gestation. The etiological factors are mechanical interference of the
gravid uterus with intestinal peristalsis, defective innervation of the
bowels, and alterations in the intestinal secretions. When the rectum
becomes filled with scybalous masses the condition predisposes to
abortion or premature labor. Diet is of primary importance in securing
regular evacuations of the bowels. Fresh fruits, brown bread, oatmeal
porridge are useful to this end. Enemata have obvious advantages over
all drugs. In the selection of aperient remedies care must be taken to
choose laxatives and avoid drastic cathartics. The compound licorice
powder and confection of senna of the U. S. Pharmacopoeia, Hunyadi,
Friederichshalle, and Pullna mineral waters, may be included in the
list.
{414} DIARRHOEA.
Diarrhoea is a less frequent but more dangerous disorder during
pregnancy than constipation. In the early and latter months of
gestation diarrhoea is liable to occur from mechanical compression of
the rectum by the gravid uterus. Dysentery, with tormina and tenesmus,
is a particularly unfavorable complication. The dangers are apparent.
Not only is the blood impoverished, but abortion or premature labor may
be induced. Every diarrhoea occurring during pregnancy demands
immediate attention. Small doses of argentic nitrate in combination
with opium, in pill form, are useful in mild cases of diarrhoea, while
the deodorized tincture of opium in starch-water enemata is indicated
in dysentery.
Diseases of the Liver.
In normal pregnancy the functions of the liver in the secretion of bile
and the excretion of cholesterin are not materially modified. The case
is different with the glycogenic function. Blot in 1856 detected the
presence of glycogen in the urine of nearly half the pregnant women
examined. He concluded that this glycosuria was physiological. Tarnier
in 1857 called attention to certain structural changes in the liver
occurring during normal gestation. The liver is enlarged in volume, and
a peculiar fatty infiltration within the lobule is perceptible. De
Sinéty confirmed Tarnier's observations, finding the fatty infiltration
within the centre of the lobule, seldom near the periphery. Robert
Barnes and Ewart have added corroboratory testimony. Tarnier ascribes
the physiological glycosuria announced by Blot to the fatty
infiltration observed by himself. Each of these three functions of the
liver, the secretion of bile, the excretion of cholesterin, and the
glycogenic function, may undergo pathological exaggeration during
pregnancy.
ICTERUS.
Icterus is observed with relative infrequency during gestation. Two
distinct forms are recognized--simple jaundice, with bright-yellow
coloration of conjunctivæ and skin, without fever and cerebral
symptoms; and malignant jaundice, with dull-yellow coloration of
conjunctivæ and skin, with fever and cerebral symptoms.
Simple Jaundice.--Simple icterus may occur at any time during
pregnancy, runs its usual course, and exercises, as a rule, no serious
influence upon the maternal health. The effect upon the foetus is
grave. If the icterus is intense and lasts for a considerable period of
time, the foetus dies and gestation is interrupted. All the foetal
tissues are found to be stained with the biliary coloring matters--a
condition termed by Lobstein cirrhonosis.
ETIOLOGY.--The causes of simple jaundice in pregnancy are identical
with those which produce the condition in the non-gravid state, and are
frequently obscure. It is in a high degree probable that pressure from
the gravid uterus is without influence, since the symptom may appear at
any time during gestation. The pathological condition usually present
is catarrh of the mucous membrane of the duct or of the duodenum in the
vicinity of the orifice, causing a narrowing of its lumen.
{415} SYMPTOMS.--The conjunctivæ, skin, and urine are colored bright
yellow, and there is entire absence of febrile and cerebral symptoms.
The PROGNOSIS and TREATMENT, so far as the mother is concerned, are the
same as in the non-pregnant state. In view of the possible causative
relation between simple and malignant icterus, and the injurious effect
upon the foetus, medical treatment should be instituted at once.
