Health and Wellness Measurement

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SPRINGER BRIEFS IN APPLIED SCIENCES AND
TECHNOLOGY  COMPUTATIONAL INTELLIGENCE

Gita Khalili Moghaddam

Christopher R. Lowe

Health and
Wellness
Measurement
Approaches for
Mobile Healthcare

123
SpringerBriefs in Applied Sciences
and Technology

Computational Intelligence

Series editor
Janusz Kacprzyk, Polish Academy of Sciences, Systems Research Institute,
Warsaw, Poland
The series “Studies in Computational Intelligence” (SCI) publishes new develop-
ments and advances in the various areas of computational intelligence—quickly and
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readership are the short publication timeframe and the world-wide distribution,
which enable both wide and rapid dissemination of research output.

More information about this series at http://www.springer.com/series/10618

Gita Khalili Moghaddam
Christopher R. Lowe

Health and Wellness

Measurement Approaches
for Mobile Healthcare

123
Gita Khalili Moghaddam Christopher R. Lowe
Department of Pharmacology Department of Pharmacology
University of Cambridge University of Cambridge
Cambridge, UK Cambridge, UK

and and

Department of Chemical Engineering Department of Chemical Engineering

and Biotechnology and Biotechnology
University of Cambridge University of Cambridge
Cambridge, UK Cambridge, UK

ISSN 2191-530X ISSN 2191-5318 (electronic)

SpringerBriefs in Applied Sciences and Technology
ISSN 2625-3704 ISSN 2625-3712 (electronic)
SpringerBriefs in Computational Intelligence
ISBN 978-3-030-01556-5 ISBN 978-3-030-01557-2 (eBook)
https://doi.org/10.1007/978-3-030-01557-2

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Acknowledgements

The authors would like to express their gratitude to the University of Cambridge for
providing the opportunity to publish this book. We also would like to offer our
appreciation to all those individuals who provided help in publication of this book.

v
Contents

1 Mobile Healthcare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.1 Current Healthcare Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.2 Mobile Healthcare (mHealth) . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.3 Mobile Technology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
1.3.1 Overview of Mobile Technology . . . . . . . . . . . . . . . . . . . 5
1.3.2 Features of Mobile Technology . . . . . . . . . . . . . . . . . . . . 7
1.3.3 Business Implications of Mobile Technology . . . . . . . . . . 8
1.4 Health Measurement in mHealth . . . . . . . . . . . . . . . . . . . . . . . . . 10
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
2 Physical Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
2.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
2.2 Sensor Technologies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
2.3 Clinical Value . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
2.3.1 Dietary Management . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
2.3.2 Premature Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
2.3.3 Non-communicable Diseases . . . . . . . . . . . . . . . . . . . . . . 25
2.3.4 Psychological Disorders . . . . . . . . . . . . . . . . . . . . . . . . . 27
2.3.5 Post-discharge Management . . . . . . . . . . . . . . . . . . . . . . 27
2.3.6 Fall Detection and Fall Prevention . . . . . . . . . . . . . . . . . 28
2.3.7 Sleepwalking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
2.3.8 Parkinson’s Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
2.3.9 Sports Science . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
3 Ex Vivo Biosignatures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
3.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
3.2 Sensor Technologies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
3.2.1 Wearables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
3.2.2 Smart Textile . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

vii
viii Contents

3.2.3 Smart Medical Devices . . . . . . . . . . . . . . . . . . . . . . . . . . 56

3.2.4 Ambient Light Imaging . . . . . . . . . . . . . . . . . . . . . . . . . 61
3.2.5 Thermal IR Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
3.3 Clinical Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
3.3.1 Vascular Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
3.3.2 Respiratory Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
3.3.3 Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
3.3.4 Objective Stress Monitoring . . . . . . . . . . . . . . . . . . . . . . 78
3.3.5 Drugs and Alcohol Consumption . . . . . . . . . . . . . . . . . . 79
3.3.6 Dermatology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
3.3.7 Optometry and Ophthalmology . . . . . . . . . . . . . . . . . . . . 81
3.3.8 Cervical Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
3.3.9 Crohn’s Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
3.3.10 Pain Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
3.3.11 Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
Abbreviations

2G Second generation of communication technology

3D Three-dimensional
4G Fourth generation of communication technology
A/D Analog-to-digital
Apps Mobile applications
ASD Autism spectrum disorder
BAN Body area network
BCG Ballistocardiogram
BMI Body mass Index
bps Bits per second
CAD Coronary artery disease
CAGR Compound annual growth rate
CE Conformité Européene—European Conformity
CIN Cervical intraepithelial neoplasia
COPD Chronic obstructive pulmonary disorder
CVD Cardiovascular diseases
D Diopter—a unit measuring a lens’ refractive power
DALYs Disability-adjusted life years
DLW Doubly labeled water
DR Diabetic retinopathy
ECG Electrocardiogram
EEG Electroencephalogram
EMG Electromyogram
FDA Food and Drug Administration
FEV1 Forced expiratory volume in one second
FOG Freeze of Gait
FuzzyEn Fuzzy entropy
FVC Forced vital capacity
GDP Gross domestic product
GPS Global Positioning System

ix
x Abbreviations

HRV Heart rate variability

Hz Hertz
iPPG Imaging photoplethysmogram
IR Infrared
ISDN Integrated Services for Digital Networks
LCD Liquid crystal Display
LED Light-emitting diode
LMICs Lower-middle-income Countries
LWIR Long-wavelength infrared
MET Metabolic equivalent
mhealth Mobile healthcare
OS Operating system
PAEE Physical activity energy expenditure
PD Parkinson’s disease
PEF Peak expiratory flow
PPG Photoplethysmogram
qEEG Quantitative electroencephalogram
REE Resting energy expenditure
RGB Red–green–blue
ROI Region of interest
RR Relative risks
SampEn Sample entropy
sEMG Surface electromyogram
SMS Short message services
SO2 Arterial oxygen saturation
T2DM Type 2 diabetes mellitus
TEE Total energy expenditure
TEF Thermic effect of food
VIA Visual inspection with 4% (v/v) acetic acid
WHO World Health Organization
Chapter 1
Mobile Healthcare

1.1 Current Healthcare Challenges

There is a substantial body of research pointing to numerous challenges in the current

provision of healthcare (Fig. 1.1). The principal issue is rising healthcare expenditure,
which is primarily posed by global and demographic changes, such as economic
growth and urbanisation. The Gross Domestic Product (GDP) value has a positive
impact on the average human lifespan, whereas urbanisation has a negative impact
on health. The total dependency ratio (the ratio of non-working age to working age
for the population) is expected to rise sharply as a result of a continued increase in
human longevity. For instance, the ratio in Japan, North America, Western Europe
and China will reach 73.8, 33, 44 and 38%, respectively, while the global average ratio
will be 25% in 2050 [1]. In terms of health status, the influence of modernisation on
lifestyle and dietary habits, such as the tendency of eating processed food, is linked
to the prevalence of chronic diseases such as Type 2 Diabetes Mellitus (T2DM),
Chronic Obstructive Pulmonary Disorder (COPD), cardiovascular diseases (CVD)
and cancer. By 2035, for example, it is expected that the prevalence of T2DM in the
EU will be 70M [2].
Managing the combination of chronic diseases and an ageing population is leading
to unsustainable healthcare costs and rising morbidity. Healthcare costs in the US,
European countries and China reached 17.9, 8–9 and 4.5% of GDP in 2010, respec-
tively [3], implying that the per capita healthcare expenditure has grown faster than
income levels and inflation [4]. The underlying cause of increasing costs is that the
current healthcare model behaves in a reactive manner and is episodic in nature and
thus, is not often suitable to manage patients who are routinely flagged for treat-
ment once their condition has deteriorated to a point where significant morbidity and
complications develop. A preferred approach is, therefore, frequent and/or real-time
monitoring of patients, which can offer a means to anticipate an increased risk of
failing health and thus act upon the warning signs at an earlier stage and eventu-
ally reduce hospital admissions for acute treatment. While this approach may lower

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2019 1

G. Khalili Moghaddam and C. R. Lowe, Health and Wellness Measurement
Approaches for Mobile Healthcare, SpringerBriefs in Computational Intelligence,
https://doi.org/10.1007/978-3-030-01557-2_1
2 1 Mobile Healthcare

Fig. 1.1 Current healthcare challenges

healthcare costs, there are two overarching concerns associated with this strategy, i.e.
the growing trend towards professional outsourcing and the resultant labour hours
lost. In response to these issues, healthcare organisations are looking at a patient-
centred model to empower patients to manage their conditions at homes or wherever
they happen to be, but outside high-cost healthcare institutions such as hospitals and
surgeries.
While the prevalence of chronic diseases and ageing are raising the burden on
healthcare systems across the world, developing countries are dealing with two addi-
tional challenges. One is the elimination of communicable diseases: In developing
countries, communicable diseases are the leading cause of mortality, 36%, while
accounting for 40% of total annual DALYs (Disability Adjusted Life Years) lost [5].
The underlying health-related causes of communicable diseases are the absence of
knowledge of appropriate health countermeasures, lack of access to public sources
of medical knowledge, shortage of high-level health professionals and inadequate
health education programs to train health educators. Therefore, efforts to address
communicable diseases need to focus on disseminating relevant health information
and strengthening healthcare surveillance at the local, national and global levels.
Another additional challenge of developing nations is extending healthcare access
in rural areas. Developing countries are predominantly rural (68.5% in 2010 and
66.3% in 2015 [6]) and are characterised by a shortage of financial resources to sup-
port both the physical infrastructure of healthcare and professionals. To cope with
the challenges of rural healthcare, the healthcare system should aim at empowering
lower-level health personnel in remote communities by linking them to higher-level
ones in the urban areas to obtain peer advice, thereby enabling evidence-based diag-
nosis by using cost-effective diagnostic instruments and, at the same time, providing
geographically remote consultation with specialists for patients.
These major challenges are exacerbated by the emerging expectations of health-
care stakeholders. From the demand perspective, individuals press for timely access
1.1 Current Healthcare Challenges 3

to high-quality personalised healthcare services anywhere at any time, namely the

third place [3], in a trusted way. On the supply side, a shift from a sick-care to a
health-care model is expected, where the focus of the former is diagnosis and treat-
ment and that of the latter is wellness and prevention. This transformation entails
activating responsible citizens to take more informed decisions on their health.

