NEONATOLOGY ON THE WEB

Historical Review and Recent Advances
in Neonatal and Perinatal Medicine

Edited by George F. Smith, MD and Dharmapuri Vidyasagar, MD
Published by Mead Johnson Nutritional Division, 1980
Not Copyrighted By Publisher

Chapter 8

Nursing in Neonatology

Mitzi L. Duxbury, R. N., Ph. D., F. A. A. N.

Historically, nursing has not until recently separated the care of infants and children from the care of mothers. Most graduate programs in nursing today that deal with care of mothers, infants and children are still called "Maternal and Child Health." Nursing has always felt that it is difficult to separate the care of the infant and child from the care of the mother and family. Accordingly, this paper will deal with nursing's contribution to the care of both mother and infant.

Nursing's contributions to such care have been significant and enduring. Errors, in the form of unscientific care practices, have been grievous. Nursing has always provided the caring part of the healing process and has had as a major focus maintaining and promoting health.

Healthy babies come from healthy families and it is in the area of health promotion and maintenance that nursing has made its most important contribution to the improvement of care for mothers and babies. Nursing, or some primitive form of nursing, has been involved in the bearing, nurturing and rearing of children since long before recorded history.

One finds mention of midwives in the Book of Genesis: midwives are present at the second labor of Rachel and at Tamar's delivery of twins. Hippocrates instituted the first formal training of midwives five centuries before the birth of Christ.

The wealthy woman of the Middle Ages might have had both nursemaids and midwives to tend her. Often the baby roomed in with the mother in the Fifteenth Century obstetric ward. The medieval midwife had developed her skill from observation and practice, having borne children of her own. In difficult labor, the midwife asked the advice of a physician, but he did not come in to help and under no circumstances would he have examined the mother.

The Sixteenth Century woman is shown in woodcuts of the time delivering her baby while seated. That was a common practice in Europe then. Either an obstetrical chair or a V-shaped stool was used.

A Hogarth etching of the 1700's shows "dropped" babies, ones left outside to freeze or starve (Fig. 1). The killing of infants was not uncommon among the masses in the Eighteenth Century. Unmarried mothers sometimes disposed of their newborn children so that they could earn their living as wet nurses (Fig. 2).

A few hospitals for foundling children -- unwanted babies, or ones orphaned in a plague -- were established in the 1700's. An example was the Paris Foundling Hospital (Fig. 3), incredibly dirty and overcrowded, where, on an average day, 90 infants were admitted and 70 bodies were carried out at night.

Throughout Europe infant mortality stood at around 50 percent. In London, between 1730 and 1750, three-fourths of all children christened died before they were five years old. England's Queen Anne, who surely must have received superb care for the time, lost 18 children in early infancy.

Wealthy women often put their children in the care of wet nurses -- women who had lost their own children to disease. These wet nurses often passed the disease on to the newborn. It was the fashion among the French upper class, for a period during the late Eighteenth Century, to bottle feed their babies. Bottle-fed babies got sick from contaminated milk and water. The death rate was three times that of breast fed babies.

Nursing entered its dark ages at about the time the rest of Western civilization emerged from them. A commandment that declared a woman's place to be in the home compromised the status of midwifery; in the place of nursemaid and midwife appeared "nurses" recruited from among ex-prisoners, drug addicts, and women whose age rendered them unfit to solicit men.

Into this world, in the middle of the Nineteenth Century, came the fresh spirit of Florence Nightingale (Fig. 4).

To call Nightingale the founder of modern nursing is to speak modestly of her accomplishments. She was that, certainly, but far more besides: humanitarian, rebel, architect of social reform, builder of hospitals and pioneer of nursing education. Her direct contribution to neonatal nursing was profound but almost incidental in terms of the transcendental nature of her contribution to nursing as a whole.

Florence Nightingale brought science and sanitation, common sense and fresh air, both figuratively and literally, into the depressing confines of the sickroom.

Nightingale's approach to nursing was "to put the body in the best condition to heal itself;" which is the basic approach nursing theorists espouse today.

Nightingale had been born into a very affluent family, had mastered Greek, Latin, French and German before she was twenty, and was well read in history, philosophy and mathematics. Her mathematical genius should be borne in mind, as some of her most significant contributions involved the gathering and analysis of data.

