MATERNAL MORTALITY AND DISEASES AFFECTED BY PREGNANCY
_This chapter shows that the female death-rate is much greater during
the child-hearing age than at other periods and notably greater than the
male death-rate at any period. The outstanding fact is that this
abnormal female death-rate, between the ages of 15 and 45, must be
ascribed to too frequent pregnancies and to those diseases of the lungs,
heart and kidneys which are hastened by pregnancy. Ninety-five per cent.
of such deaths could be averted by the dissemination of knowledge to
prevent conception._
_THE SEXUAL LIFE OF WOMAN IN ITS PHYSIOLOGICAL BIOLOGICAL AND HYGIENIC
ASPECTS. E. HEINRICH KISCH, M.D., Professor of the German Medical
Faculty of the University of Prague, Physician to the Hospital and
Spa of Marienbad, Member of the Board of Health, etc. Translated
by M. Eden Paul, M.D. Rebman Co., New York._
It is astonishing to observe the number of full term deliveries and
miscarriages that a woman will experience within a comparatively short
period of time, as is seen too frequently among the laboring classes,
and more especially, among the factory workers. If we assume the
original mortality of childbirth to be 6 per mille, a woman who in the
course of 15 years undergoes labor (at full term or prematurely) 16
times, runs a risk of death to be expressed by the ratio of 6 × 16 = 96
per mille; that is to say, on the average of 1,000 women who became
pregnant as often as this, nearly one in ten will die in childbed. P.
278.
In certain serious general disorders, in diseases of the heart, or of
the lungs, in pelvic deformity, and in pathological changes of the
female reproductive organs, it may be right to employ means for the
prevention of pregnancy—not merely sexual abstinence, but actual
measures to prevent fertilization. P. 395.
Based upon the observations of Schauta and Fellner, the latter author
advances the rule that in the case of a woman suffering from disease,
marriage should be forbidden only when the mortality from the disease in
question is not less than 10%. In this category we must include severe
cases only of pulmonary tuberculosis, whilst cases of laryngeal
tuberculosis will, according to this rule, be absolutely unfit for
marriage. Among heart affections contra-indicating marriage, he includes
mitral stenosis, other valvular affections in which there is serious
disturbance of compensation, and myocarditis; he considers marriage
inadmissible also in cases of chronic nephritis, and among surgical
affections, in case of malignant tumor. No case in which during a
previous pregnancy the patient has been affected by one of the following
diseases; viz. severe chorea, mental disorders, severe epilepsy,
pulmonary tuberculosis which progressed much during pregnancy, morbus
cordis, with considerable disturbance of compensation, severe heart
trouble due to Graves disease—in all such cases a repetition of
pregnancy should be avoided. P. 261.
FOURTH ANNUAL REPORT OF THE CHIEF OF CHILDREN’S BUREAU OF THE U. S.
DEPARTMENT OF LABOR,
JUNE 30, 1916
MATERNAL MORTALITY
A study of maternal mortality, by Dr. Grace L. Meigs, head of the
hygiene division of this bureau, has been undertaken as a direct
corollary to the infant mortality inquiry. The sickness or death of the
mother inevitably lessens the chances of the baby for life and health. A
large proportion of the deaths of babies occur in the first days and
weeks of life, and these early deaths can be prevented only through
proper care of the mother before and at the birth of her baby.
In the introduction to the report on “Maternal mortality in connection
with childbearing,” issued as a supplement to his report as medical
officer of the local government board of Great Britain for 1914–15, Sir
Arthur Newsholme says:
The present report is intended to draw attention to this unnecessary
mortality from childbearing, to stimulate further local inquiry on the
subject, and to encourage measures which will make the occurrence of
illness and disability due to childbearing a much rarer event than at
present.
The attainment of these ends is important as much in the interest of the
child as of its mother. That the welfare of the child is wrapped up in
that of the mother was fully recognized in the board’s circular letter
of 31st July, 1914, and the schedule appended to that letter; and each
year it is becoming more fully realized that, in order to insure healthy
infancy and childhood, it is necessary that, both during pregnancy and
at and after the birth of the infant, increased maternal care and
guidance and medical assistance should be provided.
The Children’s Bureau studies of infant mortality in town and country
reveal clearly the connection between maternal and infant welfare and
make plain that infancy can not be protected without the protection of
maternity.
In her report Dr. Meigs undertakes to do no more than to assemble and
interpret figures already published by the United States Bureau of the
Census and in the mortality reports of various foreign countries and to
state accepted scientific views as to the proper care of maternity. She
shows that maternal mortality, although in great measure preventable, is
not decreasing in the United States. Her report reveals an unconscious
public neglect due to age-long ignorance and fatalism. As soon as the
public realizes the facts to which Dr. Meigs calls attention it
doubtless will awake to action, and suitable provision for maternal and
infant welfare will become an integral part of all plans for local
protection of public health.
The report is summarized as follows:
“In 1913 in this country at least 15,000 women, it is estimated, died
from conditions caused by childbirth; about 7,000 of these died from
childbed fever, a disease proved to be almost entirely preventable, and
the remaining 8,000 from diseases now known to be to a great extent
preventable or curable. Physicians and statisticians agree that these
figures are a great underestimate.
“In 1913 the death rate per 100,000 population from all conditions
caused by childbirth was but little lower than that from typhoid fever;
this rate would be almost quadrupled if only the group of the population
which can be affected, women of childbearing age, were considered.
“In 1913 childbirth caused more deaths among women 15 to 44 years old
than any disease except tuberculosis.
“The death rate due to this cause is almost twice as high in the colored
as in the white population.
“Only 2 of a group of 15 important foreign countries show higher rates
from this cause than the rate in the registration area of the United
States. The rates of three countries, Sweden, Norway, and Italy, which
are notably low, show that low rates for these conditions are
attainable.
“The death rates from childbirth and from childbed fever for the
registration area of this country are not falling; during the 13 years
from 1900 to 1913 they have shown no demonstrable decrease. These years
have been marked by a revolution in the control of certain other
preventable diseases, such as typhoid, diphtheria, and tuberculosis.
During that time the typhoid rate has been cut in half, the rate of
tuberculosis markedly reduced, and the rate for diphtheria reduced to
less than one-half. During this period the death rate from childbirth
has decreased in England and Wales, Ireland, Australia, and Japan. The
other foreign countries studied show stationary or slightly increasing
rates. The death rate from childbed fever has decreased only in England
and Wales, Ireland, and Scotland.
“These facts point to the need in this country and in foreign countries
of higher standards of care for women at the time of childbirth.
“The low standards at present existing in this country result chiefly
from two causes: (1) General ignorance of the dangers connected with
childbirth and of the need for proper hygiene and skilled care in order
to prevent them; (2) difficulty in the provision of adequate care due to
special problems characteristic of this country. Such problems vary
greatly in city and in country. In the country inaccessibility of any
skilled care, due to pioneer conditions, is a chief factor.
“Improvement will come about only through a general realization of the
necessity for better care at childbirth. If women demand better care,
physicians will provide it, medical colleges will furnish better
training in obstetrics, and communities will realize the vital
importance of community measures to insure good care for all classes of
women.”
While the figures given by Dr. Meigs are a startling indication of the
great number of maternal fatalities occurring in various parts of the
country, no estimates can be made of the number of mothers who survive
only to suffer from a degree of preventable ill health which limits or
defeats the well-being and happiness of their households.
_MATERNAL MORTALITY FROM ALL CONDITIONS CONNECTED WITH CHILD BIRTH IN
THE UNITED STATES AND CERTAIN OTHER COUNTRIES. By Grace L. Meigs,
M.D. U. S. Department of Labor, Children’s Bureau, 1917._
STATISTICS RELATING TO CHILDBIRTH IN THE UNITED STATES AND IN CERTAIN
FOREIGN COUNTRIES
For the last two decades civilized countries have been absorbed in the
problem of preventing the enormous and needless waste of human life
represented by their infant death rates. The importance of this problem
has been felt more keenly in the last two years in the countries now at
war; in these countries the efforts toward saving the lives of babies
have redoubled since the war began. Side by side with this problem,
another, which is only of late finding its true place, is that of the
protection of the lives and health of mothers during their pregnancy and
confinement. This is a question so closely bound up with that of the
prevention of infant mortality that the two can not be separated.
