Nausea and Vomiting—Heartburn—Flatulence—Defective Teeth—PressureSymptoms: Swelling of the Feet; Varicose Veins; Hemorrhoids;Shortness of Breath—Leucorrhea—Toxemias.
Most of the ailments to which prospective mothers are liable are merely the natural manifestations of pregnancy, exaggerated to such an extent as to cause inconvenience and discomfort. In the early months, for example, persistent nausea and vomiting may become the source of great annoyance, and later the pressure of the womb against neighboring structures may cause a variety of symptoms. It does not follow, however, that any of these ailments will necessarily appear. On the contrary, many women are more healthy during pregnancy than at any other time.
Occasionally illness is charged to pregnancy with which in reality pregnancy has nothing to do. While awaiting the birth of a child, just as at other times, women may suffer from coughs or colds, from aches or pains, from malaria, pneumonia, typhoid fever, or in fact from any disease. It is evident that such complications are accidental; and, though pregnancy confers no immunity against them, it does not, on the other hand, render women more susceptible to all kinds of ailment.
And yet there are diseases for which pregnancy is directly responsible. These are, to a very large extent, preventable; and, though they occur rarely, precautions for their prevention should be taken in every case of pregnancy. By far the most important members of this group are the toxemias of pregnancy. These, as will be explained later, cause symptoms which the patient herself may recognize, and her physician may often detect their presence still earlier by alterations in the composition of the urine. For this reason routine examination of the urine during pregnancy is a means of prevention indispensable for safeguarding the health of the prospective mother.
A number of ailments of which prospective mothers may complain do not require treatment with medicine. This, however, will not be taken to imply that there is no need to consult a physician. On the contrary, and it cannot be emphasized too strongly, the prospective mother shouldseek professional service whenever there is anything about her condition she does not understand. Sometimes, when she thus consults the physician, he will explain to her that what she has noticed is merely one of the natural manifestations of pregnancy and that she can have no control over it; at other times he will suggest changes in her mode of life which will very likely afford her relief. The frequency with which physicians find that ailments may be corrected by the adoption of hygienic measures indicates that such ailments are more often due to ignorance or carelessness than to the existence of disease.
NAUSEA AND VOMITING.—We have already learned that nausea, especially in the morning on rising from bed, frequently corroborates the suspicion of a woman that she has become pregnant. So commonly, indeed, is this symptom expected that most women take no account of it other than as an evidence that they have conceived, and consequently do not complain of it. A few who have heard the old adage, "a sick pregnancy means a safe one," which incidentally is not correct, actually accept nausea as a favorable sign. In other cases the nausea is not to be dismissed so lightly; and a relatively small group of patients suffer from persistent vomiting. When prospective mothers are questioned systematically, it appears that at least one- half and perhaps two-thirds of them experience more or less discomfort from sick stomach. Generally this begins shortly after a menstrual period has been missed and ceases six or eight weeks later; it persists occasionally until the movements of the child have been perceived.
Nausea and vomiting are limited, in the vast majority of cases, to the early morning, but some patients are annoyed only after meals, and a few at irregular intervals during the day. The fact that the attacks do not always appear at the same time, and that they differ in severity, indicates that different causes may be concerned in their production. And it is true that there are several kinds of vomiting that occur during pregnancy, although the classification interests only physicians. The laity, however, should understand that the treatment of any given case will vary according to the class to which it belongs, and therefore the occurrence of troublesome vomiting should be promptly reported to the physician.
Most frequently it will be found that there is nothing serious the matter. The vomiting ceases or, at least, it becomes less troublesome as soon as the diet has been more carefully arranged, constipation has been corrected, or other hygienic details, such as outdoor recreation and mental diversion, have received the attention requisite for good health. In a much smaller group of cases the restoration of the womb to a proper position or the treatment of some other local condition, which can generally be remedied without difficulty, is all that is necessary. But finally, in extremely rare instances, the vomiting of pregnancy is due to a definite disease whose existence may be recognized by special methods of analyzing the urine. In any case, if the physician is given an opportunity to make the necessary observations and thus determine the variety of the vomiting, no time will be lost in beginning effective treatment. In an overwhelming majority of the cases, as I have said, nothing serious will be found; and then the control of the vomiting will lie within the power of the patient herself.
Since nausea is usually experienced in the morning on rising from the recumbent to the upright posture, measures to prevent an attack should be begun even before the patient raises her head from the pillow. In the first place something to eat should be taken as soon as she awakens. The most satisfactory results follow eating two or three pieces of crisp toast or a Bent's cracker (sold by grocers), either of which should be thoroughly chewed and swallowed without taking anything to drink. Good results are also obtained, though less uniformly, from eating other food, such as fruit, oatmeal, or eggs. The benefit secured from this procedure is explained, perhaps, by the activity of the digestive organs and the effect of that activity upon the circulation of the blood. The food eaten before rising is not intended to take the place of breakfast, which ordinarily will be eaten later. Furthermore, it is essential to remain in bed until half an hour after the food was taken; and not to rise then unless perfectly comfortable. Anyone who is inclined to be nauseated should get up slowly and dress leisurely, sitting down as much as possible while putting on the clothes. If breakfast is not desired at once, it should not be forced, but some food should be eaten between early morning and noon.
It is an exceedingly good rule to bend every effort toward escaping the initial attack of nausea, for in this way one soon gains confidence, and overcomes the depressing habit of being continually on the watch for the symptom, lest she be taken unawares. Exceptionally, however, patients feel more comfortable if they vomit in the morning; this may be helpful, for example, if a large meal has been eaten just before retiring the previous night.
Next to morning sickness in point of frequency comes the disposition to be nauseated about meal time. Those who vomit after the meal is finished are frequently inclined to eat soon again; and there is no reason why they should not. Sick stomach after meals may be due to several causes, such as eating hurriedly, eating too much, or selecting food that is difficult to digest. If a meal is bolted the stomach may be overloaded before the appetite is appeased; and consequently those who eat too much are fortunate when the stomach rejects the excess. Eating slowly and masticating the food thoroughly, we know, is the proper way to insure taking no more than is needed.
One of the most valuable precautions against persistent nausea consists in taking small amounts of food five or six times during the day. Directions regarding the frequency of meals and the choice of food have been given in Chapter IV, to which the reader may refer. It may be repeated, however, that a prospective mother should naturally avoid anything which she knows is likely not to agree with her. On the other hand, she is almost certain not to be nauseated by any article of food for which she has an appetite.
Lying down for a short while after meals frequently serves to prevent an attack of vomiting. It is a good rule, furthermore, at whatever time of day the sensation of nausea may occur, to lie down immediately. An ice bag or cloths wrung out of cold water, if applied to the abdomen, often give relief; warm applications occasionally serve the same purpose better. Some patients prevent nausea by constantly wearing a flannel bandage about the abdomen.
Many instances of the vomiting of pregnancy cannot be explained by errors in diet, for the attacks come on repeatedly whether the stomach contains food or not. Under these circumstances mental influences frequently have to be reckoned with. Indeed, in most cases of vomiting of pregnancy dietetic and other hygienic measures are of no avail unless the patient learns to divert her attention from troublesome thoughts.
