Latent diatheses are roused into activity. The graver forms of skin
disease usually disappear during or shortly after the puerperium. These
facts point to some causal relation between the diseases and gestation.
Under the increased activity of the glandular system the growth of hair
may be stimulated, giving origin to a condition termed by
dermatologists hirsuties gestationis. Slocum[23] relates the history of
a case in which a woman in successive pregnancies grew a full beard.
Anomalous deposits of pigment, constituting the condition known as
chloasma uterinum, are observed, more especially among pregnant women
exposed to sunlight. Chloasma is interesting from a diagnostic point of
view, since it is liable to be confounded with pityriasis versicolor,
an affection of frequent occurrence during pregnancy. The red nose of
acne rosacea may be one of the first signs of pregnancy. General
pruritus, a rare affection, belongs to the class of idio-neuroses
(Hebra). Spiegelberg relates the history of a case of general pruritus
occurring in an old primipara. The affection made its appearance in the
second month, and continued without material abatement of symptoms
throughout the period of gestation. Pruritus of the vulva is a common
disorder of pregnancy. It is usually symptomatic of eczema, some
inflammatory condition of the genitalia, or diabetes mellitus. The
treatment must be directed to the removal of the cause. Vaginal douches
containing vegetable or mineral astringents will {421} afford relief
when the itching is due to acrid vaginal secretions. Dilute solutions
of corrosive sublimate in water or alcohol (1:100 or 200), followed by
compresses saturated with tar-water, are recommended very highly by
Spiegelberg.
[Footnote 23: _New York Medical Record_, 1875.]
Pregnancy cannot be regarded as a cause of psoriasis. When that
affection exists, however, it is usually aggravated. The elder
Hebra[24] in 1872 described a rare form of skin disease occurring in
the course of pregnancy which he called herpes impetiginiformis, and of
which he encountered five cases. Grouped vesicles upon inflamed bases
appear about the genitalia, and subsequently diffuse themselves by
successive crops over the body. Great prostration, rigors, and intense
fever accompany the eruption. Four of the five cases terminated
fatally. Milton and Duncan Bulkley a few months later described a rare
skin affection peculiar to pregnancy which they designated herpes
gestationis. Erythema, papules, vesicles, and bullæ are developed.
Vesicles predominate, appear on the lower extremities, subsequently
spreading over the body. Intense itching and burning attend the
vesicles. Urticaria, neuralgia, and other neurotic troubles accompany
the affection. The disease appears early in pregnancy, continues until
after delivery, and is apt to recur with succeeding pregnancies. The
constitutional symptoms are much less severe than in the condition
described by Hebra. At the meeting of the American Dermatological
Society, 1885, L. A. Duhring[25] called attention to the relation of
impetigo herpetiformis, herpes gestationis, pemphigus, and certain
other forms of disease to dermatitis herpetiformis. Attention was
briefly directed to the identity of the impetigo herpetiformls of Hebra
with dermatitis herpetiformis. Herpes gestationis was a misnomer, the
affection being found in men as well as in women. The disease was the
vesicular variety of dermatitis herpetiformis. The peculiar forms of
pemphigus observed during pregnancy, not of syphilitic origin, may be
viewed as examples of the same disease. Duhring thinks that "we stand
on the threshold of our knowledge of the disease."
[Footnote 24: _Wiener Med. Woch._, No. 48, 1872.]
[Footnote 25: _Journal of Cutaneous, etc. Dis._, October, 1885, p.
317.]
Neuroses.
Of all the neuroses occurring in the course of pregnancy, puerperal
eclampsia is of chief clinical importance. Puerperal convulsions,
however, occur more frequently during labor and the lying-in period
than during gestation. For this reason the subject is usually discussed
in connection with the pathology of the puerperium. The various
psychoses are referred for a similar reason to the same chapter.
TETANUS.
Tetanus, a rare affection, especially in women, is occasionally
observed in pregnancy. It occurs with greatest relative frequency in
hot climates after abortion and the removal of placental or decidual
remains. Sir James Y. Simpson collected 28 cases which sustained some
relation to abortion or labor. Mr. Waring[26] has collected 232 cases
occurring in a tropical climate.
[Footnote 26: _Indian Annals_, 1855.]
{422} The PROGNOSIS is unfavorable. Of Sir James Y. Simpson's 28 cases,
only 6 recovered; 2 cases observed by Wiltshire terminated unfavorably.
In the entire absence of knowledge of the pathology of the disease,
TREATMENT is empirical. Chloroform, the narcotics, curare, and nitrite
of amyl are the remedial agents usually employed.