It is now realized that a large proportion of the deaths of babies occur
in the first days and weeks of life, and that these deaths can be
prevented only through proper care of the mother before and at the birth
of her baby. It is also realized that breast feeding through the greater
part of the first year of the baby’s life is the chief protection from
all diseases; and that mothers are much more likely to be able to nurse
their babies successfully if they receive proper care before, at, and
after childbirth. Moreover, in the progress of work for the prevention
of infant mortality it has become ever clearer that all such work is
useful only in so far as it helps the mother to care better for her
baby. It must be plain, then, to what a degree the sickness or death of
the mother lessens the chances of the baby for life and health.
This question has also another side. Each death at childbirth is a
serious loss to the country. The women who die from this cause are lost
at the time of their greatest usefulness to the State and to their
families; and they give their lives in carrying out a function which
must be regarded as the most important in the world.
Questions then of the most vital interest to the whole Nation are these:
How are the lives of the mothers in this country and other countries
being protected? To what degree are the diseases caused by pregnancy and
childbirth preventable? If preventable, how far are they being prevented
in this country? Has there been the same great decrease in the last few
years in sickness and death from these causes as that which has marked
the great campaigns against other preventable diseases such as typhoid,
tuberculosis, or diphtheria? How do the conditions in the United States
compare with those in other countries?
_Puerperal septicemia (childbed fever)._—The fact is now well known that
puerperal septicemia, or childbed fever, is in reality a wound
infection, similar to such an infection after an accident or an
operation, and that it can be prevented by the same measures of
cleanliness and asepsis which are used so universally in modern surgery
to prevent infection. The proof of the nature of this disease is one of
the tremendous results of the scientific discoveries which were made in
the latter part of the nineteenth century.
During the early part of that century childbed fever was one of the
greatest hospital scourges known. It occurred also in private practice;
but in hospitals where there was great opportunity for the spreading of
infection the death rate from this disease was appalling. The average
death rate in hospitals in all countries was 3 to 4 per cent. of all
women confined; sometimes it reached 10 to 20 per cent. and even over 50
per cent. during short periods of epidemics. In the face of this
terrific mortality many obstetrical hospitals were closed. Commissions
were appointed to investigate the cause of these epidemics, and medical
congresses devoted sessions to the discussion of the problem. In 1843
Oliver Wendell Holmes, and in 1847 Semmelweiss, published articles
stating the theory that this fever was similar to a wound infection and
was due chiefly to the carrying of infectious material on the hands of
attendants from one case to another.
NUMBER OF DEATHS IN THE UNITED STATES FROM CHILDBIRTH
In 1913 in the “death-registration area” of the United States 10,010
deaths were reported as due to conditions caused by pregnancy and
childbirth. Of these deaths, 4,542 were reported as caused by puerperal
septicemia or childbed fever.
Using the death-registration area as a basis, we are justified in
estimating that in 1913 in the whole United States 15,376 deaths were
due to childbirth, and 6,977 of these were due to childbed fever. As
will be shown later, these figures are without doubt a gross
underestimate. As it is, they are striking enough—almost 7,000 deaths in
one year in this country due to childbed fever, a disease to a large
degree easily preventable; and over 8,000 due to the other diseases
caused by pregnancy and confinement, most of which are preventable or
curable by means well known to science.
DEATH RATES IN THE UNITED STATES FROM CHILDBIRTH
The death rate from all diseases caused by pregnancy and confinement in
1913 in the registration area was 15.8 per 100,000 population (which
includes all ages and both sexes). The death rate from puerperal
septicemia was 7.2.
These figures, however, mean little to us unless we compare them with
the death rates from other preventable diseases. In the same year and
area the typhoid rate was 17.9 per 100,000 population; the rate from
diphtheria and croup 18.8. The highest death rate from any one disease
was that from tuberculosis, 147.6 per 100,000 population. Any such
comparison with the rates from diseases to which both sexes and all ages
are liable is of course very misleading; but in spite of that fact it is
interesting to note that typhoid fever, the disease against which so
great an amount of effort is now directed, has a rate at present but 2
per 100,000 population higher than that from the diseases caused by
pregnancy and confinement.
_Death rates per 100,000 women._—The death rates from childbirth are
approximately doubled when worked on the basis of 100,000 women. This
will be seen when Tables IV and III (p. 50) are compared. The former
gives for the period 1900 to 1910, the annual death rates per 100,000
women in the group of 11 States which were in the death-registration
area in 1900, the latter the death rates per 100,000 population in the
same group of States for the same period. It is evident that the rates
in Table IV for each year are slightly more than twice those in Table
III for the same year.
_Death rates per 100,000 women of childbearing age...._ Again, a much
higher but a more accurate death rate from these diseases is found when
the basis taken is the group which alone is affected by these
diseases—women of childbearing age. When the rate is based not upon
100,000 population of both sexes and all ages but upon 100,000 women 15
to 44 years of age, the rate as ordinarily given is multiplied several
times.
In 1900, the only year for which the rates can be computed, the death
rate in the registration area per 100,000 women 15 to 44 years of age
from all diseases of pregnancy and confinement was 50.3; from puerperal
infection, 21.6. The corresponding rates for the same year per 100,000
population were 13.1 and 5.6. In this year, therefore, the rates are
almost quadrupled when based on that group of the population which alone
can be affected by these diseases.
Moreover, the death rates as ordinarily given per 100,000 population
conceal the fact that the diseases of pregnancy and childbirth are
indeed among the most important causes of death of women between 15 and
44 years of age; the actual number of deaths shows this to be the case.
In 1913 in the registration area these diseases caused more deaths than
any other one cause of death except tuberculosis. In that year there
were, among women 15 to 44 years of age, 26,265 deaths from
tuberculosis; 9,876 deaths from the diseases of pregnancy and
confinement; 6,386 from heart disease; 5,741 from acute nephritis and
Bright’s disease; 5,065 from cancer; and 4,167 from pneumonia. Other
diseases, such as typhoid, appendicitis, and the infectious diseases
show far fewer deaths.
_Death rates per 1,000 live births._—This rate, as will be shown
repeatedly throughout the report gives a far clearer picture of the
actual risk of childbirth than do any of the rates so far considered.
This rate can be given only for one year, 1910, and only for the
provisional birth-registration area for that year. The rate from all
diseases caused by pregnancy and confinement is 6.5, from puerperal
septicemia, 2.9, and from all other diseases of pregnancy and
confinement, 3.6 per 1,000 live births. That is, in this area for every
154 babies born alive one mother lost her life.
COMPARISON OF THE AVERAGE DEATH RATES FROM CHILDBIRTH IN CERTAIN FOREIGN
COUNTRIES AND IN THE UNITED STATES
Are the death rates from these diseases in the death-registration area
of the United States higher or lower than those in other civilized
countries? Have these rates in other countries been falling or rising in
the last 13 years, while the rates of this country have been apparently
stationary? These questions, like all those of comparative international
statistics, are of immense interest, but they involve many difficulties
and sources of error. They should be considered in reading the following
summary.
In order to make possible a comparison of the death rates from these
causes for 15 foreign countries with those for the United States, an
average rate has been computed for the years 1900 to 1910 for each of
the countries, using the same method as that in use in the United
States. When the 16 countries studied are arranged in order, with the
one having the lowest rate first, the death-registration area of the
United States stands fourteenth on the list. (See Table XII, p. 56.)
Only two countries, Switzerland and Spain, have higher rates; many of
the countries, however, show rates differing but little from that of the
United States. Markedly low rates are those of Sweden (6), Norway (7.8),
and Italy (8.9); a strikingly high rate is that of Spain (19.6).
The death rate from childbirth per 1,000 live births is not available
for the death-registration area of the United States, but can be given
only for the small number of States and cities included in the
provisional birth-registration area and for one year, 1910. (See p. 31.)
This rate, 6.5, is considerably higher than that for 1910 of any of the
countries studied. When the average rates for a number of years of the
15 countries are reckoned per 1,000 live births and arranged in order,
it will be seen that the same group of countries—Sweden, Italy, and
Norway—shows the lowest rates. (See Table XIII, p. 56.) Spain in this
table shows the rate which is next to the highest, while Belgium now has
the highest rate. For a comparative study of the rates of these
countries the rates per 1,000 live births give undoubtedly the clearest
picture of the actual conditions.
