Books: The Prospective Mother
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J. Morris Slemons >> The Prospective Mother
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LEUCORRHEA.--The meaning of the white discharge from the vagina known
as leucorrhea is variable: at times it indicates the existence of an
ailment requiring treatment, and at other times it does not. To be on
the safe side, therefore, anyone who is troubled by leucorrhea should
obtain her physician's opinion as to its significance.
Normally, as we learned in Chapter V, there is an increase in the
vaginal secretion during pregnancy; but this fact is rarely
noticeable until the latter months. Usually it is pronounced only
during the last few weeks. At that time, owing to its antiseptic
qualities, this pale white fluid should not be disturbed by the use
of douches. In the early months of pregnancy, however, leucorrhea may
cause such inconvenience as to demand medical treatment.
While itching is the most disagreeable effect of such a vaginal
discharge, it should be known that itching is not always due to
leucorrhea. Thus it may be caused by a highly concentrated urine, and
in that event will be relieved by drinking a larger amount of water;
or it may be due to the presence of unusual constituents in the
urine. Skin diseases also cause itching; and light haired people,
since they have more delicate skins that brunettes, are especially
susceptible to these ailments. To such skin affections soap and water
may be very irritating; so that when they exist it is often advisable
to cleanse the parts with olive oil. In other cases, ointments are
required and will be prescribed by the physician.
Itching of the skin over the extremities or over the whole body, it
is clear, cannot be attributed to leucorrhea, but in these very rare
cases the irritation would seem to be caused by some waste product
which is being eliminated through the sweat glands. We do not know
what the substance is, but, as the symptom appears so seldom, it must
be due to an unusual kind of waste product or else to one whose
elimination normally occurs through other channels. The affection of
the skin thus brought about is really a very mild kind of poisoning,
and since the offending substance arises in the body of the patient
herself the condition is called an autointoxication. Effective
treatment consists in drinking water freely and taking a cathartic,
for the one stimulates the kidneys and the other the bowels to assist
in getting rid of the cause of the trouble.
TOXEMIAS.--In order to understand what are known as the
toxemias of pregnancy, we must remember that the nutrition of our
bodies involves three separate and distinct sets of processes. What
we eat is, in the first place, digested and absorbed into the body;
secondly, the products of digestion are utilized by the tissues; and,
finally, the waste material is thrown off from the body. Any one of
these processes may be carried out in a way that is not consistent
with health. Most of us realize that disturbances may occur in the
course of digestion, and we are also aware that the excretory organs
occasionally fail to do their work in a satisfactory way. But what
laymen, perhaps, do not appreciate is that the intermediary steps--
between the time when the food is absorbed and the time when the
waste material is finally eliminated--may not be taken precisely as
health requires. Of course, any person may be the subject of one or
another of these nutritional disorders, but unquestionably such
disorders are somewhat more frequent during pregnancy than at other
times. Nor is this difficult to understand, for the nutritional
processes of two beings are here linked together. They generally
proceed harmoniously, but if they do not there results an
autointoxication of the mother which is called a toxemia.
Such toxemias, with extremely rare exceptions, do not occur in the
early months, but are associated with the period of the active growth
of the fetus, namely, the second half of pregnancy. For this reason,
and for some others which do not concern us here, it seems probable
that the nutritional processes of the child are primarily responsible
for these ailments. This view, however, must be somewhat modified,
for experience has clearly taught that the efficiency with which the
maternal excretory organs do their work has a great deal to do with
the effect that the fetal waste products have upon the mother. On
this account she has been urged to pay attention to personal hygiene.
It is also necessary, however, that she should become acquainted with
the symptoms which give warning that the excretory organs are acting
imperfectly.
Autointoxication can almost always be prevented. The means of
prevention are neither mysterious nor difficult to carry out; they
lie within the power of every prospective mother, for they consist
merely of what has already been discussed, namely, the intelligent
regulation of the diet, the care of the body, and a correct ordering
of the daily life. To the chapters dealing with these subjects
reference should be made and particular attention should be paid to
what has been said concerning:
(1) Wearing suitably warm clothes,
(2) Bathing regularly,
(3) Taking a proper amount of exercise,
(4) Drinking water liberally,
(5) Avoiding an excessive quantity of meat,
(6) Guarding against constipation.