Restricted diet, mercurials or ipecacuanha, followed by saline
cathartics, are the more important measures. Artificial abortion or the
induction of premature labor has no effect upon the condition. This
operative procedure is indicated in the interest of the child, however,
when the icterus is intensive, of long duration, the foetus living and
viable, the frequency of the foetal heart-beats diminished, and there
is reason to fear its death. Carl Braun recognizes very distinctly the
force of this indication.
Malignant Icterus.--Malignant icterus, due to the acute yellow atrophy
of the liver of the pregnant woman (Rokitansky), is a very rare
disease. Carl Braun has observed the condition only once in
twenty-eight thousand cases from 1857 to 1863.
ETIOLOGY AND PATHOLOGY.--Very little is known as to the causes of acute
yellow atrophy of the liver. Virchow ascribes one case coming under his
own observation to compression of the lower half of the liver and
gall-bladder by the growing uterus. The rarity of the affection and its
occurrence irrespective of the time of pregnancy prove the limited
operation of this etiological factor. It is in a high degree probable
that the disease may have its starting-point in simple catarrhal
icterus.
The liver is ochre-colored, shrunken to one half its volume, and
flaccid. On section no signs of lobular structure are visible.
Microscopical examination reveals total destruction of the acini and
hepatic cells. In the place of the glandular elements, fat-globules,
fine granular detritus, crystals of leucin and tyrosin are noted. The
spleen is enlarged and the kidneys show acute inflammatory changes.
Extensive ecchymoses are observed under the skin, pericardium, and
gastric mucous membrane.
SYMPTOMS.--The prodromal symptoms of acute yellow atrophy of the liver
are usually overlooked. A trivial jaundice with slight elevation of
temperature may precede by several days the development of cerebral
symptoms. Difficulty in speech, headache, disorders of the senses
followed by delirium, convulsions (cholæmic eclampsia), and coma are
the more important symptoms of cerebral origin. The pulse is remarkably
frequent and small. The temperature is at first elevated several
degrees, but becomes subnormal prior to death. The urine is sparingly
secreted, highly colored by the bile-pigments, and contains albumen,
tube-casts, leucin, tyrosin, and cholesterin. Urea, uric acid, and the
urates are diminished. The combination of symptoms points to the
retention within the system of the waste products usually excreted by
the liver and kidneys. Ultimately, a condition of complete hepatic and
renal insufficiency obtains.
DIAGNOSIS.--The dull yellow color of the skin and conjunctivæ, with
fever and cerebral symptoms, is a sign of greatest diagnostic value.
Physical exploration reveals tenderness on pressure over the hepatic
region, and rapidly diminishing area of hepatic dulness on percussion.
Care must be taken to exclude acute phosphorus-poisoning--a toxæmia
{416} simulating very closely acute yellow atrophy, and repeatedly
confounded with that affection.
PROGNOSIS.--No case of recovery has been recorded up to the present
time. The disease pursues a rapidly fatal course, terminating within a
few days after the development of the icterus.
TREATMENT.--Therapeutic measures must be addressed to prophylaxis. It
is necessary to regard simple icterus as a possible prodrome of the
malignant form of the disorder.
DIABETES MELLITUS.
The most superficial discussion of the disorders of pregnancy would not
be complete without some mention of diabetes. The existence of
physiological glycosuria during pregnancy and lactation has been
demonstrated. Bernard has shown that sugar appears in the placenta of
calves at an early period, attains its maximum in the third or fourth
month, and when the glycogenic function of the foetal liver is
established entirely disappears. The relation between physiological
glycosuria and that pathological exaggeration of a normal process,
diabetes mellitus, is very obscure. It is, however, a clinical fact
that diabetes mellitus occurs more frequently in the pregnant than in
the non-gravid woman. Diabetic women are less apt to conceive. When
conception does occur, pregnancy is liable to interruption from the
death of the foetus. Under these circumstances glucose is found in the
amniotic liquor and foetal urine. A case related by Bennewitz and cited
by Matthews Duncan indicates that diabetes mellitus may be developed
during successive pregnancies, and entirely disappear during the
intervals. The influence of pregnancy in developing a latent diabetic
tendency may be accepted as established. A clinical observation of some
importance is that diabetic coma is seldom developed.