These rates show a wide variation. While in Sweden but one mother is
lost for every 430 babies born alive, in Belgium one mother dies for
every 172 babies, and in Spain one for every 175 babies born alive. The
rates in Belgium and Spain are two and a half times as high as the rate
in Sweden.
Far more significant than a comparison of actual death rates of various
countries is a comparison of the changes which have occurred in these
death rates in each country in recent years. England and Wales, Ireland,
Japan, New Zealand, and Switzerland have shown a decrease in the death
rate per 1,000 live births from all diseases caused by pregnancy and
confinement; but, in this group, only in England and Wales and in
Ireland has the death rate from puerperal septicemia decreased; in the
other three countries this rate has remained practically the same,
though the total rate has decreased.
In Australia, Belgium, Hungary, Italy, Norway, Prussia, Spain, and
Sweden both the rate from childbirth and that from puerperal septicemia
remained almost stationary during the periods studied.
The total rate for Scotland shows a definite increase, though the rate
from puerperal septicemia has decreased. (See Table XVI, p. 66.)
Communities are still to a great extent indifferent to or ignorant of
the number of lives of women lost yearly from childbirth; many
communities which are proud of their low typhoid or diphtheria rates
ignore their high rates from childbed fever. Communities are only
beginning to realize that among their chief concerns is the protection
of the babies born within their limits, and necessarily also of the
mothers of those babies before and at confinement.
DEATH-REGISTRATION AREA
The statistics of causes of death are available only for a certain
portion of the United States, included in the so-called
“death-registration area.” Unlike other civilized countries, the United
States has no uniform laws for the registration of births and deaths.
Moreover, the efficiency of enforcement of existing laws varies greatly
in the different States. The Bureau of the Census in 1880 therefore
established a “death-registration area,” which comprises “States and
cities in which the registration of deaths is returned as fairly
complete (at least 90 per cent. of the total), and from which
transcripts of the deaths recorded under the State laws or municipal
ordinances are obtained by the Bureau of the Census.” In 1880 this area
included but 17 per cent. of the total population of the United States.
As States and cities have passed better laws and obtained better
enforcement they have been added to the registration area; the latter
has increased greatly in size, but even in 1913 included only 65.1 per
cent. of the population of the United States. For the remaining 34.9 per
cent. of the population of the country we have no reliable statistics.
This 34.9 per cent. includes the population of the greater number of the
Southern States and of many Middle Western and Western States outside of
certain registration cities in these States which are included in the
area. No statements can be made, therefore, of the number of deaths from
any cause in the United States as a whole; only an estimate can be made
on the assumption that for any cause of death the same rate prevails in
the remainder of the United States as in the death-registration area.
PROVISIONAL BIRTH-REGISTRATION AREA
The registration of births is still more incomplete in this country than
is the registration of deaths. For 1910 the United States Bureau of the
Census established a “provisional birth-registration area,” including
the New England States, Pennsylvania, Michigan, New York City and
Washington, D. C.
_Death rates per 1,000 births._—As shown above, the method of
computation of death rates which gives the clearest picture of the
hazards of childbirth is that which takes into account only the women
giving birth to children in that year. This is the method in use in a
large number of foreign countries. The advantages of the method are
self-evident. A demonstration of the superiority of this method of
computation is obtained by a study of the tables giving the death rates
from these diseases for foreign countries. In certain countries, as for
instance Belgium and Hungary, there has been in recent years an apparent
fall in the average death rates as computed per 100,000 population,
while the average rates computed per 1,000 live births have remained
stationary or risen. This phenomenon is due, evidently, to a decline in
the birth rate in these countries during these years, and shows how
misleading the rates as given per 100,000 population undoubtedly are in
countries with declining birth rates. Whether a fall in the birth rate
has occurred in the United States is not known. If it has occurred in
the registration area, it would mean that the slight rise in rates per
100,000 population between 1900 and 1913 means a greater rise in rates
computed according to the number of births. Such an error might
compensate for the opposite error due to the more complete registration
of deaths from childbirth in the later years of this period.
Miscarriages are not reportable in any country, although a number of
miscarriages (as the term is usually defined) probably are reported as
stillbirths in certain countries. The fact that women having
miscarriages are not considered in the base would lead to a somewhat
higher death rate than that which would express absolutely the number of
deaths per 1,000 women at risk.
COMPARISON OF THE CHANGES IN THE DEATH RATES FROM CHILDBIRTH IN CERTAIN
FOREIGN COUNTRIES FOR THE YEARS 1900 TO 1913
Far more valuable than a comparison of average rates of foreign
countries is a study of the rates of each country for a series of years
in order to discover whether they are decreasing or increasing and to
compare such changes in the various countries. While it may be dangerous
on account of different countries, no such source of error is attached
to the comparison of rates in the same country for a number of years.
The period 1900 to 1913 (or the latest year for which figures are
available) is a very short one for a study of a change in death rates.
It would have been far more interesting to study the death rates for a
long series of years in each country, choosing a period beginning before
the introduction of methods of asepsis. But such a study for the
complete list of countries considered was not thought advisable, because
of the difficulties caused by variations in classification of causes of
death in the earlier years.
In order to study the rates for any increase or decrease occurring
during the last 13 years, the rates per 1,000 live births will be used
rather than those per 100,000 population. In several countries—Belgium,
Hungary, Italy, Norway, Prussia, and Spain—the rate from childbirth per
100,000 population apparently has fallen during the period, while the
rate per 1,000 live births has remained almost the same, or has risen.
The cause of this inconsistency is the fact that in these countries the
birth rate or the proportionate number of births to the number of
inhabitants has decreased.
_Number of deaths of women from 15 to 44 years of age in the
death-registration area from each cause and class of causes
included in the abridged International List of Causes of Death
(revision of 1909),[49] 1913._
Footnote 49:
Except No. 25, diarrhea and enteritis (under 2 years), and No. 34,
senility.
(Computed from figures in Mortality Statistics, 1913, pp. 338 to 349, in
which causes of death are given according to the detailed International
List of Causes of Death.)
Abridged Number
International Cause of death. of
List No. deaths.
13, 14, 15 Tuberculosis of the lungs, tuberculous 26,265
meningitis, other forms of tuberculosis
Puerperal septicemia (puerperal fever,
31, 32 peritonitis) and other puerperal accidents of 9,876
pregnancy and labor
19 Organic diseases of the heart 6,386
29 Acute nephritis and Bright’s disease 5,741
16 Cancer and other malignant tumors 5,065
22 Pneumonia 4,167
35 Violent deaths (suicide excepted) 3,262
1 Typhoid fever 2,706
30 Noncancerous tumors and other diseases of the 2,669
female genital organs
26 Appendicitis and typhlitis 1,620
36 Suicide 1,562
23 Other diseases of the respiratory system 1,458
(tuberculosis excepted)
18 Cerebral hemorrhage and softening 1,398
24 Diseases of the stomach (cancer excepted) 940
27 Hernia, intestinal obstruction 854
28 Cirrhosis of the liver 598
9 Influenza 489
17 Simple meningitis 484
8 Diphtheria and croup 330
12 Other epidemic diseases 312
6 Scarlet fever 307
5 Measles 304
3 Malaria 250
21 Chronic bronchitis 184
20 Acute bronchitis 90
33 Congenital debility and malformations 24
11 Cholera nostras 18
4 Smallpox 16
7 Whooping cough 9
2 Typhus fever 2
10 Asiatic cholera
37 Other diseases 11,688
38 Unknown or ill-defined diseases 458
_A MUNICIPAL BIRTH CONTROL CLINIC. MORRIS H. KAHN, M. D., in New York
Medical Journal for April 28, 1917._
_Showing that large families among the poor are the result of ignorance
of methods to prevent conception among the mothers._
The following studies were undertaken with a view to determining whether
there was an actual need and demand for birth control education and
whether such a demand, if it existed, could be supplied with any effect
by a scientifically conducted clinic in the dispensaries of the
Department of Health of the City of New York; we felt that it might be
of scientific and sociological interest to publish a report and an
analysis of the observations made, probably the first of their kind in
this country. Section 1142 of our Penal Code was ignored in conducting
this birth control study.
