is an important practical fact, and one well worth remembering.
In regard to the treatment of flooding after delivery, I refer you to
what I have already said under the head of uterine hemorrhage. Cold,
remember, is the great agent here, as all acknowledge.
If the woman faints from loss of blood—and she may also faint
from mere debility—you should not be alarmed at the circumstance.
People generally make a great deal too much ado when a patient
faints. It should be remembered that the object nature has in causing
a person to faint from loss of blood, is to arrest the heart’s action, for
the most part, so that the blood may, as it were, cease its movement
in the uterus, and a coagulum or plug be formed in the orifice of the
bleeding vessel or vessels. This is nature’s method of arresting an
hemorrhage. This being so, it is no doubt often the case that bringing
a person to, is the cause of more harm than good. There should be no
hurry; give the patient good air to breathe, and nature will, as a
general thing, do her own work better than we can do it for her in
these cases.
LETTER XXVII.
ADVICE CONCERNING LABOR.

The Medical Attendant—State of Mind—The Room—State of the Bowels—The


Dress—The Bed—The Position, Exercise, Food, and Drink.

It will be inferred, from what I have already said in these letters,


that I am in favor of employing a physician, male or female, in all
cases of parturition. Most cases, I admit, will get along well without
any medical aid whatever; but, as you are well aware, there are
exceptions to all rules; and it is for these exceptions that a physician
is needed.
In the first place, then, it is always advisable in labor that you call
your medical attendant early. If it is worth your while to have aid at
all, it is best to have it in good season. The physician himself always
prefers to be called early.
Once you have fixed upon your medical attendant, resolve to be
guided by him in every particular, and follow his directions faithfully.
If you have, from necessity or otherwise, chosen a man-midwife, you
need have none of those foolish whims which some among the so-
called reformers of the present day would have you to believe.
It is always an unpleasant duty for one to attend a woman in
childbed; and be assured that, of all places in the world, a delivery is
the last one in which lascivious or lustful excitement is experienced. I
wish you, then, one and all, to remember that if it is unpleasant for
you to be attended by a man under such circumstances, it is equally
so to him. If he is a conscientious and benevolent physician, he will
cheerfully do that which he considers his duty to do; but as far as his
own personal self is concerned, he would much rather be at home,
enjoying its quiet and its sleep, if need be.
In regard to your preparation for labor, I will suppose that you
have done all in your power to maintain an equable and healthful
state of both mind and body, and that you are resigned to encounter
whatever God in His mercy may see fit to bring upon you. If you have
done all that you could for yourself, and are still willing and
determined to do so, surely you should feel contented; you can do no
more.
The Room.—As to the apartment in which you are to be confined,
you should take the best one in the house. If possible, you should
have one which is well lighted and aired, and which can be readily
warmed, if there is need of raising the temperature. If it is in a city, a
back room should be preferred in preference to one in front, on
account of the noise of the street.
If the labor is to be a tedious one, it is particularly necessary that
the air of the apartment be kept as pure as possible. Not only should
the strictest attention be paid to ventilation, but all odors and
perfumes should be dispensed with. These do no good, for mere
hiding the bad air is not destroying it, and they always do more or
less harm.
There should not be too many persons in the room when the
woman is to be confined. In the country it is by far too much the
fashion for a large company of women to get together on such
occasions. This always renders the air of the apartment more foul
than it otherwise would be, and for other reasons it ought not to be
permitted.
I have many a time pitied the condition of women whom I have
attended, who had but one room to live in, cook, wash, iron, and at
last to be confined in; and yet those women have in general got along
better than such as live in a more sumptuous way. Such women are,
in fact, workers, and employment, as I have before remarked, is a
most blessed thing in regard to preparing the system for the
important function of labor.
The Bowels.—If the bowels should be constipated at the time when
labor is about to come on—and such is likely to be the case—the
woman should use clysters freely. This practice is, in fact, advisable
in all cases, inasmuch as it can do no harm. If there is fecal matter in
the colon, it is better that it be removed before the birth is about to
take place. Hardened excrementitious matters in the lower bowel are
always a hindrance to labor.
The Dress.—Formerly it was considered a matter of importance as
to how a woman was dressed in labor. Different countries and
provinces had their particular forms of gowns, jackets, chemises, and
head-dresses. The great thing, however, to be observed, is simplicity;
that is, nothing should be worn which at all interferes with the body
in any of its functions or parts. If the dress is such as causes no
constriction of the abdomen, the chest, or the neck, such as gives free
motion to the limbs, and is of such material that it makes the body
neither too hot nor too cold, it is all that is required. Generally too
much clothing is worn at the time of labor. It is safer to be on the side
of too great coolness than of the opposite extreme.
The Bed.—This has been called by different names; the lying-in
bed, bed of labor, bed of pain, bed of misery, little bed, etc.
Some women will not make use of any sort of couch whatever. I
know a lady in this city who has borne a pretty large family of
children, who affirms that she gets along much better upon her
hands and knees on the floor than in any other way. Some are
delivered standing up, the elbows resting on some object, as the
mantle-piece, bureau, the back of a chair, or some other piece of
furniture, or perhaps upon the shoulders of a friend. “A strong and
well-formed woman,” says Velpeau, “may be delivered in any
posture, on a chair, on the floor, a bundle of straw, on foot, and on all
the kinds of beds that have been proposed; so that it is only in the
cases where nothing interferes with the accoucheur’s doing just what
he thinks best, that he ought to attach some value to the composition
of the lying-in bed; further, the only essential matter is, that the
woman should lie as comfortable as possible, that she should not be
incommoded, neither during the pains nor the intervals between
them, and that the perineum may have room to dilate.”
Oftener than otherwise in this country, the woman is delivered on
the same bed on which she sleeps. Sometimes, also, a cot is used,
which also is a very convenient contrivance, since it allows of the free
passing of the physician and others about it. It is, likewise, a
healthful plan to move from one bed to another after labor; but this
is by no means strictly necessary. Cleanliness, comfort, and good air
—these are the great requisites in regard to the bed.
The Position.—If the patient is to lie upon a bed, which is doubtless
the preferable plan in the majority of cases, what shall be her
position?
This, like many other things, is a matter somewhat of fashion. In
Great Britain the woman is always placed upon the left side, with the
thighs flexed, that is drawn up toward the body, and the hips brought
close to the right side of the bed. The same position is usually
adopted in this country; but on the Continent, the woman is placed
on her back to be delivered. This, I am inclined to think, is the most
favorable, as well as most agreeable position, although perhaps not
the most convenient for the medical attendant.
Exercise.—During a considerable portion of an ordinary labor, it is
doubtless better for the patient, especially if she feel inclined to it, to
sit up, and walk about a little from time to time. This not only affords
some relief, but likewise aids in causing more efficient contraction of
the uterus.
Food and Drink.—It would always be better, so far as food is
concerned, for the patient to fast a meal or two before labor comes
on. She should, however, be allowed all the drink she desires, pure
soft water being the best she can have. If she drink pretty freely, it
will be of essential service to her in keeping off feverishness, and in
helping the renal organs to act properly. If the pains are tardy, taking
now and then a drink of cold water, even against the inclination, will
help on the pains. Even ice is used with good effect for this purpose.
LETTER XXVIII.
MANAGEMENT AFTER DELIVERY.

