bacteriology has thrown new light upon the causation of such
maladies. The question naturally suggests itself, can the germs
causing the acute infections pass through the villi of the chorion
and the inter-villous placental septa and infect the foetus as well ?
At the present time an affirmative answer can be given to this
question as regards typhoid infection, malaria, pneumonia,
syphilis, tuberculosis and gonorrhoea. It is also stated that
cholera and yellow fever are transmitted from mother to child,
the latter in such a manner as to convey immunity from subse-
quent attacks upon the foetus which survives, while in the uterus,
an attack of the disease.
The exanthematous infections are conveyed to the foetus,
variola, measles, scarlatina, and erysipelas frequently causing
foetal death, before or after delivery.
It seems to have been demonstrated that pregnancy neither
exempts or exposes a woman to the acute infections. She incurs
greater dangers than the non-pregnant from abortion, from
haemorrhage and from the fact that in some of the infections
mentioned, as variola, scarlatina and erysipelas, the micrococci
which cause puerperal pyaemia frequently develop in company
with the germs of the original infection, and hence puerperal
sepsis is added as a complication.
The symptoms of these diseases in pregnancy do not essentially
differ from those in the non-pregnant. The symptoms of
abortion are likely to be added to those of the original infection,
and should not fail to attract the physician's attention. As
175
176 MANUAL OF PRACTICAL OBSTETRICS.
regards prognosis, if the patient's temperature does not remain
long at or above 104 F. her chances and those of the foetus are
not desperate so far as fever is concerned. The occurrence of
abortion is unfavorable ; a premature labor is not especially
dangerous. The prognosis of abortion or premature labor occur-
ring during an acute infection will be greatly influenced by the
observance or disregard of antiseptic precautions. As there is,
in these cases, especial danger of the development of micrococci,
so there is indicated especial precaution. If haemorrhage be
prevented, the patient's strength be conserved, and sepsis does
not complicate the case, a better prognosis can be given than
would otherwise be justifiable.
The treatment of the acute infections during pregnancy is
that proper in the non-pregnant, with especial attention to the
reduction of temperature. No theory or method of treatment
appropriate in such cases is contra indicated because of preg-
nancy, but whatever will best further the mother's interests will
be best for the child. Quinine may be given freely during
malarial infection without fear of producing abortion. When
abortion or labor has begun, quinine, in common with many
tonics acting upon the nervous system, is most efficient in
strengthening the contraction of the uterus. It will rarely cause
abortion or labor before such a process has actually commenced.
Stimulants may be used as freely as needed with the best results.
Abortion should not be intentionally produced, as it increases the
mother's dangers.
In variola and syphilis, preventive medication may be em-
ployed advantageously for the interest of the foetus. Vaccina-
tion should be performed so soon as variola is suspected, and
pregnancy is no counter indication to vaccination in all cases.
The prompt use of mercury 'in recent syphilitic infection is
demanded in the interests of the foetus. Preventive inocula-
tions with tuberculin do not as yet give promise of success in
threatened foetal tuberculosis. Gonorrhoeal infection during
pregnancy demands prompt treatment. The vagina should be
thoroughly douched with a solution of bi-chloride of mercury,
INFECTIOUS AND CARDIAC DISEASE DURING PREGNANCY. 177
one to one thousand, followed by boiled water. lodoform is
then to be thoroughly applied to the mucous membrane, a tam-
pon of iodoform gauze, which distends the vagina moderately, is
especially useful. Injections may be given to advantage through
a cylindrical speculum. The early destruction of the gonococci
is desirable, as they tend to nest in the folds of the vaginal mu-
cous membrane, and thus infect the mucous surfaces of the foetus
during labor. They also threaten the mother with infection of
the urinary tract. Continued gonorrhoeal inflammation during
pregnancy causes in many cases adherence of the foetal mem-
branes to the cervix and os ; at labor premature rupture of the
membranes results, and a tedious and difficult labor may follow.