CHOREA.
Chorea occurs in pregnancy as an accidental complication or as the
direct result of that state. It is a rare disorder of pregnancy.
Spiegelberg has observed 3 cases; Barnes has collected 56 cases;
Fehling[27] brings the number up to 68; altogether, 84 cases are on
record.
[Footnote 27: _Lehrb. d. Geburtshülfe_, 1882, p. 239.]
ETIOLOGY.--The investigations of Robert Barnes show that where chorea
arises in pregnancy in the large majority of cases there is a history
of chorea in childhood, acquired predisposition prior to pregnancy, or
hereditary "nervous diathesis predisposing to chorea." The connection
between rheumatism, endocarditis, and chorea is a well-established
fact. The precise nature of this relation is unknown. Hughlings Jackson
has constructed the theory of "embolism of the small branches of the
middle cerebral artery supplying the structures near the corpus
striatum." Robert Barnes[28] calls attention to the following facts,
which invalidate this ingenious theory: "(1) The frequent recovery of
choreic patients; (2) the occasional immediate cessation of choreic
fits upon delivery; (3) the progressive character of the disease during
pregnancy, convulsions increasing in severity, and the gradual
development of mania in some cases; (4) the fact that embolism is rare
during pregnancy." In the absence of any definite cause, Spiegelberg
refers a large number of these cases to the class of reflex neuroses.
All the elements essential to a reflex neurosis are present. We have
(1) a predisposition to chorea, inherited or acquired; (2) inanition of
the central nervous system incident to the hydræmic state of the blood
in pregnancy; (3) various potential peripheral irritants in connection
with the sexual organs. Intense emotions, terror and the like, may act
as exciting causes.
[Footnote 28: _Obstetric Medicine and Surgery_, London, 1884, p. 379.]
COURSE AND SYMPTOMS.--Chorea usually makes its appearance in the course
of the first half of pregnancy, and continues until the beginning of
labor. Sometimes choreic attacks are witnessed during parturition. In
only 3 out of the 84 recorded cases the disease continued after the
puerperium. Primiparæ are more frequently affected than multiparæ. The
disease is liable to recur with succeeding pregnancies, entirely
disappearing in the intervals. The choreic movements are the same as in
the non-gravid woman affected with the disease. They are usually
bilateral. As in chorea in the non-gravid state, transitory albuminuria
and glycosuria may be observed. The increase of urates and phosphates
in the urine is interpreted as the result of nervous excitement and
muscular activity. Pregnancy is interrupted in about one-half the
cases. The child may be born alive and affected with the disease.
PROGNOSIS.--Out of the 84 cases, 23 terminated fatally as the result of
complications. Mania, loss of memory, grave cerebral and spinal lesions
are occasionally traceable to the chorea of pregnancy. The {423}
prognosis with reference to the child is unfavorable, from the tendency
to the premature interruption of pregnancy.
TREATMENT.--The palliative treatment of chorea occurring in pregnancy
is unsatisfactory in the extreme. All the specifics of greater or less
value in the non-gravid state are frequently without influence during
gestation. The diet must be nutritious and easily digestible. Large
doses of iron and quinine are indicated. As in other convulsive
disorders, during the paroxysms chief reliance is placed upon
anæsthetics, subcutaneous injections of morphine, potassium bromide,
and chloral. Charcot recommends the exhibition of large doses of
bromide of potassium through a considerable period of time. Clifford
Albutt extols succus conii. In over one-half the recorded cases the
most judicious combinations of hygienic and medical therapeutic
resources have proved of no avail. In view of the prognosis, the
induction of premature labor is usually indicated, in the interest of
both the mother and child, at an early stage of the disease. Sometimes
the question of the artificial induction of abortion comes up for
consideration. In view of the grave cerebral and spinal lesions which
may result from the affection, the mother is justly entitled to the
benefit of the doubt. It may not be amiss to add that this indication
for the induction of abortion is not generally recognized.
EPILEPSY.
Epilepsy is usually an accidental complication of pregnancy.
Spiegelberg[29] is responsible for the observation that in chronic
epilepsy pregnancy sometimes modifies the course of the affection in a
favorable manner. The seizures occur less frequently and are not so
violent in character. Acute epilepsy may be developed as the result of
pregnancy when a latent predisposition, inherited or acquired, exists.
The epileptogenous zone in acute epilepsy comprehends the distribution
of the ischiatic nerve. Acute epilepsy disappears with the cessation of
pregnancy, but is apt to recur with succeeding gestations.