Importance of Attention to this Period—Evils of too much Company—Bathing—


The Bandages, Compresses, etc.—Sleep—Sitting up soon after the Birth—Walking
about—The Food and Drink.

Supposing that the mother has been safely delivered, the child
separated, and the after-birth cast off, what advice have we to give in
regard to her recovery?
I have before remarked that the birth of the secundines is the most
dangerous part of labor, although not the most painful. I have now to
remark, that the real danger in midwifery does not commence until
after the whole birth is completed. Childbed fever, inflammation and
abscess of the breasts, these are the sad mishaps which we have to
fear in these circumstances, and for which I feel an anxious solicitude
in your behalf.
You may think me strange when I inform you, that I have had
more trouble in the practice of midwifery from the one circumstance
of the woman having too much mental excitement within a few days
after delivery, than from all other things combined. I am sure I am
not mistaken when I assert that I have known more accidents and
mishaps to occur from this one cause of seeing company too soon
after the birth, than from all other causes put together. So important
do I consider it for you to keep, as it were, quiet in this respect, I
should think my labor in writing these letters a hundred-fold
rewarded, if I could be successful in warning you of the danger of
over-excitement at the time when you are getting up from
confinement. As the most important advice, then, which I can give in
regard to all the subjects connected with midwifery, Do not allow
yourself to see company for many days after the birth.
“Most of the diseases which affect a woman in childbed,” says the
great Velpeau, “may be attributed to the thousands of visits of
friends, neighbors, or acquaintances, or the ceremony with which she
is too often oppressed; she wishes to keep up the conversation; her
mind becomes excited, the fruit of which is headache and agitation;
the slightest indiscreet word worries her; the slightest emotions of
joy agitate her in the extreme; the least opposition instantly makes
her uneasy, and I can affirm, that among the numerous cases of
peritonitis met with at the Hospital de Perfectionnement, there are
very few whose origin is unconnected with some moral commotion.”
Is it not possible to change the fashion in regard to this matter?
This remains wholly with yourselves; for we of the masculine gender
have nothing to do with it. Are you not all sisters? Why, then, be
offended with each other if you do not go to see the sick woman for a
whole month after her child is born. Could you not write her now and
then a friendly note, or send her some little delicacy to eat, which
would be evidence enough that you had not forgotten her? I am
aware there are among your sex a certain set of gossiping idlers, who
do not know how to kill time in any better way than to be gadding
abroad when they are least needed. If one is really sick and needs aid,
they are the last persons in the world to leave their homes; they are
good for nothing among the sick. To such women I care to say but
little, for I consider the task of reforming them a very hopeless one,
as all experience proves. Especially where a new method of
treatment, as, for example, the water-cure, is practiced, do these
twattlers gad about, making mischief wherever they go.
Bathing.—It is no new thing for a woman to be bathed, and that in
cold water, soon after delivery. It was practiced among the Romans,
and, as we have seen in another part of these letters, is still the
custom among several of the savage nations.
I need not remind you, however, that this practice has, for a long
time at least, found no place among the more enlightened portions of
our race; that instead of cold water being regarded as a most
estimable remedy in childbirth, it has been considered as a very
dangerous agent, which, in truth, it is when improperly
administered. Many of you can but too easily call to mind the old
notions which were instilled into your minds on this subject; notions
which you now know to be not only erroneous, but sadly mischievous
when carried out in practice.
More than ten years ago, and while I was yet a student in
medicine, and had never heard of the water-cure as practiced by the
great Priessnitz, I was in the habit of revolving these matters in my
mind. It occurred to me often, that if the Roman women, and the
Indian women of different nations, could reap so great a benefit as
appeared to be derived from ablutions performed soon after
childbirth, that our own females too, weakly although they are many
of them, could gain similar advantages from pursuing a like course.
It was thus that I was led, as far back as 1843, to strike out a course
of treatment for myself in these cases, having no medical authority or
precedent to go by. The result of this treatment is now, fortunately,
getting to be pretty well understood, and the merits of the new
method appreciated in almost all parts of our country. In Europe
they are altogether behind us in the improvement to which I allude.
I need not here go into any lengthy details concerning the methods
of bathing that are proper to be adopted in the parturient state. The
numerous cases which I have given will serve as a sufficient guide, I
trust, to all of you who are concerned. I may remark, however, in
general terms, that there is no need of doing any violence in the way