That the brain can exert an influence over the stomach is a fact well substantiated both by physiological experiment and by medical observation. In all probability there is a definite spot in the brain, called the "vomiting center," the irritation of which causes retching and the upheaval of the contents of the stomach. As this nervous mechanism is possessed by everyone, it is not called into existence by the advent of pregnancy. Nevertheless, it seems likely that pregnancy renders it more sensitive, and it is certain that pregnancy establishes new means by which the center may be stimulated. This admission does not imply, however, that the prospective mother must submit to inevitable discomfort, for she can and should muster the strength to resist it.
Time and again an unhappy frame of mind exaggerates or prolongs the vomiting of pregnancy. Thus, disappointment, anxiety, grief, fright, and other types of mental uneasiness not only magnify the discomfort but sometimes are its sole cause. The curious cases in which the husband suffers from nausea while his wife is pregnant are explained by mental influences. As a result of the same kind of influence, women who imagine themselves to be pregnant often suffer from violent vomiting, which ceases as soon as they discover their error. On the other hand, women who for several months remain ignorant of the fact that they are pregnant rarely suffer from sick stomach.
Any kind of worry may be and often is the direct cause of the vomiting of pregnancy, though patients are often unwilling to confess it; and occasionally do not seem to know what it is that troubles them. In any event, having received the assurance of her physician that there is nothing serious the matter, the prospective mother who is annoyed by nausea should make every effort not to become self- centered. She should have congenial companionship and should interest herself in pursuits outside of, as well as within, her home. Of all the measures that may be employed to overcome this manifestation of pregnancy the most fundamental and essential is mental diversion.
HEARTBURN.—Obviously, it would not be fair to consider indigestion as one of the ailments peculiar to pregnancy, for anyone is liable to suffer from indigestion. Yet dyspeptic symptoms, more especially heartburn and flatulence, occur so frequently at this time that something should be said regarding their causation and treatment.
A burning sensation rising from the stomach into the throat, familiarly called heartburn, is generally due to an overabundant secretion of hydrochloric acid, which is, as we have learned, a normal constituent of the gastric juice. Of late, the conditions which influence its secretion have been the subject of laboratory investigation, which has disclosed, among other interesting facts, the way topreventheartburn. These experiments have taught that the introduction of fat into the stomach shortly before a meal decreases the amount of acid secreted during digestion. Consequently, anyone who is troubled by heartburn and wishes to avoid itshould take a tablespoonful of olive oil, a cup of cream, or a glass of rich milk fifteen or twenty minutes before meal-time.
On the other hand, fatty food eaten with the meals prolongs the stay of food in the stomach and causes an increase in the secretion of hydrochloric acid. An excess of the acid, as we have just learned, is favorable to the development of heartburn. Therefore, as a further precaution against this source of discomfort, it is advisable not to use a large amount of butter or of salad oil, and to refrain from fried food, rich desserts, or any other article of diet known to contain a relatively large amount of fat.
Once it has developed, heartburn will be aggravated by taking cream or olive oil. The most rationalcurative measuresthen consist in diluting the acid by drinking a couple of glasses of water and in counteracting (neutralizing) the acid by taking a teaspoonful of baking soda (bicarbonate of soda) or a tablespoonful of limewater; and, if necessary, either of these doses may be repeated. Patients often adopt the very sensible habit of carrying with them a block of magnesium carbonate, which they nibble whenever the symptom appears.
FLATULENCE.—The distention of stomach and intestines with gas, technically called flatulence, may be associated with heartburn or appear independently. The gas arises from the action of bacteria upon the food. There can be little doubt that flatulence occurs so regularly during pregnancy because the pressure of the enlarged womb prevents the contents of the intestine from moving along as rapidly as they have done previously.
To be relieved from this source of discomfort, it is necessary, in the first place, that the bowels should be regularly evacuated; very often nothing further is required than to overcome the habit of constipation. Occasionally, however, the diet must be arranged so as to exclude food which is likely to form gas. For example, parsnips, beans, corn, fried food, candy, cake, and sweet desserts, all of which are known to cause flatulence, should be avoided; in aggravated cases the allowance of starchy food of every kind should be cut down to small portions.
Since the production of gas in the intestine is due to the action of bacteria sometimes relief from flatulence is secured only after the administration of intestinal antiseptics. Drugs, however, will be prescribed by the physician, and will not be employed until the simpler hygienic measures have failed. Similarly, the physician should decide whether it is advisable for the patient to drink milk inoculated with harmless bacteria (The Bulgarian Bacillus) which has lately been placed on the market. The bacteria thus administered in the milk are antagonistic to the intestinal bacteria that produce gas, and consequently have been recommended for the treatment of flatulence. If this commercial product cannot be conveniently obtained, one may use instead tablets containing the bacteria, which can be supplied by druggists.
DEFECTIVE TEETH.—Unless suitable precautions are observed, the digestive disturbances of pregnancy have a tendency to injure the teeth. The regurgitation of the acid contents of the stomach, for example, may cause cavities to develop or may enlarge those that already exist. In all probability the damage done in this way—and not the removal of lime from the teeth for the formation of the child's skeleton, as some have thought—is responsible for the origin of the saying that "every child costs a tooth." This notion is of course absurd, yet it is quite true that toothache and the decay or loosening of the teeth are not infrequently associated with pregnancy. On this account, throughout the period of pregnancy particular care should be given the teeth.
One of the very first duties of a prospective mother, after she knows that conception has taken place, is to visit her dentist. This step is very important as a means of insuring the teeth against such harmful influence as pregnancy may have upon them. If the dentist finds the teeth in poor condition, the patient should consent to have them treated immediately. That this is the reasonable course seems sufficiently obvious, yet the majority of women have been slow to adopt such a view.
For a long time dental work of every description was incorrectly believed to have an untoward effect upon the development of the child; and the extraction of a tooth, it was thought, would surely be followed by miscarriage. Although the extraction of teeth is not frequently undertaken nowadays, I have known several prospective mothers who required the operation, and who had it performed without experiencing a single untoward symptom. Very naturally dental work should be restricted during pregnancy to that which is absolutely necessary, and temporary fillings generally suffice; but whatever is needed should be done without delay.
Brushing the teeth after meals and removing particles of food that may have been caught between them—important enough at all times—are of even greater importance during pregnancy. If the gums are sore and the teeth show a tendency to loosen, the best tooth-paste is one containing potassium chlorate.
An alkaline mouth-wash should be used several times a day; after an attack of vomiting it is always advisable to rinse the mouth with such a solution. As a wash either lime water or milk of magnesia, or a solution of bicarbonate of soda may be used; they are equally good. Lime water may be prepared at home inexpensively in the following way: Place a teacupful of builders' lime in a large bowl and add two quarts of water; thoroughly mix and allow to settle. Pour off and throw the water away, since it often contains impurities. Add two quarts of water again and allow the mixture to stand three or four hours, stirring occasionally. Strain through a piece of muslin into bottles and keep well corked. One tablespoonful of this solution should be added to a glass of water to obtain the proper strength for a mouth-wash.