CARDIAC DISORDERS DURING PREGNANCY. The physiological
changes occurring in normal pregnancy tend to exaggerate a dis-
eased condition of the heart before pregnancy. The tax put
upon the mother's circulatory system by the needs for foetal nu-
trition favors, in advanced cardiac lesions, failure in nutrition in
the hypertrophied heart muscle and dilatation occurs, increasing
to a dangerous degree during labor. If the valvular lesion be
slight, compensation may be maintained, and no immediate
harm follow pregnancy and labor. Repeated pregnancies and
labor should be avoided; in fact, women with well-marked car-
diac lesions should not become pregnant. During pregnancy
violent exertion must be avoided, and chilling the surface of
the body. The clothing should be perfectly loose ; the skin,
bowels, kidneys and lungs should be kept in proper activity.
The nutrition of the heart muscle is to be maintained by attention
to nutrition, with the use of cardiac tonics. The sensation of
breathlessness, which so often annoys pregnant women, should
be explained to the patient, and should not be allowed to
cause undue apprehension. The* physician will inform himself
by physical examination of the actual condition present. At
labor the patient's dyspnoea is best relieved by the hypodermic
use of ether, atropia, strophanthus or digitalis and strychnia,
with inhalations of chloroform or ether. If possible, oxygen
should be in readiness for inhalation. Labor may be judiciously
178 MANUAL OF PRACTICAL OBSTETRICS.
expedited by forceps or version. Haemorrhage is to be feared,
and possible thrombosis after delivery. The relief afforded by
anaesthetics in cases of labor with advanced valvular lesions is
surprising and immediate. In common with other disorders,
cardiac lesions are not incurred by pregnancy, but are aggravated
by it. Endocarditis, caused by rheumatism, is most frequent,
atheroma and aneurism are less commonly observed than in
men.
The occurrence of failure of nutrition in the heart muscle,
with beginning dilatation, may justify the production of abor-
tion.
CHAPTER XXVII.
AFFECTIONS OF THE GENITO-URINARY ORGANS OCCURRING DURING
PREGNANCY.
THE condition of pregnancy predisposes to inflammation of the
mucous membrane of the vagina and cervix. Simple engorge-
ment, with increased secretion of mucus, is almost a constant
condition of the vaginal mucous membrane. Unless precautions
are taken to insure cleanliness, micrococci will breed in the de-
composed secretions, and inflammation and ulceration will result.
The symptoms of such conditions are vaginal discharges, and
pain and irritation upon micturition and walking. Treatment
should be addressed first to destroying micrococci and next to
maintaining a condition of cleanliness by vaginal injections.
Bichloride of mercury, i to 5000 or 2000, will be useful at first,
to be followed later by injections of boric acid or alum in dilute
solutions. The treatment of gonorrhoea has been considered under
the acute infections.
When micrococci invade the bladder, a trying complication of
pregnancy, and one likely to occasion trouble after labor, is
present. Urethritis, cystitis, pyelitis and suppurating kidney have
all followed this accident. When pus is found in the urine the
bladder should be douched twice daily with creoline solution, a
teaspoonful to the pint of warm water. Internally salol may be
given, 10 grains three times daily, or boracic acid 15 to 20 grains
three times daily. Milk diet, if possible, with rest in bed and
careful disinfection of the vagina, will also be of advantage. It
is of interest to note that cystitis of moderate degree may be
present with an acid urine in the case of women. In pyelitis,
catheterization of the ureters is of value to determine which
179
180 MANUAL OF PRACTICAL OBSTETRICS.
kidney is affected : in severe and prolonged cases lumbar incision
and drainage of the kidney are indicated.
Displacement of the uterus and vagina are among the complica-
tions of pregnancy. Prolapse of the vaginal walls is usually the
result of repeated parturitions, with a relaxed condition of the
tissues.
Prolapse of the uterus may occur early in pregnancy, accom-
panied by endocervicitis ; although previous distension of the
vagina during labor is an exciting cause, it may be observed in
primagravida. Its symptoms are sensations of weight and drag-
ging, the presence of a tumor, with interference with the functions
of the bladder and rectum. Abortion may result if the case be
neglected, with septic infection following it.
Replacement of the prolapsed organ and its retention in its
normal position can usually be effected by manipulation. An
antiseptic tampon is a convenient and efficient agent for retaining
the uterus in its normal position. Surgeons' lint, in strips three
inches wide, smeared with an antiseptic ointment, is a useful
material for tampon. Hard and elastic pessaries are not contra-
indicated in these cases. In extensive prolapse of the vaginal
walls, with laceration and erosion of the cervix, colporrhaphy and
trachelorrhaphy may be performed without fear of abortion, if
undue violence be avoided and antiseptic precautions be taken to
secure union by first intention.