At present the value of prevention in the treatment of the toxemias
of pregnancy is so clearly recognized that charitable organizations
employ nurses to visit women of the poorer classes during pregnancy
in order to instruct them about the measures that I have just
indicated. Remarkable results have already been obtained. In one
clinic where this method has been adopted the frequency of all kinds
of toxemia, I am told, has notably diminished, and serious types are
not permitted to develop. Similar results should be obtained in
private practice when patients place themselves under medical
supervision at the beginning of pregnancy. Under these favorable
circumstances symptoms of autointoxication probably occur not oftener
than once in every hundred pregnancies, but nine out of ten of them,
being promptly recognized, yield readily to relatively simple
treatment.
The early detection of such complications depends largely upon the
patient herself. As has been emphasized--and it cannot be said too
frequently--she should not fail to submit, at appropriate intervals,
a specimen of urine for examination. It is by such an examination
generally that the development of a toxemia is first detected.
Occasionally, however, significant signs will attract the patient's
attention before there is any change in the urine. For that reason,
it is important to notify the physician if any of the following
symptoms appear:
(1) Serious vomiting.
(2) Persistent headache.
(3) Dizziness.
(4) Puffiness about the face.
(5) Blurring of vision, or the appearance of black
spots before the eyes.
(6) Neuralgic pains, especially in the pit of the stomach.
It must be clearly understood, however, that any of these symptoms
may be present without indicating that a toxemia is developing.
Nevertheless, they should be brought to the physician's attention
without delay, and, at the same time, a specimen of urine should be
given him for examination.
Although the kidneys are not responsible for all the toxemias of
pregnancy, an analysis of the urine affords the most definite means
of determining whether or not such a condition is present. When thus
detected, prompt treatment will guarantee to the patient almost
certain relief. On the other hand if, as usually happens, the
analysis shows conclusively that there is nothing serious the matter,
this reassurance fully justifies the trouble taken to secure it.
CHAPTER VIII
MISCARRIAGE
Frequency--Causes and Prevention--Habitual Miscarriage--Warning
Symptoms--After-effects--Criminal Abortion--Therapeutic Abortion--
Premature Delivery.
We have learned that forty weeks are required for the full
development of the human embryo, but this fact carries no assurance
that pregnancy will last so long; in reality, it may end abruptly at
any time. If growth is interrupted before the twenty-eighth week (the
seventh lunar month), the infant will be too immature to live. Even
when born alive, it will usually perish within a few hours, or a few
days at most. Children born during the seventh month have
occasionally survived; but the prevalent belief that they are more
likely to do so than if born a month later is erroneous. That
superstition originated at a time when great virtue was ascribed to
numbers. Since seven was a sacred number, it was considered more
auspicious to be born in the seventh month than in the eighth.
Universal experience, however, teaches us that the likelihood of
rearing a premature child is, by a rapidly increasing proportion, the
greater for every week that it remains within the uterus. This is
precisely what we should expect, for the period of its existence
there measures the perfection of its development; and that, under
ordinary conditions, determines how strong and hardy the child will
be.
Although during the first six months the outlook for the infant will
be equally unfavorable at whatever time pregnancy may be interrupted,
physicians prefer to distinguish cases which terminate in the earlier
part of this period from those which terminate in the latter part.
For technical reasons, the sixteenth week represents a natural point
of division. A birth which takes place before that time is called an
abortion; one which takes place between the sixteenth and the twenty-
eighth week is called a miscarriage. The anatomical reasons which
justify such a distinction do not concern us here, and the matter
deserves mention merely because the same terms are often employed in
a very different sense by the laity. As most of us know, the
interruption of pregnancy results sometimes from purely natural
causes, and sometimes from the employment of artificial means. As a
rule, persons who are unacquainted with medical terminology call a
birth of the former kind a miscarriage, and reserve the term abortion
for an interruption of pregnancy that is deliberately provoked.