of a bath; and those who have not access to the personal advice and
superintendence of a physician who understands the practice, may
always act safely by washing the patient in her bed. Thus, if a blanket
or some other extra article is placed beneath her, she may easily be
washed over the whole surface, piecemeal, a practice which, though
it is neither so thorough nor useful in most cases, as it would be to go
at once into the tub, is yet a good one, and productive of great
comfort.
The Binder, Compresses, etc.—As to the use of the wet bandage,
the compresses, etc., a few words will here be in place. If a dry
bandage is ever needed as a support, the wet one is much to be
preferred to it. As a general thing, however, we put no bandage upon
the woman soon after the birth, as will be seen by reference to the
cases given in this work; we wish to change and rewet the application
frequently, and for this reason the simple compresses are the most
convenient. But when the patient is to sit up or walk about, the wet
girdle, if properly arranged with tapes to secure it, and made pretty
tight at the lower part of the abdomen, affords a good deal of
support. The wet bandage does not slip upward and get out of place
near so readily as the dry one.
It will naturally occur to you, whether the going without the old-
fashioned belly-bandage will not be likely to prove injurious to the
woman’s form. The sum and substance of this whole matter is just
this: whatever tends to weaken the constitution in general, and the
abdominal muscles in particular, must have a tendency to produce
laxity of the fibers, thus rendering the part more pendulous. On the
other hand, whatever tends to strengthen the system and to give tone
to its fibers, must have a contrary effect. Now, the dry belly-band,
even when it is so arranged as to keep its place—which it generally is
not—is too apt to become heating, and, of course, a source of debility
under such circumstances. For this reason it is plain that a cold wet
girdle is altogether better than a dry one. Nor should this even be left
on too long a time without changing and rewetting it. This should be
done, as a general thing, every three or four hours at farthest, and in
warm weather oftener.
The Repose.—Some have feared to allow the woman to go to sleep
for some hours after delivery, fearing that she might be taken in
hemorrhage as a consequence. It is possible that a patient under
such circumstances may wake suddenly with a flooding upon her,
particularly if she be too warmly covered up in bed. But by all of the
best authorities it is regarded that the sooner the woman sleeps after
she has passed through the agony of labor the better. Sleep is,
indeed, no less “nature’s sweet restorer” under such circumstances
than at other times; and it would be most cruel to deny a patient this
privilege, when it would be so grateful and refreshing to her.
Sitting up soon after the Birth.—I have proved satisfactorily to
myself, that there is great error abroad in this country generally in
regard to the parturient woman rising soon after the labor is past. It
appears to be the belief of physicians generally in this country, that it
is highly dangerous for a woman to sit up before some days after
accouchement. The common saying concerning the ninth day you
have all of you heard.
Velpeau, of Paris, who is higher authority by far than any old-
school man in this country, says: “After this first sleep—that is to say,
after the lapse of two or three hours—the patient should sit up in
bed, and take a little broth; this position seems to rest her, and
allows the lochia which had accumulated in the vagina to flow
readily off.” That is the point: it serves to REST her; that is, when a
woman is tired of lying down, both common sense and instinct
declare that she should change her position; in other words, sit up.
This very same thing I have taught strenuously for these seven or
eight years, as many of you know; and just now, while I am writing, I
find that Velpeau long ago recommended the same thing.
Walking About.—Precisely the same principle holds good in regard
to walking and all other modes of exercise as in sitting up. A little
and often should be the rule. The cases which I shall give you will
form a sufficient guide on this point.
I have known a great many more persons to be injured by
inactivity, remaining too much in bed and in overheated rooms, than
by walking about too much and too soon.
The Food and Drink.—I have but a word here to say on this
subject. The patient should begin directly after birth with the same
kinds of food and drink which she intends to use during the period of
nursing. If she is to eat fruit, which I consider good for her, she
should take it from the first. Prudence should, of course, be exercised
in regard to quantity as well as quality of food under these
circumstances.
One of the greatest and most common errors in regard to the diet
soon after labor, is that of partaking of articles which are of too fine
and concentrated a nature. The bowels tend naturally to sluggishness
for some days after confinement; hence the diet should be of an
opening nature, such as brown bread, cracked-wheat mush, good
fruit in its season, and good vegetables. It is a poor practice to keep
the patient for nine days on tea, superfine bread, toast and butter,
and the like articles. It is no wonder that women dieted in this way
become constipated, nervous, low-spirited, and feverish.
LETTER XXIX.
MANAGEMENT OF THE CHILD.