Her family vigorously opposed her interest in nursing. It was not until she was thirty years of age that she was able to steal away from her family and find her way to the city o£ Kaiserwerth on the Rhine, where she worked for a few months with the Deaconesses of Kaiserwerth. These were a group of Lutheran ministers who provided care to the poor with Pastor Theodor Fliedner who, with his wife Frederika, had quietly brought about a revolution for the good in the training of nurses. Nightingale received some on-the-job training in England operating a charity hospital and, when she was 34, she was called on to help the British wounded at a place called Scutari, near Constantinople, on the Black Sea, in Turkey. She found four miles of men reclining in their own excrement without medical supplies, eating utensils, food or blankets. Two-thirds of the Queen's army had fallen ill; half of them would die not of wounds but of hospital-borne disease.

In her wards, Florence Nightingale with her lamp of compassion, broom of efficiency, and slide rule,^[1] reduced the death count from 50% to 2%. She recruited to the cause every able body she could find including soldiers' wives and bystanders; she set up kitchen and laundry; she organized the care and took part in it as well, slaving by day and staying up whole nights drawing up vast detailed plans for improvement of the entire principle of hospital care, not only in military hospitals but everywhere. She introduced science to the hospital ward: gathered information and evaluated it with a statistician's measures.

How she brought sanitation to the wards -- light and fresh air, plentiful space, good food, warmth, cleanliness and quiet -- and how she brought forth the idea that the nurse's function is to work as a team with sanitarian and doctor to promote the health of the patient; all this is well known. She went on to set up schools for nurses and to advise hospitals, to innovate in the field of hospital physical plants. She intervened directly to make childbirth safer. Having collected and analyzed data on puerperal fever, she documented the following association: when 8 beds are in one hospital room, 8 per thousand die; when 4 beds are in one room, 4 per thousand die. She noted that mortality rates for mothers and babies in hospitals were higher than those in most homes, however informally cared for or unclean those homes were.

Florence Nightingale died in 1910 at 90 years of age, having seen the arrival of the first female physicians, the adoption of many of her ideas and the rejection of most of them in the cold face of the Industrial Revolution.

In the late 1800's teaching hospitals sprang up, based on the Nightingale idea of thorough grounding in every aspect of medicine and hospital administration. Nurses in such hospitals became active participants in all aspects of hospital care.

As the Nineteenth Century closed, immigrants from around the globe were swarming through New York's Ellis Island and on into the tenements of the city. By the middle of the 1890's, two-thirds of New York's 3,500,000 people lived in tenements and were packed into 90,000 tenement houses in districts without parks or other recreation areas. In one New York block of tenements, 577 people were packed into 96 rooms.

Needless to say, such slums endangered health. One especially crowded tract in New York City was known as "lung block" because of its high rate of tuberculosis deaths. Vermin was rampant, sanitary facilities were broken down and diseases were inevitable.

Lillian D. Wald, who had graduated from the New York Hospital Training School for Nurses in 1891, conceived and implemented a nursing service that helped the sick poor of the Lower East Side of New York City. With her classmate, Mary Brewster, she opened what became the world-famous Henry Street Settlement in 1893, on the top floor of a tenement in the Lower East Side. Workers at the Settlement provided nursing services at the Settlement house and at the homes of the sick and poor immigrants in New York City.

The Henry Street public health nurses made great efforts to get to their clients' homes; much of their practice was directed toward assisting immigrant families in child care. Along with home nursing service, families received instruction in bathing, hygiene, diet and infant care. Showing a mother how to feed and bathe a newborn often saved the child's life (Fig. 5).

We could contrast this approach with the impersonal mass production bathing approach used in many hospitals then and on into the 1930's: one sees, in photographs of the time, babies lying side-by-side on a table like cigars on an assembly line with nurses training hoses on them.

Suffice it to note that the Henry Street venture was a success. The plan eventually spread to cities all over America. An organized program of social and educational services evolved; each settlement house became a generalized social project. Many nurses specialized in maternity and infant welfare and in tuberculosis work.

Physicians had labored long to find formulas that a newborn would tolerate. Unmodified raw milk upset digestion; highly diluted cow's milk formula failed to give good weight gains or adequate nourishment; switching around from formula to formula was apt to cause vomiting, diarrhea, dehydration and acidosis, and this would spur the physician on to try still another formula. Much of a nurse's time was spent in "formula rooms." In 1910, diseases of the digestive system accounted for well over one-third of neonatal deaths.