1.2 Mobile Healthcare (mHealth)

To tackle the challenges being imposed on the healthcare industry, healthcare organ-
isations are looking at value as a solution strategy. Value in healthcare systems is a
function of favourable outcomes and healthcare costs:
Outcomes
Value  (1.1)
Costs
where the health outcomes encompass timely access, service quality, equity, afford-
ability, quality of life and the overall national health status [7], while variables con-
tributing to healthcare costs include the number of patients, the number of visits,
the number and type of services per episode of care and costs per service (Fig. 1.2)
[8]. Given the low cost, immediacy and widespread availability of mobile tech-
nology (Sect. 1.3), healthcare experts agree that the integration of mobile technol-
ogy with existing healthcare settings appears to have the potential to maximise the
value proposition for healthcare. The deployment of a mobile-enabled healthcare
(mhealth) model can leverage the capacity and quality of health services by shar-
ing accountability and responsibility between healthcare consumers and suppliers.
In this healthcare system, the focus is on prevention by enabling self-management
and, if care is needed, it is based on evidence, informed patient preferences and
shared decisions. Additionally, mhealth services can improve health outcomes by
the arrival of healthcare everywhere, transparency in pricing, convenience in routine
testing and efficiency of treatment. Moreover, mhealth can reduce healthcare costs
over time and thus offer a financially sustainable system. For instance, promoting
healthy behaviour and prevention using mhealth interventions can reduce the number
of patients, while mhealth enables remote monitoring of patients and thus reduces the
number of outpatient follow-up visits. Accordingly, mhealth can potentially create a
broad socio-economic impact for the various beneficiaries.
The architecture of an mhealth ecosystem integrates three key components: A
Body Area Network (BAN), a cloud-based server and healthcare providers (Fig. 1.3),
where a BAN is a subset of a sensor network (body gateway) and a host device. Nodes
in the body gateway are capable of generating sensory information using a combina-
tion of on- and off-body, embedded and ambient sensors. On-body sensors refer to
wearable sensors and intelligent clothes and off-body sensors are home, workplace
and point-of-care diagnostics tests. Every sensor node has a wired/wireless commu-
nication module to establish a secure connection with the cloud server through a host
4 1 Mobile Healthcare

Fig. 1.2 Potential of mhealth in improving healthcare outcomes and reducing healthcare expendi-
ture

Fig. 1.3 The mHealth system architecture

device to transfer data from and to the patient remote site. Besides data gathering,
aggregation and dissemination, the host device performs other key tasks: Preliminary
data processing, data visualisation and local data storage. The advanced data analysis
and big data storage capabilities offered by cloud services allow healthcare centres
to gain data literacy and provide the required health information to the user, medical
professionals and payers.
To provide a historical perspective and technical background on the concept of
mhealth, the first following section reviews mobile technology by presenting the evo-
lution of mobile technology, value-added mobile features and its business implication
1.2 Mobile Healthcare (mHealth) 5

and emerging trends. Then, new horizons for health through mobile technology, the
process of implementing mobile technology into the healthcare industry and chal-
lenges are thoroughly described.

1.3 Mobile Technology

Mobile technology has unique features not available to traditional wired electronic
technologies and is revolutionising both our society and the business world. Mobile
technology offers a novel mode of liberty for individuals: “free, yet tracked; mobile,
yet contained” [9]. In this respect, mobile technology presents a new mode of business
transaction which promises many alluring market opportunities.

1.3.1 Overview of Mobile Technology

The mobile phone presents itself as something that followed the trajectory of the
telephone, and then telecommunications. However, very quickly, mobile phones have
established themselves as a central culture in their own right, and tend towards
an emphasis on constant contact with the individual rather than the household as
well as qualities of mobility, portability and customisation. With continually rising
expectations about mobility and a widening access to wireless connectivity, mobile
technology has taken a turn forward and picked up significant speed since the first
mobile phone was introduced in 1979 [10]. The evolution of mobile technology has
to a large extent been spawned by technological advances in both mobile networks
and mobile phone handsets.

1.3.1.1 Mobile Networks

The mobile network is one platform involved in enabling mobile technology. Mobile
networks are commonly divided into generations: The first mobile network gener-
ation (1G) was analogue and only supported voice transmission. As demand grew,
the second generation (2G) of communication technology was developed in 1991.
This generation was a type of Integrated Services for Digital Networks (ISDN) and
therefore supported both voice and data, while it enhanced the number of services
for global evolutions such as text messages, picture messages and multi-media mes-
sages (MMS). Later in the 1990s, the operators of 2G systems offered more efficient
forms of data transmission, known as 2.5G and 2.75G, to enhance the speed of data
transmission from 56 to 153.6 Kbps. In 2001, so-called 3G networks were commer-
cially launched, which not only enabled the worldwide use of services such as web
browsing, metre accuracy GPS (Global Positioning System) and multimedia ser-
6 1 Mobile Healthcare

vices, but also provided better bandwidth and higher data transmission rates, up to 2
Mbps [10]. Currently, 4G is available in networks around the world and has enabled
mobile ultra-broadband internet access to support data-transmission speeds as high
as, and in excess of, 100 Mbps. According to the International Telecommunication
Union specifications in 2015, 5G networks are expected to be deployed by 2020,
which will support up to 1 Tbps, with the promise of an enhanced quality of service.

1.3.1.2 Mobile Phones

It is not just mobile network technology that makes mobile communication possible;
users need personal devices to access the mobile network through mobile terminals.
Since the technology incorporated into mobile handsets has a significant impact on
services that can be offered, their development was another fundamental brick in the
emergence of advanced mobile technology.
When mobile networks first began, there was a basic model of mobile phone
available to support only voice. Basic mobile phones offered a simple model with
a monochrome screen and single-tasking environment, and were often bulky and
had poor battery lives. Advances in all aspects of mobile phone technology dur-
ing the 1980s meant that handsets became smaller and battery life improved. These
internet-enabled handsets, so-called feature phones, incorporated advanced features
such as megapixel cameras, video capture, Bluetooth, expandable memory slots, and
Java capability. By the late 1990s, smartphones started to enter the marketplace at
a fast pace. The smartphone is generally defined as a hybrid device whose primary
function is that of a phone, communication, with added advanced computing capabil-
ities with a low-power Operating System (OS). Meanwhile, high-quality graphical
interfaces have provided a platform to introduce virtual keyboards and sophisticated
touchscreen capability. The design of smartphones also relies on the use of embed-
ded sensors to optimise the platform operation and to offer higher level services to
the users. Embedded sensors (Fig. 1.4) in handsets include motion detectors (for
measuring acceleration and rotational forces), environmental sensors (for measur-
ing temperature, illumination, pressure, humidity), position sensors (for measuring
orientation and magnetic North), sound sensors (for sound processing) and CMOS
image sensors (for capturing image, colour analysis and pattern recognition).
Alongside the hardware innovations, new software architectures have been created
to support the device hardware features, which are referred to as mobile applications
(apps). Smartphone users can download apps through app stores using built-in Wi-Fi
features to perform specific functions in various sectors such as agriculture, educa-
tion, financial services, social networking, information services, gaming and health.
In terms of development and implementation, it is possible to run apps on mobile
devices, native apps, and or remotely in the cloud, cloud apps.
Native apps invade the mobile space and rely on its restricted computational
power while anchoring users to a proprietary OS (Google Android, iOS, Microsoft
and Symbian), whereas cloud apps can be used independently of the OS, albeit using
a mobile broadband subscription. Another benefit arising from cloud computing
1.3 Mobile Technology 7

Fig. 1.4 Embedded sensors in smartphones and their potential application in healthcare (Source
for the smartphone image Adapted from [11])

is that less mobile space and computational power on the phone are required; the
latter is related to lower power consumption and thus saving battery life. In this
context, the cloud-computing strategy has the potential to leverage an infrastructure
to perform computationally expensive tasks such as digital image/sound processing
and therefore holds opportunities for app development in new domains. Despite
the advantages of cloud apps over native apps, a compelling argument is that most
embedded sensors are not accessible via cloud apps. However, cloud apps are gaining
access to more built-in sensors as the technology progresses.
The interaction between apps and sensors has transformed smartphones to afford-
able and easy-to-use measuring tools and will continue to incorporate more innovative
functionality in the following years by interacting with developments in a diverse
range of vertical sectors such as healthcare. The list of sensors that apps in the health-
care sector can interact with is going beyond solely embedded phone sensors. Emerg-
ing apps, namely sensor apps, work in conjunction with external peripheral sensors.
Auxiliary sensors, including a wide range of sensors from implantable to wearable
to portable sensors, measure quantities (vital signs, chemicals and metabolites) and
then interface with embedded sensors (e.g. Bluetooth and optical) to transfer raw
data to sensor apps for visualization, recording, preliminary/advanced processing
and transferring to a predefined cloud.

1.3.2 Features of Mobile Technology

The essence of mobile technology is about providing the technological infrastructure

for maintaining easy access to information at the right time regardless of where
users are with minimal upfront expenditure [12]. Accordingly, mobile technology is
associated with a set of value-added features:
8 1 Mobile Healthcare

Ubiquity Easy, timely access to information is the primary advantage of mobile

technology. Mobile technology enables users to get any information that they are
interested in, whenever they want regardless of their location. In this sense, mobile
technology makes a service or an application available wherever and whenever such
a need arises. This will also result in an increase in revenue to the company providing
the mobile services.

Improved Accessibility Mobile technology presents the opportunity to provide

additional value to hard-to-reach end customers. Through mobile devices, business
entities are able to reach customers anywhere anytime. With a mobile terminal, on the
other hand, a user can be in touch with any available other people anywhere anytime,
subject to mobile coverage. Moreover, the user might also limit his/her reachability
to a particular person or at particular times.

Localisation The knowledge of the user’s physical location at a particular moment

also adds significant value to mobile technology. With location information available,
many location-based services (LBS) can be provided including emergency caller
location, navigation, and geographically targeted advertisements.

Personalisation Given the enormous number of services and apps that are currently
available in the app market, the mobile ecosystem can be explicitly adapted based
on the preference of the user to represent information and provide services in a way
appropriate to the user.

Feedback Loop Mobile technology has the ability to collect objective data from
users, share them and provide insight and goals which can be achieved through
personalised choices.

Dissemination Some wireless infrastructures support simultaneous delivery of data

to all mobile users within a specific geographical region. This functionality offers an
efficient means to disseminate information to a large consumer population.