[Footnote 29: _Lehrb. d. Geburtshülfe_, 1882, p. 241.]
The occurrence of acute or chronic epilepsy during pregnancy is of
great diagnostic interest from the resemblance of the epileptic
seizures to the convulsions produced by renal inadequacy. The urine
secreted during or after an epileptic fit is usually free from albumen.
In the severest forms of puerperal eclampsia the urine may also be
entirely free from albumen and tube-casts. In the ultimate stages of
amyloid degeneration[30] and atrophy of the kidney, the most formidable
forms of Bright's disease, albumen may not appear in the urine.
[Footnote 30: Carl Braun, _Lehrb. d. g. Gynaek._, 1881, p. 827.]
The DIAGNOSIS is usually cleared up by the history of the case and the
course of the affection.
The PROGNOSIS with reference to mother and child is favorable. Epilepsy
rarely leads to the premature interruption of pregnancy.
The TREATMENT is the same as in the non-gravid state.
Disorders of the Special Senses.
Disorders of the special senses usually occur in the course of
pregnancy as symptoms of acute or chronic Bright's disease. Amblyopia,
amaurosis, {424} ringing in the ears, sudden deafness, loss of taste
and smell, may be developed under the influence of renal inadequacy
before or after the occurrence of puerperal convulsions. Apart from the
disorders of the special senses dependent upon lesions of the kidney,
disturbances of vision are of chief clinical interest.
Amblyopia, hemeralopia, and color-blindness are occasionally observed
as the result of nutritive disturbances in the retina. Nyctalopia,
Spiegelberg says, is not recorded in the literature of the subject.
The PROGNOSIS is favorable as a rule. The disorders of vision usually
disappear during the puerperium, and evince no tendency to recurrence.
Generous diet, iron, and a tonic plan of treatment are indicated.
* * * * *
II. THE PECULIARITIES OF CERTAIN ACCIDENTAL ACUTE AND CHRONIC DISEASES
OCCURRING IN THE COURSE OF PREGNANCY.
The older obstetricians believed not only that pregnant women possessed
a certain immunity from accidental diseases, but also that the course
of such affections was favorably modified by gestation. Modern research
has demonstrated the groundless nature of this belief. It is an
established fact that pregnancy confers upon the individual no immunity
from the disorders to which the non-gravid woman is liable. Moreover,
such accessory diseases are usually aggravated by pregnancy, and, in
turn, exercise an unfavorable influence upon gestation, frequently
leading to its interruption.
Acute Infectious Diseases.
Of all the so-called accessory diseases occurring in the course of
pregnancy, the acute infectious diseases are of the gravest clinical
significance. These diseases are peculiarly dangerous complications for
two reasons:
I. They have a marked tendency to cause the death of the foetus and the
interruption of pregnancy, when the loss of blood and the muscular
exertion consequent upon the expulsion of the product of conception
from the uterine cavity seriously imperil the mother's life.
II. Hemorrhagic endometritis, caused in part by changes in the
constitution of the blood, is not an uncommon symptom in the course of
acute infectious diseases in the non-gravid state. In pregnancy this
symptom is of more constant occurrence, just as it is of graver
prognostic moment, both with reference to the mother and to the child.
I. The death of the foetus and the interruption of pregnancy may result
from the operation of a variety of etiological factors.
1. The foetus usually dies in consequence of the elevation of maternal
temperature. The case is a veritable example of that condition which H.
C. Wood of Philadelphia terms heat-stroke. The normal foetal
temperature is slightly more elevated than the maternal. The foetus in
its membranes, surrounded by maternal tissues, must possess at least
the {425} same temperature as the maternal body. But it has its own
heat-producing apparatus in addition. A very slight elevation of the
maternal temperature produces a disproportionate rise in the
temperature of the foetal body. Kaminsky[31] has shown that an
elevation of maternal temperature to 104° F. imperils foetal life.
Increased frequency of the pulsation of the foetal heart and abnormally
active foetal movements are followed by diminished cardiac and muscular
activity, and the foetus dies. The autopsy reveals the characteristic
lesions of heat-stroke.
[Footnote 31: _Moskauer Med. Z._, 1867, Nos. 13-19.]
2. Runge[32] has demonstrated the occurrence of foetal death from
asphyxia when the maternal blood-pressure is seriously lowered. This
lowering of the maternal blood-pressure occurs as the result of
diminution in the force and frequency of the heart's action observed in
the course of acute infectious diseases or from the sudden loss of
blood. Asphyxia may also be caused by structural changes in the
epithelium covering the foetal placenta, due to the state of the
maternal blood.