The social and economic status of the patients was fairly uniform, about
the same as that of patients attending the other dispensary institutions
in this city. A tabulation of the results was made under the following
headings: Name and nationality; age; number of years married; number of
living children and their ages; number of deceased children; number of
miscarriages or abortions; contraceptive methods known or practised.
More or less complete data were secured in 464 cases.
The average number of procreative years of married life was 16.1, the
age of fifty years being considered in this study as the end of the
procreative period for the seventy-two women who were older than that.
The average number of living children was 3.27 and of deceased children
1.2, making a total average of 4.47 children born to each family. Of the
464 women, 176, or three eighths, had had abortions or miscarriages, the
total number of such interruptions of pregnancy being 324, or an average
of 1.8 each for the women involved.
Of the 464 women, 192 knew of no contraceptive methods and therefore had
used none. The remaining 272 women knew of one or more methods, more or
less effectual, for the prevention of conception. Of the 192 women who
were ignorant of the use of contraceptives, practically one half, or
104, had a history of abortions, with a total of 202 abortions, or an
average of two apiece. In contrast with this, of the 272 women who knew
of one or more contraceptives, only one fourth, or seventy-two, had
undergone abortions, with a total of 122 abortions, or an average of
only 1.6 apiece.
A further analysis of our tables shows an interesting and striking
relationship between ignorance of methods for the prevention of
conception and the number of children. Sixty-eight women had had three
children each. Of these, twenty-six, or thirty-eight per cent., were
ignorant of contraceptives. Twenty-eight women had had four children
each. Of these fourteen, or fifty per cent., were ignorant of
contraceptives. Fifty-five women had had five children each. Of these
thirty were ignorant of contraceptives, or fifty-four per cent.
Thirty-two women had had six children each. Of these twenty were
ignorant of contraceptives, or sixty-two per cent. Forty women had had
seven children each. Of these thirty-eight were ignorant of
contraceptives, or ninety-five per cent. Twenty-one women had had eight
children each. Of these twenty were ignorant of contraceptives, or
ninety-five per cent. Forty-four women had had nine or more children
each, and of these all were ignorant of contraceptive measures. Arranged
in tabular form, these data would appear as follows:
Number of Women Number of Number Ignorant Percentage
Children of Contraceptives
68 3 26 38
28 4 14 50
55 5 30 54
32 6 20 62
40 7 38 95
21 8 20 95
44 9 to 17 all 100
It is sometimes stated by opponents of birth control that contraceptive
methods are known by every married person and that the fault and
immorality of having a large family of unprovided for dependents lies
not in ignorance of contraceptives but rather in a lack of determination
on the part of one or both parents to use preventive measures; in other
words, that the failure to use contraceptives results from the
inconvenience attending some methods and also from the influence of
religious sentiment.
The above data, however, tend to show that ignorance of contraceptives
not only is a great factor in the production of large families, but is
also a great factor in increasing the number of abortions. From the fact
that two thirds of these women knew absolutely no contraceptive method,
while the methods used by many of the others were ineffectual or
positively harmful, it is apparent that there is a definite opportunity
for educating these women in methods of regulating conception. That
there is need and demand for such education is voiced in unmistakable
language by the multitude of poor who seek advice from all practising
physicians.
MATERNAL MORTALITY
Prof. Theodate L. Smith, director of the Library Department, Child Study
Institute, Clark University, investigated the records of the families of
early graduates of Yale University (1701 to 1745) and of Harvard
University (1658 to 1690); and found that of the wives of Harvard men,
37.3 per cent. died under the age of 45 years, while of the wives of
Yale men, 40 per cent. died under 50 years. Prof. Smith also showed that
there is a tendency for families very large in the first generation to
die out in the third or fourth generation. One family of twenty
children, by two wives, has living descendent by one son only, one
daughter being untraceable. A family of ten brothers and sisters, only
two of whom lived until 50, produced three surviving children, who in
turn have produced one, and that a sickly specimen. Another family had
fourteen in the first generation, eight in the second, six in the third
and only two in the fourth.—Mary Alden Hopkins in _Harper’s Weekly_,
June, 1915.
TUBERCULOSIS, CAUSE OF THE GREATEST NUMBER OF DEATHS OF WOMEN DURING THE
CHILD-BEARING PERIOD
_OBSTETRICS. A Text Book for the Use of Students and Practitioners. J.
Whitridge Williams, Professor of Obstetrics, John Hopkins
University, Obstetrician-in-Chief to the John Hopkins Hospital,
Gynaecologist to the Union Protestant Infirmary, Baltimore, Md. D.
Appleton & Co. 1912._
As a rule, all diseases which subject the organism to a considerable
strain are much more serious when occurring in the pregnant woman. In
general it may be said that pregnancy exerts a deleterious influence
upon all chronic organic maladies, while its effect is usually less
marked in acute infectious processes. The latter, however, frequently
lead to premature delivery and the additional physical strain attending
the latter matter render the course of the disease much less favorable.
Page 489.
“Owing to the well known fact that pulmonary tuberculosis usually
progresses much more rapidly after child bearing, it is advisable that
tubercular women take every precaution to avoid the possibility of
conception.” Page 383.
It would appear therefore that in the vast majority of cases the disease
(tuberculosis) is not transmitted directly from the mother to the fetus,
and that the latter is born with a tendency to tuberculosis, rather than
with the disease itself. Hence it follows that the children of
tubercular mothers should be brought under the best hygienic
surroundings, and should not be suckled by their mothers. In view of the
fact that the tubercular process usually becomes exacerbated either
during pregnancy or after child birth, most authorities recommend that
abortion be induced as a matter of routine in all tubercular women, and
many that they be rendered sterile by artificial means. This appears to
be a somewhat too extreme point of view, but I consider that abortion
should be induced in the first pregnancy occurring after the onset of
the disease, and whenever it makes its appearance during the early
months of pregnancy. Page 494.
_THE PRACTICE OF OBSTETRICS. In original contributions by American
Authors. Edited by Reuben Peterson, A.B., M.D., Professor of
Obstetrics and Gynaecology in the University of Michigan, Ann
Arbor, Mich. Obstetrician-in-Chief to the University of Michigan
Hospital. Lea Bros. & Co. Philadelphia and New York. 1907. Chapter
IX._
COMPLICATIONS ARISING FROM MATERNAL DISEASES AND ANOMALIES
Exact observations on a large number of cases have demonstrated beyond
doubt that with very rare exceptions a pregnancy exerts a harmful effect
upon the course of the disease (tuberculosis). Page 344.
So seriously is the tubercular process affected by a concomitant
pregnancy that it seems the duty of the physician to warn every
tubercular girl against marriage. Especially deleterious to the patient
are pregnancies which follow each other at short intervals. In such
instances the patient must be strongly advised against a new
impregnation. It hardly can be denied that in some of these cases
artificial sterilization may be justified. An additional argument in
favor of this procedure is the comparative frequency with which, if not
the infection itself, at least a marked disposition to it is transmitted
to the fetus in utero. P. 344.
_A TEXT BOOK OF OBSTETRICS. Barton Cooke Hirst, M.D., Professor of
Obstetrics in the University of Pennsylvania; Gynaecologist to the
Howard and Orthopaedic and the Philadelphia Hospitals, etc. W. B.
Saunders Co. 1909._
The influence of pregnancy upon tuberculosis is most unfavorable and in
women predisposed to tuberculosis, gestation may be the determining
factor in lighting up an attack. It is the duty of a physician to advise
strongly against marriage and maternity in the case of a woman already
infected, or predisposed to tuberculosis. If the patient is pregnant an
induction of labor should be considered. P. 427.
_THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Jos. B. De Lee, M.D.,
Professor of Obstetrics at the Northwestern University Medical
School; Obstetrician to the Chicago Lying-in-Hospital and to
Wesley and Mercy Hospitals, etc. W. B. Saunders Co. 1913._
Women with tuberculosis should not marry, first, because this aggravates
their own disease. Second, they may infect the husband, and third, they
propagate tuberculous children. Knowing the tendency for a latent
tuberculosis to break out in pregnancy, marriage is to be forbidden. If
the woman marries, she should avoid conception. P. 481.
If tuberculosis of the lungs is manifested in early pregnancy, if there
is fever, wasting, hemoptysis and advancing consolidation, that is, the
process seems to be florid, abortion should be induced without delay.
