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.