PRESSURE SYMPTOMS.—Because human beings walk erect, and not on all fours, they are liable to suffer from various ailments of pregnancy that quadrupeds escape. Thus the upright posture is the chief factor, at least, in causing such complaints as swollen feet, varicose veins, hemorrhoids, and cramps in the legs. The attention of patients should be called to the source of these troubles, for in most instances they can be prevented by forethought and prudence.
During the last two or three months of pregnancy every prospective mother should carefully avoid being too much on her feet; she should lie down, as has already been emphasized, at regular times of day and frequently sit down to rest. Proper support for the abdomen, such as is afforded by a correct corset or a maternity supporter, lifts the pregnant uterus, and to a notable extent relieves of pressure the structures beneath it. On the other hand, incorrectly made corsets, the use of circular garters, and running a sewing machine by foot- power all aggravate the pressure symptoms of pregnancy.
Swelling of the Feet.—So long as the swelling is confined to the feet and legs it does not mean that there is trouble with the kidneys; the swelling is satisfactorily explained by the pressure of the enlarged uterus upon the veins which pass through the lower part of the abdomen and conduct the blood from the legs on its way back to the heart. The womb is rarely heavy enough during the first half of pregnancy to interfere with the flow of blood through these vessels, but in the last few months such interference is very common.
Generally the limbs are equally affected, yet occasionally the swelling is more marked on one side or the other. The characteristic changes begin in the feet. The skin covering the back of the foot becomes tense and has a waxen appearance; it is easily indented, bearing for a moment the imprint of anything that is pressed against it. Often the swelling extends no higher than the ankles, but it may involve the calves, the thighs, or even the vulva, which is the region between the thighs.
If the swelling remains slight, no attention need be paid to it. But if it becomes extensive or painful, nothing will give relief except going to bed. Patients observe for themselves that the swelling lessens during the night, and from this usually learn that the proper treatment is rest. When it is absolutely impossible to remain in bed long enough for the swelling to disappear, the next best plan is to accept every opportunity, during the day, to sit down and prop up the feet.
Varicose Veins.—The distention of the surface veins of the legs, the condition known as varicose veins, is not a peculiarity of pregnancy. Anyone who must be on his feet a great deal is liable to suffer from this ailment. It is true, nevertheless, that pregnancy increases the likelihood of the development of varicose veins. The walls of the vessel are generally able to withstand whatever strain is placed upon them during the first pregnancy, and usually the varicosed condition does not develop until after there have been several pregnancies.
As a rule, both legs are similarly affected, but if only one, it is more likely to be the right. This is explained by the fact that the position of the child within the womb is ordinarily such as to cause greater pressure on the vessels of the right side. For the same reason when the legs are unequally affected, generally the veins of the right side are the larger. In any case, however, the birth of the child removes the source of the interference, and during the lying-in period, provided that the patient remains quiet for a sufficient length of time, the vessels regain their normal caliber. Once they have been distended, however, the veins remain more susceptible to engorgement. Consequently, in order not to increase the strain these vessels naturally bear during the latter months of pregnancy, the precautions just mentioned for the avoidance of all the pressure symptoms should be strictly observed. Upon the first intimation that the veins are becoming dilated, a patient should be unusually careful to keep off her feet all that she can. Only in extreme cases will it be compulsory to go to bed. But, if the veins are large and painful, she should stay in bed until material improvement has taken place. Subsequently she should wear a flannel bandage, snugly applied, about the leg from the toes to a point somewhat above the knee; the bandage should extend higher whenever the veins of the thigh also are dilated. In putting on the bandage the heel may be left uncovered; after leaving the foot a turn of the bandage will be taken around the ankle and thence applied upward. A flannel bandage may be easily made at home. Bias strips are cut about three inches in width and sewed together end to end so that the joining will lie flat. Unless the bandage must extend far above the knee, eight yards will be a sufficient length.
Elastic stockings, which may be purchased from a druggist, serve the same purpose as the bandage, but are very much less durable. Even if worn during the day they should be taken off at night; and when protection of the veins is required after going to bed, the bandage is the most sanitary way of securing it.
The danger that one of the vessels will break may be disregarded, if they are constantly protected by the measures that have been mentioned. In the event of accident, however, make firm pressure over the bleeding point with a freshly laundered handkerchief, and apply an ice bag outside the dressing until the doctor arrives.
Hemorrhoids.—Hemorrhoids are caused in the same way as varicose veins of the legs. The two conditions differ merely in point of location; but hemorrhoids, on account of their location, are much more exposed to irritation.
Although the development of hemorrhoids cannot always be prevented, it is a well-known fact that constipation renders the chance of their appearance much greater. In a measure, therefore, regular, daily evacuation of the bowels serves to prevent the ailment, and also to cure it, once it has developed. But walking and even standing aggravate hemorrhoids. The recumbent posture, as might be expected, is of itself frequently enough to give relief. It is much more likely to do so, however, if the hips are elevated by placing a pillow under them.
In severe cases it is helpful to restrict the diet for a few days until the congestion and acute suffering have subsided. If the hemorrhoids protrude, they should be replaced (which the patient may generally do for herself), and an ice bag should be applied to the seat of pain. Various ointments and suppositories of different composition are valuable in the treatment of this ailment, but, as not all cases are relieved by the same medicine, a physician should be consulted to learn what is most suitable in any given instance.
Hemorrhoids often grow progressively worse as pregnancy advances, and are frequently aggravated immediately after the birth of the child; but they generally disappear within a few weeks. Whenever a natural cure is not thus effected, it may become necessary to resort to surgical treatment. Operative procedures, however, should not be undertaken during pregnancy, since the condition is likely to reappear before the child is born.
Cramps in the Legs.—There are nerves as well as blood vessels that the pregnant uterus may press upon, and pressure of this kind may cause pain. At times the pain is definitely localized at the point where the nerve is pressed upon; under these circumstances the discomfort is felt in the lower part of the back. On the other hand, the pain may be referred to the point where the nerve ends. In this way is explained not only pain in the leg but also those sensations of numbness and tingling which prospective mothers not infrequently complain of. The presence of these pressure symptoms is usually limited to the last few weeks of pregnancy. They often begin about the time the child's head enters the bony canal through which it is ultimately born; engagement of the head, as this is called, occurs simultaneously with the dropping of the waist-line, that is, about two or three weeks before delivery. From the time the head is engaged all the pressure symptoms become somewhat more intense.
From the very nature of their causation, it is clear that cramps in the legs are difficult to treat. The recumbent posture lessens the discomfort, and, if in addition the hips are elevated, absolute comfort will occasionally be secured. Whether or not the administration of medicine is advisable must be determined by the physician who has the opportunity to see the patient. The birth of the child, of course, removes the cause of the pressure and permanently relieves this discomfort.
Shortness of Breath.—Besides the ailments caused by the downward pressure of the pregnant uterus, there are also symptoms due to its upward growth. Thus shortness of breath is regularly noted toward the end of pregnancy, and, as has already been mentioned, it is one of the reasons for exercising leisurely.