Trembley, of Saranac Lake induces abortion in the early months in all
cases. Urgent symptoms of cardiac nature, persistent hemoptysis and
dyspnea may require emptying of the uterus. Complicating nephritis,
heart disease, and contracted pelvis, which is said to be more frequent
in the tuberculous, will give early indications for interference. P.
481.
_TUBERCULOSIS. Jos. B. De Lee._
The woman should be instructed how to avoid pregnancy in the future.
Something must be done until the woman is cured of her tuberculosis, so
that she may safely go through a confinement, because every accoucheur
recoils with horror from the task of repeatedly doing abortions on these
tuberculous women. P. 482.
_THE PRACTICE OF OBSTETRICS. Designed for the use of Students and
Practitioners of Medicine. J. Clifton Edgar, Prof. of Obstetrics
and Clinical Midwifery in the Cornell University Medical College;
Visiting Obstetrician to Bellevue Hospital, New York City; Surgeon
to the Manhattan Maternity and Dispensary; Consulting Obstetrician
to the New York Maternity and Jewish Maternity Hospitals. 5th
Edition. Revised. P. Blakiston’s Co., Phil._
The subject of the relationship between tuberculosis and pregnancy has
recently attained an increased degree of importance through the
agitation in favor of the justification of abortion in the tuberculous
pregnant woman. P. 314.
Statistics appear to show, according to Lancereaux, that a considerable
number of cases of tuberculosis develop solely as a result of pregnancy.
If pregnancy can thus affect health, how much more likely would it be
for the disease to assert itself in a woman who is a fit subject for it,
or in one who is actually consumptive. In the former class are so called
candidates for tuberculosis who have a family history of the disease of
much significance under these circumstances. One should strongly
dissuade girls with tubercular history and antecedents from early
marriage, fearing that repeated childbearing will infallibly light up
the dreaded malady. What has been said of the candidate for tuberculosis
applies with the same, or greater force in the case of so-called latent
tuberculosis and of apparent recovery from the disease. Present
sentiment is beginning to dissuade such women from marriage, not less
for their own benefit than for the sake of posterity, and all organized
movements which are seeking to eradicate tuberculosis from the world lay
much stress on discouraging marriage in tuberculosis suspects. Until
this view prevails there will necessarily be some justification for
interrupting a pregnancy already under way. P. 314.
Sanatoria for consumptives do not care to admit pregnant women, and this
prohibition is equivalent to ranking them as incurable. The fact that a
candidate for tuberculosis runs a very great risk of becoming
consumptive through childbirth is a most stubborn one, and when in
addition to becoming a consumptive herself she also brings into the
world an individual who is likely to become tubercular, it readily
becomes apparent that the question of the propriety of therapeutic
abortion is bound to become an issue in the future in the practice of
obstetrics. P. 315.
EXCEPTIONAL CASES
A tubercular woman may go through gestation with no undue acceleration
of her malady, only to succumb after delivery to acute general
tuberculosis, or acute tubercular pneumonia. P. 315.
Tubercular pregnant women also show no little tendency to abort. P. 316.
_TUBERCULOSIS A PREVENTABLE AND CURABLE DISEASE. S. Adolphus Knopf,
M.D.; Professor of Phthisio-therapy at the New York Post-Graduate
Medical School and Hospital; Associate Director of the Clinic for
Pulmonary Disease of the Health Department; Attending Physician to
the Riverside Sanitorium for Consumptives of the City of New York,
etc. Moffat Yard & Co., 1909. New York._
We have emphasized the fact that tuberculosis is very rarely directly
hereditary, but that what is often transmitted by tuberculous parents is
a weakened system, or physiological poverty. Nevertheless it is evident
that tuberculous individuals ought not to marry, and when tuberculosis
develops in a married couple it is best that they should have no
children. P. 354.
_PULMONARY TUBERCULOSIS. Its Modern Prophylaxis and the Treatment in
Special Institutions and at Home. S. Adolphus Knopf, M.D. P.
Blakiston’s Sons & Co., Phil., 1899._
If conception has taken place in a tuberculous woman institute
treatment, preferably in a sanatorium near the home of the patient. But
as Treaudeau says, it is essential that the treatment be continued for a
long time afterwards, and I should like to add that a repetition of
pregnancy must be prevented. P. 283.
_THE TUBERCULOSIS PROBLEM AND SECTION 1142 OF THE PENAL CODE OF THE
STATE OF NEW YORK. S. Adolphus Knopf, M.D. Reprinted from the New
York Medical Journal for June 12th, 1915._
There seems to be no difference of opinion in the minds of men and women
who have studied rational eugenics and sociology concerning the
necessity of beginning to work with the preceding generation, and of
teaching parents that quality is better than quantity, and that a large
number of children, underfed or of mental, moral and physical
inferiority, means race suicide, while the reverse means race
preservation.
I cannot defend my attitude better than by telling you the conclusions I
have arrived at in my study of the tuberculosis situation in the United
States. In the families of the poor where there are usually numerous
children, it really matters little whether it is the father or the
mother who is acutely tuberculous. Since almost invariably they live in
close and congested quarters, are underfed and insufficiently clad, it
is of relatively rare occurrence when most of the children do not become
infected with tuberculosis. In some of our tuberculosis clinics where we
insist on an examination of all the children of the tuberculous parents
visiting these special dispensaries, we find as many as fifty per cent.
of the children to be afflicted with tuberculosis as the result of
postnatal infection. In taking the history of a patient in my private
consultation work, it is my invariable custom to ask whether he comes
from a large family, and if so whether he was among the first or latter
born children. As a rule, especially among the poor, it proves to be one
of the latter born, (the fifth, sixth, seventh, eighth, ninth, etc.) who
contracts tuberculosis, and I believe this to be because when he came to
the world there were already many mouths to feed and food was scant, for
the father’s income rarely increases with the increase of the family;
and the mother, worn out with repeated pregnancies, cannot bestow upon
the latter born children the same care which was bestowed upon the
first. We know tuberculosis to be a preventable and curable disease, but
we also know that it is the disease of poverty, privation, malnutrition,
and bad sanitation. P. 4.
I do not know the penalty to be visited upon a physician who offends the
majesty of the law as set forth in section 1142 of the penal code, but I
for one am willing to take the responsibility before the law and before
my God for every time I have counselled, and every time I shall counsel
in the future, the prevention of a tuberculous conception, with a view
to preserving the life of the mother, increasing her chances of
recovery, and, last, but not least, preventing the procreation of a
tuberculous race. P. 5.
_THE SEXUAL LIFE OF WOMAN IN ITS PHYSIOLOGICAL, BIOLOGICAL AND
HYGIENIC ASPECTS. E. Heinrich Kisch, M.D., Professor of the German
Medical Faculty of the University of Prague; Physician to the
Hospital and Spa of Marienbad; Member of the Board of Health, etc.
Translated by M. Eden Paul, M.D. Rebman Co., New York._
As regards the marriage of any woman suffering from tuberculosis we must
take into consideration a fact that medical experience has conclusively
established, namely, that the processes of generation have an
unfavorable influence upon pulmonary tuberculosis. P. 259.
During pregnancy tuberculosis advances with such rapid strides that
pregnancy and lying-in accelerate the fatal event. In some cases of
consumption it is the first pregnancy that is the most perilous, but in
other cases a later pregnancy proves more perilous. P. 260.
_Dr. S. Adolphus Knopf, M.D., Professor of Medicine, Department of
Phthisio-therapy of the New York Post Graduate Medical School
and Hospital; Senior Visiting Physician to Riverside
Hospital-Sanatorium for the Consumptive Poor of the City of New
York, etc._
Reprinted from the _Women’s Medical Journal_, September, 1915.
Of the 150,000 who it is estimated die annually from tuberculosis in the
United States, I venture to say 50,000 have been bread winners.
Estimating the value of such a single life to the community at only
about $5,000, this makes a loss of $250,000,000 each year. Another
third, I venture to say, represents children at school age. They have
died without having been able to give any return to their parents or to
the community. Making the average duration of their young life only 7.5
years, and estimating the cost to parents and the community at only $200
per annum, the community loses another $75,000,000. The value of lives
of little babes, children below and above school age, adolescents not
yet bread winners, and men and women no longer able to earn their living
can not be estimated in exact figures, but is reasonable to suppose the
total annual financial loss from tuberculosis in the United States to be
at least half a billion dollars. This does not include the expenditures
for hospitals, sanatoria, clinics, dispensaries, colonies, preventoria
and other agencies, devoted to the solution of the tuberculosis problem.