RETRO-DISPLACEMENT OF THE PREGNANT UTERUS It is not
uncommon for the uterus to tip backward early in pregnancy.
The frequency of backward displacements in the non-pregnant,
tight clothing and corsets worn during pregnancy, and relaxation
of the supports of the uterus as its weight increases, have all been
alleged as causes of this condition. Between the third and fourth
month, when the uterus rises out of the pelvis, such a displacement
is usually spontaneously corrected ; if inflammation and adhesions
exist, binding the uterus down, abortion or death of the foetus
and impaction of the uterus in the hollow of the sacrum will
result.
The symptoms of retro-displacement of the pregnant uterus are
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frequent and irritating micturition, constipation, and pain over
the sacral and gluteal regions. Digital examination will confirm
the physician's suspicions.
The treatment of this complication of pregnancy, in mild cases,
consists in emptying the bladder and rectum, anteverting the
uterus by pressure with the fingers in the vagina or rectum, and
fitting a pessary, either of hard rubber or some softer material, to
retain the uterus in position. In replacing the uterus, violent
manipulation must be avoided ; if the patient be placed in the
knee-chest posture the uterus will generally go easily into place.
A support will not be needed after the fourth month, when the
uterus has risen above the pelvic brim.
In impaction of the pregnant uterus in the hollow of the
sacrum, persistent but gentle efforts are needed to dislodge it
from its abnormal position. The cervix may be grasped by a
tenaculum forceps and drawn downward and backward, while
with the fingers of the other hand an effort is made to dislodge
the fundus. If the uterus cannot be replaced, its size must be
lessened by producing abortion ; this is best accomplished by
introducing a sound, rupturing the membranes. When the
uterus is bound down by adhesions, impacted in the hollow of
the sacrum, and death and decomposition of the foetus ensue,
the condition is one of gravity. The obstetrician is then obliged
to forcibly break up such adhesions, replace the uterus and
empty and disinfect its cavity. The uterus has been extirpated
through the vagina for the relief of this condition, with success.
ANTERIOR DISPLACEMENT OF THE PREGNANT UTERUS. In
women whose abdominal walls are ill developed, weakened by
many pregnancies, and in pregnant women having contracted
pelves so small that the uterus cannot enter the pelvic cavity,
exaggerated ante-version of the pregnant uterus has been observed.
Its symptoms are interference with the function of the bladder,
first frequent micturition, then infrequent difficult micturition,
and finally the retention of the contents of the bladder with
almost constant dribbling of urine. The abdomen protrudes as
the uterus grows larger, until the German term of "hanging
1 82 MANUAL OF PRACTICAL OBSTETRICS.
belly" seems appropriate. Pain and "dragging" are felt in
the sacral region.
The diagnosis of the condition is readily made by examination
after the bladder has been emptied by a catheter. In early
pregnancy a ring pessary will usually correct the malposition ;
later in pregnancy a broad abdominal band will be found use-
ful.
RELAXATION OF THE PELVIC JOINTS is an occasional complication
of pregnancy. Although these joints become more vascular, and
contain more synovial fluid than in the non pregnant, it is rare
for their mobility to become excessive. The pubic joint is
most affected in these cases, and can be felt to move freely when
the patient steps. Walking may become impossible, and stand-
ing be scarcely endured. There is no one cause which seems
responsible for this condition, and hence no treatment except
mechanical devices for partly immobilizing the joint is of avail.
The application of a broad, well fitting bandage of strong
material, passing around the entire pelvis from the trochanters
above the crests of the ilia, is usually efficient. A plaster-of- Paris
bandage has been necessary in severe cases, and in others rest in
bed.
THE NERVOUS SYSTEM. Pregnancy affects the nervous sys-
tem, often profoundly. The reflexes are exaggerated; the tro-
phic and secretory nerves are more active, and more easily
excited. The brain shares in the generally sensitive condition
of the patient, and the pregnant woman is often easily frightened,
irritable and usually apprehensive. A generally stimulating
effect is observed with others, and such women feel better than
when not pregnant. Such patients have better appetite and
digestion than before pregnancy. The sensitive condition of
the sympathetic nervous system causes cardiac palpitation, dys-
pnoea, flushing of the features and often perspiration on very
slight provocation. Salivation, discoloration of the skin about the
face and often the genital organs, and, in many cases, excessive
nausea and vomiting, are all to be referred to hyperaesthesia
of the various portions of the nervous system, caused by pregnancy.