Unlike the other pressure symptoms, shortness of breath is ordinarily aggravated by the recumbent posture, for lying flat on the back increases the compression of the chest. At night, which is frequently the time when difficulty in breathing is most pronounced, the patient may, if necessary, sleep propped up in bed. For this purpose an appliance called a back-rest may be used, but an extra pillow under the head and shoulders is usually sufficient.
LEUCORRHEA.—The meaning of the white discharge from the vagina known as leucorrhea is variable: at times it indicates the existence of an ailment requiring treatment, and at other times it does not. To be on the safe side, therefore, anyone who is troubled by leucorrhea should obtain her physician's opinion as to its significance.
Normally, as we learned in Chapter V, there is an increase in the vaginal secretion during pregnancy; but this fact is rarely noticeable until the latter months. Usually it is pronounced only during the last few weeks. At that time, owing to its antiseptic qualities, this pale white fluid should not be disturbed by the use of douches. In the early months of pregnancy, however, leucorrhea may cause such inconvenience as to demand medical treatment.
While itching is the most disagreeable effect of such a vaginal discharge, it should be known that itching is not always due to leucorrhea. Thus it may be caused by a highly concentrated urine, and in that event will be relieved by drinking a larger amount of water; or it may be due to the presence of unusual constituents in the urine. Skin diseases also cause itching; and light haired people, since they have more delicate skins that brunettes, are especially susceptible to these ailments. To such skin affections soap and water may be very irritating; so that when they exist it is often advisable to cleanse the parts with olive oil. In other cases, ointments are required and will be prescribed by the physician.
Itching of the skin over the extremities or over the whole body, it is clear, cannot be attributed to leucorrhea, but in these very rare cases the irritation would seem to be caused by some waste product which is being eliminated through the sweat glands. We do not know what the substance is, but, as the symptom appears so seldom, it must be due to an unusual kind of waste product or else to one whose elimination normally occurs through other channels. The affection of the skin thus brought about is really a very mild kind of poisoning, and since the offending substance arises in the body of the patient herself the condition is called an autointoxication. Effective treatment consists in drinking water freely and taking a cathartic, for the one stimulates the kidneys and the other the bowels to assist in getting rid of the cause of the trouble.
TOXEMIAS.—In order to understand what are known as the toxemias of pregnancy, we must remember that the nutrition of our bodies involves three separate and distinct sets of processes. What we eat is, in the first place, digested and absorbed into the body; secondly, the products of digestion are utilized by the tissues; and, finally, the waste material is thrown off from the body. Any one of these processes may be carried out in a way that is not consistent with health. Most of us realize that disturbances may occur in the course of digestion, and we are also aware that the excretory organs occasionally fail to do their work in a satisfactory way. But what laymen, perhaps, do not appreciate is that the intermediary steps— between the time when the food is absorbed and the time when the waste material is finally eliminated—may not be taken precisely as health requires. Of course, any person may be the subject of one or another of these nutritional disorders, but unquestionably such disorders are somewhat more frequent during pregnancy than at other times. Nor is this difficult to understand, for the nutritional processes of two beings are here linked together. They generally proceed harmoniously, but if they do not there results an autointoxication of the mother which is called a toxemia.
Such toxemias, with extremely rare exceptions, do not occur in the early months, but are associated with the period of the active growth of the fetus, namely, the second half of pregnancy. For this reason, and for some others which do not concern us here, it seems probable that the nutritional processes of the child are primarily responsible for these ailments. This view, however, must be somewhat modified, for experience has clearly taught that the efficiency with which the maternal excretory organs do their work has a great deal to do with the effect that the fetal waste products have upon the mother. On this account she has been urged to pay attention to personal hygiene. It is also necessary, however, that she should become acquainted with the symptoms which give warning that the excretory organs are acting imperfectly.
Autointoxication can almost always be prevented. The means of prevention are neither mysterious nor difficult to carry out; they lie within the power of every prospective mother, for they consist merely of what has already been discussed, namely, the intelligent regulation of the diet, the care of the body, and a correct ordering of the daily life. To the chapters dealing with these subjects reference should be made and particular attention should be paid to what has been said concerning:
(1) Wearing suitably warm clothes, (2) Bathing regularly, (3) Taking a proper amount of exercise, (4) Drinking water liberally, (5) Avoiding an excessive quantity of meat, (6) Guarding against constipation.
At present the value of prevention in the treatment of the toxemias of pregnancy is so clearly recognized that charitable organizations employ nurses to visit women of the poorer classes during pregnancy in order to instruct them about the measures that I have just indicated. Remarkable results have already been obtained. In one clinic where this method has been adopted the frequency of all kinds of toxemia, I am told, has notably diminished, and serious types are not permitted to develop. Similar results should be obtained in private practice when patients place themselves under medical supervision at the beginning of pregnancy. Under these favorable circumstances symptoms of autointoxication probably occur not oftener than once in every hundred pregnancies, but nine out of ten of them, being promptly recognized, yield readily to relatively simple treatment.
The early detection of such complications depends largely upon the patient herself. As has been emphasized—and it cannot be said too frequently—she should not fail to submit, at appropriate intervals, a specimen of urine for examination. It is by such an examination generally that the development of a toxemia is first detected. Occasionally, however, significant signs will attract the patient's attention before there is any change in the urine. For that reason, it is important to notify the physician if any of the following symptoms appear:
(1) Serious vomiting. (2) Persistent headache. (3) Dizziness. (4) Puffiness about the face. (5) Blurring of vision, or the appearance of black spots before the eyes. (6) Neuralgic pains, especially in the pit of the stomach.
It must be clearly understood, however, that any of these symptoms may be present without indicating that a toxemia is developing. Nevertheless, they should be brought to the physician's attention without delay, and, at the same time, a specimen of urine should be given him for examination.
Although the kidneys are not responsible for all the toxemias of pregnancy, an analysis of the urine affords the most definite means of determining whether or not such a condition is present. When thus detected, prompt treatment will guarantee to the patient almost certain relief. On the other hand if, as usually happens, the analysis shows conclusively that there is nothing serious the matter, this reassurance fully justifies the trouble taken to secure it.
Frequency—Causes and Prevention—Habitual Miscarriage—WarningSymptoms—After-effects—Criminal Abortion—Therapeutic Abortion—Premature Delivery.
We have learned that forty weeks are required for the full development of the human embryo, but this fact carries no assurance that pregnancy will last so long; in reality, it may end abruptly at any time. If growth is interrupted before the twenty-eighth week (the seventh lunar month), the infant will be too immature to live. Even when born alive, it will usually perish within a few hours, or a few days at most. Children born during the seventh month have occasionally survived; but the prevalent belief that they are more likely to do so than if born a month later is erroneous. That superstition originated at a time when great virtue was ascribed to numbers. Since seven was a sacred number, it was considered more auspicious to be born in the seventh month than in the eighth. Universal experience, however, teaches us that the likelihood of rearing a premature child is, by a rapidly increasing proportion, the greater for every week that it remains within the uterus. This is precisely what we should expect, for the period of its existence there measures the perfection of its development; and that, under ordinary conditions, determines how strong and hardy the child will be.