In the face of these figures and the suffering, misery and
disappointment of parents who lose their children after having tenderly
loved and cared for them for some years, I wonder if there can be any
doubt in the minds of sane men that it would have been better if these
children had never been born. Surely all this is race suicide instead of
race preservation.
Not so very long ago I was asked by a young colleague to aid in the
diagnosis of tuberculosis in a day laborer. The man earned $12 a week,
was thirty-six years of age on the day the examination and diagnosis was
made, had been married fourteen years, and his eleventh child had been
born on his last birthday; four or five had already died, two of them of
tuberculous meningitis. A glance at the rest of the family showed that
nearly all of them were predisposed to tuberculosis, if not already
infected, and that a few years of continued underfeeding and bad housing
would finish their earthly career. With two or three children to provide
for the family might have lived in relative comfort; with better food
and better home environments the father might never have become
tuberculous and none of the children might have contracted the disease.
The commonwealth would have been the gainer by two or three mentally and
physically vigorous future citizens.
Only a few days ago, while an article for the _Journal of Sociologic
Medicine_ was in preparation, an Italian woman presented herself to me
for examination. She gave her age as fifty-six, and had married quite
young. She had borne her husband seventeen children, of which, however,
only four were living. Some had died in infancy, some at school age, and
some during adolescence. What useless suffering! What useless economic
loss to the individual family and society at large. Upon examination, I
found the woman’s mental condition even worse than her physical status.
The repeated pregnancies, the frequent diseases in the family, thirteen
deaths among her children, had made a mental and physical wreck of her.
Yet the woman belonged to the better and well-to-do class of our
population of Italian birth. What would her condition have been if she
had also had to share in the struggle for the existence of the family,
and had had to work in sweatshops or factories, as so many of the poor
Italians have to do?
When pregnancy means danger to the life of the mother, or exacerbation
of an existant mental or physical ailment, as, for example,
tuberculosis, which is always aggravated by child-bearing, every
conscientious physician should do his utmost to prevent childbirth in
such an invalid.
Where there is tuberculosis or any other serious transmissible disease
in one or both of the parents, or there is danger that it may be
transmitted to the offspring, it should not only be the right but the
sacred duty of the physician to prevent the conception of any physically
and mentally handicapped offspring destined to become a burden to the
community.
KIDNEY DISEASES
_THE PRACTICE OF OBSTETRICS. In Original Contributions by American
Authors. Edited by Reuben Peterson, A.B., M.D., Professor of
Obstetrics and Gynecology in the University of Michigan, Ann
Arbor, Mich. Obstetrician and Gynecologist in Chief to the
University of Michigan Hospital. Lea Bros. & Co., Phil. and New
York. 1907. Chapter XIX._
Pephritis. From statistics we find that even excluding the cases of
eclampsia, the maternal mortality from nephritis during pregnancy is
33%, and the fetal mortality between 50% and 60%. P. 352.
Women suffering from a chronic nephritis should be advised strongly
against marriage, especially in the presence of a cardiac or pulmonary
lesion. Married women should be warned against impregnation. P. 354.
Pyelitis. “On account of the increased dangers of pyelitic and
especially of a pyelonephritic process during pregnancy, women suffering
from these diseases should be warned against marriage. Married women
should be warned against a new impregnation, on account of the marked
tendency of pyelitis to recur with every pregnancy.” P. 355.
_PRACTICAL OBSTETRICS. Thos. Watts Eden. Obstetrician, Physician and
Lecturer on Midwifery and Gynecology, Charing Cross Hospital;
Consulting Physician to Queen Charlotte’s Lying-in-Hospital;
Surgeon to In-Patient Chelsea Hospital for Women. 4th Edition. C.
V. Mosby Co. 1915._
Certain of the conditions enumerated form _absolute_ indications for the
induction to abortion. These are nephritis, (a form of kidney disease),
uncompensated valvular lesions of the heart, advanced tuberculosis,
insanity, irremediable malignant tumors, hydatidiform mole,
uncontrollable uterine haemorrhage, and acute hydramnios. P. 652.
_PRINCIPLES AND PRACTICE OF OBSTETRICS. Jos. B. De Lee, M.D.,
Professor of Obstetrics at the Northwestern University Medical
School; Obstetrician to the Chicago Lying-in-Hospital and
Dispensary, and to Wesley and Mercy Hospitals, etc. W. B. Saunders
Co. 1913._
All forms of nephritis have a very bad influence on the pregnancy,
abortion and premature labor being common. (66% Hofmeier) Seitz found
that only from 20% to 30% of the children survived. One of the causes of
habitual death of the fetus, abortion, and premature labor is chronic
nephritis. P. 497.
“The children of nephritics are usually puny and pale.” P. 497.
Both mother and child are seriously jeopardized by chronic nephritis,
the mortalities being about 30% respectively. P. 497.
Women with chronic nephritis should not marry, and if married, should
not conceive. P. 498.
Diabetes. Sterility is common. Abortion and premature labor occur in 33%
of the pregnancies. The children, if the pregnancy goes to term, often
die shortly after birth, the total mortality being 66%. P. 502.
True diabetes has a very bad diagnosis. Offergold found over 50%
mortality. Of the children 51% were still born, 10% died within a few
days after birth, and 5% more before six months. P. 503.
If a woman comes under treatment with a history of diabetes it is best
to terminate the pregnancy at once. P. 503.
_THE PRACTICE OF OBSTETRICS. Designed for the use of Students and
Practitioners of Medicine. J. Clifton Edgar. Professor of
Obstetrical and Clinical Midwifery in the Cornell University
Medical College; Visiting Obstetrician to Bellevue Hospital, New
York City; Surgeon to the Manhattan Maternity Dispensary;
Consulting Obstetrician to the New York Maternity and Jewish
Hospitals. 5th Edition, Revised. P. Blakiston’s & Co.,
Philadelphia._
Statistics appear to show that labors in these women, (diabetes) are
quite apt to end unfavorably, in one or another way. When diabetic women
become pregnant their disease usually takes a turn for the worse.
According to Lecorche, true diabetes who become pregnant, usually
succumb to the disease within a short time after delivery. P. 305.
ECLAMPSIA
_THE PRINCIPLES AND PRACTICE OF OBSTETRICS. By Joseph B. De Lee, M.D._
Over 20% of women with eclampsia die and statistics show that 10% of
such cases developed in the maternities. For the child the chances are
not good, nearly one half of the children dying as a result, that is,
due to: prematurity, toxemia, asphyxiation by repeated convulsions of
the mother, drugs administered to the mother, and injuries sustained
during birth, especially forced delivery. Eclampsia is more easily
developed in a pregnant woman because the kidneys are carrying an
increased burden, and too often diseased through the pregnancy changes.
The cause of eclampsia are unknown but in 20% of cases the convulsions
begin during pregnancy, in 60% during labor, and in 20% after delivery.
Page 365.
The treatment is to stop the gestation at a point before either mother
or child, or both, are in danger either to life or to health. Page 1041.
_MATERNAL MORTALITY. Grace L. Meigs, M.D., U. S. Department of Labor.
1917._
Puerperal albuminuria and convulsions, called also eclampsia, or toxemia
of pregnancy, is a disease which occurs most frequently during pregnancy
but may occur at or following confinement. It is a relatively frequent
complication among women bearing their first children. When fully
established its chief symptoms are convulsions and unconsciousness. In
the early stages of the disease the symptoms are slight puffiness of the
face, hands, and feet; headache; albumen in the urine; and usually a
rise in blood pressure. Very often proper treatment and diet at the
beginning of such early symptoms may prevent the development of the
disease; but in many cases where the disease is well established before
the physician is consulted, the woman and baby can not be saved by any
treatment. In the prevention of deaths from this cause it is essential,
therefore, that each woman, especially each woman bearing her first
child, should know what she can do, by proper hygiene and diet, to
prevent the disease; that she should know the meaning of these early
symptoms if they arise, so that she may seek at once the advice of her
doctor; and that she should have regular supervision during pregnancy,
with examination of the urine at intervals.