PROGNOSIS.--Matthews Duncan[18] has collected the histories of 22
pregnancies in fifteen women varying in age from twenty-one to
thirty-eight years: 4 of the 22 pregnancies terminated fatally by
collapse, rather than by coma. The majority of the children died during
pregnancy after attaining to the age of viability. Two children were
feeble at birth, and died a few hours later. One infant was diabetic.
[Footnote 18: _Obstet. Trans._, vol. xxiv. p. 256.]
TREATMENT.--The hygienic and medical treatment of diabetes mellitus
occurring during pregnancy does not differ from the therapy in the
non-gravid state. There is great diversity of opinion upon the subject
of the induction of premature labor. On a priori grounds it would seem
to be indicated in the interest both of the mother and the child in the
graver cases. In the entire absence of authoritative clinical
experience, however, the operation must be resorted to with an extreme
degree of caution.
Diseases of the Kidneys.
Albumen is found in the urine of from 3 to 5 per cent. of all pregnant
women.[19] In parturient women albuminuria is of much more frequent
occurrence. Leube's researches indicate the existence of physiological
{417} albuminuria in the pregnant as in the non-gravid state. It is a
matter of great practical difficulty to determine the limits of this
normal functional activity. In a large proportion of cases the
boundary-line between health and disease is passed. The physiological
function undergoes pathological exaggeration, and various forms of
nephritis are produced.
[Footnote 19: Schroeder, _Lehrb. d. Geburtshülfe_, Bonn, 1884, p. 373.]
ETIOLOGY AND PATHOLOGY.--The types of renal disease to which pregnancy
stands in more or less direct causal relation are numerous.
1. Leyden describes a condition, the kidney of pregnancy, which may be
regarded as the intermediate stage between health and disease. The
amount of albumen is increased; hyaline and granular casts, with renal
epithelium, showing fatty changes, appear in the urine. This fatty
degeneration of the cells covering the glomeruli and lining the
uriniferous tubules is not of an inflammatory nature. Anasarca of the
lower extremities is usually present. The condition may last for an
indefinite period of time without causing serious symptoms. With the
expiration of the term of pregnancy it may disappear, leaving no trace
of its former existence. On the other hand, the kidney of pregnancy may
be the starting-point of some serious renal lesion.
2. Latent chronic interstitial nephritis, chronic tubal nephritis, and
lardaceous degeneration of the kidney are usually influenced
unfavorably by pregnancy, and, in turn, may lead to the interruption of
that state. Chronic interstitial nephritis and chronic tubal nephritis
may have their origin in the kidney of pregnancy. The cirrhotic kidney
is distinguished from the other forms by the abundant aqueous urine,
containing comparatively little albumen--none at all at times--cardiac
hypertrophy, and hard pulse. In the differential diagnosis of chronic
tubal nephritis and the kidney of pregnancy chief reliance must be
placed upon the history of the case and the course of the affection.
Albuminuria is a very inconstant symptom of the lardaceous kidney,
especially in the beginning and ultimate stages of the disease.
3. Mixed types of chronic Bright's disease are frequently observed.
Thus, the interstitial and tubal forms of the disease may be combined.
Lardaceous degeneration may be present with either form, and fatty
changes are common in all the types of Bright's disease. Eclampsia is
of relatively infrequent occurrence in chronic Bright's disease,
although anasarca and its consequences may cause the interruption of
pregnancy.
4. Acute Bright's disease is one of the most serious disorders
occurring in the course of pregnancy. The urine is diminished in
quantity, and contains a large amount of albumen, tube-casts, and red
blood-corpuscles. Eclampsia is of frequent occurrence, and usually
induces abortion or premature labor.
The causes of renal disease and of its symptom albuminuria are not
always evident. In the kidney of pregnancy there is no inflammatory
change. The cells covering the glomeruli and the glandular cells lining
the uriniferous tubules undergo fatty degeneration, and are cast off as
the result of anæmia.