[Footnote 32: _Arch f. Gyn._, Bd. xii. p. 16.]
3. The foetus may perish in consequence of infection with the specific
poison of the acute disorder. Death as the result of acute infection
has been observed in variola and relapsing fever.
4. Pregnancy may be interrupted, independently of the condition of the
foetus, as the result of the thermic irritation of the uterine muscular
fibre by the maternal blood. Spiegelberg on a priori grounds asserted
the possibility of this event. Runge[33] has since demonstrated by
experimental methods its actual occurrence.
[Footnote 33: _Volkmann's Sammlung_, No. 174; _Arch. f. Gyn._, Bd. xii.
p. 16.]
II. Hemorrhagic endometritis in the course of acute infectious diseases
complicating pregnancy has been demonstrated by Slavjansky's[34]
researches. In cholera this symptom is observed with relative
frequency. Following hemorrhage into the decidua, according to the
time, extent, and site, pregnancy may be immediately interrupted, or
secondarily as the result of the pathological changes in the placenta
or membranes induced by the extravasated blood. The hemorrhage may be
so severe as to jeopardize the life of the mother.
[Footnote 34: _Arch. f. Gyn._, iv. p. 285.]
Of the eruptive fevers, smallpox, scarlet fever, and measles are of
especial clinical interest. Smallpox is observed most frequently. The
eruptive fevers usually occur early in pregnancy, but the disposition
to the severer forms and the mortality, as remarked by Spiegelberg,
grow with the duration of gestation.
SMALLPOX.
A mutually unfavorable relation exists between smallpox and pregnancy.
A distinct tendency to the hemorrhagic form of the disease is notable.
Pregnancy frequently terminates in abortion or premature labor under
circumstances which seriously imperil the mother's life from loss of
blood. When the disease pursues its course without interrupting
pregnancy, the effect upon the foetus is interesting and instructive.
The child may be born alive with characteristic variolous cicatrices or
in the eruptive stage. Usually the eruption appears from eight to ten
days after birth. Very rarely the child may escape infection
altogether. The foetus may be infected in utero, while the mother {426}
remains apparently unaffected. Fumée of Montpellier narrates the
history of a remarkable case of twin pregnancy. Only one of the
children showed variolous pustules.
During smallpox epidemics abortions and premature labors, accompanied
by abnormally severe hemorrhages, are frequently observed when no
exanthem or other sign of the disease is noticeable in the mother. The
healthy child of a mother affected with variola in the course of
pregnancy is usually insusceptible to vaccinia for a long time after
birth.
In the event of a smallpox epidemic the vaccination or revaccination of
pregnant women is advisable. The effect of the vaccination of the
pregnant woman upon the foetus is still a subject of controversy.
Thorburn in 1870 successfully vaccinated a number of pregnant women,
and found no insusceptibility in their children. Behm[35] vaccinated 33
women pregnant in the eighth, ninth, and tenth months. The vaccination
was completely successful in 22 cases, partially in 7, and failed in 4.
Of the 33 children, 25 were successfully vaccinated. In 8 cases
vaccination was not attended with success. Failure was ascribed in 7
cases to bad lymph, leaving only 1 case of presumed protection from
intra-uterine vaccination. Bollinger and Burckhardt, supported by the
results of Rickett and Roloffs in the inoculation of sheep, maintain
that over one-half the infants are protected from vaccinia and smallpox
by the vaccination of the mother during pregnancy.
[Footnote 35: _Centralbl. f. Gynaek._, 1882.]
MEASLES.
Rubeola, of infrequent occurrence in the adult generally, is a very
rare complication of pregnancy. It is of serious prognostic moment,
from the tendency to the hemorrhagic form of the disease, and
pneumonia.
SCARLET FEVER.
Scarlatina, like measles, occurs infrequently in the course of
pregnancy. Olshausen has collected 7 cases. Pregnancy was interrupted
in 4 out of these 7 cases, probably as the result of the elevation of
maternal temperature. The renal complications also add an unfavorable
element to the prognosis.
TYPHOID FEVER.