Of Separating the Umbilical Cord—Practices of different Nations—Of Still-Birth,


and Resuscitation of the Child—Washing and Dressing it.

It was necessary, in describing the three stages of labor, to pass


over for the time an important matter, namely, that which relates to
our attention to the umbilical cord. In treating of this subject, it will
be necessary for me to repeat some things which I have said in
another volume, a “Treatise on the Management and Diseases of
Children.”
Soon after the birth of the child, separating the umbilical cord
requires our attention. How shall this be done? Shall we use a sharp
or a dull instrument in making the division? Shall we apply a
ligature? where, and in what manner to the cord?
It is reported of the aborigines of Brazil, that they merely bite or
chew off the cord, as many of the animal tribes are found to do. This
is imitating nature closely enough, certainly, and more so, perhaps,
than the usages of civilized society would warrant us in doing at the
present day.
Dr. William Hunter, in 1752, remarked in his manuscript lectures
concerning the method which the instinct of animals leads them to
adopt, as follows:
“I will give you an idea of their method of procedure, by describing
what I saw in a little she dog of Mr. Douglass’. The pains came on,
the membranes were protruded; in a pain or two more they burst,
and the puppy followed. You cannot imagine with what eagerness the
mother lapped up the waters, and then taking hold of the
membranes with her teeth, drew out the secundines; these she
devoured also, licking the little puppy as dry as she could. As soon as
she had done, I took it up, and saw the navel-string much bruised
and lacerated. However, a second labor coming on, I watched more
narrowly, and as soon as the little creature was come into the world,
I cut the navel-string, and the arteries immediately spouted out
profusely. Fearing the poor thing would die, I held the cord to its
mother, who, drawing it several times through her mouth, bruised
and lacerated it, after which it bled no more.”
This chewing, bruising, or tearing a part in which blood-vessels
exist, causes them to contract in such a way as to prevent the
occurrence of hemorrhage. This fact we see exemplified in cases
where an arm or other limb is torn off with machinery, in which it is
found that no bleeding of consequence takes place. But if a limb is
severed with a sharp-cutting instrument, the arteries must be
secured.
The New Zealanders, I am informed by a medical friend who spent
some time among that people, cut, or rather tear off the umbilical
cord with the edge of a shell, something like that of the clam or
oyster of our own country.
It matters little, however, what instrument or material is used to
effect the object in question. The cord being immediately after birth a
dead substance, possessing no sensibility whatever, we may bite it
off, or we may use a shell, a sharp knife, or a pair of good scissors or
shears, whichever method we choose, remembering always that it is
of little consequence how we do it, and that it is as natural, precisely,
for a man to exercise his ingenuity in making and using a convenient
instrument as it is for a brute to use his teeth.
In the time of Hippocrates, it was not customary to divide the
umbilical cord previously to the expulsion of the placenta. If this was
slow in coming away, the child was placed upon a pile of wool, or on
a leather bottle with a small hole in it, so that by the gradual
subsidence of the skin or pile of wool, the weight of the child might
draw almost by insensible degrees upon the placenta. In this way it
was extracted without violence.
In modern times, it has been almost universally the custom to
separate the child very soon after delivery, and before the after-birth
has come away. “As soon as the child cries lustily, proceed at once to
separate the cord,” is the common doctrine among medical
practitioners. But it is better, evidently, to wait, before this is done,
until all pulsation has ceased in the cord. If we take the cord between
the thumb and finger, we readily ascertain when its pulsation has
ceased. It has a large vein in it for the transmission of blood from the
mother to the child, and two small arteries, which return the impure
or worn-out blood after it has gone the rounds of the fetal
circulation. Blood is the only nourishment the child has while it is in
the mother’s womb. Hence it would be manifestly improper to rob
the child of any portion of the fluid coming from the mother to it.
The ancients not only waited for the expulsion of the after-birth
before tying the cord, but if the child was at all feeble or dead at
birth, the placenta, when expelled, was laid upon its belly as a
comforting and restoring application. This practice, singular as it
may appear to us in modern times, is not altogether without its
philosophy; the mild, genial warmth of the after-birth was supposed
to act favorably on the feeble powers of life, if such existed, or if it
was dead, it was supposed the infant might thus be recovered.
Speaking of later methods, Dr. Denman observes: “It has been the
practice to divide the funis (cord) immediately after the birth of the
child; and the weaker this was, the more expedition it was thought
necessary to use; for the child being supposed to be in a state similar
to that of an apoplectic patient, a certain portion of blood might, by
this means, be discharged from the divided funis, and the imminent
danger instantly removed. There is another method which I have
seen practiced, the very reverse of the preceding; for in this the loss
of any quantity of blood being considered as injurious, the navel-
string was not divided, but the blood contained in its vessels was
repeatedly stroked from the placenta toward the body of the child. In
all these different methods, and many others founded on caprice, or
on directly contrary principles, children have been treated in
different times and countries, and yet they have generally done well;
the operations of nature being very stubborn, and, happily, admitting
of considerable deviation and interruption, without the prevention of
her ends.”
“There is yet, in all things,” continues this author, “a perfectly right
as well as a wrong method; and, though the advantage or
disadvantage of either may be overlooked, the propriety and
advantage of the right method must be evidently proved by
individual cases, and of course by the general result of practice. In
this, as well as in many other points, we have been too fond of
interfering with art, and have consigned too little to nature, as if the
human race had been destined to wretchedness and disaster, from
the moment of birth, beyond the allotment of other creatures.”
It is the testimony of this author, however, that some children,
after they had began to breathe, had respiration checked, and died
after the cord was divided in consequence, this having been done too
soon. Beyond a doubt, many children have been destroyed in this
way, and in this, as in many other things in the healing art, medical
men have been too much in the habit of interfering with nature, and
thwarting her in her operations.
It is the order of nature, and moreover a truly wonderful
phenomenon, that in proportion as respiration becomes established
in the new-born child, the pulsation in the umbilical cord begins to
cease, first at the placenta, and so gradually onward to the child;
physiologists are puzzled to explain the circumstance, but the fact is
plain.
Hence it follows, that if the cord were left to itself, without any
ligature, it would not expose the child to hemorrhage, or other
accidents, even though it should be cut clean, and not contused or
torn; some little blood might flow from the cut end, but every thing