Physicians, however, make no such distinction. They use these words,
as I have said, simply to indicate how far development has progressed
before the termination of pregnancy. Since the term abortion is apt
to carry with it the implication of a criminal act, confusion will be
avoided if we agree for the time to depart from strictly medical
usage and designate as miscarriage the spontaneous termination of
pregnancy prior to the twenty-eighth week.
FREQUENCY.--Early interruption of pregnancy is extremely common. Some
sociologists declare that it is becoming more and more frequent, and
see in it a grave national danger. French statesmen attribute the
alarming decline of the birth-rate in their country, in great part,
to a rapid increase in the number of pregnancies which end
prematurely. Reliable English and German statistics indicate that of
the pregnancies which come under the observation of physicians
approximately twenty per cent, end in miscarriage. In our own
country, though extensive and complete data are not available, it is
likely that the incidence is equally high.
The actual frequency of miscarriage is generally underestimated.
Patients themselves often do not know what has really happened. When
the accident occurs a few days after conception, bleeding may be its
only evidence, which will almost certainly be misinterpreted as an
irregularity of menstruation; and professional advice will not often
be thought necessary. Moreover, in other cases in which the true
situation is appreciated the patient does not feel sick enough to
seek medical assistance. If it were possible to include in the
statistics all these cases as well as those which are concealed
because intentionally provoked, the frequency with which pregnancy is
interrupted during the early months would be found somewhat greater
than is usually supposed.
If we omit the miscarriages which occur within the first few weeks of
pregnancy, and which consequently often escape detection, the
majority of cases fall within the second and third months. After the
fourth month has passed, the probability of such an accident, though
not excluded, is greatly diminished. Some statistics recently
published by Taussig make this clear. In a series of several hundred
cases of miscarriage, one hundred and fifty-seven instances occurred
in the second month, two hundred and twenty-two in the third month,
seventy-three in the fourth month, thirty-seven in the fifth month,
and five in the sixth month. This order of frequency might be
anticipated from the anatomical conditions which prevail during the
early months of pregnancy, since the attachment of the embryo to the
mother is at first relatively insecure, but gradually grows firmer,
and becomes as secure as it ever will be by about the fifth month.
It is noteworthy that miscarriage occurs much less commonly in the
first than in subsequent pregnancies. Indeed, a somewhat greater
liability to the accident with each succeeding pregnancy goes far
toward explaining the greater frequency of miscarriage among women
who have passed the thirty-fifth year than among those who are
younger.
CAUSES AND PREVENTION.--We have seen that the proportion of
pregnancies which end in miscarriage is quite formidable. But this
should not be true, as the accident is frequently preventable, and
many of these accidents could be avoided by the cooperation of
patients. As self-denial and personal inconvenience are often
essential, it is only fair to explain their value. Furthermore, the,
patient who appreciates the reason for certain directions the
physician gives becomes responsible to herself, and is much more
likely to carry them out than is one who is cautioned without
receiving a satisfactory explanation. At best, however, the advice
which the physician is able to offer will be imperfect, for it must
not be imagined that everything is known concerning the causation and
prevention of miscarriage. While our knowledge is so imperfect we
must be content to make the most of what we possess. It must be added
that no suggestion such as can be given here will enable anyone to
dispense with her own medical adviser. On the contrary, if there is
reason to fear miscarriage, the prospective mother should be
encouraged to seek his counsel as early as possible. Aside from the
hygienic measures which she may learn to carry out for herself,
various drugs are often of great value in preventing miscarriage.
Since these are not applicable to all cases, they should be employed
only upon medical advice.
Very early miscarriages may be explained by the loose attachment of
the ovum during the first six weeks of pregnancy. This tiny, living
sphere, it will be recalled, reaches the womb a few days after
conception, and adheres to the uterine mucous membrane. At first,
however, its roots are short and delicate, and not so capable of
anchoring the ovum as they become later. It is only toward the end of
the eighteenth week that the union between the womb and its contents
becomes firm.
From what we have learned in Chapter II regarding the anatomical
conditions in the early days of pregnancy it is obvious that we need
not be greatly surprised at the frequency of miscarriage. On the
other hand, it must not be forgotten that there are many natural
safeguards against accident: to mention only one, the uterus is
ingeniously swung in the abdominal cavity so as to afford a large
measure of protection against mechanical shock. Usually, the
provisions nature has made are sufficient to resist forces from
without which tend to dislodge the ovum. Now and then it happens that
the most irrational acts will not interrupt pregnancy; indeed, they
often seem particularly inert when practised intentionally.