In the acute and chronic forms of renal inflammation there is a variety
of probable etiological factors. Mechanical pressure from the gravid
uterus may impede the return of venous blood and determine congestion
of the kidneys. This explanation is rendered more probable by the fact
{418} that albumen usually appears in the urine after the fifth month,
when the uterus has attained considerable size. Albuminuria is of
comparatively more frequent occurrence in primiparæ with tense
abdominal walls. It is frequently observed in cases of large ovarian
cysts and uterine fibroids. The increased functional activity of the
organs, the elevation of blood-pressure, the alterations in the
constitution of the blood, are doubtless potential factors. When any
latent tendency to Bright's disease exists, exposure to cold and
impeded cutaneous functional activity are more likely to develop the
disease in the pregnant than in the non-gravid state. Compression of
the ureters is regarded by Halbertsma as a cause of great importance.
SYMPTOMS.--The symptoms of Bright's disease in pregnancy are neither
uniform nor constantly present. Anasarca frequently directs attention
to the patient's condition long before the appearance of more
significant signs. Oedematous swellings of the face, hands, arms, feet,
legs, and labia majora are always suspicious, and should lead to an
examination of the urine. These oedematous swellings are
wandering--appear when the patient is lying down, and disappear when
she rises and walks about. Sometimes, toward the end of pregnancy, they
become less marked, not infrequently entirely disappearing, while the
albuminuria is increasing. The skin covering the oedematous portions of
the body is dry, of a chalkish-white appearance, and the surface
temperature is depressed.
Anomalous nervous phenomena, such as headache, vertigo, dimness of
vision, spots before the eyes, ringing in the ears, sudden deafness,
obstinate nausea and vomiting, sleeplessness, neuralgia, are often
observed, and should always excite suspicion. These various nervous
symptoms may be viewed as produced by the retention within the blood of
certain substances normally excreted by the kidneys.
Convulsions, due to renal insufficiency, may occur during pregnancy,
but are observed more frequently during parturition and the puerperium.
Attention has already been called to the characters of the urine. It is
necessary to remember that in the granular, contracted kidney and
lardaceous degeneration albuminuria may escape observation.
Bright's disease strongly predisposes to abortion or premature labor.
PROGNOSIS.--Any organic disease of the kidneys is serious. When the
disease is extensive and involves both organs the prognosis is
especially unfavorable. Accurate conclusions as to the dangers of
Bright's disease during pregnancy are not justified by the present
state of our knowledge. It is only possible to say, in a general way,
that the prospect of recovery is less favorable than in the non-gravid
state. Owing to the strong predisposition to abortion and premature
labor, the chances of the foetus surviving pregnancy are relatively
slight. Even if the child is not prematurely expelled from the uterus,
it usually succumbs to the influence of the excrementitious products
retained within the maternal blood.
TREATMENT.--In view of the serious complications arising in pregnancy
from interference with the functions of the kidneys, the absolute
necessity of chemical examination of the urine at regular intervals in
every case, especially during the latter half of gestation, is
apparent. When pathological albuminuria is present, rational therapy
will be directed to the removal of the cause. Evacuation of the uterine
contents is the only mode of removing the pressure from the gravid
uterus, but {419} we have a variety of expedients, hygienic and
medical, which must be invoked before resorting to such a radical
procedure.