Typhoid fever occurs with greatest frequency during the early months of
gestation. It is a very rare complication of the puerperium. Pregnancy
is usually interrupted. Abortion rather than premature labor is
observed. This tendency to the interruption of gestation is more marked
than in any of the acute infectious diseases with the possible
exception of smallpox. Of 98 cases collected by Kaminsky, interruption
of pregnancy occurred in 63; Zülzer reports 14 interruptions of
pregnancy in 24 cases; Scanzoni, 6 out of 10 cases. In about 63 per
cent. of the cases collected by these observers pregnancy was
interrupted. The causes of abortion or premature labor in typhoid fever
are found in the elevation of maternal temperature, the hemorrhagic
endometritis, and perforation (Kleinwächter). The transmission of the
infection from mother to child is a disputed point. The prognosis
depends largely upon the stage of the disease in which the interruption
of pregnancy occurs. If abortion or {427} premature labor occurs early
in the course of the disease, before the mother is exhausted, the
outlook is naturally more favorable.
RELAPSING FEVER.
Murchison states very positively that pregnancy is invariably
interrupted by the occurrence of relapsing fever. Recent
investigations, however, indicate that this assertion is entirely too
general. Weber[36] has collected 63 cases of pregnancy complicated by
this disease. Pregnancy was interrupted in 23 cases, or 36.5 per cent.
Hemorrhagic endometritis is of less frequent occurrence than in typhoid
fever. In two cases (Wyss-Ebstein and Albrecht) spirilla were found in
the foetal blood, indicating the infection of the child by the mother.
[Footnote 36: _Berlin. klin. Woch._, vii., 1870, p. 22.]
TYPHUS FEVER.
Typhus fever manifests much less tendency to the production of
hemorrhagic endometritis than typhoid and relapsing fevers. The
interruption of pregnancy is the exception rather than the rule. When
abortion or premature labor occurs, it is usually caused by the
elevation of the maternal temperature. There is no evidence pointing to
the infection of the child with the specific poison of the disease.
MALARIAL FEVER.
The popular belief that pregnant women enjoy a certain[37] immunity
from malarial fever seems to have some foundation in fact. This
apparent immunity may be due in part to the environment and freedom
from exposure to the malarial poison--in part to the condition of
pregnancy. In latent, chronic malarial poisoning gestation may be the
cause of the explosion or acute exacerbation of the affection. The
course and symptoms of malarial fever are materially modified by the
coexistence of pregnancy. The attacks lose something of their
rhythmical character. Chills are of irregular occurrence, and the fever
assumes a remittent or continued type. In the latter months of
gestation acute attacks of malarial fever are especially distressing to
the patient.
[Footnote 37: Ritter, _Virchow's Archiv_, 1867.]
The interruption of pregnancy is not an uncommon event. Göth has
recently reported 46 cases, in 19 of which either abortion or premature
labor took place. When pregnancy is interrupted hemorrhage is apt to be
profuse.
The communication of the disease to the foetus is a well-authenticated
clinical fact. Hubbard reports an interesting case of intra-uterine
malarial fever. Autopsies of infants born of mothers affected with
acute or chronic malarial poisoning reveal the characteristic lesions
of that pathological condition. Malarial paroxysms are usually
suspended during labor, but may reappear during the lying-in period.
Very rarely the fever assumes a pernicious type, and then may stand in
a certain causal relation to the essential anæmia of pregnancy, of
which mention has already been made.
In the TREATMENT of malarial poisoning during pregnancy large doses of
quinine are indicated. Spiegelberg points out the important fact that,
owing to the impairment of the digestive and assimilative functions,
only {428} a portion of the quinine is absorbed. There is no ground for
fearing any untoward effect from quinine. The researches of Chiara of
Milan and numerous other observers prove that even the largest
therapeutic doses of quinine are not abortifacient in malarial fever or
in health.
CHOLERA.
Pregnant women evince no proclivity to, nor immunity from, cholera. As
in variola, the disposition to, and mortality of, the disease grow with
the duration of gestation. The prospect of recovery is especially
unfavorable during the sixth and seventh months. Pregnancy is usually
interrupted when the woman survives the terribly rapid course of the
disease. Many women die with the product of conception in the cavity of
the uterus. Exceptionally, in the lighter forms of the disease recovery
may occur without the interruption of gestation. The causes of
premature labor or abortion may be found in the constant hemorrhagic
endometritis and the changes in the pressure and constitution of the
maternal blood. As the result of the operation of the two latter
factors, asphyxia is usually produced. Buhl, Gütterbock, and others are
of the opinion that the disease may be communicated by the mother to
the foetus.
Pregnancy undoubtedly exercises an unfavorable influence on the course
of the disease, chiefly from the tendency to uterine hemorrhage.
Pregnancy is interrupted in over 50 per cent. of the cases. Premature
labor is observed more frequently than abortion. The prognosis with
reference to the life of the child is absolutely unfavorable.