1.3.3 Business Implications of Mobile Technology

According to the latest annual report from ITU, the United Nations agency responsi-
ble for looking into the world’s Information and Communication Technology issues,
there would be 6.8B mobile subscriptions by the end of 2013, taking global mobile
penetration to close to 100%. The massive growth of adoption and advancement of
mobile technology creates opportunities for providing a range of innovative mobile
services through mobile apps. The market for mobile apps was launched by the
Apple App Store in 2008 and, after its immediate success, app stores of other OS
providers emerged. In two years, the apps market reached 10B app downloads with
a global revenue of US$2.2B, demonstrating a 160.2% increase. In 2017, global app
downloads from both App Store and Google Play reached 175B where users spent
1.3 Mobile Technology 9

Fig. 1.5 a Global smartphone penetration, 2010–2019* (Adopted from [14]). Note *Estimate, b
download of mobile apps from all stores worldwide, 2012–2017* (Adopted from [15])

US$58.6B on apps, including in-app purchases, subscriptions and premium apps

[13].
The most important trend underpinning the fast pace of growth of the apps mar-
ket is global smartphone penetration, although there are differences in the estimated
growth rate. For example, according to Ericsson [14], global smartphone subscrip-
tions will amount to 5.6B, or 60% of the total mobile subscriptions, by the end of
2019, compared to 1.9 billion in 2013, or 30% of the total mobile subscriptions
(Fig. 1.5a). This growth will be led by markets in Africa and Eastern Europe, fol-
lowed by the Middle East, Latin America, and Asia-Pacific, while the advanced
markets of Western Europe and North America are approaching saturation [16]. The
first and foremost driving factor in the global spread of smartphones is the rapid
fall in their price, particularly in emerging markets [17]. Today, smartphone users
usually come from top-earning socioeconomic groups; however, with various factors
(local subsidies, domestic manufacture, high-level competition) combining to low-
ering smartphone prices, smartphones are expected to become accessible to a greater
proportion of the world population. According to the International Data Corporation
the average global price of a smartphone, which was US$368 in 2013, fell to US$303
in 2017 [18].
Another trend that is driving the increased download of mobile apps is the
growth of mobile-broadband subscriptions which provides access to bandwidth-
intense value-added services. Mobile-broadband subscriptions are estimated to reach
6.5B by 2018 [19]. It should be noted that mathematical models predict a substan-
tial difference in average annual growth (CAGR) of mobile broadband subscription
(2007–2017) in developed and developing regions, with 18% in the former compared
with 38% in the latter. The predicted upsurge in mobile-broadband subscriptions in
developing countries is primarily driven by the lack of infrastructure for deploy-
ment of the fixed (wired)-broadband, particularly in rural areas. Rural inhabitants
of developing countries account for 66.3% in 2015 [6] of the population. Given
the infrastructure challenge to provide fixed-broadband services for these people,
mobile-broadband, which is less complicated to deploy, is considered an alterna-
tive. Accordingly, developing countries are playing an increasingly important role
10 1 Mobile Healthcare

in the global apps market and thus global economy. Given the continued growth in
the apps market, Forrester predicts revenues would reach to US$38B by end 2015,
while Granter expects four times of this amount for cloud-based computing apps.
Figure 1.5b highlights the year-on-year growth of global app downloads and the
revenue for the period 2012–2017.

1.4 Health Measurement in mHealth

The concept of health is overarching and the index of health status includes a com-
plex set of physical, physiological, psychological, subjective and social indicators.
Accordingly, defining a set of standard criteria to fulfil the broad definition of health
and incorporate various levels of complexity and the relationships among them is
challenging [20–23]. In line with the framework of this book, a choice of indicators
on different aspects of health status that can be remotely monitored is considered. For
each health indicator, the capacity of sensor technologies to be applicable to mhealth
and the likely clinical outcomes are explored in depth in two sections of physical
activity and ex vivo biosignatures in following chapters.

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4. The World Bank (2016) Health nutrition and population statistics
5. Skolnik R (2008) Essentials of global health. Jones & Bartlett Learning, USA
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and sex, 1980–2015
7. Adams J, Bakalar R, Boroch M, Knecht K, Mounib EL, Stuart N (2013) Healthcare 2015 and
care delivery: delivery models refined, competencies define. IBM Global Business Services
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opportunity? A. T. Kearney Korea LLC
9. May P (2001) Mobile commerce: opportunities, applications, and technologies of wireless
business. Cambridge University Press, UK
10. Wakefield T, McNally D, Bowler D, Mayne A (2012) Introduction to mobile communications:
technology, services, markets: technology, services, markets. Taylor & Francis, UK
11. Zanetti D Iphone 4. Wikipedia. https://de.wikipedia.org/wiki/Datei:Iphone_4G-3_grey_scree
n.png#/media/File:Iphone_4G-3_grey_screen.png. Accessed Feb 2018
12. Siau K, Lim E-P, Shen Z (2001) Mobile commerce: promises, challenges and research agenda.
J Database Manag 12(3):4–13
13. Nelson R (2018) Global app revenue grew 35% in 2017 to nearly $60 billion SensorTower Inc.
https://sensortower.com/blog/app-revenue-and-downloads-2017. Accessed Feb 2018
14. Ericsson (2013) Ericsson mobility report: global smartphone subscriptions to reach 5.6 billion
by 2019
15. Gartner (2013) Gartner says free apps will account for nearly 90 percent of total mobile app
store downloads in 2012. http://www.gartner.com/newsroom/id/2592315. Accessed Jan 2018
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16. Portio Research (2013) Portio research mobile factbook 2013

17. Lemaitre G (2012) The smartphone boom in emerging markets. http://www.gfk-geomarket
ing.com/en/about_geomarketing/gfk_geomarketing_magazine/012013/the_smartphone_boo
m_in_emerging_markets.html. Accessed Apr 2016
18. International Data Corporation (2013) IDC finds worldwide smartphone shipments on pace
to grow nearly 40% in 2013 while average selling prices decline more than 12% busi-
ness wire. https://www.businesswire.com/news/home/20131126005293/en/IDC-Finds-World
wide-Smartphone-Shipments-Pace-Grow. Accessed May 2016
19. International Telecommunication Union (2013) Measuring the information society 2013
20. Jenkinson C, McGee HM (1998) Health status measurement: a brief but critical introduction.
Radcliffe Medical Press, UK
21. McDowell I (2006) Measuring health: a guide to rating scales and questionnaires. Oxford
University Press, UK
22. Kaplan RM, Bush JW, Berry CC (1976) Health status: types of validity and the index of
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France
Chapter 2
Physical Activity

2.1 Introduction

The correlation between sedentary lifestyles and health consequences such as over-
weight (Body Mass Index (BMI) of 25–29.9) and obesity (BMI > 30) [1–5], dia-
betes mellitus (DM) [6–8], cardiovascular diseases (CVD) [9–11] and cancer [12]
is clinically proven [13]. According to the WHO [14], sedentary lifestyles with a
prevalence of 23% in adults (>18 years) accounts for 6% of global mortality. The
total economic burden of a sedentary lifestyle in the US in 2003 was ~US$251B
[15]. Physical activity also plays a critical role in achieving a greater level of life
quality and independence [16]. Therefore, it is desirable to develop an automated
lifestyle intervention paradigm which will boost awareness and incentivise changes
in physical behaviour.
Before one considers the implementation of such interventions to promote phys-
ical activity, it is necessary to understand the key concepts behind this paradigm:
Physical activity, models of conceptualising physical activity and the assessment
and quantitation of the level of physical activity. According to the Department of
Health and Human Services [17], physical activity is “any bodily movement pro-
duced by skeletal muscles that result in increased energy expenditure above a basal
level (resting level)”. Physical activity can occur in four broad domains including
occupational (labour task, carrying objects), domestic (housework, gardening, child
care, chores), transportation (walking, cycling, standing), and leisure time (sport,
exercise, hobbies) [18]. Conventional approaches promote physical activity with a
focus primarily on the leisure time domain. However, the substitution effect of phys-
ical activity and hence the health benefits from all four domains of physical activity
have been identified in cohort studies [19]. This necessitates monitoring of the total
physical activity during daily life to obtain habitual activity levels. Furthermore,
it is important to identify the relative time spent in each of the physical activity
dimensions.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2019 13

G. Khalili Moghaddam and C. R. Lowe, Health and Wellness Measurement
Approaches for Mobile Healthcare, SpringerBriefs in Computational Intelligence,
https://doi.org/10.1007/978-3-030-01557-2_2
14 2 Physical Activity

Fig. 2.1 a Physical activity domains and dimensions, b physical activity assessment methods

As shown in Fig. 2.1a, physical activity has four dimensions including mode/type
(walking, running, gardening), frequency, duration and intensity (metabolic demand;
light, moderate, vigorous) [19]. Accurate monitoring of activity dimensions is critical
for translating epidemiological assessments into prevention strategies. If a health
target such as sustained weight loss is associated with moderate-vigorous intensity
activity, increasing participation in more intensive activities is suggested. However,
if the association is closer with the total physical activity, the public health action
would be to encourage physical activity in general. Hence, monitoring the dimension
of activity facilitates the design of interventions.
Despite the well-established health benefits of physical activity and the broader
national and global impact, many individuals are insufficiently physically active.
The deployment of an mhealth platform to promote physical activity necessitates
an understanding of aspects affecting the level of physical activities and its sus-
tained maintenance. Research on behavioural strategies has shown that individu-
alising lifestyle interventions based on motivational needs are the main factor to
induce an individual to adopt physical activity [16]. To maintain physical activity,
self-monitoring [4] and feedback provision [20] are critical behavioural strategies.
These requirements are attainable using the remote monitoring aspect of mhealth
where personal activity plans will be developed either based on the index of activity
by an automated analysis algorithm or a remote coach where needed.
Remote monitoring of physical activity also enables efficient surveillance. The
potential of mhealth for surveillance can be mapped to remote monitoring and cloud
computing strategic points. This facilitates data collection on physical activity of the
community, storage of heavyweight information and data analytics to derive patterns.
These patterns help decision makers understand the outcome of different types of
2.1 Introduction 15

interventions, develop predictive models of intervention schemes and better identify