DIABETES
_THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Joseph B. De Lee, M.D.
Page 514._
Without doubt pregnancy has a bad effect on the course of this disease.
It may develop a latent diabetes, there being cases where severe
symptoms appeared only during successive pregnancies, and others where
the disease grew progressively worse each time. Coma occurs in 30% of
the cases and is almost always fatal. It may be brought on by a slight
shock in pregnancy, but more often during and just after labor. Delivery
seems to have a worse effect than most surgical operations, causing
collapse, coma, or sudden death. Bronchitis has been noted in the
puerperium, and this has been found to eventuate in tuberculosis. True
diabetes has a very bad prognosis, authorities finding over 50%
mortality, of which 30% died in coma, within two and one half years, and
too often the child dies in utero.
PELVIC DEFORMITIES
_MATERNAL MORTALITY. Grace L. Meigs, M.D., U. S. Department of Labor,
1917._
Some obstruction to labor in the small size or abnormal shape of the
pelvic canal causes many deaths of mothers included in the class “other
accidents of labor” and also many stillbirths. If such difficulty is
discovered before labor, proper treatment will in almost all cases
insure the life of mother and child; if it is not discovered until labor
has begun, or perhaps until it has continued for many hours, the danger
to both is greatly increased. Every woman, therefore, should have during
pregnancy—and above all during her first pregnancy—an examination in
which measurements are made to enable the physician to judge whether or
not there will be any obstruction to labor. A case in which a
complication of this kind is found requires the greatest skill and
experience in treatment, but with such treatment the life and health of
the mother are almost always safe.
_PRINCIPLES AND PRACTICE OF OBSTETRICS. Jos. B. De Lee, M.D.,
Professor of Obstetrics at the Northwestern University Medical
School; Obstetrician to the Chicago Lying-in-Hospital and
Dispensary, and to Wesley and Mercy Hospitals, etc. W. B. Saunders
Co. 1913._
No subject in medicine presents greater difficulties in all its aspects
than this one, (treatment of contracted pelves) and none demands such
art or practical skill. Science aids little here. P. 709.
Outside factors must also be considered: 1—The environment, whether the
parturient is in a squalid tenement, in the country, in a home where
every appliance is attainable, or in a well equipped maternity.
2—Whether in the hands of a general practitioner or a trained
specialist. 3—If the patient is a Catholic, all medically indicated
procedures not being permitted. 4—The age of the parturient, and the
probability of her having more children. Even with these enumerations,
the possible factors which might influence a labor, or our decision
regarding the course to pursue have not all been mentioned. P. 709.
_THE PRACTICE OF OBSTETRICS. Designed for the use of Practitioners and
Students of Medicine. J. Clifton Edgar, Professor of Obstetrics
and Clinical Midwifery in the Cornell University Medical College.
Visiting Obstetrician to Bellevue Hospital, New York City; Surgeon
to the Manhattan Maternity Dispensary; Consulting obstetrician to
the New York Maternity and Jewish Maternity Hospitals. 5th
Edition, Revised. P. Blakiston’s & Co., Phila._
A knowledge of the female bony pelvis is the very alphabet of
obstetrical science, and the foundation of obstetrical art. This
structure is most important since it is from the disproportion between
its size and that of the fetus, or from its abnormal shape that many of
the difficulties of labor arise.
_PRACTICAL OBSTETRICS. Thos. Watts Eden. Obstetrician; Physician and
Lecturer on Midwifery and Gynecology, Charing Cross Hospital;
Consulting Physician to Queen Charlotte’s Lying-in-Hospital;
Surgeon to In-Patient Chelsea Hospital for Women. 4th Edition. C.
V. Mosby Co. 1915._
The general course of labor is modified by pelvic contractions in
various ways. 1—Abnormal presentations are three or four times commoner
in contracted than in normal pelves. 2—Prolapse of the cord is much
commoner than in normal pelves. 3—When natural delivery occurs labor is
prolonged and the mechanism is modified. 4—Unless the true conjugate is
at least 3¼ inches, even with artificial aid the survival of the child
is seriously jeopardized. 5—The maternal risks are increased by the
greater length and difficulty of the labor and by the frequent necessity
of employing artificial methods of delivery. 6—The fetal risks are
increased in natural delivery by severe compression of the head during
its passage through the narrow pelvis, and other circumstances by the
operations required to effect delivery, some of which involve the
destruction of the fetus. P. 409.
_THE PRACTICE OF OBSTETRICS. In Original Contributions by American
authors. Edited by Reuben Peterson, A.B., M.D. Lea Bros. & Co.,
Phil. and New York. 1907._
Labor complicated by anomalies of the Bony Pelvis. John F. Moran, M.D.
The frequency with which pelvic contraction occurs can only be
determined with relative accuracy. There is in existence a comparatively
large amount of statistical data on this subject, but the reports of
different investigators vary within wide limits, and these variations
are naturally not to be explained entirely on the assumption of racial
conditions, or geographic distribution. Between these wide limits are
arrayed the figures of about 20 modern observers in different parts of
the civilized world who have reported statistics of cases. The combined
figures of 19 observers include a total of over 150,000 cases examined
for pelvic contraction. In these cases the average of contraction is
found to be about 10%. Williams concludes that contracted pelves occur
in from 7% to 8% of the white women of this country. P. 658–659.
HEART DISEASE
_THE SEXUAL LIFE OF WOMAN IN ITS PHYSIOLOGICAL, BIOLOGICAL AND
HYGIENIC ASPECTS. E. Heinrich Kisch, M.D. Professor of the German
Medical faculty of the University of Prague; Physician to the
Hospital and Spa of Marienbad; Member of the Board of Health, etc.
Translated by M. Eden Paul, M.D. Rebman Co., New York._
These are cases (severe heart disease) in which, in my opinion, it is
the physician’s duty to concern himself with the subject of the use of
preventive measures, and having regard for the preservation of a woman’s
life, and uninfluenced by any false delicacy, but with simple
earnestness to inform his patient with respect to the needful
prophylactic measures. The artificial termination of pregnancy, which
unquestionably is often justified in women suffering from heart disease,
but which unfortunately is apt to have very unfavorable results, will
rarely need to be discussed if by the proper employment of preventive
measures care is taken that pregnancy does not recur too frequently. P.
255.
_OBSTETRICS. A Text Book for the use of Students and Practitioners.
Whitridge Williams, Professor of Obstetrics, Johns Hopkins
University; Obstetrician in Chief to the Johns Hopkins Hospital;
Gynecologist to the Union Protestant Infirmary, Baltimore, Md. D.
Appleton & Co., 1912._
Some authorities recommend that women suffering from heart lesions
should be dissuaded from marriage, or if married, from becoming
pregnant. This, however, appears to be an extreme view, though of course
when the lesion is serious and the compensation faulty the dangers of
child-bearing should be carefully explained. P. 498.
_THE PRACTICE OF OBSTETRICS. In Original Contributions by American
authors. Edited by Reuben Peterson, A.B., M.D., Professor of
Obstetrics and Gynecology in the University of Michigan, Ann
Arbor, Mich.; Obstetrician and Gynecologist-in-Chief to the
University of Michigan Hospital. Lea Bros. & Co., Phil. and New
York. 1907. Chapter XIX._
“Leyden claims that about 40% of all women with serious heart lesions
meet their death in connection with childbirth. Still greater than the
demands upon the heart during pregnancy are those made by labor. The
strain, mental excitement, and especially the sudden changes in the
blood pressure, conditions which are well recognized as extremely
harmful to every patient with a chronic heart lesion, and which cannot
be avoided in the course of labor, make the situation extremely
dangerous.” (Hugo Ehrenfest, M.D.) P. 357.
“The prognosis for the fetus is unfavorable. Fellner, whose figures
undoubtedly are low, places the frequency of premature, spontaneous
interruption of pregnancy as 20%, other writers at from 40% to 60%.” P.
358.
“No marriage for the unmarried, no pregnancy for the married, no nursing
for the confined,” is a statement which has been made by a French
author, and has been accepted by many writers. It is incompatible with
the results of recent investigations. It would be too harsh and
unjustifiable to deny marriage to a woman who has a well compensated
valvular lesion. She should be informed of the risks of impregnation,
but should be warned against marriage only where there exist distinct
evidences of incompensation, especially in cases of mitral stenosis. P.