The move toward public intervention to bring about improved family health resulted in city ordinances that regulated milk and water sanitation; "milk stations" were set up in many cities, dispensing clean milk. The Henry Street pioneers brought to their clientele the information that boiling cow's milk for formula would enable the infant to tolerate it and to thrive. Diseases of vitamin and protein deficiency such as scurvy, rickets, beriberi and pellagra were no longer the inevitable lot of bottle-fed babies. Mortality of these infants decreased to one-fourth. "In no other major health care area has cooperation among private practitioners, public health officials, and voluntary lay organizations accomplished so much as it accomplished in eliminating food and water contamination throughout communities."^[2]

These social advances culminated in the Sheppard-Towner Act of 1921. Specifically designed to provide federal funds for improving maternal and infant care, the Sheppard-Towner Act enabled hundreds of nurses to visit homes, give health education and encourage prevention of disease. The 1915 death rate for infants, 100 deaths for every thousand births in America, dropped to 69 deaths per thousand by 1928. In 1929, when the Sheppard-Towner Act expired, 45 states and Hawaii had child health agencies; 700,000 expectant mothers and 4 million infants and preschool children had received care. Almost 3,000 permanent prenatal and child health centers had been established.

In 1910, perhaps half of all births in the United States were attended by midwives. At the same time, the maternal death rate in the United States was third highest among countries that kept such records. It was a period of unrestricted and heavy immigration and the midwives usually shared race, nationality and language with their clientele.

At this time, local and national medical groups were coming out with magazine articles that dealt with the problem of what was termed "medieval, dirty, ignorant and incompetent" medical care, as provided by midwives; maternal death from puerperal sepsis and blindness from neonatal ophthalmia were ascribed to midwives' negligence. The battle was joined; a survey of professors reached the conclusion that general practitioners were at least as negligent as midwives and were equally responsible for preventable deformities.

Other observers noted that poor schools with poor facilities and poor professors were turning out incompetent doctors who lost more patients from improper practices than midwives did from infection. Wry critics suggested that women often delivered themselves at the very time their doctors were scrubbing up for a cesarean; but other results of doctors' exuberant incompetence, such as the use of high forceps before dilation was complete, were not proper subjects for humor nor fortunate for the health of the mother or child.

Two opposing views on the naturalness of the birth process were at issue here. At one extreme were those who felt that the normal pregnancy and parturition was the exception and at the other extreme were those who saw birth as a normal physiologic event.

A cold pragmatic issue was at stake here as well: as the new profession of obstetrics came into being, its fresh specialists needed a clientele. Charity hospitals in the larger cities needed patients on whom their interns could practice. It was natural for the administrators of the hospitals to damn an institution that seemed to stand between them and their material. No effort was made to provide educational programs for midwives whereby they might learn how to improve the quality of the care.^[3]

By 1925, following a spite-fight that probably could have been avoided if the well-being of the mother and child had been kept in mind, and if as much zeal had been displayed in improving the midwife's praxis as damning it, lay midwifery had been all but wiped out. Large charity hospitals were the places where children of impoverished parents were born, if they were fortunate enough to be within travelling distance of such facilities.

But many women did not have access to hospitals; settlement houses such as the Henry Street venture were not ubiquitous throughout the land; remote rural areas and city tenement-tops were not being served. This is the case in many areas of America today.

Mary Breckenridge, a resourceful public health nurse who had been educated at St. Luke's School of Nursing in New York and in a London midwifery college, set out to remedy the problem in the isolated reaches of the southeastern Kentucky mountains. In May of 1925 she set up the Frontier Nursing Service. The Kentucky area she served was one whose inhabitants struggled on the margin of survival. Travel was by horse or mule. Breckenridge with her small corps of nurse-midwives provided public health nursing and midwifery, infant and child care, instruction in diet and proper health habits, preventive care, and inoculations to the approximately 200 families living in the area.

Breckenridge required her colleagues in the Service to have earned nurse-midwifery certificates in England or Scotland, no quality nurse-midwifery programs being available in America at that time.

These nurse-midwives gave prenatal, intrapartum and postnatal care; they visited their patients twice or more every month until the seventh month of pregnancy and then every week until delivery. A physician whom Breckenridge had encouraged to establish and direct a hospital in the area was available in the rare event of complications. Normal deliveries, comprising the vast majority of cases, were handled by the nurse-midwives, who stayed with their patients for ten days following delivery.

In 1932, the Metropolitan Life Insurance Company sent a physician to examine the first thousand cases of the Frontier Nursing Service. Complications, he found, were lower in number and severity than among the general (and generally far more opulent) population of Kentucky. No maternal mortality had occurred as a result of childbirth services offered by the Frontier Nursing Service.

