identical with those in anæmia and hydræmia, and produce similar
effects. Evidences of fatty degeneration are found in the musculature
of the heart, intima of the arteries, and portions of the capillary
walls; retinal hemorrhages are constant lesions. The number of white
corpuscles is not increased, and signs of leukæmia--splenic tumor,
swelling of the lymphatic glands--are wanting. The condition is that of
oligæmia or oligocythosis.
The prodromal symptoms occur during the first half of pregnancy, are
obscure, and cannot be distinguished from the effects of chlorosis and
hydræmia. After the disease has passed through its incipient stages,
food, iron, and tonics seem to have no influence upon its course.
During the second half of pregnancy abortion or premature labor usually
occurs spontaneously. Under these conditions the shock and hemorrhage
resulting from parturition are sufficient to cause a lethal issue in
many cases.
PROGNOSIS.--Graefe[3] has collected 25 cases of this rare affection: 1
case recovered, 2 cases were discharged improved; the others died
before or shortly after labor. The prognosis is obviously grave.
[Footnote 3: _Diss._, Halle, 1880.]
TREATMENT.--As food, iron, and tonics have little or no effect upon the
disease after it has passed through its incipient stages, therapeutic
resources are limited. The evacuation of the uterine cavity, as shown
by {407} Graefe's cases, exercises a favorable influence upon the
course of the affection. Gusserow advises the artificial interruption
of pregnancy whenever grave symptoms occur, and the weight of
professional opinion is very decidedly in favor of such a course.
Negative results have attended all efforts at transfusion.
HÆMOPHILIA.
Kehrer[4] has recently called attention to the apparent influence of
pregnancy in the development of the hemorrhagic diathesis. This
influence, however, is seldom observed, and then only in cases of
distinct, individual predisposition.
[Footnote 4: _Arch. f. Gyn._, x. p. 201.]
TREATMENT.--The induction of premature labor, or, at times, of
abortion, is indicated.
PLETHORA.
The experiments and observations of Spiegelberg[5] and Gscheidlen prove
the possibility of the occurrence of plethora during gestation. Actual
increase of the red corpuscles, albumen, and iron in the blood is
observed during the second half of pregnancy, and then only under the
most favorable conditions. As described by Spiegelberg, the symptoms
are--mammary and cerebral congestions, palpitation, vertigo,
constipation, hepatic torpor.
[Footnote 5: _Lehrbuch d. Geburtshülfe_, Lahr, 1882, p. 58.]
TREATMENT.--Restricted diet, muscular exercise, and an occasional
saline purge will relieve the troublesome symptoms. Spiegelberg is
convinced of the value of bleeding in selected cases.
Circulatory Disturbances.
Among the circulatory disturbances due to pregnancy, mechanical oedema
and the varices of the pelvis and lower extremities deserve attention.
De Cristoforis of Milan describes a mechanical inferior venous
hyperæmia, the result of the pressure of the gravid uterus on the iliac
veins. The mechanical oedema of the abdominal walls, vulva, and lower
extremities, intensified by chlorosis and hydræmia, is usually
associated with venous ectasis. The oedema may become so excessive that
locomotion is rendered difficult, while the labia are enormously
distended and the subcutaneous tissue of the abdominal walls becomes
pendulous. Toward the end of pregnancy, when the uterus sinks into the
pelvic cavity, the oedema and varices frequently abate.
Active measures for the relief of the symptoms produced by oedema are
frequently indicated. Threatened gangrene of the skin from
hyper-distension may render puncture of the hydropsical regions
necessary. It is quite possible to interrupt pregnancy by this little
operation, especially if the labia are punctured. Elevation of the
lower extremities, rest in the horizontal position, elastic bandages
and stockings, local hot packs, mild diuretics, usually fulfil all
indications for treatment.
Varices are observed more frequently among multiparæ, but may occur in
primiparæ. They are usually developed during the second half {408} of
pregnancy. The principal trunk of the saphena is first involved, and
subsequently the lateral branches. Congeries of veins are observed on
the inner sides of the legs and thighs, especially in the vicinity of
the knees. The iliac veins may become dilated, as shown by the
condition of the vulvar veins and the occurrence of hemorrhoids.
Varices incommode the patient, but seldom cause serious disturbances.