Although during the first six months the outlook for the infant will be equally unfavorable at whatever time pregnancy may be interrupted, physicians prefer to distinguish cases which terminate in the earlier part of this period from those which terminate in the latter part. For technical reasons, the sixteenth week represents a natural point of division. A birth which takes place before that time is called an abortion; one which takes place between the sixteenth and the twenty- eighth week is called a miscarriage. The anatomical reasons which justify such a distinction do not concern us here, and the matter deserves mention merely because the same terms are often employed in a very different sense by the laity. As most of us know, the interruption of pregnancy results sometimes from purely natural causes, and sometimes from the employment of artificial means. As a rule, persons who are unacquainted with medical terminology call a birth of the former kind a miscarriage, and reserve the term abortion for an interruption of pregnancy that is deliberately provoked. Physicians, however, make no such distinction. They use these words, as I have said, simply to indicate how far development has progressed before the termination of pregnancy. Since the term abortion is apt to carry with it the implication of a criminal act, confusion will be avoided if we agree for the time to depart from strictly medical usage and designate as miscarriage the spontaneous termination of pregnancy prior to the twenty-eighth week.
FREQUENCY.—Early interruption of pregnancy is extremely common. Some sociologists declare that it is becoming more and more frequent, and see in it a grave national danger. French statesmen attribute the alarming decline of the birth-rate in their country, in great part, to a rapid increase in the number of pregnancies which end prematurely. Reliable English and German statistics indicate that of the pregnancies which come under the observation of physicians approximately twenty per cent, end in miscarriage. In our own country, though extensive and complete data are not available, it is likely that the incidence is equally high.
The actual frequency of miscarriage is generally underestimated. Patients themselves often do not know what has really happened. When the accident occurs a few days after conception, bleeding may be its only evidence, which will almost certainly be misinterpreted as an irregularity of menstruation; and professional advice will not often be thought necessary. Moreover, in other cases in which the true situation is appreciated the patient does not feel sick enough to seek medical assistance. If it were possible to include in the statistics all these cases as well as those which are concealed because intentionally provoked, the frequency with which pregnancy is interrupted during the early months would be found somewhat greater than is usually supposed.
If we omit the miscarriages which occur within the first few weeks of pregnancy, and which consequently often escape detection, the majority of cases fall within the second and third months. After the fourth month has passed, the probability of such an accident, though not excluded, is greatly diminished. Some statistics recently published by Taussig make this clear. In a series of several hundred cases of miscarriage, one hundred and fifty-seven instances occurred in the second month, two hundred and twenty-two in the third month, seventy-three in the fourth month, thirty-seven in the fifth month, and five in the sixth month. This order of frequency might be anticipated from the anatomical conditions which prevail during the early months of pregnancy, since the attachment of the embryo to the mother is at first relatively insecure, but gradually grows firmer, and becomes as secure as it ever will be by about the fifth month.
It is noteworthy that miscarriage occurs much less commonly in the first than in subsequent pregnancies. Indeed, a somewhat greater liability to the accident with each succeeding pregnancy goes far toward explaining the greater frequency of miscarriage among women who have passed the thirty-fifth year than among those who are younger.
CAUSES AND PREVENTION.—We have seen that the proportion of pregnancies which end in miscarriage is quite formidable. But this should not be true, as the accident is frequently preventable, and many of these accidents could be avoided by the cooperation of patients. As self-denial and personal inconvenience are often essential, it is only fair to explain their value. Furthermore, the, patient who appreciates the reason for certain directions the physician gives becomes responsible to herself, and is much more likely to carry them out than is one who is cautioned without receiving a satisfactory explanation. At best, however, the advice which the physician is able to offer will be imperfect, for it must not be imagined that everything is known concerning the causation and prevention of miscarriage. While our knowledge is so imperfect we must be content to make the most of what we possess. It must be added that no suggestion such as can be given here will enable anyone to dispense with her own medical adviser. On the contrary, if there is reason to fear miscarriage, the prospective mother should be encouraged to seek his counsel as early as possible. Aside from the hygienic measures which she may learn to carry out for herself, various drugs are often of great value in preventing miscarriage. Since these are not applicable to all cases, they should be employed only upon medical advice.
Very early miscarriages may be explained by the loose attachment of the ovum during the first six weeks of pregnancy. This tiny, living sphere, it will be recalled, reaches the womb a few days after conception, and adheres to the uterine mucous membrane. At first, however, its roots are short and delicate, and not so capable of anchoring the ovum as they become later. It is only toward the end of the eighteenth week that the union between the womb and its contents becomes firm.
From what we have learned in Chapter II regarding the anatomical conditions in the early days of pregnancy it is obvious that we need not be greatly surprised at the frequency of miscarriage. On the other hand, it must not be forgotten that there are many natural safeguards against accident: to mention only one, the uterus is ingeniously swung in the abdominal cavity so as to afford a large measure of protection against mechanical shock. Usually, the provisions nature has made are sufficient to resist forces from without which tend to dislodge the ovum. Now and then it happens that the most irrational acts will not interrupt pregnancy; indeed, they often seem particularly inert when practised intentionally.
Fear of loosening the ovum from its uterine attachment prompts experienced women to caution prospective mothers against any kind of sudden or violent effort. Their advice, however, is often needlessly alarming; a great many traditional precautions lack a reasonable basis. Thus, no harm can possibly result from sleeping with the arms above the head; nor from "over-reaching," as when hanging a picture, though a fall under such circumstances might be dangerous.
Patients who have been warned by one experience should always be on their guard if they would avoid repeated miscarriages; others need only lead a sensible, hygienic life, a matter we have already discussed in the chapters dealing with the care of the body and the way to live. For the sake of emphasis, I may here repeat that no prospective mother should become fatigued from any cause; sweeping, moving heavy furniture, lifting heavy articles, and running a sewing machine are not to be attempted. But household duties which do not require strong muscular effort are better assumed than not.
Amusements which may cause jolting, or expose one to the danger of falling, involve some risk of miscarriage. Short rides in a carriage or an automobile over smooth roads are free from objection. Railway- travel and sea-voyages are not advisable in the early months; after the eighteenth week they may be undertaken with a greater degree of safety, provided comfortable accommodations are assured, and the patient has never had a miscarriage.
A few physicians, even at present, attribute the interruption of pregnancy to strong emotions, including intense joy or sorrow, anger, fright, or even jealousy. Without denying altogether the possibility of such an influence, we may be sure that its importance is greatly exaggerated. It is not unusual to see patients who are able to recall a mental shock of some kind shortly before the miscarriage occurred; nevertheless, in such cases diligent search will usually reveal a physical cause for the accident.
Another popular fallacy relates to the effect of drugs upon pregnancy. The use of castor oil and other strong purgatives do not interrupt it. Should the administration of any cathartic be followed by miscarriage, some fault inherent preexisted in the pregnancy, and no amount of precaution would have enabled the patient to reach full term successfully. Quinin in tonic doses may be taken with impunity, and even larger quantities are being constantly used for the cure of malaria without doing the pregnancy any harm. Many other drugs are reputed to have great efficacy in causing the expulsion of the product of conception; unfortunately, they are too well known to require enumeration. They are usually unreliable, and are absolutely inefficient in doses small enough not to endanger the mother's life, provided the pregnancy is a healthy one.