The doctor concluded:

"The type of service rendered by the Frontier nurses safeguards the life of mother and babe. If such a service were available to the women of the country generally, there would be a saving of 10,000 mothers' lives a year in the United States; there would be 30,000 less stillbirths and 30,000 children alive at the end of the first month of life."^[4]

The Frontier Nursing Service survives, though as a unique institution: the idea failed to catch on due to a variety of political, social and economic conditions.

By the end of the 1920's, Sheppard-Towner money was directed toward setting up courses to train midwives in 17 states. In 1929, just as they were getting started, these courses were abruptly cancelled, when the Sheppard-Towner Act was allowed to lapse. Joining forces with political conservatives, the American Medical Association had damned the Act as "wasteful and extravagant, unproductive of results and tending to promote communism."⁵

It is pleasant to note that nurse-midwifery as a profession is on the rise. No account of historical perspectives of nursing in neonatology could fail to cite the contributions of Margaret Higgins Sanger, a public health nurse who spent the greater part of her life promoting the cause of voluntary conception. Born in 1883, the sixth in a family of eleven children, Margaret Higgins experienced poverty as she was growing up. Her mother died at 49 of tuberculosis. Higgins grew up believing that her mother's "endless drudgery" of pregnancies (her own expression), was responsible for her early death.

After graduating as a nurse at the White Plains Hospital in New York, Higgins married William Sanger and during the early years of marriage gave birth to three children. She was drawn early to the plight of the unfortunate-first, the oppressed industrial workers in factories such as those in Lawrence, Massachusetts, where median family income with both parents working was $13 a week (and in the solvent families, called "high income," the children worked from the age of eight)-and then the women, rich and poor, who could not control the size of their families. When she was 29, she nursed back to health a friend who had tried to abort herself. This woman asked the physician what she could do to keep from having more children. The doctor responded with a remark to the effect that the woman's husband could sleep on the roof. Three months later the woman, again pregnant, again tried to abort herself. Sanger was at her bedside when she died.

It was her involvement in public health maternity care that had brought to her attention the need for birth control information, freely available to all. In the following years, she cited the experience as a turning point in her life.

She tried to find books on birth control but none were available. The Comstock Act of 1873 had forbidden the mailing of birth control literature; and Anthony Comstock and his disciples, whom President Grant had armed with a pistol and a posse for a war against pornography and the First Amendment, were celebrated for their raids on places that sold materials classified, under guidelines as whimsical as any lynch law, as obscene. Such materials included advice on birth control.

One of the books Sanger could have consulted in her vain search was a strange volume titled Birth Control or the Limitation of Offspring by a physician named William J. Robinson.^[6] It is an ordinary-looking book on the outside, but some of the chapters within are unusual in that they consist of blank pages. Chapter 28, titled "The Best, Safest and Most Harmless Means for the Prevention of Conception," begins as follows:

"The means for the prevention of conception may be considered under three principal heads: mechanical, chemical and physiological. Of the mechanical means, the best is"

. . . and there the text ends, except for a footnote that reads:

"The further discussion of this subject has been completely eliminated by our censorship, which tho a post factum censorship is nevertheless as real and as terrifying as any that ever existed in darkest Russia. In fact in this respect the Russian censorship is more liberal than ours. Our censorship hangs like a Damocles' sword over the head of every honest radical writer. As soon as the brutal laws have been removed from our statute books, as soon as the censorship of scientific discussion of matters of vital importance to the race has been abolished, this chapter, which is all ready, will be published, either in the body of the book or as a separate supplement."

Four blank pages follow.

Chapter 29, titled "Means for the Prevention of Conception Which are Disagreeable, Uncertain or Injurious" is blank but for the footnote:

"This chapter must also be eliminated. Not only are we not permitted to mention the safe and harmless means, we cannot even discuss the unsafe and injurious means and methods. And this we call Freedom of the Press!"

. . . and more blank pages.

Margaret Sanger had to go to France to learn what she could about birth control. Contraception was accepted and practiced in Europe. She returned and published The Woman Rebel, a periodical which gave precise, detailed and accurate information on contraception and family planning. In 1916, the year the Robinson book was published, she opened the first birth control clinic in the United States, in Brooklyn. On the first day more than 150 women came to the clinic for information on birth control. Ten days after the clinic opened Sanger was arrested, taken before a judge and sentenced to 30 days in the workhouse, then physically restrained and taken off to be imprisoned and subsequently force-fed, for she refused to eat while locked up.