Fear of loosening the ovum from its uterine attachment prompts
experienced women to caution prospective mothers against any kind of
sudden or violent effort. Their advice, however, is often needlessly
alarming; a great many traditional precautions lack a reasonable
basis. Thus, no harm can possibly result from sleeping with the arms
above the head; nor from "over-reaching," as when hanging a picture,
though a fall under such circumstances might be dangerous.
Patients who have been warned by one experience should always be on
their guard if they would avoid repeated miscarriages; others need
only lead a sensible, hygienic life, a matter we have already
discussed in the chapters dealing with the care of the body and the
way to live. For the sake of emphasis, I may here repeat that no
prospective mother should become fatigued from any cause; sweeping,
moving heavy furniture, lifting heavy articles, and running a sewing
machine are not to be attempted. But household duties which do not
require strong muscular effort are better assumed than not.
Amusements which may cause jolting, or expose one to the danger of
falling, involve some risk of miscarriage. Short rides in a carriage
or an automobile over smooth roads are free from objection. Railway-
travel and sea-voyages are not advisable in the early months; after
the eighteenth week they may be undertaken with a greater degree of
safety, provided comfortable accommodations are assured, and the
patient has never had a miscarriage.
A few physicians, even at present, attribute the interruption of
pregnancy to strong emotions, including intense joy or sorrow, anger,
fright, or even jealousy. Without denying altogether the possibility
of such an influence, we may be sure that its importance is greatly
exaggerated. It is not unusual to see patients who are able to recall
a mental shock of some kind shortly before the miscarriage occurred;
nevertheless, in such cases diligent search will usually reveal a
physical cause for the accident.
Another popular fallacy relates to the effect of drugs upon
pregnancy. The use of castor oil and other strong purgatives do not
interrupt it. Should the administration of any cathartic be followed
by miscarriage, some fault inherent preexisted in the pregnancy, and
no amount of precaution would have enabled the patient to reach full
term successfully. Quinin in tonic doses may be taken with impunity,
and even larger quantities are being constantly used for the cure of
malaria without doing the pregnancy any harm. Many other drugs are
reputed to have great efficacy in causing the expulsion of the
product of conception; unfortunately, they are too well known to
require enumeration. They are usually unreliable, and are absolutely
inefficient in doses small enough not to endanger the mother's life,
provided the pregnancy is a healthy one.
Instances in which miscarriage is attributed to the use of some drug
are quite common, and we cannot dismiss them without a word of
explanation. Such cases generally fall into one of two classes. Often
a drug is given credit for efficiency where conception has been
erroneously suspected. Shortly after the menstrual date passes, some
medicine is resorted to, and the subsequent phenomenon, regarded as
the interruption of pregnancy, is really no more than normal
menstruation. In another group of cases miscarriage does actually
occur, although the medicine employed plays only a minor role in its
production. In such instances the irritation which the drug occasions
is the last link in a chain of events leading up to the miscarriage,
but the main factor lies in some fundamental imperfection in the
pregnancy. Physicians recognize a variety of these imperfections, and
know that they may be located in the womb, in the embryo, or in the
tissues which unite the one with the other. As an intimate knowledge
of pathology is often necessary to recognize the underlying, and
therefore the actual, cause of the miscarriage, it is not at all
surprising that patients frequently err in their interpretations of
such accidents, and emphasize unimportant matters.
It would lead us too far afield to attempt to discuss every cause of
miscarriage. Nevertheless, there are some very important ones, not
yet mentioned, which should be understood by the laity, as
appreciation of their significance may avert trouble. In some
instances, on the other hand, the accident is unavoidable; to know
this should afford the patient a large measure of comfort.
Irregularities in the position of the womb are often responsible for
miscarriage. Such a condition may exist in women who have not borne
children, but it is far more likely to occur as a result of
childbirth. After delivery, the enlarged womb becomes the seat of
intricate changes, the purpose of which is the restoration of the
organ to the condition which existed before conception. It dwindles
in size, and gradually drops to its accustomed location within the
pelvic cavity. Six weeks are usually required for these changes.