Instances in which miscarriage is attributed to the use of some drug are quite common, and we cannot dismiss them without a word of explanation. Such cases generally fall into one of two classes. Often a drug is given credit for efficiency where conception has been erroneously suspected. Shortly after the menstrual date passes, some medicine is resorted to, and the subsequent phenomenon, regarded as the interruption of pregnancy, is really no more than normal menstruation. In another group of cases miscarriage does actually occur, although the medicine employed plays only a minor role in its production. In such instances the irritation which the drug occasions is the last link in a chain of events leading up to the miscarriage, but the main factor lies in some fundamental imperfection in the pregnancy. Physicians recognize a variety of these imperfections, and know that they may be located in the womb, in the embryo, or in the tissues which unite the one with the other. As an intimate knowledge of pathology is often necessary to recognize the underlying, and therefore the actual, cause of the miscarriage, it is not at all surprising that patients frequently err in their interpretations of such accidents, and emphasize unimportant matters.
It would lead us too far afield to attempt to discuss every cause of miscarriage. Nevertheless, there are some very important ones, not yet mentioned, which should be understood by the laity, as appreciation of their significance may avert trouble. In some instances, on the other hand, the accident is unavoidable; to know this should afford the patient a large measure of comfort.
Irregularities in the position of the womb are often responsible for miscarriage. Such a condition may exist in women who have not borne children, but it is far more likely to occur as a result of childbirth. After delivery, the enlarged womb becomes the seat of intricate changes, the purpose of which is the restoration of the organ to the condition which existed before conception. It dwindles in size, and gradually drops to its accustomed location within the pelvic cavity. Six weeks are usually required for these changes.
At the time of birth it is impossible to predict whether the womb will finally resume a satisfactory position. Accordingly, an examination two to four weeks later is essential. In four out of five patients the organ will be found in its proper location, but, even though it is not, suitable measures adopted at once will generally serve to replace and hold it in good position. On the other hand, if the malposition is not recognized until months or years later, simple procedures will prove inefficient, and a surgical operation will become necessary. Were there no other reason for a careful examination at the end of the lying-in period, it would be amply justified by the information which it gives relative to the position of the uterus.
Although there can be no doubt that the routine correction of uterine displacements shortly after labor would go far toward restricting the occurrence of subsequent miscarriage, it would be incorrect to leave the impression that miscarriage will always occur if the uterus is out of its normal position. Not infrequently the changes wrought by pregnancy will cause the uterus to right itself spontaneously.
Another important cause of miscarriage consists in abnormalities in the lining of the uterus. Through inherent defect or acquired disease this tissue may become unsuited for anchoring or nourishing an ovum. In either event, a surgical procedure, known as curettage, affords the most likely means of restoring it to a healthful state. The operation removes the old lining; and a new one quickly develops, which is often more capable of fulfilling the purpose for which it is intended.
An appreciable number of miscarriages depend upon conditions over which medical skill has no control. Under such circumstances, though the accident may be regretted, there is no room for remorse or censure. Often the embryo should bear the blame; if its development is imperfect or if it dies, miscarriage usually occurs very promptly.
We are familiar also with a few maternal conditions which seriously affect the embryo, often seriously enough to cause its expulsion, alive or dead. In this respect, certain constitutional disorders are preeminent. Bright's disease and diabetes are prejudicial to the development of the embryo; women suffering from either of them must be watched with great care. Occasionally, such pregnancies come to a premature end in spite of every precaution. Various infectious diseases, as typhoid fever and pneumonia, also are fatal to the embryo if the causative bacteria pass into it. Fortunately this rarely happens, since the placenta generally affords an effectual barrier to their entrance into the embryo. Organic diseases of the mother's heart also may bring about miscarriage. A patient thus affected should place herself under the supervision of a physician as soon as conception is suspected.
Now and then physicians are completely at a loss to explain cases of miscarriage. Our ignorance is unfortunate, particularly when repeated miscarriages have occurred and their causation cannot be detected.
HABITUAL MISCARRIAGE.—Experience teaches that women who have had one miscarriage must be more careful than other prospective mothers if they would escape a repetition of the accident. Persons who know themselves to be subject to miscarriage should regard no precaution as too burdensome. Not only should they avoid motoring, driving, railroad journeys, sea voyages, and every kind of strenuous exertion, they must accept every opportunity to be quiet and rest. Often such hygienic care yields sufficient protection; but occasionally medicine is also necessary.
A number of causes are at hand to explain habitual miscarriage, but, in fairness, it must be acknowledged that physicians are not able to interpret all cases. With one class of patients the muscle fibers of the womb are peculiarly irritable, whereas in another its lining proves incapable of firmly anchoring the ovum. Moreover, derangements of organs which do not belong to the reproductive group may be responsible for the habit.
It is a curious fact that the accident is most likely to occur when menstruation would be expected were the individual not pregnant. Obviously, extraordinary precaution is advisable at such times, and if the patient would avoid even the slightest risk, she should not leave her bed. The same purpose will not be served by sitting quietly in a chair, nor by reclining on a couch; complete relaxation and composure are secured only when one lies flat on the back, loosely attired in sleeping garments. I have known several persons with a tendency toward miscarriage who overcame it in this way. Recently one of them who had been delivered prematurely on two former occasions, and who was anxious for a successful issue to her third pregnancy, was willing to remain in bed practically the whole period of gestation. She had her reward; a well-developed infant was born at full term, and has continued to thrive.
Prolonged rest in bed, some will say, is debilitating. While that may be true to a degree, untoward effects can always be avoided by systematic massage of the extremities. The abdomen should not be subjected to such manipulations, for they will occasionally provoke painful contractions of the uterus and defeat the purpose of staying in bed.
Patients who are not disposed to undergo a long period of enforced rest, no matter what profit may be promised, should at least consent to keep in bed during that period of pregnancy at which a previous miscarriage took place. We know that the event is particularly apt to recur at such a time. Specifically, it is important to remain in bed one week before and one week after the date in question.
When pregnancies follow one another in rapid succession, the liability to miscarriage is notably increased. A natural interval between births has been provided, an interval which depends upon the mother nursing her child. Ideally, menstruation, and with it the ripening of the ova (egg-cells), does not occur while the breasts are active; but when the infant does not suckle, the ovaries regularly resume their function in a very short time. Since the circumstances attending miscarriage always deprive the mother of the opportunity of nursing, another pregnancy may quickly ensue unless these facts are appreciated.
Those who anticipate the possibility of a premature interruption of pregnancy should realize that the marital relation is inadvisable after conception has taken place. For others, who have no reason to expect irregularity in the course of pregnancy, such a precaution is unnecessary. None the less, women who marry late in life or who first conceive toward the time of the menopause will do well to follow the same rule. The risk of accident may be very slight, but conservative persons will not assume it when the likelihood of subsequent conception is doubtful.
Not infrequently the fundamental reason for habitual miscarriage lies in some anatomical abnormality which a surgical operation alone can correct. As the necessity for interference can be determined only after a careful examination, recommendations of wide application are not possible. Nothing short of painstaking study of each case will afford a basis for advice and action.