Sanger's public health activism in birth control and sex education took the form of lecturing, organizing meetings and public rallies, fund-raising and writing books. Her crusade met with favor among influential persons who gave her financial support and helped lead the way to establishment of the American Birth Control League in 1921. The National Committee on Federal Legislation for Birth Control was organized seven years later, direct predecessor of the Planned Parenthood Federation.

In our history, Sanger (Fig. 6) resides among the titanic figures whose influence fostered increased neonatal survival, healthier babies and mothers.

Thus far, we have traced the history of nursing as it relates to the birth of a child from a time of great innocence and simplicity, when the nativity scene was made up of the mother, the child and the midwife, through a period of turmoil when civilization, so-called, intervened in the natural process, often compromising it. Religious war, overcrowding in cities, poverty and plague took their toll of newborn children along with the rest of humankind.

We saw the emergence of scientific nursing in the mid-Nineteenth Century with Florence Nightingale. Discoveries made in the chemistry and biology laboratories were applied in the delivery room to save lives, then carried out into the homes by pioneers such as Lillian Wald and Mary Breckenridge.

An ironic aspect of this history is the extent to which science, carried to extremes, has tended at times to defeat itself. In a 1930 text on nursing,^[7] one finds pictures of a "ruminating cap" applied to a newborn baby to prevent the baby from spitting up food, paralyzing the baby's face in the bargain. "Thumb sucking," the text explains, "may be prevented by the simple procedure of putting stiff cuffs on the baby's elbow . . . which make it impossible for him to reach his mouth with his thumb. . . . His hands may be put into celluloid or aluminum mitts . . . or little bags made of stiff, heavy material, which in turn are tied to his wrists... Ear pulling is not uncommon among young babies and, if allowed to continue, a long, misshapen ear may result." To prevent this, either the ruminating harness or elbow splints are to be used. Babies are placed in strait-jackets to keep from shrugging off their covers. To promote regularity and to obviate the need for a diaper change, the child is routinely fitted with a soap stick suppository and held above a potty.

This textbook is fairly representative of nursing books of its time and twenty years past it; it has chapters full of sound and sensible advice for mothers and nurses which is applicable today. The point is that "scientific" nursing without a scientific base has often prevented nature from "interfering" in the natural processes, and has often inadvertently extinguished the self-consoling behaviors of infants.

At the turn of the Twentieth Century, a French physician named Budin discovered that incubator care was associated with improved survival of premature infants. One of Budin's pupils, Martin Couney (or Cooney) brought the idea of heat maintenance for premature infants to the United States. From 1902 up through the New York World's Fair of 1939-40, where his exhibit outdrew every attraction save the dancing of Sally Rand, Couney exhibited his "child hatchery" in fairs and exhibitions throughout the world (Fig. 7). Though essentially a showman, Couney can be credited with employing well-qualified nurses and physicians in caring for these infants and also for some advances in incubator design and premature feeding techniques.

His work had a totally unexpected byproduct: when it was learned that the newborns who had been taken away from their mothers suffered ill effects after being restored to them (and the mothers, remarkably, often did not want their babies back), the first glimpses of a dynamic now known as maternal-infant bonding were dimly perceived. Still, isolation of high-risk neonates from their mothers and from other human contact was practiced in the name of asepsis fairly generally up into the 1960's, even though disquieting results of the practice had replicated Couney's findings: such children tended to have more adjustment problems than others; the children often were returned to the hospital, battered. An increased incidence of babies' idiopathic failure to thrive, weeks or months after having been discharged, healthy, from the hospital, was seen.^[8]

During the past decade, nurse researchers and others have explored this phenomenon in terms of overall behavioral organization of preterms and other newborns; significant contributions of nurse researchers include those of Gail Malloy in exploration of the effect of auditory stimulation on preterm behavior; Jacqueline Chapman on stimuli and motor patterns of preterm infants; Mary Neal on overall organizational behavior in the preterm infant; Mary Margaret Brown on parental concerns about infant behavioral organization; Ruth Rice on sensorimotor stimulation and development in high risk infants as a class; Gene Anderson-Shanklin and Ann Neeley on sucking in preterm infants; Katherine Barnard on preterm behavioral assessment; and Olive Rich on support systems. The list is long. The mother-child bond is explored as well by Ramona Mercer in her work with adolescent mothers, and by Juanita Fleming on methadone addicted infants.

