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Pregnancy





Maintenance of Health.--Women must keep up their normal health and
strength during pregnancy. By not taking sufficient exercise and by
being too much indoors, many women develop a morbid mental state in
which every discomfort is less bearable than it was before. Lack of
air and of exercise, furthermore, makes them prone to constipation,
makes their sleep less restful, and reduces the appetite. For the sake
of the being within them, they force themselves to eat, but this often
serves only to make them obese, without improving their general
health. If a woman in her ordinary condition, who was accustomed to
going out-of-doors several hours every day and having reasonable
diversion of mind and exercise of body, were to adopt the habits of
life that many pregnant women form, she, too, would become morbidly
introspective, fearful of the future, irritable over little things,
restless at night, and even have certain physical symptoms, such as
constipation, tired feelings, loss of appetite, etc. Many of the
discomforts and symptoms of which women complain during pregnancy are
really due to unfortunate habits and to their mental attitude toward
their conditions, rather than to any specific influence of pregnancy
on the general health. As a rule, women who live naturally are in
somewhat better physical health during pregnancy that at other times.


Obesity and Pregnancy.--It is important that women should not become
obese during pregnancy. The woman who is taking too much fat in her
diet and accumulating fat is likely to have a fat baby, and with these
there is more difficulty in labor itself, and the infants have less
resistive vitality than if they were unencumbered with useless adipose
tissue. Her will must overcome the tendency to lassitude and the
proneness to inactivity that comes over her, and she must feel that
labor and her condition after it are dependent on normal, healthy life
at this time.


Delayed Labor and Suggestion.--One phase of maternal impressions or of
suggestion for the mother's mind that I have always been interested in
has been that of the possibility of preventing delay in parturition by
frequent suggestion of the time that delivery should be expected.
There seems to be no doubt that expectation has some influence on the
time of delivery. We do not know just why, after the uterus has
tolerated the presence of the fetus for nine calendar months, it
should then refuse to do so any longer and contract and expel it. Any
number of theories have been suggested and even now our best
obstetricians are not agreed as to the reason for this action on the
part of the uterus. In some cases this contraction does not take place
normally. The due term of labor is past and as a consequence fetuses
grow too large within the uterus, greatly increasing the difficulties
of parturition and adding to the risk of both mother and child. It is
the custom to announce with pride the birth of twelve- and
fifteen-pound babies, but it is doubtful whether nature intended that
growth to this extent should take place before birth. There is in
this, as in other phases of pride with regard to children, a curiously
perverted feeling.

Many obstetricians feel that the babies who weigh much more than the
average of seven pounds have probably been delayed in the uterus for a
lunar month beyond the time when they should, or at least could have
been normally born. It is a question whether this delay would have
occurred if the mother's expectation of the birth had been directed to
a date a month ahead of that on which her mind became fixed as the
time of labor. Parturition usually takes place about the period of the
recurrence of the menstrual molimina, or at least of that monthly
cyclic feeling which many women experience, though there is no flow.
It is not always easy to say at which of two monthly periods the birth
should be expected. While physicians have warned patients of the
possibility of the child being born at the first of the two possible
periods, they have been inclined to dwell on the fact that it will
probably be delayed until the later term. Women themselves are more
prone to take the later than the earlier termination of their
pregnancy. Both physician and patient are timorous of the ridicule
that may follow if they make premature announcements. Whether we have
not in this way created a tradition tending to delay parturition by a
lunar month in many cases, is a problem that requires careful study.

The suggestion of as early a period as is compatible with the data
provided, so as to create a definite expectancy in the mother's mind,
seems well worth deliberate attention. This is a role that
psychotherapy has to play in lessening the dangers and the
difficulties of parturition. With most healthy women, as indeed with
most sensible normal women in life as regards all things, no
suggestion is needed and nature will take her course promptly and
properly. It is the nervous women, over-anxious about themselves,
often of lax physical fiber because of their nervous condition, that
need this phase of psychotherapy. It is in them that the unfavorable
or mistaken suggestion may be emphasized to such a degree as to delay
labor for a lunar month or even more.