being left to nature, this could amount to but little, and such as
would do no harm. But for the sake of cleanliness, it is proper that a
ligature should be applied.
But it will be objected, that in some cases—though very rare—
children have been known to bleed to death at the umbilicus. This
has, indeed, happened in some few cases, in spite of ligatures, and
every thing else in the way of styptics that could be applied. But these
extreme cases are not to serve as guides in forming rules of practice.
Nature has exceptions to all her rules. Besides, we may account for
many of these occurrences, by the fact that the natural operations are
often perverted by improper treatment. Thus, if children are swathed
tightly, as has been too often the case in civilized society,
compressing the chest and the abdomen, and causing them to cry
from distress, the embarrassed state of the viscera suffices to
disorder the general circulation, and enable the blood again to pass
out of the navel.
Hence, as a matter of practical safety, although it is not necessary,
as a rule, to apply a ligature to the umbilical cord, even when we cut
it very near the abdomen of the child, we had better do it, as no harm
can come from the procedure; it is possible for it to do good, even to
save the life of the child; properly applied, it is not possible for it to
do harm.
As to the point at which we divide the cord—whether at a half an
inch or an inch and a half from the abdomen—every one must be his
own judge. It is an old woman’s notion, both in this country and in
the old, which was derived from the physiology of the ancients, and
which requires that the cord should be cut very near the umbilicus if
the child was a girl, and very far from it if it is a boy; such a mode of
cutting being supposed to exert a great influence upon the
development of the generative organs.
Notwithstanding the objections of some of the old women, I have
separated the cord very near—say within half an inch of the
abdomen. This is a much neater and more cleanly mode than it is to
leave two or three inches of a dead substance to putrefy upon the
child; besides, the more cleanly the part is kept, the more quick does
the healing process take place.
“As to the ligature itself,” says Velpeau, “De la Motte advises us to
apply it at the distance of one inch, Deventer, Levret, and the
moderns, at the distance of two fingers’ breadths, others at three,
four, five, six, and even twelve inches from the abdomen. Some
persons have recommended the application of two, and in such a way
that the one nearest the abdomen should not be so tight as the other.
Sometimes it has been recommended to draw it very tightly, at
others very loosely. One person is content with a single turn, and a
single knot; and another thinks there should be two turns, and a
double knot; a third, like Planck and M. Desormeaux, makes first one
turn and one knot, and then bends the cord into a noose to tie
another knot upon it.”
“A majority of the Philadelphia accoucheurs,” says Professor
Meigs, of that city, “in tying the navel-cord, pass two strong ligatures
each twice around it, securing them with two knots; the one an inch
and a half, and the other two inches and a half from the abdomen,
and divide it between the two with a pair of sharp scissors. This is a
cleanly practice in all cases, and prudent, if not essential, in twins;”
cleanly, that is, because, as the professor means the second ligature—
that is, the one that is nearest the mother—prevents the blood
coming from the placenta, and soiling the bed; the same principle I
usually adopt, only the first ligature is placed half an inch, instead of
an inch and a half from the abdomen. Sometimes, however, as in the
night, it is perhaps better to leave the cord an inch or two long, and
the next day tie it nearer the body. The ligature, since we use it at all,
should be drawn very tightly; the cord being a dead animal substance
after birth, very soon shrinks; hence if the ligature is not very tightly
drawn, it may slip off in a day or two. In tying the ligature, we should
be careful not to pull at the child, for in so doing we might cause a
rupture, or a tendency to such an occurrence.
In making the division—which is usually done with a pair of good
shears or scissors—we must be careful to avoid cutting off a finger,
toe, or the private member. The infant, in its struggles, is very apt to
get some of these parts in the way just as one is making the cut.
As to the kind of ligature: some think they must always have a
narrow tape; and hence we often find, in attending a case, that the
mother has already prepared herself with this material. But a
common round thread is to be preferred; we can draw this more
tightly than we can a flat ligature. A strong linen thread, doubled and
twisted if we think it necessary, I consider the best. “Some would not
dare to use any thing except tape,” says Velpeau; “whereas wiser
persons make use of whatever they can find at hand.”
One circumstance should be particularly noticed in regard to tying
the cord. It is said that it is possible for umbilical hernia to take place
before the child’s birth. In such case a portion of its intestine must
have protruded into cord. Hence, in such case, if we were to tie a
ligature about the cord near the body, and where the intestine is—a
fact that we can know by the cord being bulged out, or enlarged at
the part—and should cut it off so as to sever the intestine, we should
inevitably kill the child. Few practitioners have ever seen such a case;
but inasmuch as it is said that such hernia may possibly exist, we
should always watch for it. It would be easy to detect, but if one
should have any doubt as to whether there is hernia or not, he may
apply the ligature an inch or two from the child’s body, and thus
make sure of doing no harm.
It is important to remember, that at the time of, and before making
the separation, the child should be so placed as to allow the most free
respiration; it has just begun to breathe for the first time in life; it is
just as important that it has good air as it is for any of us. Many a
tender infant has been injured at the very beginning by being
smothered among the bed-clothes as soon as born. People
everywhere, think it will take cold as soon as it is exposed to the air;
but think, you who understand the anatomy and physiology of the
human system, how exceedingly delicate the fine internal net-work
of its little lungs is! And think you that the external skin is less able
to bear the new impression of the atmosphere than the lungs are?
As to difficulties at the child’s navel, I have never had them. It is
certainly a very simple thing to leave it altogether to itself, with the
exception, the second day and onward, of laying upon it a soft, clean,
wet compress, of four or five thicknesses, so that it remains
constantly moist. This water-dressing, often renewed, and kept
thoroughly clean, heals the navel more quickly than can be done in
any other known way.
From what I have been able to learn, I infer that with water-
dressing this healing is effected from one fourth to one third less
time than by the usual methods.
The period of the natural separation of the cord varies
considerably in different cases. According to M. Gardien, it usually
falls off on the fourth or fifth day. M. Orfila says the fourth, fifth, or
sixth day. M. Dennis the fifth, sixth, seventh, or eighth day. M.
Billard remarks, that the desiccation is complete toward the third
day, and it is on the fourth or fifth day that the cord is separated
from the abdomen.
Dr. Churchill, of Dublin, kept an account of the period of its
decadence in 200 cases, and it occurred as follows:
In 1 case it fell on the 2d day.
„ 4 cases „ 3d „
„ 20 „ „ 4th „
„ 52 „ „ 5th „
„ 81 „ „ 6th „
„ 24 „ „ 7th „
„ 10 „ „ 8th „
„ 7 „ „ 9th „
„ 1 case „ 10th „