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DISORDERS OF THE NERVOUS SYSTEM. 183
The extremes of these nervous affections are seen in chorea
and insanity, recurring during pregnancy. It is rare that either
is caused by pregnancy, but results in a pregnant woman predis-
posed to either of them. The treatment of chorea in the pregnant
woman is essentially that in the non -pregnant. Abortion should
be resofted to only when other remedies have failed, and prema-
ture labor in the choreic rarely terminates spontaneously. Arsenic
and other tonics to the nervous system act very favorably in these
cases, especially when accompanied by disciplined nursing.
In a woman predisposed by heredity to insanity, pregnancy
not infrequently developes melancholia, with acute mania at
labor. In those not predisposed to insanity, pregnancy may be
accompanied by melancholia persisting for some time after deliv-
ery, but rarely followed by mania.
Labor in the actively insane demands careful attention. Such
patients are often strangely oblivious to pain, and labor may
proceed without demonstrations of suffering. Anaesthetics and
sedatives are required in these cases and delivery should be con-
ducted under complete anaesthesia. Constant watchfulness is to
be exercised, for suicidal tendencies and efforts to injure the child
are not infrequent. Judicious, kindly restraint is imperative in
these cases, and the physician may find his strength and patience
taxed to their utmost. It is sometimes necessary to partially an-
aesthetize the patient to give even a douche. The prognosis in
those not predisposed to insanity is good, under long-continued
and rational treatment. Seclusion, tonics, cheerful and assidu-
ous kindness, and the presence of the child usually cure these
cases. In those with whom insanity was to be feared, pregnancy
is simply the exciting, but not the predisposing cause, any one
of many might have precipitated mental disease. The prognosis
for recovery in such cases cannot be given as hopeful.
Hysteria and epilepsy are neither caused nor greatly aggra-
vated by pregnancy. Both are to be treated as in the non-preg-
nant. Hysteria may deceive the practitioner by simulating labor
and even eclampsia ; close observation will detect the decep-
tion. The diagnosis between eclampsia and epilepsy will be
184 MANUAL OF PRACTICAL OBSTETRICS.
made by the history, when available, and by the examination of
the urine; the epileptic has had fits before pregnancy, her par-
oxysms do not grow more frequent or violent ; she rarely dies
during or after labor.
PERNICIOUS VOMITING OF PREGNANCY. In some cases, with-
out anatomical lesion to account for the disorder, the nausea and
vomiting of pregnancy become so exaggerated as to threaten the
patient's life. When the examination of the patient fails to de-
tect irritation or inflammation about the uterus; when the womb
is in normal position, and no gastric or kidney disease can be
detected, the cause of the nausea must be ascribed to a hyper-
sensitive condition of the nervous system. Disease of the foetal
appendages has been found in some cases of pernicious vomiting,
but the relationship of cause and effect has not been demon-
strated. Some observers have made hysteria the cause of nausea
and vomiting, although proof that such is invariably the case is
not forthcoming.
In these cases remedies are most successful which act as seda-
tives to the nervous system. The bromides, chloral, morphia,
antipyrin, antifebrin or phenacetin, cocaine or valerian are in-
dicated. Chloroform, internally and by inhalation, is some-
times successful. Locally, counter-irritation over the epigas-
trium; heat to the cerebrum and cerebellum; galvanism along
the spine and epigastrium, or an ice-bag upon the abdomen are
measures which have been of value in different cases. When
other treatment is unavailing, and the patient is threatened with
collapse, pregnancy must be terminated. Every method of feed-
ing which modern nursing can suggest should be exhausted ; the
patient can be nourished by the rectum for some time, by the
administration of nutrient enemata.
THE MOTHER'S BLOOD DURING PREGNANCY. The view that
the blood becomes more watery during pregnancy, with a large
number of white corpuscles, is probably not true. Aside from
the condition of anaemia which follows the expulsion of the foe-
e loss of blood so often seen during labor, the healthy
'Oman may be said to be in a condition of slight ple-
-
DISORDERS OF THE BLOOD DURING PREGNANCY. 185
thora, and not anaemia Pernicious anaemia is observed at times,
and forms a serious complication of pregnancy. The symptoms
of this condition are pallid skin; rapid pulse, dyspncea; lassi-
tude and often oedema. Microscopic examination of the blood
reveals a much lessened quantity of haemoglobin ; red corpuscles
which are smaller and less perfectly formed than normally ; and
threads of fibrin stretching across the field of the microscope.