At the time of birth it is impossible to predict whether the womb
will finally resume a satisfactory position. Accordingly, an
examination two to four weeks later is essential. In four out of five
patients the organ will be found in its proper location, but, even
though it is not, suitable measures adopted at once will generally
serve to replace and hold it in good position. On the other hand, if
the malposition is not recognized until months or years later, simple
procedures will prove inefficient, and a surgical operation will
become necessary. Were there no other reason for a careful
examination at the end of the lying-in period, it would be amply
justified by the information which it gives relative to the position
of the uterus.
Although there can be no doubt that the routine correction of uterine
displacements shortly after labor would go far toward restricting the
occurrence of subsequent miscarriage, it would be incorrect to leave
the impression that miscarriage will always occur if the uterus is
out of its normal position. Not infrequently the changes wrought by
pregnancy will cause the uterus to right itself spontaneously.
Another important cause of miscarriage consists in abnormalities in
the lining of the uterus. Through inherent defect or acquired disease
this tissue may become unsuited for anchoring or nourishing an ovum.
In either event, a surgical procedure, known as curettage, affords
the most likely means of restoring it to a healthful state. The
operation removes the old lining; and a new one quickly develops,
which is often more capable of fulfilling the purpose for which it is
intended.
An appreciable number of miscarriages depend upon conditions over
which medical skill has no control. Under such circumstances, though
the accident may be regretted, there is no room for remorse or
censure. Often the embryo should bear the blame; if its development
is imperfect or if it dies, miscarriage usually occurs very promptly.
We are familiar also with a few maternal conditions which seriously
affect the embryo, often seriously enough to cause its expulsion,
alive or dead. In this respect, certain constitutional disorders are
preeminent. Bright's disease and diabetes are prejudicial to the
development of the embryo; women suffering from either of them must
be watched with great care. Occasionally, such pregnancies come to a
premature end in spite of every precaution. Various infectious
diseases, as typhoid fever and pneumonia, also are fatal to the
embryo if the causative bacteria pass into it. Fortunately this
rarely happens, since the placenta generally affords an effectual
barrier to their entrance into the embryo. Organic diseases of the
mother's heart also may bring about miscarriage. A patient thus
affected should place herself under the supervision of a physician as
soon as conception is suspected.
Now and then physicians are completely at a loss to explain cases of
miscarriage. Our ignorance is unfortunate, particularly when repeated
miscarriages have occurred and their causation cannot be detected.
HABITUAL MISCARRIAGE.--Experience teaches that women who have had one
miscarriage must be more careful than other prospective mothers if
they would escape a repetition of the accident. Persons who know
themselves to be subject to miscarriage should regard no precaution
as too burdensome. Not only should they avoid motoring, driving,
railroad journeys, sea voyages, and every kind of strenuous exertion,
they must accept every opportunity to be quiet and rest. Often such
hygienic care yields sufficient protection; but occasionally medicine
is also necessary.
A number of causes are at hand to explain habitual miscarriage, but,
in fairness, it must be acknowledged that physicians are not able to
interpret all cases. With one class of patients the muscle fibers of
the womb are peculiarly irritable, whereas in another its lining
proves incapable of firmly anchoring the ovum. Moreover, derangements
of organs which do not belong to the reproductive group may be
responsible for the habit.
It is a curious fact that the accident is most likely to occur when
menstruation would be expected were the individual not pregnant.
Obviously, extraordinary precaution is advisable at such times, and
if the patient would avoid even the slightest risk, she should not
leave her bed. The same purpose will not be served by sitting quietly
in a chair, nor by reclining on a couch; complete relaxation and
composure are secured only when one lies flat on the back, loosely
attired in sleeping garments. I have known several persons with a
tendency toward miscarriage who overcame it in this way. Recently one
of them who had been delivered prematurely on two former occasions,
and who was anxious for a successful issue to her third pregnancy,
was willing to remain in bed practically the whole period of
gestation. She had her reward; a well-developed infant was born at
full term, and has continued to thrive.
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