Sometimes, however, their tunics are lacerated, and serious even fatal
hemorrhage may result. Spiegelberg[6] records four cases of fatal
hemorrhage from the rupture of varices in pregnancy. Then there is
always the danger of phlebitis and the processes of thrombosis and
embolism, even when the loss of blood is insignificant.
[Footnote 6: _Lehrbuch d. Geburtshülfe_, Lahr, 1882, p. 235.]
TREATMENT.--The regular and gentle evacuation of the bowels will
frequently relieve the distressing symptoms due to hemorrhoids. Fordyce
Barker points out the fact that aloes is not contraindicated by
pregnancy. A pill containing a grain or a grain and a half of powdered
aloes, with a quarter of a grain of extract of nux vomica, is a very
good remedy. Frequent hot fomentations in conjunction with narcotic
ointments will relieve the pain from the congestion of the piles.
Attempts at reduction must be instituted with extreme care. It is
usually impossible to completely cure the condition during pregnancy,
and there is danger of interrupting gestation. Elevation of the lower
extremities and equable compression by an elastic bandage or rubber
stocking relieve the symptoms caused by varices of the saphena. P.
Ruge[7] and A. Martin have seen favorable results from the hypodermatic
injection of ergotin.
[Footnote 7: _Berl. Beitr. z. Geb. u. Gyn._, Bd. iii. p. 7.]
Disorders of the Alimentary Canal.
THE UNCONTROLLABLE VOMITING OF PREGNANCY.
Nausea, even vomiting, in the morning, before or shortly after meals,
during the early months of gestation, is so common and devoid of
injurious effect that it is regarded as physiological. Robert Barnes
views it as a normal means of discharging superfluous nervous energy.
The uncontrollable vomiting of pregnancy, in which the stomach retains
absolutely nothing, is a grave disorder. The patient vomits glairy
mucus, clear or colored by the bile. Ultimately the vomit is mixed with
blood. Violent retching, intense nausea, pyrosis, and hiccough are
constant and distressing symptoms. The woman becomes emaciated. The
buccal cavity is dry, the tongue red and shining, the teeth and gums
covered with sordes, the breath horribly fetid, the skin dry and harsh.
Salivation is frequently observed. Constipation and extreme thirst
usually coexist. The epigastrium is tender upon pressure. The woman
becomes restless and irritable from loss of sleep and painful efforts
at vomiting. A fever of typhoid type is developed, with a quick, rapid,
thready pulse. The urine is sparingly secreted, concentrated, and
contains albumen and tube-casts. Jaundice is frequently noticed.
Extreme marasmus supervenes, and the woman succumbs to some
intercurrent disease or dies of exhaustion in muttering delirium.
Phthisis and diarrhoea are intercurrent affections which may hasten the
lethal issue.
{409} Between the slight nausea upon rising in the morning and the
state of extreme marasmus thus briefly sketched every degree of
pathological variation may be observed.
It is a remarkable fact that the incessant vomiting, retching, and
hiccough seldom interrupt pregnancy until near its end. The muscular
effort and loss of blood at this time may precipitate the fatal
termination.
Occasionally, spontaneous abortion or premature labor occurs before the
patient's condition is desperate. Under these circumstances the severe
symptoms may disappear immediately. The same sudden cessation of the
vomiting is frequently observed after quickening, rapid excentric
hypertrophy of the uterus, and death of the foetus.
The COURSE of the disorder is chronic. Cases terminate by recovery or
death in from two to three months. Alarming symptoms are usually
developed from the second to the sixth month--very seldom during the
seventh and eighth months.
Fortunately, the uncontrollable vomiting of pregnancy is a rare
affection. So few cases are recorded in German medical literature that
Hohl[8] has denied the existence of the condition. Carl Braun[9] in a
fabulous experience of over one hundred and fifty thousand obstetrical
cases has never seen a fatal case.
[Footnote 8: _Grundriss d. Geburtshülfe_, Kleinwächter, 1881, p. 197.]
[Footnote 9: _Lehrb. d. Gynaekologie_, Wien, 1881, p. 842.]
PATHOLOGY AND ETIOLOGY.--As the essential predisposing cause of this
disorder it is necessary to bear in mind the increased functional
activity of the nervous system in general, and of the spinal cord in
particular, during pregnancy. Increased reflex mobility is apparent in
all the so-called sympathetic affections.
Peripheral irritants are not wanting. The growing ovum stretches the
uterine fibres, and consequently irritates the uterine nerves.