Vomiting of Pregnancy.--One of the dreaded complications of pregnancy
is serious prolonged vomiting. We know now that this is of two kinds,
toxic and neurotic. The toxic variety may be associated with kidney
changes, but is more commonly the consequence of certain rare forms of
degeneration of the liver. The pathological picture after death is not
unlike that of phosphorus poisoning. These cases are due to some
serious disturbance of metabolism or to the absorption of some little
understood poison. They are probably always fatal. The cases of
neurotic vomiting are rather common. They are exaggerations, of the
ordinary familiar vomiting of pregnancy which is exhibited by nearly
all women at the recurrence of the menstrual times in the early
portion of pregnancy. In some of these cases, however, the vomiting is
so persistent and so prolonged that the patient's nutrition suffers
severely, and there seems to be danger of a fatal termination. The
condition has received the unfortunate name of "pernicious vomiting."
In these cases there is sometimes question of the advisability of
terminating the pregnancy lest the woman should die. Unfortunately
this question has been so commonly discussed that most prospective
mothers are likely to know something about it, so that when vomiting
begins they are fearful lest they should have to lose their child.
This becomes an obsession in some minds and an unfavorable suggestion
that helps to maintain the vomiting.

A number of remedies have been highly recommended for this at various
times. Nearly every alterative drug has had its period of popularity.
In the older time nitrate of silver was said to be efficacious. Small
doses of ipecac were highly recommended at one time. Small doses of
cocain were suggested, and the painting of the back of the throat with
cocain. Small doses of morphin had a vogue; codein had its turn after
its introduction, and heroin also had a time of popularity. Oxalate of
cerium was highly recommended. Any obstetrician of experience will
remember many other remedies that have been supposed to be
efficacious. Various gynecological procedures have been suggested: the
touching of the cervix uteri with a mild caustic, with iodin or with
nitrate of silver, slight dilatation of the cervix, sometimes the
application of a tampon with just enough glycerin to produce a
reaction, but not enough to terminate the pregnancy. Occasionally
local applications over the stomach region, a mustard leaf, or certain
plasters, or finally even a piece of sized paper bound on over this
region have been known to be followed by the cessation of the
vomiting. When as many different remedies are recommended and seem for
a time to be successful and then later prove to be inefficacious, it
is reasonably clear that it is not the remedies but the effect
produced by these on the mind that is the important therapeutic
factor.

Many obstetricians of wide experience now teach that most of these
cases of vomiting in pregnancy are merely neurotic and are to be
treated entirely as if they were hysterical. The patient's mind
is to be distracted from her condition; she is to be assured that even
severe vomiting is quite common in pregnancy, that it is annoying, but
never serious in its consequences, that it always ends without
unfortunate incident for mother or child, and that there need be no
solicitude. Above all, no hint of the possibility of the necessity for
the termination of the pregnancy, if vomiting continues, should be
given. Some physicians are entirely too solicitous in the matter and
have by their anxiety made the neurotic condition of their patients
worse. Some men see what they call a "pernicious vomiting" in every
hundred labors. A well-known obstetrician in New York has had 3,000
births without seeing a single case. He is known for his placidity and
lack of over-anxiety. In the great obstetrical clinics in Europe
vomiting to the extent that will put mother or child in danger is
extremely rare. The greatest obstetrician of the later nineteenth
century reports 100,000 obstetrical cases with only one artificial
labor.

In foreign obstetrical clinics these cases in recent years have been
treated expectantly, without any active interference, especially with
pregnancy, and the results have been much more satisfactory than any
other method of treatment. There are a number of cases on record now
in which pregnant women have lost from twenty to forty pounds as the
result of vomiting for weeks, yet after a time the attack has passed
and they have carried the child to full term. Where vomiting has
occurred and relief has once been afforded by the termination of
pregnancy, it is very unlikely that succeeding pregnancies will pass
without corresponding conditions in which no remedy will prove
effective, except the dreaded obstetrical intervention for the
termination of the pregnancy. It is extremely important then that
these cases should be treated conservatively and that from the very
beginning there should be nothing to arouse the patient's solicitude
with regard to herself or above all to give her any hint of the
possibility of obstetrical intervention being necessary in her case.
For some women the knowledge that a consultation has been held to
discuss such a possibility will of itself prove a persistent
unfavorable suggestion, that will surely prolong the vomiting.