Hygienic.--The diet should be restricted, as far as possible, to milk,
and nitrogenous articles of food must be forbidden. The functional
activity of the skin can be maintained by frequent baths in lukewarm
water. Vapor baths are of still greater value. Hot-water baths are
employed on an extensive scale in the obstetrical clinics of the Vienna
General Hospital. Carl Braun, Josef Spaeth, and Gustav Braun give
testimony to their efficacy. Indeed, in Vienna chief reliance is placed
upon the hot-water bath as a prophylactic and remedial agent. Breus[20]
has recently described the method usually practised. The patient is
placed in a bath-tub filled with water at a temperature slightly above
99° F. The tub is then covered with a heavy blanket, leaving the face
free, and the temperature of the water is gradually elevated to 110° or
112° F. She remains in the bath thirty minutes. A towel wrung out of
ice-water and placed upon the head relieves any distressing cephalic
sensations. While in the bath the patient drinks large quantities of
water. Upon emerging from the bath she is covered with a warm sheet and
enveloped in an upper and lower layer of thick blankets, so that only
the face is exposed. Within a very few minutes free perspiration is
observed. The sweating is continued for two or three hours. According
to the gravity of the case the hot-water bath may be repeated once
daily for an indefinite period. The relief of all threatening symptoms
under this simple plan of treatment alone is surprising. Sometimes the
hot-water bath acts as an efficient excitant of uterine contractions,
and premature labor is induced. A. Sippel[21] calls attention to this
fact, and proposes hot-water baths as a harmless method of induction of
premature labor. Although such an event is not undesirable, it is
unusual, and occurs only when the temperature of the water reaches a
great elevation or the baths are frequently repeated, or, finally, when
there is a very decided predisposition to the interruption of
pregnancy. The lateral or latero-prone posture during sleep serves to
relieve in some degree the kidneys of the pressure from the gravid
uterus, and should be advised.
[Footnote 20: _Arch. f. Gynaek._, vol. xix. p. 219.]
[Footnote 21: _Centralb. f. Gynaek._, No. 44, 1885, p. 693.]
Medical.--The exhibition of non-irritating diuretics, such as the
acetate and bitartrate of potassium, in large quantities of water,
causes an increased secretion of urine and lessens the congestion of
the renal vessels. Among the mineral waters Bilin, Giesshübel, Preblau,
Selters, and Vichy deserve commendation. Benzoic acid, in conformity
with Frerichs' suggestion, is employed in Vienna. The tincture of the
chloride of iron, alone or in combination with small doses of tincture
of digitalis, is an efficient diuretic, and at the same time an
excellent tonic.
Cathartics which produce large, watery stools without much irritation
supplement the action of diuretics. The compound powder of jalap and
the saline purges fulfil this indication. Care must be taken, however,
to avoid the drastic effects of too large a dose.
Jaborandi and pilocarpine have been, and are at the present time,
extensively used to aid in the elimination by the skin of retained
excrementitious matters. The weight of authority is decidedly against
the exhibition of this remedy. At best, it is uncertain in its action.
It is a cardiac depressant, and frequently stands in a causal relation
to {420} pulmonary oedema. For these reasons the drug has been
condemned in unequivocal terms by Carl Braun and Fordyce Barker. The
same effect, with less risk, can be produced by the hot-water baths.
Local Treatment.--In the acute forms of Bright's disease various modes
of counter-irritation are useful. Wet and dry cups and leeches applied
to the loins are indicated. Frerichs recommends pills of the extract of
aloes and tannin with the view of restoring the normal tonus to the
blood-vessel walls.
By a judicious combination of these varied therapeutic resources,
hygienic and medical, threatening symptoms may be averted. Cure of
Bright's disease, acute or chronic, is seldom if ever achieved during
pregnancy. Not unfrequently, however, notwithstanding all efforts, the
amount of albumen steadily increases, hydræmia becomes more pronounced,
hydropsies appear with threatening cerebral, cardiac, or pulmonary
symptoms. More active treatment is demanded, and the subject of the
induction of premature labor must be seriously considered. Without
entering into a detailed discussion of the arguments for and against
the artificial premature interruption of pregnancy under these
conditions, let it suffice to say that clinical experience furnishes
overpowering evidence in favor of the operation. The weight of
professional opinion is also very decidedly in favor of the artificial
induction of premature labor. In the selection of the method for the
induction of premature labor it is well to bear in mind the possible
excitant effect on uterine contractions of hot-water baths, as pointed
out by A. Sippel.[22]
[Footnote 22: _Centralb. f. Gynaek._, No. 44, 1885, p. 693.]
Skin Diseases.