Bretonneau adduces many facts in favor of this theory. Vomiting is
severer in first pregnancies, and occurs during the first half of
pregnancy. Vomiting is observed in connection with passive distension
of the uterus caused by the unusually rapid growth of the ovum, as in
hydramnion and multiple pregnancy. Immediate cessation of all symptoms
is frequently noted after quickening, rapid excentric hypertrophy of
the uterus, death of the foetus, evacuation of the uterine contents.
Henry Bennet directs attention to the importance of congestions,
inflammations, and lacerations of the cervix uteri as etiological
factors. Graily Hewitt maintains that uterine displacements, with or
without incarceration, producing irritation of the uterine nerves, are
potent causes. The round gastric ulcer, chronic catarrhal gastritis,
are sufficient causes in many cases.
Diseases of the endometrium, decidua, foetal envelopes, or of the
foetus itself may supply adequate excentric irritants.
Frerichs has pointed out the connection of hyperemesis with the renal
insufficiency of Bright's disease. Kiwisch finds a sufficient cause in
the relation between the hyperæsthetic gastric nerves and the hydræmic
condition of the blood of the pregnant woman. Lebert and Rosenthal are
of the opinion that hyperemesis is symptomatic of extreme general
inanition of nervous tissue. Numerous other theories more or less
ingenious, and adequately explanatory of certain cases, exist in the
literature of the subject. Notwithstanding the extent and accuracy of
etiological research {410} into the uncontrollable vomiting of
pregnancy, a large class of cases remains in which no organic change
capable of objective demonstration can be found.
DIAGNOSIS.--The diagnosis of the uncontrollable vomiting of pregnancy
is not so easy as at first apparent. Guéniot[10] pertinently calls
attention to three distinct elements: (1) The diagnosis of pregnancy;
(2) the diagnosis of the adjuvant or determining cause of hyperemesis;
(3) the differential diagnosis between the uncontrollable vomiting of
pregnancy and obstinate vomiting from some other cause entirely
independent of the pregnant condition.
[Footnote 10: _Thèse Agrégation_, Paris, 1863.]
Experienced clinicians have committed mistakes, particularly in the
third element. Trousseau once made the diagnosis of uncontrollable
vomiting of pregnancy in a case in which the autopsy revealed cancer of
the stomach. This case was observed by Depaul. Charpentier[11] reports
a serious error in diagnosis made by Beau. The case was diagnosticated
as hyperemesis of pregnancy. The autopsy showed that the obstinate
vomiting was probably due to tuberculous meningitis.
[Footnote 11: _Traité pratique des Accouchements_, Paris, 1883, t. i.
p. 621.]
PROGNOSIS.--Severe vomiting in pregnancy is always ground for anxiety,
and the prognosis must always be guarded. The majority of cases
terminate in recovery without the interruption of pregnancy. Guéniot
records 118 cases: of these, 46 died; of the 72 survivals, 42 recovered
after the spontaneous or artificial evacuation of the uterine contents.
Recovery usually, though not always, rapidly follows the cessation of
pregnancy. The prognosis is absolutely unfavorable after the appearance
of fever and typhoid symptoms.
TREATMENT.--The treatment of hyperemesis may be effective. Its
efficiency, however, depends largely upon the accurate recognition of
the adjuvant and determining causes. A rational therapeusis must
consist in the elimination of these etiological factors. The treatment
naturally resolves itself into (1) hygienic; (2) medical; (3)
gynæcological; (4) obstetrical.
Hygienic.--The hygienic treatment is of avail in the minor degrees of
the disorder, although not without influence in the more serious cases.
Diet is of primary importance. Let the patient breakfast upon a small
cup of strong coffee or tea, half a cup of milk and lime-water, a
morsel of cracker or toast early in the morning, in bed, and lie
quietly for one or two hours following the meal. Small quantities of
easily-digestible food at short intervals will be tolerated when the
patient has given up all pretence at keeping to regular meals. Liquid
foods, as sparkling koumiss, egg-albumen in water, iced milk with
lime- or soda-water, commend themselves. Absolute dietetic rules,
however, cannot be maintained. The stomach of the pregnant woman is
proverbially capricious and fanciful. Charpentier narrates the history
of a case suggestive in connection with this subject. The patient, four
months advanced in pregnancy, in a critical condition from
uncontrollable vomiting, came under the care of Beau in the Hôpital de
la Charité. One day she asked for Bordeaux crawfishes. Beau granted her
request. On the first day two crawfishes were retained; on the second,
six; on the third, crawfishes ad libitum, bouillon, and milk. Within
six days {411} the vomiting disappeared. Cazeaux and Guéniot cite cases
in which ham and paté de foie gras were retained after the rejection of
easily-digestible foods. It is necessary to respect these caprices and
fancies.