According to Dr. Churchill, then, it would appear, that the fifth and
sixth days are the ordinary periods of the detachment. The cord has
been known to remain undetached as long as fifteen days; but such
cases must be very rare.
Complete cicatrization is commonly effected by the end of the
second week. The healing powers vary somewhat in different cases.
In one case, where both the father and the mother were of scrofulous
tendency, it was a number of weeks before the healing process was
fully completed. The child, however, in the end did well.
OF STILL-BIRTH.
The child may be born still, from its not having passed to its full
period, or from various causes it may not have vital stamina enough
to enable it to live. In some cases the child is born without any
manifestations of life whatever appearing. The face is swollen and
livid, the body flaccid, and the navel-string does not pulsate.
In such cases we should not at once wholly despair of life, although
there is not usually much to hope for; yet, inasmuch as cases of this
kind are now and then recovered, they ought not to be immediately
abandoned without making suitable efforts for the resuscitation of
the vital powers.
A frequent cause of the absence of respiration in the new-born
infant is, separating the umbilical cord too soon after birth. Such is
the opinion of Denman, Burns, Baudeloque, Dewees, Elberle, etc.,
etc., and there can be no doubt that many a child has been destroyed
by this inconsiderate practice. By all well-qualified and skillful
practitioners it is laid down as a rule, “that the cord is not to be tied
until the pulsations in its arteries have ceased;” and this any person
of ordinary understanding, and without medical knowledge, can
easily ascertain, by simply taking the cord between the thumb and
forefinger.
In consequence of the neglect of this rule, Doctor Dewees tells us
that he had reason to believe he had seen several instances of death,
and this of a painful and protracted kind. “And that this is probably
one of the causes of the many deaths, in the hands of ignorant
midwives and practitioners,” this author observes, “we have too
much reason to suppose.” The practice with many is, to apply a
ligature to the cord the instant the child is born, without any regard
whatever to its pulsation, or the state of the child’s respiration.
Treatment.—In the cases of asphyxia, to which I have referred,
various methods of treatment have been adopted, some of which are,
no doubt, valuable, while others are meddlesome, and worse than
useless.
If the child is livid and dark-colored, it has been recommended to
abstract blood. This is best done at the umbilical cord; that is, by
separating it. If the blood will not flow, it is recommended to strip
some blood from it. It is, however, admitted that, in general, very
little, if any, can be obtained in this way.
It has also been recommended to apply a cupping-glass to the
umbilicus, so that by exhausting the air from the part the blood may
be brought into motion, and thus made to flow, and this even after
the heart has ceased to act. I know of no author, however, who has
succeeded in this method.
The object of abstracting blood in any of these various ways is to
set the vital fluid in motion, and to relieve the congested parts. But it
appears to me that there is a far better method than this, and that is
simply by friction with the wet hand. The child has in no case too
much blood; it is only in the wrong place. The wet hand does not at
all injure the skin; the cold water—for cold only should be used here
—acts as a stimulus to the vital power, and the motion of the hand
and the pressure will set a hundred-fold more blood in circulation
than the mere separating of the umbilical cord could do. Hence it is
that I would depend much upon friction, and very little, if any, upon
the abstraction of blood. This latter practice is destined to become as
obsolete in time, as that of bleeding in a severe injury or shock of the
system—a method which has deservedly gone out of date among all
scientific practitioners of the medical art.
In conjunction with the measure which I have just recommended,
there is another of importance, which should be faithfully made; and
that is, an effort to excite the respiratory function by artificial
inflation of the lungs, and compression of the chest with the hands,
so as to imitate in a measure the natural acts of inspiration and
expiration. In doing this the operator must apply his mouth to that of
the infant—the latter having been first freed of the mucus that
attaches to it—at the same time closing its nostrils, and endeavor by
a moderate but uniform force of expelling the air from the mouth, to
fill the lungs of the child. As the air is thrown into the lungs, the
chest of the child must be allowed to expand as much as it will; and
then, as this act is discontinued, the chest should be compressed a
little, carefully, so as to imitate the natural motion of these parts.
Authors disagree as to the amount of force allowable in forcing air
into the lungs of a new-born child. Some have recommended a
“forcible insufflation,” while others contend that such a practice is
fraught with danger to the child. It appears from a series of
experiments that have been made in France on animals, and from
observations relative to the human subject, that no very great force of