A wide variety of programs has emerged to prepare nurses to function in a highly technological health care system. Terms such as nurse practitioner, nurse clinician, clinical nurse specialist and critical care nurse have become familiar to all of us. At times, the precise meaning of these various terms has eluded us. Today, clarification emerges as we realize that the demarcations cannot be rigidly made, that these classifications must be viewed with an eye toward holism of neonatal care-keeping uppermost in our minds the essence of nursing and the unique contribution nursing can make toward the improvement of perinatal outcome and the strengthening of the family.

Graduates of these programs have helped to ensure that the caring component of nursing is maintained; they have worked hard for parental visitation, have helped the family stay together, and have supported and promoted attachment between mother and infant.

Today 21 programs in major universities in the United States offer a doctoral degree in nursing and more are being planned. Most nurses holding doctorates today have their degrees in areas other than nursing, such as education, psychology, physiology, sociology and administration. The need is for nurses trained in nursing to validate and explicate the body of knowledge on which nursing practice rests. We are moving in that direction.

In this brief history, we have touched on the work of a number of pioneers each of whom has made unique and priceless contributions to the health and well-being of humankind: Florence Nightingale who introduced science and humanity to nursing; Lillian Wald and Mary Breckenridge who carried the healing profession into the homes; and Margaret Sanger whose work in birth control promoted neonatal and maternal health as well.

It is a history full of paradoxes-as full of heroes and villains as any history of the human race. In neonatal nursing, as in all medicine and all professions, humanity and intelligence must prevail, bringing about improved infant, maternal and family health and a better world.

 

	Figure 1. Hogarth's conception of the foundlings. Two "dropped" infants are on the extreme right. (Dolan, Nursing in Society)
	Figure 2. Left: A woman carrying a baby approaches the receiving box of a foundling asylum. Right: Interior of asylum with the box opened. From L'Illustration, 1852. (Dolan)
	Figure 3. This contemporary drawing of the Paris Foundling Hospital is much idealized. The actual hospital was a teeming "agar-plate" of infection. (Kalisch & Kalisch, The Advance of American Nursing)
	Figure 4. Florence Nightingale. (Kalisch & Kalisch)
	Figure 5. In this turn-of-the-c ntury photograph, one sees an immigrant family being helped by a visiting nurse. (Kalisch & Kalisch)
	Figure 6. Margaret Higgins Sanger and two of her children. (Kalisch & Kalisch)
	Figure 7. Couney's exhibitions of prematures at the New York World's Fair in 1939 led to advances in premature care and opened the door to the concept of MaternalInfant bonding. (Klaus & Kennell, Maternal Infant Bonding)

REFERENCES

1. Winslow C. E. A.: Florence Nightingale and Public Health Nursing. Public Health Nursing 46:331, 1946. Quoted in Dolan, J. A., Nursing in Society, 14th ed. Philadelphia: W. B. Saunders Co., 1978.

2. Kalisch P. A., Kalisch B. J.: The Advance of American Nursing. Boston: Little, Brown & Co., 1978, p. 123.

3. Kobrin F. E.: The American midwife controversy: A crisis of professionalism. Bulletin of the History of Medicine, XL (4), 350-363. Also Ehrenreich & English (below).

4. Dublin Louis L: The First One Thousand Midwifery Cases of the Frontier Nursing Service. New York: Metropolitan Life Insurance Company, 1932, pp. 1-2. Quoted in Kalisch & Kalisch, p. 388.

5. American Medical Association: Proceedings of the Eighty-First Session of the House of Delegates, June, 1930. Chicago: AMA, 1930.

6. Robinson W. J.: Birth Control or the Limitation of Offspring by the Prevention of Conception. New York: The Critic & Guide Co., 1917.

7. Van Blarcom C. C.: Obstetrical Nursing. New York: The Macmillan Co., 1930, pp. 383-387.

8. Klaus M. A. & Kennell J. H.: Maternal-Infant Bonding. St. Louis: C. V. Mosby Co., 1976.

A selected bibliography would give credit to Kalisch & Kalisch, above, and Dolan, above, for providing some of the material and many of the illustrations for this paper. Also, Ehrenreich, B. & English, D. For Her Own Good. New York: Anchor Press, Doubleday, Garden City, 1978; and Pollard, E. F. Florence Nightingale. London: S. W. Partridge Co., 1902.