This may seem a rather strong opinion from one who is not in practical
touch with obstetrics. It has been the growing opinion, however, among
the great German obstetricians for the last generation. Ahlfeld, in
the Archiv fuer Gynaekologie (Band 18 Heft 2 page 310) said that he
had seen [in a very large obstetrical practice] three cases of
so-called pernicious vomiting (unstillbaren Erbrechen) in all of
which the patients wanted an abortion because they had previously
learned the success of this method of treatment, but all of them
recovered without incident and carried their children to term. Kronig,
ten years ago, in his monograph on "The Significance of Functional
Nervous Diseases for Diagnosis and Treatment in Gynaecology"
[Footnote 36] said: "The excessive vomiting of pregnant patients has
for a long time seemed to be a genital reflex neurosis. We thought
that the growing uterus irritates certain nerve tracts which are
connected with the mucous membrane of the stomach. We owe it to
Kaltenbach that this opinion was overturned and hyperemesis
gravidarum set down as the result of a functional neurosis,
hysterical in character. A large number of gynaecologists have
accepted this opinion in recent years (men of all nations) among
others Calderini, Charpentier, Schaeffer, Klein, and Graefe."

[Footnote 36: Ueber die Bedeutung der Funktionellen Nervenkrankhelten
fuer die Diagnostik und Therapie in der Gynakologie von Dr. B.
Kronig. Leipzig, 1902.]


Winkel and the leading obstetricians of Germany, especially the
directors of obstetrical clinics in the large cities, must be quoted
as of the same opinion, since Winkel has collected the statistics of
100,000 pregnancies in the large German clinics in which 6,555
obstetrical operations were performed and in only one case was
artificial abortion produced. German opinion is rather strong in the
assertion that a number of cases of abortion in the practice of an
obstetrician indicates over-hastiness in coming to conclusions as to
danger, or leaves him open to the suspicion of yielding too readily to
the wishes of mothers who would prefer not to carry their children to
term. The suggestion of the possible necessity for abortion has done
much to make the hysterical vomiting of these patients continue until
this remedy is employed. Insistence from the very beginning that
vomiting, though it may injure both mother and child, never
necessitates abortion--one out of 100,000 cases is practically
never--would be the best possible contrasuggestion.

Kronig thinks that the vomiting of pregnancy is an especially
favorable subject for suggestive treatment. He inclines to the opinion
that the remedies that have been reported to do good and so many of
which have subsequently proved unavailing have really owed whatever
success they have had to the suggestion that went with them. Bumm, in
his text-book of obstetrics (Grundriss zum Studium der Geburtshuelfe
von Dr. Ernst Bumm, Wiesbaden, 1902), accepts Kaltenbach's and
Ahfeld's conclusions and thinks that the consideration of
hyperemesis as an hysterical neurosis is well supported by the
success and failure of our therapeutics. All sorts of remedies, any
number of drugs, all manner of gynecological procedures short of
abortion, though also including abortion, have been reported as doing
good. All of them even including abortion have failed in a certain
number of cases. Evidently suggestion plays a large role. Hypnosis
often proves an excellent remedy.


Excessive Salivary Secretion.--Bumm considers that the excess of
secretion of saliva which is so often noticed in pregnancy is of the
same nature and should be treated rather by suggestion than by any
particular remedy, though remedies should be tried because of certain
helpful physical effects, and then the psychic element that goes with
them. The less importance given to the symptom, the less attention it
attracts, the more its passing trivial character is emphasized, the
sooner it will subside. Solicitude causes it to persist and even
increase.





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Previous: Suggestion In Obstetrics



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