insufflation is necessary to rupture the delicate air-cells, and cause a
fatal emphysema of the pulmonary structure. In sheep, and in the
dead human subject, the air-cells were ruptured by a force of
insufflation not greater than that which may be made by a person of
ordinary respiratory vigor, without any very violent effort.
To obviate the unfortunate accident of rupturing the air-cells of
the lungs, the air should be thrown into the respiratory passage
through a silk handkerchief folded double, or a fine napkin laid over
the mouth of the infant.
In all cases of retarded, impeded, or suspended respiration
immediately after birth, care should be promptly paid to the removal
of the viscid mucus, which is usually to be found lodged in the mouth
and throat of new-born infants. In some instances the quantity of
mucus is so great, and its quality so tough, that it is believed the child
could not possibly breathe if the obstruction was not removed from
the parts. In all cases, therefore, if there appears to be any difficulty
whatever in regard to respiration, it is best to remove this mucus by
means of the finger, surrounded by a handkerchief or piece of soft
linen. If there is reason to believe that the mucus is also lodged in the
throat and beyond the reach of the finger, it has been recommended
that the child should be turned with its face downward, and the body
raised higher than the head. In this position, the child’s back,
between the shoulders, is to be patted with the hand, and its body
gently shaken, so as to disengage any matters that may be lodged in
the trachea, and permitting it to flow out of the mouth by making
this the depending part. At the same time, if the back is rubbed with
the hand wet in cold water, the stimulating effect will aid in the
expulsion of the offending cause from the throat.
Infants are sometimes born in a state of asphyxia, when, instead of
lividity and swelling of the countenance, there is the opposite
extreme, the face and surface of the body, generally, being pale,
exhibiting a want of vitality. In such cases, it is of the utmost
importance that the cord be not divided too hastily; on no account,
indeed, should this be done until the pulsation has ceased. The viscid
mucus should at once be removed from the mouth and fauces by the
methods before mentioned; and it has been recommended to apply
brandy, spirits of camphor, hartshorn, etc., to the mouth and
nostrils, with the view of exciting the respiratory function. It is
doubtful, however, if such articles do any permanent good whatever,
and they are certainly liable to harm. At any rate, it is better, I am
confident, to sprinkle cold water upon the surface, and to make
friction with the cold wet hand. This will set the blood in motion, and
aid the vital powers incomparably more than the stimulants
mentioned.
It is also advisable in these cases, if respiration is particularly
tardy, to inflate the lungs carefully, according to the method before
recommended. But the applying hot brandy, flannels wrung out of
hot spirits, etc., which have often been used on such occasions, are
worse than useless, and ought never to be resorted to.
Infants, in this condition, should not be given up too hastily.
Numbers of cases have happened in which a half hour or more has
elapsed before respiration has been established. Even a much longer
period than thirty minutes has transpired in some cases before the
breathing has been established.
The time will come, probably, when electricity will become so well
understood as to enable us to make it a valuable agent in cases of
still-birth and suspended animation. In the present state of
knowledge, however, it is better, I think, to depend on the stimulus
of cold water, frictions, and the other means to which I have already
referred. But great care is necessary in the management of all such
cases; and I have no doubt that many more infants have been killed
by too meddlesome and injudicious management, than have been
saved by the use of artificial means. The tendency in cases of this
kind always has been to do too much. It is one of the greatest
acquirements in art to learn when not to do.
WASHING AND DRESSING THE CHILD.
I have a few words to say here on these topics; but I must refer you
to my Treatise on Children for a much more full and explicit
explanation of them than the limits of this work would admit of. You
can all of you who have need obtain that work, I trust; and surely,
after you have borne a child, you will feel the greatest interest in
learning all that it is possible for you to know respecting the best
modes of rearing it.
In general terms, then, I remark, that a child should, soon after its
birth, be carefully cleansed by means of pure water and the addition
of a little mild soap. The water should not be either too warm or too
cold; a moderate temperature, as from 70° to 80° Fah., will be found
best. The child should be carefully washed, I said; and in all that is
done in handling it, you should remember that it is a frail, delicate
thing. Nor need I hint to a mother that inasmuch as some one had to
perform all of these small yet multiform offices for us, so should we
be willing to perform them for others.
The dress should be loose, and merely sufficient for the purposes
of warmth. The child should not be in any way bound with its
clothing; nor should a binder or bandage be used.
LETTER XXX.
HYGIENE OF NURSING.