359.
_A TEXT BOOK OF OBSTETRICS. Barton Cooke Hirst, M.D.; Professor of
Obstetrics in the University of Pennsylvania; Gynecologist to the
Howard and Orthopaedic, and the Philadelphia Hospitals, etc. 7th
Edition. W. B. Saunders Co., Philadelphia and London. 1912._
Abortion is induced in about 25% of all cases, as the result of
placental apoplexies, or of the stimulation of the uterus to contraction
by the accumulation of carbondioxid gas in the blood. Pregnancy
distinctly increases the danger of the heart lesion. In 58 serious
cases, 23 died after premature delivery of the child. In milder cases
prognosis is not grave, yet the woman’s condition is by no means free
from danger. If the disease be of long standing and serious in
character, it appears from statistical studies that about half the women
die. P. 423.
_PRINCIPLES AND PRACTICE OF OBSTETRICS. Jos. B. De Lee, M.D.;
Professor of Obstetrics at the Northwestern University Medical
School; Obstetrician to the Chicago Lying-in-Hospital, and to
Wesley and Mercy Hospitals, etc. W. B. Saunders Co. 1913._
Abortion and premature labor, especially the latter, occur in cases of
dis-compensation, in from 20% to 40%, and stillbirth in 29% to 70%,
giving figures collected from various sources by Fellner. P. 489.
_THE PRACTICE OF OBSTETRICS. Designed for the use of Students and
Practitioners of Medicine. J. Clifton Edgar, Professor of
Obstetrics and clinical midwifery in the Cornell University
Medical School; Visiting Obstetrician to Bellevue Hospital, New
York City; Surgeon to the Manhattan Maternity and Dispensary;
Consulting Obstetrician to the New York Maternity and Jewish
Maternity Hospitals. 5th Edition, Revised. P. Blakiston’s & Co.,
Philadelphia._
Acute Endocarditis not only has an injurious influence upon pregnancy,
but it is also apt itself to become extremely grave. Regarding
treatment, induced labor will be demanded. P. 310.
TOO FREQUENT PREGNANCIES
_BEING WELL BORN. An Introduction to Eugenics. Michael F. Guyer,
Ph.D., Professor of Zoology, University of Wisconsin.
Bobbs-Merrill Co. Indianapolis. 1916._
Too short an interval between childbirths would also seem to be an
infringement on the rights of the child as well as of the mother. Thus
Dr. R. J. Ewart, (“The Influence of Parental Age on Offspring,” _Eugenic
Review_, Oct., 1911) finds that children born at intervals of less than
two years after the birth of the previous child still show at the age of
six a notable deficiency in height, weight and intelligence, when
compared with the children born after a longer interval, or even with
first-born children. P. 166.
_FREQUENT PREGNANCIES. The Contributions of Demography to Eugenics.
Dr. Corrado Gini, Professor of Statistics at the Royal University
of Cagliari, Italy._
If the possibility of generation at any season of the year cannot, as
has been shown, have any deleterious effect on the vitality of human
offspring, it can none the less have indirect deleterious consequences,
in so far as it allows pregnancies to succeed each other at too short
intervals. P. 323.
“The deleterious consequences which too short a period after the
preceding birth have upon the vitality of the child are indisputable, at
least during the first year of life.” P. 323.
_THE SEXUAL LIFE OF WOMAN IN ITS PHYSIOLOGICAL, BIOLOGICAL AND
HYGIENIC ASPECTS. E. Heinrich Kisch. Rebman Co., N. Y._
“Frequently recurring pregnancies and childbirth, according to Kronig,
act as the predisposing cause in the production of neurasthenia.” P.
257.
_NEO-MALTHUSIANISM AND RACE HYGIENE, IN “PROBLEMS IN EUGENICS.” Vol.
2. Dr. Alfred Ploetz, President of the International Society for
Race Hygiene. London, 1913._
Malthusianism further affects the quality of the offspring by increasing
the intervals between single births. In families in which the parents
intend to have only a few children, the mother is usually exempt from so
frequent child-bearing, and she has ample time for regaining her
strength. The greater interval between births has evidently a favorable
effect upon the expectation of life of the children that are born.
Westergard has stated that in 21,000 births, if the interval between
birth is:—
The percentage of deaths before
five years of age is
Less than one year 20%
One to two years 14%
More than two years 12%
That means a difference in the mortality between first and last class of
40% in favor of the longer interval. P. 186.
_THE LIFE INSURANCE EXAMINER. A Practical Treatise by Charles F.
Stillman, M.S., M.D., Medical Examiner for the Mutual Life
Insurance Co.; Clinical Professor of Orthopaedic Surgery in the
Women’s Medical College of the N. Y. Infirmary; Orthopaedic
Surgeon to the N. Y. Infant Asylum; Member of the Am. Orthopaedic
Association; Permanent member of the American Medical Association;
Fellow N. Y. Academy of Medicine, etc. 3rd Edition. Spectator Co.,
N. Y., 1890._
“Postpone (as dangerous insurance risks) all cases of pregnancy; all
instances where the mother seems, in the judgment of the Examiner, to
have been bearing children too fast.” P. 186.
_RASSENVERBESSERUNG. Translated from the Dutch of Dr. J. Rutgers. 2nd
Edition. Dresden, 1911._
The combatting of self-induced abortion is one of the problems of Sexual
Hygiene. The two causes of most weight in this situation are syphilis
and too frequent pregnancy. It is quite evident that both of these
causes would be favorably influenced by the use of contraceptive
measures. P. 81.
_THE MALTHUSIAN, May 15, 1914. Sexual Ethics. A Study of Borderland
Questions. Robert Michels, (Review)._
Prof. Michels perceives that race control has two aspects; it may be an
urgent duty, and it is in any case an inalienable human right. It may be
regarded as a duty to actual or potential children, in view of either
bad economic conditions,—such as affect the bulk of all European
populations,—or defective heredity, and it may also be considered as an
obligation of humanity towards the wife and mother. Prof. Michels here
speaks with no uncertain voice: “The type of woman continually engaged
in child-bearing is a primitive one, out of harmony with the needs and
ideas of modern civilized life. Even as few as six pregnancies that go
to full term rob a woman of about ten years of her life, and these the
best. It is evidently far easier to provide a clear-sighted affection
and a wisely conceived and individualized upbringing for two or three
children than it is for eight or nine.”
_MR. SIDNEY WEBB, in The Times of October 16, 1906._
Assuming, as I think we may, that no injury to physical health is
necessarily involved (in the volitional regulation of the marriage
state); aware, on the contrary, that the result is to spare the wife
from an onerous and even dangerous illness for which in the vast
majority of homes no adequate provision in the way of medical
attendance, nursing, privacy, rest, and freedom from worry can possibly
be made, it is, to say the least of it, difficult on any rationalist
morality to formulate any blame of a married couple for the deliberate
regulation of their family according to their means and opportunities.
PERNICIOUS VOMITING
_THE PRINCIPLES AND PRACTICE OF OBSTETRICS. By Joseph B. De Lee, M.D._
Among diseases incidental to pregnancy must be counted pernicious
vomiting. Page 370.
Statistics are uncertain, but out of 118 cases there were 46 deaths.
Page 357.
The keynote of treatment is to stop the gestation at a point before
either mother or child, or both, are in danger to life or to health.
Page 1041.
_THE PRACTICE OF OBSTETRICS. By J. Clifton Edgar, M.D., Professor of
Obstetrics and Clinical Midwifery in the Cornell University
Medical College; Visiting Obstetrician to Bellevue Hospital, New
York City; Surgeon to the Manhattan Maternity and Dispensary;
Consulting Obstetrician of the New York Maternity and Jewish
Maternity Hospitals, New York City._
Under certain circumstances labor may be much disturbed by pernicious
vomiting. The causes comprise actual organic disease of the stomach and
functional disturbances from errors in diet. The determining cause of a
paroxysm of vomiting is a severe labor pain. The coincidence of labor
and vomiting is not unusual in anemic primiparae. Mental emotion is also
a cause. As this vomiting may presage the development of eclampsia or
some other affection it is best to terminate labor at once. Page 648.