SYMPTOMS.—Very definite warning usually precedes a miscarriage, but the threatening symptoms vary greatly in severity and duration. If appropriate measures are taken promptly, these symptoms may disappear with no harmful result Everyone concedes that bleeding and pain are the chief indications of impending miscarriage, although an occasional patient, profiting by former experience, may find other signs prophetic in her own case.
Mature women, accustomed to the regular monthly function of their sex, are prone to treat with indifference a slight discharge of blood occurring during pregnancy. Indeed, it is widely believed that menstruation frequently continues after conception. In point of fact, however, it is very unusual in early pregnancy, and becomes entirely impossible after the fourth month. Accordingly, whenever vaginal bleeding is noticed, some other explanation should be sought; and the patient who would adopt the wisest plan should assume that she is threatened with miscarriage. There are other possibilities, but these are for her doctor to consider.
It is true that small hemorrhages are not necessarily followed by miscarriage. One may even experience slight loss of blood repeatedly, and yet give birth to a healthy child at the natural end of pregnancy. None the less, bleeding, however moderate, should always excite suspicion, as we know it usually denotes the breaking to some degree of the connection between mother and child. The extent of the separation usually determines the degree of the hemorrhage, which in turn indicates the seriousness of the accident. The fate of the fetus will depend upon the area of placenta, which has been incapacitated. Flooding, however, always imperils the fetus, and generally warrants the inference that so much of the placenta has been separated as to render further development impossible. On the other hand, so long as the hemorrhage does not exceed the customary flow at the monthly periods, the life of the child is rarely endangered; while a chocolate-colored discharge, and even the loss of small clots, may continue indefinitely without doing serious harm. Under such circumstances, however, the patient should communicate with her medical adviser, and should save for his inspection whatever may be expelled.
Pain, the other conspicuous symptom of threatened miscarriage, has not a uniform significance. Since it frequently occurs during the course of pregnancy in association with a number of conditions, it is not a reliable sign of danger. Moreover, the susceptibility to pain varies; thus, of two patients in the same stage of threatened miscarriage one may suffer intensely, while the other remains comparatively comfortable.
Typically, the onset of miscarriage is attended by discomfort in the small of the back, which may be continuous, but more often is intermittent. If preventive measures are instituted at the outset, there is hope of relieving the discomfort and averting the miscarriage; but if the warning goes unheeded, the pain will gradually shift to the lower part of the abdomen and become more severe. It often happens that the cramp-like abdominal pain of threatened miscarriage is confused with that associated with intestinal indigestion. A simple test will sometimes decide the question. If due to the latter cause, the discomfort will usually yield to a teaspoonful of paregoric, whereas it will be without effect if miscarriage is imminent. Exceptions to this rule are not uncommon, yet a better one cannot be given; as a physician, even after considering the technical evidence, may find it impossible to decide at once whether or not miscarriage is threatened.
No confidence can be placed in many so-called signs of miscarriage, though implicitly trusted by the laity. Lassitude, depression of spirits, and general bodily ill-feeling may forecast the interruption of pregnancy; but more frequently they have no such significance. The same estimate holds true of other symptoms, including diarrhea and a persistent inclination to empty the bladder. Nor does fever always lead to the termination of pregnancy. A moderate rise of temperature is without significance; but high fever, persisting for several days, may result in the death of the fetus and subsequent miscarriage. Nevertheless, prolonged febrile affections, such as typhoid fever, frequently leave pregnancy unharmed.
So long as the symptoms are confined to slight bleeding and mild attacks of pain, physicians regard miscarriage merely as threatened. If the bleeding increases, the outlook becomes less favorable, and, as I have said, miscarriage is inevitable when it amounts to flooding. Likewise, rupture of the sack containing the fetus, with escape of the amniotic fluid, indicates that the culmination of events will not long be delayed.
The most favorable outcome is when the entire contents of the womb are spontaneously expelled, which unfortunately does not always occur. There is, to be sure, rarely any difficulty in the natural birth of the fetus, for its meager development prevents serious complications. The separation and extrusion of the placenta, on the contrary, are apt to be imperfect when pregnancy ends in the early months, and medical attention is necessary to determine whether the uterus has been emptied completely. This is particularly important, because the retention of placental tissue affords opportunity for several unpleasant complications; and neglect in this regard accounts in part for the belief that miscarriage is certain to leave women irreparably broken in health.
AFTER-EFFECTS.—No one will deny that invalidism follows the untimely interruption of pregnancy more often than the birth of children at full term. This is not due, as is sometimes said, to the fact that a miscarriage differs from a normal birth in that it is unnatural, for other reasons are apparent. One of them, the retention of placental tissue, has just been mentioned, but serious consequences resulting from it are almost inexcusable, for, although the placenta may separate less readily and be cast off less thoroughly after miscarriage, modern medical skill can successfully cope with such conditions. Another fruitful source of unfortunate after-effects is the imprudence of the patient. Women should remain in bed fully as long after a miscarriage as after the birth of a mature infant; if they would consent to do so, many ill-effects would be averted. But physicians frequently encounter strong opposition to precautionary measures such as this. Many patients argue, illogically, that less precaution is necessary since pregnancy failed to attain its natural conclusion, and infer that the earlier that it ends the more quickly one may leave the bed. In point of fact, even greater precaution is required than if all had gone normally. Still a third cause for ill- health may be found in physical ailments which antedated the miscarriage but were not recognized until after its occurrence.
Invalidism which follows pregnancy and which may be fairly regarded as chargeable to it depends, in most instances, upon an infection acquired at the time of delivery. Infection occurs more frequently when pregnancy ends during the early months, because in this category is included the great majority of criminal abortions, which are usually induced without regard for surgical cleanliness. Fatal complications, or serious consequences which narrowly escape a fatal ending, are common among women who attempt to rid themselves of an unwelcome pregnancy. As they are ignorant of aseptic precautions, their manipulations must necessarily contaminate the site of operation; for this reason and others as well women who attempt to perform an abortion upon themselves imperil their lives. The danger is scarcely less when abortion is induced unlawfully by incompetent operators; for lack of skill, the need of secrecy, and the desire of haste all interfere with necessary aseptic technique. Everyone knows that sad accidents befall those who submit to such operations; but it is not generally recognized that these cases are largely responsible for the ill-repute borne by miscarriage in general. On the other hand, properly supervised miscarriages are attended by no greater danger and probably less than delivery at full term.
CRIMINAL ABORTION.—The destruction of a pregnancy, except when its continuance threatens the life of the patient, is forbidden by law. The important ethical and religious aspects of the act which the law thus stigmatizes as criminal we may properly neglect. Although various religions present a diversity of teaching relative to its moral nature, all agree in regarding it as sinful. Equally important, however, is the fact that no matter what opinion anyone may hold as to the morality of the act he is bound to obey the law. This is apparently not clearly understood by the laity, for many persons think that a physician may terminate pregnancy whenever he is so inclined. If the liability to criminal prosecution which a physician would assume should he comply with a request for the means of destroying pregnancy were clearly realized, patients would not beseech him to incur the risk of heavy find and long imprisonment merely to gratify their own convenience or to save them from disgrace.