suitable strategies with the best health outcomes. A surveillance study by Rovniak
et al. [21] identified two major physical activity patterns of adults in two regions of
the US. The first pattern emphasises the importance of peer psychosocial support.
The social networking aspect of mhealth improves communication between indi-
viduals who receive peer advice on their commitment to physical fitness. A second
pattern suggests a lack of awareness to be involved in physical activities, particu-
larly vigorous-intensity activities, and hence interventions for encouraging intense
activities is desirable. The solution of mhealth for this pattern is information dissem-
ination. Short Message Services (SMS) empower individuals with information and
motivation to adopt healthy lifestyles and spread awareness in communities [22]. A
third pattern suggests that physical activities are biased towards leisure and occupa-
tional domains and the active occupational group is more prone to sedentary lifestyles
when not engaged in work. The implication of mhealth for the institutionalisation of
physical activity in four domains can be mapped to incorporating economic, social
and cognitive behavioural feedback interventions that are specifically tailored to the
need of individuals [23–28]. While such interventions provide encouragement and
positive reinforcement for the activity, the probability of cheating behaviour, partic-
ularly in youth, should be taken into consideration in the design of the platform [29,
30]. The tailorability concept of interventions is also critical to improving compli-
ance. Long et al. [31] developed an algorithm to evaluate the risk of dropping out of
the scheme and tailored interventions accordingly to trigger motivation and improve
compliance.
To develop a personalised physical activity scheme, quantification of physical
activity is essential. As demonstrated in Fig. 2.1b, practitioners have attempted to
derive an index of physical activity using various subjective and objective methods
[18, 32]. The index of activity can be obtained using self-report questionnaires or
diaries [33, 34]. The metric is simple and easy to interoperate; however, it is subjec-
tive and lacks validity and reliability due to individual observation and interpretation
[35]. Moreover, it is more accurate for assessing vigorous-intensity physical activity
rather than light-moderate ones [36, 37]. An objective metric for physical activity
assessment is measuring walking steps using pedometers [32]. Commercially avail-
able pedometers estimate the walking/running distance and also the time spent in
different intensity levels [18]. Although walking is the most common form of activ-
ity in the general population, there is a need for a more generic metric to capture
various modes of physical activities [38].
An objective index for physical activity quantification is the physical activity
energy expenditure (PAEE), where the rate of PAEE is strongly associated with the
intensity of physical activity [18]. PAEE is 15–30% of the total energy expenditure
(TEE). Resting energy expenditure (REE) and thermic effect of food (TEF) are
respectively 60–75% and 10% of TEE [39]. Hills et al. [39] reviewed individual
characteristics that determine REE; however, three factors including age, gender and
body size, have a significant impact on REE. Typically, the Harris and Benedict
equation [40] is used for REE estimation:
16 2 Physical Activity

– Male
     
REE  66 + 13.7 × Weightkg + 5 × Heightcm − 6.8 × Ageyrs (2.1)

– Female
     
REE  655 + 6.9 × Weightkg + 1.8 × Heightcm − 6.9 × Ageyrs (2.2)

Consequently, TEF is calculated as:

TEF  0.1 × REE. (2.3)

Gold standard methods for measuring PAEE are indirect calorimetry [41, 42] and
Doubly Labelled Water (DLW) [43, 44] that measure TEE from oxygen consump-
tion and carbon dioxide production followed by deriving PAEE from a formula as
explained in Ainslie et al. [45]. The cost and time associated with these laboratory-
based methods and the provision of skilled operators are prominent barriers to deploy-
ment as mhealth monitoring methods. To address these challenges, portable indirect
calorimetry devices have been developed. Although the performance of both Meta-
max™ and Cosmed K4 b2 ™ have been validated, they have limited use in free-living
settings due to their cumbersome and costly nature [45, 46].
In an alternative method, the PAEE can be estimated indirectly using sensors
embedded in smartphones or wearables. Because there are many wearable choices
available and there is no gold standard, systematic decision-making processing is
proposed [18, 32]. The selection methods consider four characteristics of physical
activity assessment including study characteristics (budget, population, objectives),
population characteristics (age, health status, socio-economic status), instrument
characteristics (mode of administration, measured constructs, psychometric prop-
erties) and physical activity domain and dimensions. However, exploiting mhealth
solutions for physical activity assessment requires a generic platform that integrates
the entire characteristics mentioned above. Commonly available sensor technologies
rely on either physiological or inertial metrics to derive PAEE.
Estimation of PAEE using physiological metrics is convenient and inexpensive.
The main metric of interest is heart rate because it is linearly correlated to oxygen
consumption and hence PAEE [47]. With the development of on-body heart rate
monitoring sensors, this method of PAEE measurement sounds practical. However,
the applicability of this method is mainly limited to moderate-vigorous physical
activities [18, 48]. Furthermore, heart rate can be affected by factors besides physical
activity and hence requires individual calibration [49]. Another indirect method of
measuring PAEE is using motion sensors by converting counts of inertial sensors to
energy expenditure units [18, 45]. Physical activity assessment using inertial sensors
available in smartphones and on-body sensors is discussed in the next section, as
is the challenging endeavour to address the needs of inertial sensors as an optimal
physical activity assessment approach.
2.2 Sensor Technologies 17

2.2 Sensor Technologies

For remote monitoring of physical activity, two motion sensor platforms can be
incorporated into the lifestyle of individuals. One is inertial sensors embedded in
smartphones, wearable sensors and intelligent clothes, and the other is ambient sen-
sors such as infrared (IR) cameras [50, 51]. Although the ambient method provides a
remote, passive mode of monitoring, efforts for the deployment in infrastructure such
as buildings and or baby cribs is required for the full body monitoring and therefore
are beyond the scope of this book.
Monitoring physical activity using inertial sensors (accelerometer and gyroscope)
and magnetometers is widely accepted (Fig. 2.2a). Triaxial accelerometers (Triax) are
sensitive to acceleration in periodic (vibration), instantaneous (shock) and static (tilt
and rotation) modes [52], gyroscopes respond to Coriolis forces and determine the
angular velocity and changes in orientation and magnetometers detect the absolute
orientation by sensing the strength of the earth’s magnetic field [53]. Accelerometers
are used typically in conjunction with gyroscopes and/or magnetometers to provide
low-cost, quantitative three-dimensional (3D) measurements of body movements.
Recent advances in sensor technologies allow for raw data acquisition at a rela-
tively high sampling frequency (40–100 Hz) that can be processed using native or
cloud-based apps to extract the information of interest [32]. Although a low sampling
rate is of interest for energy saving, it is prone to excluding signal details. A recent
study by Khan et al. [54] suggested an automated method for optimising sampling
rates for a specific mode of activity to balance performance and power consumption.
Another energy-efficient approach in which the activity is first classified as dynamic
or static and then the sampling frequency and window size of classification duration
are adapted. This method achieved more than 64% average energy saving and 92%
average accuracy in recognising 6 activities [55].
The raw inertial data obtained at an optimised sampling rate is typically expressed
in the counts per defined time interval (epoch) and the intensity of activity is projected
to counts per epoch. The count value is strongly dependent on technical specifications
of individual sensors such as A/D conversion scale and frequency filtering range
[56]. To standardise the readings of inertial sensors, the sensors are calibrated to
convert counts to physiologically meaningful PAEE units including kilocalories or
metabolic equivalent (MET) [18, 39] using prediction equations [57–61]. Prediction
equations can be obtained from the laboratory-based calibration process against DLW
or calorimeters [62].
Since most physical activity recommendations, for example, the 2008 physical
activity guidelines for Americans [63], stress the duration and intensity of the physical
activity, the PAEE value can be expressed in an alternative metric. For this purpose,
thresholds are applied to translate the PAEE value into an intensity-based construct
including sedentary (MET: 1–1.5), light (MET: 1.6–2.9), moderate (MET: 3.0–5.9)
and vigorous (MET > 6.0) activities [59] (Fig. 2.2b).
To evaluate the validity of the prediction equation, an estimation of inertial sensors
of PAEE was compared with the DLW technique over a broad range of datasets [64];
18 2 Physical Activity

Fig. 2.2 a Inertial sensors and detectable motion types, b components of total energy expenditure
(TEE): Resting energy expenditure (REF), thermic effect of food (TEF) and physical activity energy
expenditure (PAEE). PAEE is used as a metric to classify the physical activity based on the intensity
into four categories of vigorous, moderate, light and sedentary activity in accordance with the MET
(metabolic equivalent) value, c the wearability map of inertial sensors

most inertial sensors performed poorly compared to the gold standard of DLW. One
factor affecting the accuracy of PAEE estimation using inertial sensors is the lim-
ited datasets. To address this issue, Freedson et al. [61] have provided best practice
recommendations for researchers. Development of a public access inertial data repos-
itory including a broad range of human characteristics (age, gender, body mass and
cardiorespiratory fitness) and activities (sedentary lifestyle, sport and leisure activ-
ities) is recommended. This provides researchers access to large inertial databases
for developing prediction equations.
A second factor affecting the validation studies against DLW is the error associ-
ated with prediction equations. In the light of concerns about validation of prediction
equations across the continuum of activity dimensions, the development of a single
equation across the continuum of population and activities is still a matter of debate.
This is due to the inherent limitations of single prediction equations imposed by
the calibration approach [65]. A comprehensive study on the performance of com-
monly used prediction equations by Lyden et al. [56] has identified challenges in the
2.2 Sensor Technologies 19

validation of these methods. Prediction equations tend to perform accurately within

a specific range of physical activity mode that is used to develop the equation and
over/underestimate the energy cost of other activities.
To overcome the limitation of single prediction equations, one recommends a
combination with physiological sensors such as heart rate monitors [66]. However,
the application of multi-sensor platforms in free-living settings can be limited by
factors such as the cost, potential discomfort of wearing multiple sensors for long
periods of time and computationally resource-intensive requirements of multisen-
sory platforms [32]. Additionally, developments in the field of inertial sensors is
promising. Consequently, there is an emphasis on exploring methods to improve the
performance of inertial sensors through the utility of separate estimation equations
for different modes of activities.
A two-equation system showed comparable PAEE values relative to DLW [67]
and calorimetry [68] in adults. However, a study on youth has shown the perfor-
mance of single- and two-equation models were not truly equivalent to the calorime-
try, although the two-equation system performed relatively more accurately [69].
Besides activity-specific equations, more detailed divisions might be advantageous.
Strath et al. [70] evaluated the accuracy and precision of a single prediction equation
in three target populations: Children, senior adults and adults with limited func-
tionality. Despite a good agreement across different populations, individual-specific
characteristics may enhance the performance of prediction equations. However, it is
not known, where appropriate, what population characteristics should be considered
as classifying variables. Another study evaluated the importance of disease-specific
prediction equations in children with chronic conditions [71].
There are challenges for the development of a multi-equation platform that should
be addressed. To switch effectively between equations that each maps to a mode of
activity, the count value should meet a threshold condition. However, the count value
is integrated over time and does not reflect the profile of activity, and consequently,
two activities with a similar integrated count value but different profiles (walking
and lifting boxes) results in similar estimates of PAEE [56]. To address this issue,
it is proposed to use further features of inertial sensors, such as signal distributions
and frequency spectra. Staudenmayer et al. [72] initiated the use of artificial neural
networks to identify the mode of activity based on the pattern of inertial sensor
signal over time. Further development and refinements have been carried out using
other machine learning techniques such as support vector machines [73, 74], hidden
Markov models [75] and other types of artificial neural networks [72, 76].
There is extensive research on physical activity recognition where the classifiers
are aimed at differentiating various combinations of dynamic and static activities.
Physical activity recognition using multiple inertial sensors placed on different parts
of the human body results in high performance in terms of accuracy and sensitivity
[77–79]. However, a multi-sensor platform may reduce compliance due to obstruc-
tiveness; hence, a single sensor monitoring system is desirable. Mathie et al. [80]
suggested a 2-stage classification using a single triaxial accelerometer in which activ-
ities are first labelled as activity and rest, followed by a classification of the activ-
ity category. The work was followed by Ravi et al. [81] by increasing the variety
20 2 Physical Activity