When everything is rejected absolute stomach-rest is indicated. Then
nutrient enemata may be tried. Of the great value of rectal
alimentation under these conditions there can be no doubt. Henry F.
Campbell of Georgia relates the history of a case in which he nourished
the patient for fifty-two days by the rectum alone. There is danger,
however, of irritating the rectum and causing diarrhoea--a peculiarly
unfavorable complication at this time; and this fact must be clearly
borne in mind. Of the various nutrient enemata, peptonized milk, cream,
defibrinated blood, Leube's beef-and-pancreas mixture, eggs, and
beef-tea containing albumens are among the best. From four to six
ounces should be exhibited not more frequently than once every six
hours.
Inunctions of oil are of undoubted value. Absolute moral and physical
rest frequently exercises a favorable influence. Seyfert advised his
patients to go home on a visit to their mothers, and return to the
conditions to which they were accustomed prior to marriage. Coitus may
be a disturbing factor. Rest in the horizontal decubitus exercises as
favorable an influence as in sea-sickness.
Medical.--There are few drugs in the Pharmacopoeia which have not been
vaunted as specifics by some and found utterly worthless by others.
This fact indicates, as remarked by Schroeder, that all remedies are
unreliable, and that spontaneous cures frequently occur. Various
effervescent liquids, as dry champagne, carbonic-acid water containing
one drachm of potassium bromide to the siphon, are sometimes grateful.
Subnitrate of bismuth and the antacids are of great value in cases of
excessive gastric acidity. Oxalate of cerium, a much-vaunted remedy, is
of very little value. Small doses of the tincture of nux vomica are
useful in cases of gastric catarrh. The various local anæsthetics are
of great importance. Small doses of creasote, carbolic acid, tincture
of aconite-root, hydrocyanic acid, and the volatile oils have been used
with varying degrees of success. Of this class of remedies cocaine
hydrochlorate deserves especial attention. On a priori grounds there is
much in its favor. Clinical experience with the drug is not such as to
warrant very positive deductions. W. Otto[12] has employed cocaine in
sea-sickness, especially in pregnant women, with favorable results.
Manassein[13] reports several cases of hyperemesis of pregnancy cured
by its exhibition. The subject is certainly worthy of thorough
investigation. G. Gaertner of Vienna states that 0.1 cocainum
muriaticum has no toxic effect upon adults. Doses of 0.015-0.02 of the
solution (cocain. muriat. sol. Merck, 1.0; aq. destill. 9.0) may be
given to an adult three times daily without fear of toxæmia. Goodell
recommends drop doses of wine of ipecacuanha and tincture of
belladonna, repeated every fifteen minutes.
[Footnote 12: _Berl. klin. Woch._, 1885, No. 43.]
[Footnote 13: _Ibid._, 1885, No. 35.]
Of all medical agents, however, opium, the bromides, and chloral are
the most reliable. A clyster containing thirty or forty drops of the
deodorized tincture, or a half-grain suppository of the aqueous extract
of opium, sometimes produces a happy effect. Hypodermatic injections of
morphine will frequently allay the distressing symptoms after the
failure of other measures. In the German hospitals large doses of the
bromides {412} and chloral are exhibited per rectum with gratifying
success in many cases.
Flying blisters, the ether spray, and the faradic current applied to
the pit of the stomach may give relief in the milder forms of the
disorder.