The Common Law, an inheritance from England, enriched with authoritative decisions by our own courts, is the groundwork of the law in all the States, and its principles are binding in the absence of express statutes. At Common Law, abortion is punishable ashomicidewhen the woman dies or when the operation results fatally to the infant after it has been born alive. If performed for the purpose of killing the child, the crime ismurder; in the absence of such intent, it ismanslaughter.The woman who commits an abortion upon herself is likewise guilty of the crime.
The great majority of those who desire the interruption of pregnancy feel they have not assumed an illegal position so long as they avoid instrumental procedures. That is not correct, for even at Common Law it is a misdemeanor to bring about the death of an unborn childby the use of drugs or by any other means.
At Common Law there was a difference of opinion as to whether all induced abortions were illegal. Many courts formerly held that quickening was a necessary prerequisite; but under the modern statutes, practically without exception, the law disregards the period of pregnancy at which the abortion is provoked. Since the time of conception determines the beginning of embryonic development, to prove that the act was committed before fetal movements were perceived is no longer a valid defense. This has been emphatically stated by Judge Coulter, of Pennsylvania, who said: "It is not the murder of a living child which constitutes the offense, but the destruction of gestation by wicked means and against nature. The moment the womb is instinct with embryonic life and gestation has begun, the crime may be perpetrated."
Each commonwealth has enacted its own statutes for the regulation of abortion. In many states, simplyto seek the means for destroying pregnancy is a criminal act. Thus, Indiana, perhaps the most progressive of the States in reconstructing its criminal code to accord with modern sociological teaching, has enacted a law which I quote from Burn's Indiana Statutes, Revision of 1908, Vol. I, page 1029. "Every woman who shall solicit of any person any medicine, drug or substance, or thing whatever and shall take the same, or shall submit to any operation or other means whatever with intent thereby to procure a miscarriage, except when done by a physician for the purpose of saving the life of the mother or child, shall, on conviction, be fined not less than ten dollars, and be imprisoned in the county jail not less than thirty days nor more than one year." To include the woman as a party to the crime is a signal mark of progress toward bringing abortion under effective legal control. Heretofore, the perpetrator alone has been responsible, and in most States he remains so, while the woman is regarded as a victim. Clearly, that is unjust, for criminal abortions are rarely, if ever, performed without application by the subject of the operation. According to most of the statutes no distinction is made between the attempt at abortion and its accomplishment. Irrespective of the outcome, those who supply drugs or employ instruments purposing the destruction of pregnancy are guilty of the offense.
An extensive analysis of the various State laws is unnecessary; the mention of a few statutes, selected from different sections of the country, will suffice to indicate the character of prevalent legislation. Massachusetts imprisons those found guilty of abortion for a period of three years or less, and permits a fine of one thousand dollars. In Pennsylvania the same prison sentence is imposed, though the fine may not exceed five hundred dollars. Three years is the minimum imprisonment in Virginia, and a maximum of ten years is allowed. Colorado's law duplicates that of Massachusetts. California imposes no fine, and prescribes a sentence of from two to five years in the State prison. All the statutes make the offense much graver when the woman dies as a result of the practice. Under these circumstances, the crime never takes lower rank than manslaughter; and generally it is murder.
Evidently we possess sufficiently stringent laws regarding criminal abortion; yet, as everyone knows, they do not prevent perpetration of the crime. On good authority, we are informed that eighty thousand unlawful abortions are performed annually in New York, in spite of a possible penalty of four years in the State prison. This is due in part to difficulty in securing evidence and failure to prosecute when evidence could be gathered, but more particularly to the fact that the general public does not appreciate the gravity of the offense. The same feeling is illustrated in the advertising of abortifacients. Newspapers and magazines unhesitatingly carry, under the guise of remedies to regulate the health of women, notices of drugs and equipment intended to destroy pregnancy. This is expressly forbidden by many statutes. [Footnote: Thus, the Maryland law provides that "any person who shall knowingly advertise, print, publish, distribute or circulate any pamphlet, printed paper, book, newspaper notice, advertisement or reference containing words or language or conveying any notice, hint, or reference to any person or to the name of any person, real or fictitious, from whom, or to any place, house, shop, or office, where any poison, drug, mixture, preparation, medicine, or noxious thing or any instrument or means whatever; or from whom advice, direction, information or knowledge may be obtained for the purpose of causing the miscarriage or abortion of any woman pregnant with child, at any period of pregnancy, shall be punished by imprisonment in the penitentiary for not less than three years, by a fine of not less than five hundred dollars, nor more than one thousand dollars, or by both, in the discretion of the court."]
The knowledge that prohibitory laws exist is sufficient to deter reputable physicians from illegal practice; whereas known laxity in the enforcement of the law continually tempts unscrupulous persons to provoke abortion. Among the poorer classes the procedure is undertaken by ignorant women, while persons in more comfortable circumstances avail themselves of the services of medical men who are usually incompetent and value money above professional honor. The net result is an unpardonable death-rate and a large proportion of invalids. Aside from the legal aspect of the act, the element of personal danger would seem a warning to be heeded by women who contemplate becoming a party to this crime.
THERAPEUTIC ABORTION.—If a woman is suffering from tuberculosis or some organic affection, pregnancy may add a serious strain upon the already crippled machinery of her body. Occasionally gestation itself may cause changes which threaten life. In either event the duty of the physician is plain. The law is acquainted with such emergencies, and explicitly permits the termination of pregnancy when undertaken to relieve or cure such conditions. When performed to restore health the operation is called therapeutic abortion.
The Maryland law, for example, grants the right to induce abortion whenever two or more physicians see the patient and agree that "no other method will secure the safety of the mother." Similar rules are prescribed by the statutes of other States, but none concedes the right of abortion as a means of keeping the woman from suicide.
Since therapeutic abortions are legal, they may be done openly; hence the operation is performed in appropriate surroundings and with every refinement of surgical technique. These fortunate conditions materially alter the outlook; serious consequences of the operation itself need not be feared. Competent surgeons, employing modern methods, may perform hundreds of abortions without the loss of a single patient. Moreover, pregnancy may be terminated safely and expeditiously at any time; the lay view which regards abortion as more serious after the second month than before it is a relic of days gone by.
PREMATURE DELIVERY.—In the introduction to this chapter we noted that the infant becomes viable after the twenty-eighth week, which marks in a practical sense, the transition of the fetus from an immature to a premature stage of development. In point of frequency, premature delivery ranks far below either abortion or miscarriage.
Unlawful interference with pregnancy generally proceeds from a desire to avoid offspring, and lacks incentive after the infant becomes capable of living independently. Criminal operations, therefore, are not a conspicuous cause of premature delivery. Occasionally physicians resort to artificial means to end gestation during the later months in order that organic complications may be relieved; but most premature births occur spontaneously. Sometimes they are due to ill-health, while in other instances no evidence of disease is found in either mother or child. Careful study of the individual patient, however, is generally helpful toward the prevention of repeated premature delivery.
The course of premature labor closely resembles delivery at full term. But it is shorter because the infant is small; and the subsequent loss of blood is not so great. The recovery of the mother is never retarded by the fact of earlier delivery, though the conditions which caused it may prevent rapid convalescence.