Lactation a Natural and Healthful Process—Rules for Nursing—At what time


should Lactation cease?—Food and Drink proper during the Period.

You who reside in the country—as, indeed, most of you do—can


hardly credit me when I tell you that it is getting to be quite
fashionable in our large cities for a woman not to nurse her own
child.
There is in some cases policy on the part of the physician, which
lies at the root of this matter. “Why, madam, you are too weak,” the
fashionable pill-monger sagely says. “It will injure your constitution,
and you cannot raise your child; you must have a wet-nurse.”
Now, all this is very easy for a man to declare. Some say it from
ignorance, no doubt, and some from other motives; for physicians,
although as a body of men they are as honest as any other, are yet
sometimes selfish, and do that which is dishonest and wrong. The
selfish doctor knows, of course, very well where his money comes
from. He knows—if he is not an ignoramus—that the mother, if she
does not nurse her child, is more apt to become sick, so that she will
need his services; and, what is more, she is more apt to become
pregnant, in which case he will look for another job at midwifery,
which pays well.
I would have every one of you to understand that the health of the
unnatural mother, who will not nurse her child, suffers from her not
fulfilling the order of nature in giving suck. Her system must
inevitably get harm from not allowing it to go through the period of
lactation naturally. Her life of dissipation, too, is poorly calculated to
contribute to health, compared with staying at home and fulfilling
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