of activities and assessing the potential of a single inertial sensor. In more recent
years, emerging advanced sensor technologies have shifted towards smartphones
and wearables. Kwapisz et al. [82] evaluated the performance of a smartphone-based
accelerometer to recognise six physical activities. Woznowski et al. [83] systemat-
ically reviewed existing sensor technologies for activity recognition to understand
technological requirements for a specific activity. Current methods of activity recog-
nition have evolved to the point that they can be considered ready for being part of
routine clinical monitoring. Additionally, anti-cheating algorithms have been devel-
oped [30]. Nonetheless, there are challenges for the development of this paradigm
as an assistive clinical tool.
Conventional methods of activity recognition are based on static features that
limit the generalisability of the system across users and activity modes [84]. Deep
learning has the potential to leverage a dynamic approach for adaptive activity learn-
ing and improve the performance for new users of a system or to identify new
behaviour of a known user [85]. Hammerla et al. [86] assessed the performance
of three methods including deep feed-forward networks, conventional networks and
recurrent networks; the latter two experienced less variability across data sets. Recur-
rent networks (Long Short-Term Memory cells [87]) outperformed other methods
by a significant margin particularly in long-term, repetitive activities by exploiting
the temporal dependencies. A more recent study by Le et al. [88] reported the use
of a Sequential Forward Feature Selection algorithm to recognise 19 daily activities
with the average classification accuracy of 99.91%. Although significant progress
in the field of activity mode recognition has been made, there are challenges for
the advancement of the field that should be addressed. These challenges include
improving the performance in naturalistic environments and enhancing the sensi-
tivity of activity recognition methods across the entire spectrum of activity types,
including low-speed walking.
Although the activity classification methods appear to be successful in laboratory-
based settings, their validity decreases in a free-living environment. This implies that
independent datasets from real-world settings are required to develop and validate
the classifiers to assure they are transportable to other datasets. Previous studies have
shown the improvement in performance of activity recognition methods using free-
living datasets [89, 90]. An alternative method is a semi population-based approach in
which activity models are developed using a training dataset and models are adapted
to a new user using a small dataset [91].
The sensitivity of activity classifiers is considerably limited in a range of physical
activities, such as low-speed walking and non-ambulatory activities, such as cycling,
weight lifting and steps [32, 92, 93]. The performance of inertial sensors at low-speed
walking is deficient; the gait speed in seniors with frailty syndrome and a mean age
of above 82 is less than 0.75 m/s [94, 95]. Previous studies on step detection using
a single sensor for this target group resulted in a minimum 19.1% error [96–98].
Increasing the number of sensors or wearing a single sensor on the ankle can enhance
the performance at the cost of decreasing compliance due to discomfort [99–101].
A recent study improved the performance of step detection algorithms in low-speed
walking using a single waist-wear sensor and achieved an error of 10%, with a mean
Another random document with
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generally a slight moisture upon their surface, sufficient in some
instances to mark the linen.
226. A dark-brown areola or disk may usually be noticed around
the nipple,[53] the change of color commencing about the second
month. The tint at first is light brown, which gradually deepens in
intensity, until, toward the end of pregnancy, the color may be very
dark. Dr. Montgomery, who has paid great attention to the subject,
observes: “During the progress of the next two or three months the
changes in the areola are in general perfected, or nearly so, and then
it presents the following characters: a circle around the nipple, whose
color varies in intensity according to the particular complexion of the
individual, being usually much darker in persons with black hair,
dark eyes, and sallow skin, than in those of fair hair, light-colored
eyes, and delicate complexion. The area of this circle varies in
diameter from an inch to an inch and a half, and increases in most
persons as pregnancy advances, as does also the depth of color.” The
dark areola is somewhat swollen. “There is,” says Dr. Montgomery,
“a puffy turgescence, not only of the nipple, but of the whole
surrounding disk.”
227. A fourth symptom is quickening. This generally occurs about
the completion of the fourth calendar month; frequently a week or
two before the end of that period; at other times a week or two later.
A lady sometimes quickens as early as the third month, while others,
although rarely, quicken as late as the fifth, and, in very rare cases,
the sixth month.
228. It will therefore be seen that there is an uncertainty as to the
period of quickening, although, as I before remarked, the usual
period occurs either on, or more frequently a week or two before, the
completion of the fourth calendar month of pregnancy.
229. A lady at this time frequently either feels faint, or actually
faints away; she is often either giddy, or sick, or nervous, and in
some instances even hysterical. Although, in rare cases, some women
do not even know the precise time when they quicken.
230. The sensation of “quickening” is said by many ladies to
resemble the fluttering of a bird. “Quickening” arises from the ascent
of the womb higher into the belly, as, from its increased size, there is
not room for it below. The old-fashioned idea was that the child was
not alive until a woman had quickened. This is a mistaken notion, as
he is alive, or “quick,” from the very commencement of his
formation.
231. Hence the heinous and damnable sin of a single woman, in
the early months of pregnancy, using means to promote abortion: it
is as much murder as though the child were at his full time, or as
though he were butchered when he was actually born!
232. An attempt, then, to procure abortion is a crime of the
deepest dye, viz., a heinous murder! It is attended, moreover, with
fearful consequences to the mother’s own health; it may either cause
her immediate death, or it may so grievously injure her constitution
that she might never recover from the shock. If these fearful
consequences ensue, she ought not to be pitied: she richly deserves
them all. Our profession is a noble one, and every qualified member
of it would scorn and detest the very idea either of promoting or of
procuring an abortion; but there are unqualified villains who practice
the damnable art. Transportation, if not hanging, ought to be their
doom. The seducers, who often assist and abet them in their
nefarious practices, should share their punishment.
233. Flatulence has sometimes misled a young wife to fancy that
she has quickened; but, in determining whether she be pregnant, she
ought never to be satisfied with one symptom alone; if she be, she
will be frequently misled. The following are a few of the symptoms
that will distinguish the one from the other: in flatulence, the patient
is small one hour and large the next; while in pregnancy the
enlargement is persistent, and daily and gradually increases. In
flatulence, on pressing the bowels firmly, a rumbling of wind may be
heard, which will move about at will; while the enlargement of the
womb in pregnancy is solid, resistant, and stationary. In flatulence,
on tapping—percussing—the belly there will be a hollow sound
elicited as from a drum; while in pregnancy it will be a dull, heavy
sound, as from thrumming on a table. In flatulence, if the points of
the fingers be firmly pressed into the belly, the wind will wobble
about; in pregnancy they will be resisted as by a wall of flesh.
234. The fifth symptom is, immediately after the quickening,
increased size and hardness of the belly. An accumulation of fat
covering the belly has sometimes led a lady to suspect that she is
pregnant; but the soft and doughy feeling of the fat is very different
to the hardness, solidity, and resistance of pressure of pregnancy.
 235. The sixth symptom is pouting or protrusion of the navel. This
symptom does not occur until some time after a lady has quickened;
indeed, for the first two months of pregnancy the navel is drawn in
and depressed. As the pregnancy advances, the navel gradually
comes more forward. “The navel, according to the progress of the
pregnancy, is constantly emerging, till it comes to an even surface
with the integuments of the abdomen [belly]; and to this
circumstance much regard is to be paid in cases of doubtful
pregnancy.”[54]
236. Sleepiness, heartburn, increased flow of saliva, toothache,
loss of appetite, longings, excitability of mind, a pinched
appearance of countenance, liver or sulphur-colored patches on the
skin, and likes and dislikes in eating,—either the one or the other of
these symptoms frequently accompany pregnancy; but, as they might
arise from other causes, they are not to be relied on further than this
—that if they attend the more certain signs of pregnancy, such as
cessation of being “regular,” morning sickness, pains and
enlargement of and milk in the breasts, the gradually darkening
brown areola or mark around the nipple, etc., they will then make
assurance doubly sure, and a lady may know for certain that she is
pregnant.[55]

CLOTHING.

237. A lady who is pregnant ought on no account to wear tight

dresses, as the child should have plenty of room. She ought to be, as
enceinte signifies, incincta, or unbound. Let the clothes be adapted
to the gradual development both of the belly and the breasts. She
must, whatever she may usually do, wear her stays loose. If there be
bones in the stays, let them be removed. Tight lacing is injurious
both to the mother and to the child, and frequently causes the former
to miscarry; at another time it has produced a crossbirth; and
sometimes it has so pressed in the nipples as to prevent a proper
development of them, so that where a lady has gone her time, she has
been unable to suckle her infant, the attempt often causing a
gathered bosom. These are great misfortunes, and entail great misery
both on the mother and the child (if it has not already killed him),
and ought to be a caution and a warning to every lady for the future.
 238. The feet and legs during pregnancy are very apt to swell and
to be painful, and the veins of the legs to be largely distended. The
garters ought at such times to be worn slack, as tight garters are
highly injurious, and, if the veins be very much distended, it will be
necessary for her to wear a properly-adjusted elastic silk stocking,
made purposely to fit her foot and leg, and which a medical man will
himself procure for her.

ABLUTION.