Gynæcological.--Under the gynæcological treatment of hyperemesis quite
a number of important operative procedures are included: 1. If bimanual
examination reveals a displacement of the uterus capable of producing
symptoms, the organ must be replaced if possible, and retained in
position by a properly fitting pessary. 2. Henry Bennet suggested the
cauterization of the cervix in all cases, basing his therapy upon his
peculiar views of the pathology of the condition. Welponer, Sims, and
Jones recommend the application of a 10 per cent. solution of argentic
nitrate to the vaginal portion of the cervix in all cases, irrespective
of the condition of the cervical tissues, when other means have proved
useless. Carl Braun[14] bears testimony as to the value of this
procedure. 3. As an ultimate resource before artificially interrupting
gestation, the plan of dilating the os externum and cervix uteri with
the index finger should be tried. Copeman[15] of Norwich, England,
desirous of inducing abortion in the case of a patient afflicted with
hyperemesis, pushed his finger through the cervical canal to the
membranes and attempted to puncture the amnion with a sound. Failing to
accomplish his purpose, he went home for assistance, and returned at
the expiration of two hours. To his surprise, the uncontrollable
vomiting had ceased. Since 1875, when he published the results of this
experience, cases have accumulated proving the great value of this
method. W. Gill Wylie[16] of New York has devised a steel dilator to
substitute the finger. When the os externum is at all patulous, the
index finger is the safest and most efficient dilator. The method is a
purely empirical one, does not always secure the desired result, and
frequently causes abortion or premature labor. Still, as the ultimate
gynæcological resort it has important functions.
[Footnote 14: _Lehrb. d. g. Gynaekoloqie_, 1881, p. 841.]
[Footnote 15: _Brit. Med. Journal_, 1875, 1879.]
[Footnote 16: _N. Y. Med. Record_, Dec. 6, 1884.]
Obstetrical.--The evacuation of the uterine contents, if effected
before the development of the febrile stage, is usually followed by
immediate disappearance of all distressing symptoms. In the large
majority of cases, however, the same end may be secured by a judicious
combination of the hygienic, medical, and gynæcological methods of
treatment to which attention has been directed. The weight of
professional opinion is decidedly opposed to the procedure. For
practical purposes the induction of premature labor may be excluded
from consideration. The woman usually recovers or dies before the
period of foetal viability. Carl Braun[17] gives expression to the very
general professional conviction upon this subject in the following
words: "I myself have never observed a lethal issue in consequence of
the uncontrollable vomiting of pregnancy, lay the greatest weight upon
the expectant management and more modern medicamentation, and am of the
opinion that after a conscientious estimate of all considerations and
contraindications, artificial abortion can be omitted, notwithstanding
its permissibility from a scientific point of view when extreme danger
to maternal life has been determined by several physicians."
[Footnote 17: _Lehr. d. g. Gynaekologie_, 1881, p. 842.]
{413} PTYALISM.
The excessive secretion of saliva is a rare disorder of pregnancy. At
all times distressing, it may seriously endanger the patient's life
when the quantity of fluid amounts to several quarts per diem. The
parotid and submaxillary glands are swollen and tender. The buccal
mucous membrane is red and tumid. The absence of fetor serves to
distinguish the salivation of pregnancy from the ptyalism of mercurial
poisoning. A generous diet and the free exhibition of iron mitigate in
some degree the distressing symptoms. Dewees recommends a strictly
animal diet. Astringent mouth-washes, small doses of potassium iodide,
and subcutaneous injections of atropine over the submaxillary glands
are indicated, but seldom influence the condition.
TOOTHACHE.
Toothache in pregnancy may be a purely functional disorder. In the
majority of cases, however, actual caries is present. During gestation
the secretions of the buccal cavity are sometimes altered, and become
sufficiently acid to dissolve the lime salts out of the enamel. Again,
when for any reason an insufficient quantity of lime salts is ingested
with the food, the foetus is supplied with ossific materials derived in
part from the maternal teeth. The condition of pregnancy is not
infrequently detected in the dentist's chair from these changes.
Popular recognition of these dental changes gave origin to the familiar
saw, "For every child a tooth." The indications for treatment are
obvious. Quinine and local anæsthetics relieve the symptoms of the
functional forms of the disorder. Caries may be prevented, to a certain
degree, by extreme attention to the teeth and secretions of the buccal
cavity and a free, generous mixed diet. Doubtless, the popular belief,
that an absolute fruit diet will limit the deposition of ossific
material in the foetal skeleton and render labor easier, is responsible
for much of the caries observed in American women. It is needless to
say that such a belief is utterly without foundation in fact. When
structural changes in the teeth have occurred the decalcified dentine
should be excavated, and temporary fillings of oxyphosphates or
gutta-percha inserted. This little operation can be performed rapidly,
without pain or fatigue, and preserves the contour of the teeth.
CONSTIPATION.