Blood counts show a lessened number of red corpuscles; less-
ened haemoglobin percentage; sometimes increased number of
white cells. When not pregnant, these patients are simply chlor-
otic ; at labor haemorrhage is very slight, the labor pains often
deficient, and delivery instrumental. The child is pale, chlorotic
and of feeble vitality. In other cases the child is strong, its
blood being found normal on microscopic examination.
The treatment of this condition is best accomplished by the
persistent administration of oxygen by inhalation, and arsenic in
small doses, with nourishing food. Peptonized milk, soups,
broths, raw meat in finely chopped and seasoned preparations, and
eggs are of especial value. The importance of oxygen and arsenic
must be emphasized, as they are superior to iron and other drugs.
JAUNDICE in parturient patients may be hepatogenic or haemato-
genic. The former is caused by catarrh of the bile ducts, with
occlusion of the ducts and absorption of bile. It usually accom-
panies enteritis, and yields to treatment addressed to the secretion
of bile and the intestinal tract.
Haematogenic jaundice results from an acute infection affecting
the red blood corpuscles and causing their disintegration, with
absorption of haematin. Acute yellow atrophy of the liver accom-
panies profound, malignant jaundice, and is considered by some
to be caused by the same infection. Haematogenic, infectious
jaundice is but little amenable to treatment ; stimulants and tonics
are indicated to enable the patient to resist the infection.
DISORDERS OF THE SKIN DURING PREGNANCY. Pregnant
women are often greatly annoyed by discoloration of the skin
about the face and genital organs ; the facial blemish is known as
the "mask of pregnancy," and is usually of a yellowish- brown
8*
1 86 MANUAL OF PRACTICAL OBSTETRICS.
color. It is not amenable to treatment and usually disappears
after delivery.
Pruritus about the genital organs occasions great suffering in
some cases. Thorough cleanliness must be first secured. Hot or
cold sponging ; sitz baths of warm, but not hot water; anaesthetics,
locally applied, and the galvanic current have all been employed.
But little more than palliation can be expected until the termina-
tion of pregnancy.
VARICOSE VEINS. Few women pass through pregnancy without
dilatation of the veins of the lower extremities, and often the
vulva and vagina. Rupture of varicose veins of the vulva and
vagina often results in the extravasation of blood into the sub-
mucous tissue, without admitting the external air. When dilata-
tion is excessive, rupture may take place at labor or when very
slight violence is offered, and free haemorrhage result. The recum-
bent posture and the use of an antiseptic tampon will control such
haemorrhage.
Varicose veins of the lower extremities occasion great discom-
fort when distension is excessive, and sudden and alarming
haemorrhage follows rupture. Before rupture, itching and burning
sensations and often an eczematous eruption add to the patient's
discomfort. Patients suffering from varicose veins should avoid
constipation, and can often derive comfort from some form of
support. An elastic stocking or flannel bandage, with frequent
bathing in a saturated solution of boracic acid, will often be of
great service. Such patients should be instructed in the applica-
tion of a compress and bandage, and cautioned to avoid rupture
of a vein if possible. Garters and clothing which interfere with
the circulation in the lower limbs should not be worn.
HERNIA OF THE PREGNANT UTERUS. In rare cases the preg-
nant uterus protrudes in the umbilical, crural, or inguinal ring. In
umbilical hernia reposition is usually not difficult, and the uterus
is retained by an abdominal bandage. Abortion or Caesarean
section, if the foetus be movable, is indicated in these cases, with
removal of the uterus if it cannot be returned to the abdominal
cavity.
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FOREIGN GROWTHS IN THE PELVIS. 187
PREGNANCY COMPLICATED BY FOREIGN GROWTHS IN THE
UTERUS AND PELVIS. Fibroid tumors of the pregnant uterus
usually grow softer and larger as pregnancy progresses. A fibroid
polyp which protrudes from the os may be removed, but a less
easily accessible tumor should not be disturbed. Cancer of the