239. A warm bath in pregnancy is too relaxing. A tepid bath once a

week is beneficial. Sponging the whole of the body every morning
with lukewarm water may with safety and advantage be adopted,
gradually reducing the temperature of the water until it be used quite
cold. The skin should, with moderately coarse towels, be quickly but
thoroughly dried.
240. Either the bidet or sitz-bath[56] ought every morning to be
used. The patient should first sponge herself, and then finish up by
sitting for a few seconds, or while, in the winter, she can count fifty,
or while, in the summer, she can count a hundred, in the water. It is
better not to be long in it; it is a slight shock that is required, which,
where the sitz-bath agrees, is immediately followed by an agreeable
glow of the whole body. If she sits in the water for a long time she
becomes chilled and tired, and is very likely to catch cold. She ought,
until she become accustomed to the cold, to have a dash of warm
water added; but the sooner she can use quite cold water the better.
While sitting in the bath she should throw either a woolen shawl or a
small blanket over her shoulders. She will find the greatest comfort
and benefit from adopting the above recommendation. Instead of
giving, it will prevent cold, and it will be one of the means of warding
off a miscarriage, and of keeping her in good health.
241. A shower-bath in pregnancy gives too great a shock, and
might induce a miscarriage. I should not recommend, for a lady who
is pregnant, sea-bathing; nevertheless, if she be delicate, and if she
be prone to miscarry, change of air to the coast (provided it be not
too far away from home), and inhaling the sea breezes, may brace
her, and ward off the tendency. But although sea-bathing be not
desirable, sponging the body with sea water may be of great service
to her.

AIR AND EXERCISE.

242. A young wife, in her first pregnancy, usually takes too long
walks. This is a common cause of flooding, of miscarriage, and of
bearing down of the womb. As soon, therefore, as a lady has the
slightest suspicion that she is enceinte, she must be careful in the
taking of exercise.
243. Although long walks are injurious, she ought not to run into
an opposite extreme; short, gentle, and frequent walks during the
whole period of pregnancy cannot be too strongly recommended;
indeed, a lady who is enceinte ought to live half her time in the open
air. Fresh air and exercise prevent many of the unpleasant symptoms
attendant on that state; they keep her in health; they tend to open
her bowels; and they relieve that sensation of faintness and
depression so common and distressing in early pregnancy.
244. Exercise, fresh air, and occupation are then essentially
necessary in pregnancy. If they be neglected, hard and tedious labors
are likely to ensue. One, and an important, reason of the easy and
quick labors and rapid “gettings about” of poor women, is the
abundance of exercise and of occupation which they are both daily
and hourly obliged to get through. Why, many a poor woman thinks
but little of a confinement, while a rich one is full of anxiety about
the result. Let the rich lady adopt the poor woman’s industrious and
abstemious habits, and labor need not then be looked forward to, as
it frequently now is, either with dread or with apprehension.
245. Stooping, lifting of heavy weights, and overreaching ought to
be carefully avoided. Running, horse exercise, and dancing are
likewise dangerous—they frequently induce a miscarriage.
246. Indolence is most injurious in pregnancy. A lady who, during
the greater part of the day, lolls either on the sofa or on an easy-
chair, and who seldom walks out, has a much more lingering and
painful labor than one who takes moderate and regular open-air
exercise, and who attends to her household duties.
 247. An active life is, then, the principal reason why the wives of
the poor have such quick and easy labors, and such good recoveries;
why their babies are so rosy, healthy, and strong; notwithstanding
the privations and hardships and poverty of the parents.
248. Bear in mind, then, that a lively, active woman has an easier
and quicker labor, and a finer race of children, than one who is
lethargic and indolent. Idleness brings misery, anguish, and suffering
in its train, and particularly affects pregnant ladies. Oh, that these
words would have due weight, then this book will not have been
written in vain. The hardest work in the world is having nothing to
do! “Idle people have the most labor;” this is particularly true in
pregnancy; a lady will, when labor actually sets in, find to her cost
that idleness has given her most labor. “Idleness is the badge of
gentry, the bane of body and mind, the nurse of Naughtiness, the
step-mother of Discipline, the chief author of all Mischief, one of the
seven deadly sins, the cushion upon which the Devil chiefly reposes,
and a great cause not only of Melancholy, but of many other diseases,
for the mind is naturally active; and, if it be not occupied about some
honest business, it rushes into Mischief or sinks into Melancholy.”[57]
249. A lady sometimes looks upon pregnancy more as a disease
than as a natural process; hence she treats herself as though she was
a regular invalid, and, unfortunately, she too often makes herself
really one by improper and by foolish indulgences.

VENTILATION—DRAINAGE.

250. Let a lady look well to the ventilation of her house; let her
take care that every chimney be unstopped, and during the daytime
that every window in every unoccupied room be thrown open.
251. Where there is a skylight at the top of the house, it is well to
have it made to open and to shut, so that in the daytime it may,
winter and summer, be always open; and in the summer time it may,
day and night, be left unclosed. Nothing so thoroughly ventilates and
purifies a house as an open skylight.
252. If a lady did but know the importance—the vital importance—
of ventilation, she would see that the above directions were carried
out to the very letter. My firm belief is that if more attention were
paid to ventilation—to thorough ventilation—child-bed fever would
be an almost unknown disease.
253. The cooping-up system is abominable; it engenders all
manner of infectious and of loathsome diseases, and not only
engenders them, but feeds them, and thus keeps them alive. There is
nothing wonderful in all this, if we consider but for one moment that
the exhalations from the lungs are poisonous! That is to say, that the
lungs give off carbonic acid gas (a deadly poison), which, if it be not
allowed to escape out of the room, must over and over again be
breathed. That if the perspiration of the body (which in twenty-four
hours amounts to two or three pounds) be not permitted to escape
out of the apartment, must become fetid—repugnant to the nose,
sickening to the stomach, and injurious to the health. Oh, how often
the nose is a sentinel, and warns its owner of approaching danger!
254. Truly the nose is a sentinel! The Almighty has sent bad smells
for our benefit to warn us of danger. If it were not for an unpleasant
smell, we should be constantly running into destruction. How often
we hear of an ignorant person using disinfectants and fumigations to
deprive drains and other horrid places of their odors, as though, if
the place could be robbed of its smell, it could be robbed of its
danger! Strange infatuation! No; the frequent flushings of drains, the
removal of nuisances, cleanliness, a good scrubbing of soap and
water, sunshine, and the air and winds of heaven, are the best
disinfectants in the world. A celebrated and eccentric lecturer on
surgery,[58] in addressing his class, made the following quaint and
sensible remark: “Fumigations, gentlemen, are of essential
importance; they make so abominable a stink that they compel you
to open the windows and admit fresh air.”
255. It is doubtless, then, admirably appointed that, we are able to
detect “the well-defined and several stinks;” for the danger is not in
them,—to destroy the smell is not to destroy the danger; certainly
not! The right way to do away with the danger is to remove the cause,
and the effect will cease; flushing a sewer is far more efficacious than
disinfecting one; soap and water and the scrubbing-brush, and
sunshine and thorough ventilation, each and all are far more
beneficial than either permanganate of potash, or chloride of zinc, or
chloride of lime. People nowadays think too much of disinfectants
and too little of removal of causes; they think too much of artificial,
and too little of natural means. It is a sad mistake to lean so much
on, and to trust so much to, man’s inventions!
256. What is wanted, nowadays, is a little less theory and a great
deal more common sense. A rat, for instance, is, in theory, grossly
maligned; he is considered to be very destructive, an enemy to man,
and one that ought to be destroyed—every man’s hand being against
him. Now, a rat is, by common sense, well known to be, in its proper
place—that is to say, in sewers and in drains—destructive only to
man’s enemies—to the organic matter that breeds fevers, cholera,
diphtheria, etc.; the rat eats the pabulum or food which would
otherwise convert towns into hot-beds of terrible diseases. That
which is a rat’s food is often a man’s poison; hence a rat is one of the
best friends that a man has, and ought, in his proper place, to be in
every way protected; the rat, in drains, is the very best of scavengers;
in a sewer he is invaluable; in a house he is most injurious; a rat in a
sewer is worth gallons of disinfectants, and will, in purifying a sewer,
beat all man’s inventions hollow; the maligned rat, therefore, turns
out, if weighed by common sense, to be not only one of the most
useful of animals, but of public benefactors! The rat’s element, then,
is the sewer; he is the king of the sewer, and should there reign
supreme, and ought not to be poisoned by horrid disinfectants.
257. If a lady, while on an errand of mercy, should in the morning
go into a poor person’s bedroom after he, she, or they (for oftentimes
the room is crowded to suffocation) have during the night been
sleeping, and where a breath of air is not allowed to enter—the
chimney and every crevice having been stopped up—and where too
much attention has not been paid to personal cleanliness, she will
experience a faintness, an oppression, a sickness, a headache, a
terribly fetid smell; indeed, she is in a poisoned chamber! It is an
odor sui generis, which must be smelt to be remembered, and will
then never be forgotten! Pity the poor who live in such styes—not fit
for pigs! For pigs, styes are ventilated. But take warning, ye well-to-
do in the world, and look well to your ventilation, or beware of the
consequences. “If,” says an able writer on fever in the last century,
“any person will take the trouble to stand in the sun and look at his
own shadow on a white plastered wall, he will easily perceive that his
whole body is a smoking dunghill, with a vapor exhaling from every
part of it. This vapor is subtle, acrid, and offensive to the smell; if
retained in the body it becomes morbid, but if reabsorbed, highly
deleterious. If a number of persons, therefore, are long confined in
any close place not properly ventilated, so as to inspire and swallow
with their spittle the vapors of each other, they must soon feel its bad
effects.”[59]
258. Not only should a lady look well to the ventilation of her
house, but either she or her husband ought to ascertain that the
drains are in good and perfect order, and that the privies are
frequently emptied of their contents. Bad drainage and overflowing
privies are fruitful sources of child-bed fever, of gastric fever, of
scarlatina, of diphtheria, of cholera, and of a host of other infections
and contagious and dangerous diseases. It is an abominable practice
to allow dirt to fester near human habitations; more especially as
dirt, when mixed with earth, is really so valuable in fertilizing the
soil. Lord Palmerston wisely says that “dirt is only matter in the
wrong place.”
259. A lady ought to look well to the purity of her pump-water,
and to ascertain that no drain either enters or percolates, or
contaminates in any way whatever, the spring; if it should do so,
disease, such as either cholera, or diarrhœa, or dysentery, or
diphtheria, or scarlet fever, or gastric fever, will, one or the other, as
a matter of course, ensue. If there be the slightest danger or risk of
drain contamination, whenever it be practicable, let the drain be
taken up and be examined, and let the defect be carefully rectified.
When it be impracticable to have the drain taken up and examined,
then let the pump-water, before drinking it, be always previously
boiled. The boiling of the water, as experience teaches, has the power
either of destroying or of making innocuous the specific organic fecal
life poison, which propagates in drain contamination the diseases
above enumerated.

NECESSITY OF OCCASIONAL REST.

260. A lady who is pregnant ought, for half an hour each time, to
lie one or two hours every day on the sofa. This, if there be either a
bearing down of the womb, or if there be a predisposition to a
miscarriage, will be particularly necessary. I should recommend this
plan to be adopted throughout the whole period of the pregnancy: in
the early months, to prevent a miscarriage, and, in the latter months,
on account of the increased weight and size of the womb.
261. There is, occasionally, during the latter months, a difficulty in
lying down; the patient feeling as though, every time she makes the
attempt, she should be suffocated. When such be the case, she ought
to rest herself upon the sofa, and be propped up with cushions, as I
consider rest at different periods of the day necessary and beneficial.
If there be any difficulty in lying down at night, a bed-rest, well
covered with pillows, will be found a great comfort.

DIETARY.

262. An abstemious diet, during the early period of pregnancy, is

essential, as the habit of body, at that time, is usually feverish and
inflammatory. I should therefore recommend abstinence from beer,
porter, and spirits. Let me, in this place, urge a lady, during her
pregnancy, not to touch spirits, such as either brandy or gin; they
will only inflame her blood, and will poison and make puny her
unborn babe; they will only give her false spirits, and will depress her
in an increased ratio as soon as the effects of the brandy or of the gin
have passed away. She ought to eat meat only but once a day. Rich
soups and highly-seasoned stews and dishes are injurious.
263. A lady who is enceinte may depend upon it that the less
stimulants she takes at these times the better it will be both for
herself and for her infant; the more kind will be her labor and her
“getting about,” and the more vigorous and healthy will be her child.
264. It is a mistaken notion that she requires more nourishment
during early pregnancy than at any other time; she, if anything,
requires less. It has often been asserted that a lady who is pregnant
ought to eat very heartily, as she has two to provide for. When it is
taken into account that during pregnancy she “ceases to be unwell,”
and therefore that there is no drain on that score; and when it is also
considered how small the ovum containing the embryo is, not being
larger for the first two or three months than a hen’s egg, it will be
seen how futile is the assertion. A wife, therefore, in early pregnancy,
does not require more than at another time; if anything, she requires
less. Again: during pregnancy, especially in the early stages, she is
more or less sick, feverish, and irritable, and a superabundance of
food would only add fuel to the fire, and would increase her sickness,
fever, and irritability. Moreover, she frequently suffers from
heartburn and from indigestion. Can anything be more absurd, when
such is the case, than to overload a stomach already loaded with food
which it is not able to digest? No, let nature in this, as in everything
else, be her guide, and she will not then go far wrong! When she is
further advanced in her pregnancy,—that is to say, when she has
quickened,—her appetite generally improves, and she is much better
in health than she was before; indeed, after she has quickened, she is
frequently in better health than she ever has been. The appetite is
now increased. Nature points out that she requires more
nourishment than she did at first; for this reason, the fœtus is now
rapidly growing in size, and consequently requires more support
from the mother. Let the food, therefore, of a pregnant woman be
now increased in quantity, but let it be both light and nourishing.
Occasionally, at this time, she has taken a dislike to meat; if she has,
she ought not to be forced to eat it, but should have instead, poultry,
game, fish, chicken-broth, beef-tea, new milk, farinaceous food, such
as rice, sago, batter puddings, and, above all, if she has a craving for
it, good sound, ripe fruit.
265. Roasted apples, ripe pears, raspberries, strawberries, grapes,
tamarinds, figs, Muscatel raisins, stewed rhubarb, stewed pears,
stewed prunes, the inside of ripe gooseberries, and the juice of
oranges, are, during pregnancy, particularly beneficial; they both
quench the thirst and tend to open the bowels.
266. The food of a pregnant woman cannot be too plain; high-
seasoned dishes ought, therefore, to be avoided. Although the food
be plain, it must be frequently varied. She should ring the changes
upon butcher’s meat, poultry, game, and fish. It is a mistaken notion,
that people ought to eat the same food over and over again, one day
as another. The stomach requires variety, or disease, as a matter of
course, will ensue.
267. Light puddings, such as either rice, or batter, or suet-pudding,
or fruit puddings, provided the paste be plain, may be taken with
advantage. Rich pastry is highly objectionable.
 268. If she be plethoric, abstinence is still more necessary, or she
might have a tedious labor, or might suffer severely. The old-
fashioned treatment was to bleed a pregnant patient if she were of a
full habit of body. A more absurd plan could not be adopted!
Bleeding would, by causing more blood to be made, only increase the
mischief; but certainly it would be blood of an inferior quality,
watery and poor. The best way to diminish the quantity of blood is to
moderate the amount of food, to lessen the supplies.

SLEEP.

269. The bedroom of a pregnant lady ought, if practicable, to be

large and airy. Particular attention must be paid to the ventilation.
The chimney should on no account be stopped. The door and the
windows ought in the daytime to be thrown wide open, and the
bedclothes should be thrown back, that the air might, before the
approach of night, well ventilate them.
270. It is a mistaken practice for a pregnant woman, or for any one
else, to sleep with closely-drawn curtains. Pure air and a frequent
change of air are quite as necessary—if not more so—during the night
as during the day: and how can it be pure, and how can it be
changed, if curtains are closely drawn around the bed? Impossible.
The roof of the bedstead ought not to be covered with bed furniture;
it should be open to the ceiling, in order to prevent any obstruction
to a free circulation of air.
271. The bed must not be loaded with clothes, more especially with
a thick coverlet. If the weather be cold, let an extra blanket be put on
the bed, as the perspiration can permeate through a blanket when it
cannot through a thick coverlet.
272. A lady who is pregnant is sometimes restless at night—she
feels oppressed and hot. The best remedies are:—(1) Scant clothing
on the bed. (2) The lower sash of the window, during the summer
months, to be left open to the extent of six or eight inches, and
during the winter months, to the extent of two or three inches;
provided the room be large, the bed be neither near nor under the
window, and the weather be not intensely cold. If any or all of these
latter circumstances occur, then (3) the window to be closed and the
door to be left ajar (the landing or the skylight window at the top of
the house being left open all night, and the door being secured from
intrusion by means of a door-chain.) (4) Attention to be paid, if the
bowels be costive—but not otherwise—to a gentle action of the
bowels by castor oil. (5) An abstemious diet, avoiding stimulants of
all kinds. (6) Gentle walking exercise. (7) Sponging the body every
morning—in the winter with tepid water, and in the summer with
cold water. (8) Cooling fruits in the summer are in such a case very
grateful and refreshing. (See paragraph 264.)
273. A pregnant woman sometimes experiences an inability to lie
down, the attempt occasionally producing a feeling of suffocation
and of faintness. She ought, under such circumstances, to lie on a
bed-rest, which must, by means of pillows, be made comfortable; and
she should take, every night at bedtime, a teaspoonful of sal-volatile
in a wineglassful of water.
274. Pains at night, during the latter end of the time, are usually
frequent, so as to make an inexperienced lady fancy that her labor
was commencing. Little need be done; for unless the pains be violent,
nature ought not to be interfered with. If they be violent, application
should be made to a medical man.
275. A pregnant lady must retire early to rest. She ought to be in
bed every night by ten o’clock, and should make a point of being up
in good time in the morning, that she may have a thorough ablution,
a stroll in the garden, and an early breakfast; and that she may
afterwards take a short walk either in the country or in the grounds
while the air is pure and invigorating. But how often, more especially
when a lady is first married, is an opposite plan adopted! The
importance of bringing a healthy child into the world, if not for her
own and her husband’s sake, should induce a wife to attend to the
above remarks.
276. Although some ladies, during pregnancy, are very restless,
others are very sleepy, so that they can scarcely, even in the day, keep
their eyes open! Fresh air, exercise, and occupation are the best
remedies for keeping them awake.

MEDICINE.
 277. A young wife is usually averse to consult a medical man
concerning several trifling ailments, which are nevertheless, in many
cases, both annoying and distressing. I have therefore deemed it well
to give a brief account of such slight ailments, and to prescribe a few
safe and simple remedies for them. I say safe and simple, for active
medicines require skillful handling, and therefore ought not—unless
in certain emergencies—to be used except by a doctor himself.
278. I wish it, then, to be distinctly understood that in all serious
attacks, and in slight ailments if not quickly relieved, a medical man
ought to be called in.
279. A costive state of the bowels is common in pregnancy; a mild
aperient is therefore occasionally necessary. The mildest must be
selected, as a strong purgative is highly improper, and even
dangerous. Calomel and all other preparations of mercury are to be
especially avoided, as a mercurial medicine is apt to weaken the
system and sometimes even to produce a miscarriage.
280. An abstemious diet, where the bowels are costive, is more
than usually desirable, for if the bowels be torpid, a quantity of food
will only clog and make them more sluggish. Besides, when labor
comes on, a loaded state of the bowels will add much to a lady’s
sufferings as well as to her annoyance.
281. The best aperients are castor oil, salad oil, compound rhubarb
pills, honey, stewed prunes, stewed rhubarb, Muscatel raisins, figs,
grapes, roasted apples, Normandy pippins, oatmeal and milk gruel,
coffee, brown bread and treacle, raw sugar (as a sweetener of the
food), Du Barry’s Arabica Revalenta.
282. Castor oil, in pregnancy, is a valuable aperient. Frequent and
small are preferable to occasional and large doses. If the bowels be
constipated (but certainly not otherwise), castor oil ought to be
taken regularly twice a week. The best time for administering it is
early in the morning. The dose is from a teaspoonful to a
dessertspoonful.
283. The best ways of administering it are the following: Let a
wineglass be well rinsed out with water, so that the sides may be well
wetted; then, let the wineglass be half filled with cold water, fresh
from the pump. Let the necessary quantity of oil be now carefully
poured into the center of the wineglass, taking care that it does not
touch the sides; and if the patient will, thus prepared, drink it off at
one draught, she will scarcely taste it. Another way of taking it is,
swimming on warm new milk. A third and a good method is, floating
on warm coffee; the coffee ought, in the usual way, to be previously
sweetened and mixed with cream. There are two advantages in giving
castor oil on coffee: (1) it is a pleasant way of giving it—the oil is
scarcely tasted; and (2) the coffee itself, more especially if it be
sweetened with raw sugar, acts as an aperient; less castor oil, in
consequence, being required; indeed, with many patients the coffee,
sweetened with raw sugar, alone is a sufficient aperient. A fourth
and an agreeable way of administering it is on orange-juice—
swimming on the juice of one orange.
284. Some ladies are in the habit of taking it on brandy and water;
but the spirit is apt to dissolve a portion of the oil, which afterwards
rises in the throat.
285. If salad oil be preferred, the dose ought to be as much again
as of castor oil; and the patient should, during the day she takes it,
eat either a fig or two, or a dozen or fifteen of stewed prunes, or of
stewed French plums, as salad oil is much milder in its effects than
castor oil.
286. Where a lady cannot take oil, one or two compound rhubarb
pills may be taken at bedtime; or a Seidlitz powder early in the
morning, occasionally; or a quarter of an ounce of tasteless salts—
phosphate of soda—may be dissolved in lieu of table salt, in a cupful
either of soup, or of broth, or of beef-tea, and be occasionally taken
at luncheon.
287. When the motions are hard, and when the bowels are easily
acted upon, two, or three, or four pills made of Castile soap will
frequently answer the purpose; and if they will, are far better than
any ordinary aperient. The following is a good form:
Take of—Castile Soap, five scruples;
Oil of Caraway, six drops:

To make twenty-four pills. Two, or three, or four to be taken at bedtime,

occasionally.[60]
288. A teaspoonful of honey, either eaten at breakfast, or dissolved
in a cup of tea, will frequently comfortably and effectually open the
bowels, and will supersede the necessity of taking aperient medicine.
 289. A basin of thick Derbyshire oatmeal gruel, made either with
new milk or with cream and water, with a little salt, makes an
excellent luncheon or supper for a pregnant lady; it is both
nourishing and aperient, and will often entirely supersede the
necessity of giving opening medicine. If she prefers sugar to salt, let
raw sugar be substituted for the salt. The occasional substitution of
coffee for tea at breakfast usually acts beneficially on the bowels.
290. Let me again urge the importance of a lady, during the whole
period of pregnancy, being particular as to the state of her bowels, as
costiveness is a fruitful cause of painful, of tedious, and of hard
labors. It is my firm conviction that if a patient who suffers from
constipation were to attend more to the regularity of her bowels,
difficult cases of labor would rarely occur, more especially if the
simple rules of health were adopted, such as: attention to diet—the
patient partaking of a variety of food, and allowing the farinaceous,
such as oatmeal and the vegetable and fruit element, to
preponderate; the taking of exercise in the open air; attending to her
household duties; avoiding excitement, late hours, and all
fashionable amusements.
291. Many a pregnant lady does not leave the house—she is a
fixture. Can it, then, be wondered at that costiveness so frequently
prevails? Exercise in the fresh air, and occupation, and household
duties are the best opening medicines in the world. An aperient, let it
be ever so judiciously chosen, is apt, after the effect is over, to bind
up the bowels, and thus to increase the evil. Now, nature’s medicines,
—exercise in the open air, occupation, and household duties,—on the
contrary, not only at the time open the bowels, but keep up a proper
action for the future: hence their inestimable superiority.
292. Where a lady cannot take medicine, or where it does not agree
with her, a good remedy for constipation in pregnancy is the external
application of castor oil—castor oil as a liniment—to the bowels The
bowels should be well rubbed every night and morning with the
castor oil. This, if it succeed, will be an agreeable and safe method of
opening the bowels.
293. Another excellent remedy for the costiveness of pregnancy is
an enema, either of warm water or of Castile soap and water, which
the patient, by means of a self-injecting enema apparatus, may
administer to herself. The quantity of warm water to be used is from
half a pint to a pint; the proper heat is the temperature of new milk;
the time for administering it is early in the morning, twice or three
times a week. The advantages of clysters are, they never disorder the
stomach—they do not interfere with the digestion—they do not
irritate the bowels—they are given with the greatest facility by the
patient herself—and they do not cause the slightest pain. If an enema
be used to open the bowels, it may be well to occasionally give one of
the aperients recommended above, in order, if there be costiveness,
to insure a thorough clearance of the whole of the bowels.
294. If the bowels should be opened once every day, it would be
the height of folly for a pregnant lady to take either castor oil or any
other aperient. She ought then to leave her bowels undisturbed, as
the less medicine she takes the better. If the bowels be daily and
properly opened, aperients of any sort whatever would be highly
injurious to her. The plan in this, as in all other cases, is to leave well
alone, and never to give physic for the sake of giving it.
295. Diarrhœa.—Although the bowels in pregnancy are generally
costive, they are sometimes in an opposite state, and are relaxed.
Now, this relaxation is frequently owing to their having been too
much constipated, and nature is trying to relieve itself by purging.
Such being the case, a patient ought to be careful how, by the taking
of chalk and of astringents, she interferes with the relaxation.
296. The fact is, that in all probability there is something in the
bowels that wants coming away, and nature is trying all she can to
afford relief. Sometimes, provided she is not unnecessarily interfered
with, she succeeds; at others, it is advisable to give a mild aperient to
help nature in bringing it away.
297. When such be the case, a gentle aperient, such as either castor
oil or rhubarb and magnesia, ought to be chosen. If castor oil, a
teaspoonful or a dessertspoonful, swimming on a little new milk, will
generally answer the purpose. If rhubarb and magnesia be the
medicine selected, then a few doses of the following mixture will
usually set all to rights:
Take of—Powdered Turkey Rhubarb, half a drachm;
Carbonate of Magnesia, one drachm;
Essence of Ginger, one drachm;
Compound Tincture of Cardamoms, half an ounce;
Peppermint Water, five ounces and a half:
 Two tablespoonfuls of the mixture to be taken three times a day, first shaking
the bottle.
298. The diet ought to be simple, plain, and nourishing, and
should consist of beef-tea, of chicken-broth, of arrow-root, and of
well-made and well-boiled oatmeal gruel. Meat, for a few days, ought
not to be eaten; and stimulants of all kinds must be avoided.
299. If the diarrhœa be attended with pain in the bowels, a flannel
bag filled with hot table salt, and then applied to the part affected,
will afford great relief. A hot-water bag, too, in a case of this kind, is a
great comfort.[61] The patient ought, as soon as the diarrhœa has
disappeared, gradually to return to her usual diet, provided it be
plain, wholesome, and nourishing. She should pay particular
attention to keeping her feet warm and dry; and, if she be much
subject to diarrhœa, she ought to wear around her bowels, and next
to her skin, a broad flannel belly-band.
300. Heartburn is a common and often a distressing symptom of
pregnancy. The acid producing the heartburn is frequently much
increased by an overloaded stomach. The patient labors under the
mistaken notion that, as she has two to sustain, she requires more
food during this than at any other time; she consequently is induced
to take more than her appetite demands, and more than her stomach
can digest;—hence heartburn, indigestion, etc. are caused, and her
unborn babe, as well as herself, is thereby weakened.
301. An abstemious diet ought to be strictly observed. Great
attention should be paid to the quality of the food; greens, pastry,
hot buttered toast, melted butter, and everything that is rich and
gross, ought to be carefully avoided.
302. Either a teaspoonful of Henry’s magnesia, or half a
teaspoonful of carbonate of soda—the former to be preferred if there
be constipation—should occasionally be taken in a wineglassful of
warm water. If these do not relieve—the above directions as to diet
having been strictly attended to—the following mixture ought to be
tried:
Take of—Sesquicarbonate of Ammonia, half a drachm;
Bicarbonate of Soda, a drachm and a half;
Water, eight ounces:
 To make a mixture. Two tablespoonfuls to be taken twice or three times a day,
until relief be obtained.
Chalk is sometimes given in heartburn, but as it produces
costiveness, it ought not in such a case to be used.
303. Piles are a common attendant upon pregnancy. They are
small, soft, spongy, dark-red tumors, about the size either of a bean
or of a cherry—they are sometimes as large as a walnut—and are
either within or around the fundament; they are then, according to
their situation, called either internal or external piles—they may be
either blind or bleeding. If the latter, blood may be seen to exude
from them, and blood will come away every time the patient has a
stool; hence the patient ought to be as quick as possible over
relieving her bowels, and should not at such times sit one moment
longer than is absolutely necessary.
304. When the pile or piles are very large, they sometimes, more
especially when she has a motion, drag down a portion of the bowel,
which adds much to her sufferings.
305. If the bowel should protrude, it ought, by means of the
patient’s index finger, to be immediately and carefully returned,
taking care, in order that it may not scratch the bowel, that the nail
be cut close.
306. Piles are very painful and are exceedingly sore, and cause
great annoyance, and frequently continue, notwithstanding proper
and judicious treatment, during the whole period of pregnancy.
307. A patient is predisposed to piles from the womb pressing
upon the blood-vessels of the fundament. They are excited into
action by her neglecting to keep her bowels gently opened, or by
diarrhœa, or from her taking too strong purgatives, especially pills
containing either aloes or colocynth, or both.
308. If the piles be inflamed and painful, they ought, by means of a
sponge, to be well fomented three times a day, and for half an hour
each time, with hot chamomile and poppy-head tea;[62] and at
bedtime a hot white-bread poultice should be applied.
309. Every time after and before the patient has a motion, she had
better well anoint the piles and the fundament with the following
ointment:
 Take of—Camphor (powdered by means of a few drops of
Spirits of Wine), half a drachm;
Prepared Lard, two ounces:

Mix, to make an ointment.

310. If there be great irritation and intense pain, let some very hot
water be put into a close stool, and let the patient sit over it. “In piles
attended with great irritation and pain, much relief is often obtained
by sitting over the steam of hot water for fifteen or twenty minutes,
and immediately applying a warm bread-and-milk poultice. These
measures should be repeated five or six times a day (Greeves).”[63]
311. If the heat be not great, and the pain be not intense, the
following ointment will be found efficacious:
Take of—Powdered Opium, one scruple;
Camphor (powdered by means of a few drops of
Spirits of Wine), half a drachm;
Powdered Galls, one drachm;
Spermaceti Ointment, three drachms:

Mix.—The ointment to be applied to the piles three times a day.[64] Or the

compound Gall Ointment (B.P.) may, in the same manner, be applied.
312. If the heat and the pain be great, the following liniment will be
found useful:
Take of—French Brandy,
Glycerin, of each, half an ounce:

Mix.—The liniment to be frequently applied, by means of a camel’s-hair pencil,

to the piles, first shaking the bottle.
313. The bowels ought to be kept gently and regularly opened,
either by taking every morning one or two teaspoonfuls of compound
confection of senna, or by a dose of the following electuary:
Take of—Sublimed Sulphur, half an ounce;
Powdered Ginger, half a drachm;
Cream of Tartar, half an ounce;
Confection of Senna, one ounce;
Simple Syrup, a sufficient quantity:

To make an electuary. One or two teaspoonfuls to be taken early every morning.

314. Magnesia and milk of sulphur is an excellent remedy for piles: