University of Virginia Library

CHAPTER IX.
PREGNANCY.

Nature of Conception; Pregnancy Defined; Duration of Pregnancy; the Signs of Pregnancy; Quickening; the Determination of Sex at Will; the Influence of the Male Sexual Element on the Female Organism; Heredity; Hygiene of Pregnancy; Causes of Miscarriage.

Nature of Conception.--Conception, or impregnation, is the union of the germ and the sperm cell, the result of which is a new being. On coition, the semen being received into the female organs, which are at that time in a state of turgescence, the spermatozoa, by means of their own vibratile activity, find their way into the Fallopian tubes, and here come in contact with the ovule.

The ovule is a minute cell with a transparent membrane, within which is the yolk containing the germinal

vesicle. The spermatozoon penetrates into the ovule and becomes fused with it. The processes of development begin at once to occur. There is congestion of the uterine mucous membrane out of proportion to the rest of the uterus; the ovum finds lodging here, and becomes surrounded by a membrane which incloses it in a separate sac.

Pregnancy Defined.--Pregnancy begins with conception and ends with parturition; it provides for the nutrition and the expulsion of the embryo and for its nutrition for a short time after birth.

The average duration of pregnancy is ten lunar months, or two hundred and eighty days. The date of the confinement is calculated by reckoning from the date of the last menstrual flow; count backward three months from the date of the first appearance of the last menses; to this add twelve months and seven days, five days being for the average menstrual duration and two days for the possibility of fecundation.

Duration of Pregnancy.--Many difficulties are experienced in determining the date of the expected confinement. As most pregnancies occur in married women, we cannot base any calculations on a single act of coitus. And even if there was but one, all physiologists agree that there is a variable period in different women, and in the same woman at different times, between insemination and the fertilization of the ovum. It is the moment of fecundation, or the union of the germ and sperm cells, which marks the beginning of

pregnancy. The uncertainty becomes still greater owing to our inadequate knowledge as to the length of time during which the sexual elements, the ova and the spermatozoa, retain their vitality after liberation from their respective sources. While it is not certainly known, it is probable that the ovum is capable of impregnation any time during its sojourn within the oviduct and before reaching the uterus, or probably for a period of about one week from the time of its escape from the Graafian follicle. The remarkable vitality of the spermatozoa even under less favorable circumstances--direct observation shows that these elements retain their movements for over nine days outside of the body--renders it almost certain that their powers of fertilization are maintained for a long time after they are deposited within the healthy female genital tract; it is believed that the spermatozoa are capable of fertilization after a sojourn of three or more weeks within the oviduct.

Consideration of these facts renders apparent the impossibility of fixing with certainty the date of the beginning of pregnancy, since conception may result from the union of the ovum liberated at the beginning of the period with the spermatozoon introduced at the end of that time; or it may result from the meeting of the male elements already within the oviduct with an ovum discharged a day or two before the occurrence of the menstrual period.

The Signs of Pregnancy.--The cessation of the

menstrual period is the sign of the greatest value in women who have been regular; but it must always be remembered that there may be an irregularity of menstruation for the first few months after marriage. The appetite is capricious; morning sickness or nausea in the morning on first getting up is a very common symptom in the early months of pregnancy; enlargement of the abdomen; in the first two months of pregnancy the abdomen is flattened and the umbilicus is depressed; after this the abdomen begins to enlarge. There is also an increase in the size of the breasts, with a deepened color of their areolae and later a watery secretion. The external genitals become swollen and of a bluish color. Feeling of the fetal movements--that is, the movements of the small parts of the child in the womb--by the mother is not always reliable, since gas in the intestines has sometimes been mistaken for this. These signs are more valuable when several exist together.

The nausea and vomiting of pregnancy, the so-called morning sickness, consists of nausea accompanied often by vomiting or retching of a glairy fiuid, showing itself most frequently on rising in the morning, but sometimes appearing after breakfast. It is aggravated by the assumption of the erect position. It may begin within a few days, but as a rule it does not show itself until the fourth week of pregnancy; and it generally ceases about the fourth month, rarely persisting throughout the entire time. In the majority of cases it does not sensibly impair the health. It is a sympathetic

disorder reflected from the uterus; it is aggravated by indigestible food, by sexual excitement, and by emotional disturbances; it is most marked in first pregnancies and in women of highly emotional natures. It is not infrequently due to some inflammation of the uterus or erosion about the external orifice, and disappears on the removal of the cause.

Mammary Changes.--During pregnancy the mammary glands are in immediate sympathy with the growing reproductive organs of the pelvis; consequently a genuine physiologic enlargement commences in these organs from the beginning of gestation. Their glandular structure becomes larger, fuller, and firmer; a sensation of weight or pricking is felt by the patient; the veins become more prominent. The nipples also become enlarged, more elongated, and somewhat erect. Surrounding the nipple is the areola; this becomes darker in color.

In most women a drop of watery fiuid, the so-called colostrum, may be squeezed out from the nipple at the end of the third month of pregnancy.

The signs of pregnancy are divided into the presumptive, the probable, and the positive. The presumptive signs are: menstrual suppression, morning sickness, irritable bladder, mental and emotional phenomena. The probable signs are: mammary changes, abdominal enlargement, changes in the neck of the womb, and certain changes which are felt on bimanual examination. The positive signs are: feeling the various parts of the

fetus, active movements of the fetus, and hearing the fetal heart sounds.

Functional disturbances of the bladder are quite often noticeable in the early part of the pregnancy. In the first part of the pregnancy the bladder is dragged upon, and later it is pressed upon by the enlarged uterus so that the bladder capacity is lessened and frequency of urination is the result. In the fourth month, when the uterus ascends into the abdominal cavity, these bladder symptoms subside, until the very close of the pregnancy, when by the descent of the now greatly enlarged uterus there may be even incontinence of urine.

Changes in the Abdomen.--During the first two months of the pregnancy there is a flattening of the abdominal surface, due to the descent of the uterus into the pelvic cavity, thus slightly dragging the bladder downward and drawing the umbilicus inward. In the latter part of the fourth month there is noticeable a slight abdominal enlargement, and the umbilicus is no longer sunken. By the end of the fourth month the base of the uterus has risen two inches above the symphysis, and at the end of the thirty-eighth week it touches the lower extremity of the breast-bone; the umbilicus has been for many weeks protruding; during the last two weeks of pregnancy the uterus again descends and the woman feels more comfortable.

On the inspection of the abdomen of a pregnant woman there will be noticed a brown line which extends from the umbilicus to the pubes, and all over the surface

the presence of striae, or long purple grooves, due to the distention of the abdomen; on the sides of the abdomen and down the thighs, red, blue, or white markings, like cicatrices, may be seen.

Quickening.--Quickening is the sensation experienced by the mother as the result of the active fetal movements of the child in the womb. These movements are first felt between the eighteenth and the twentieth week; the common rule is that quickening occurs at the middle of pregnancy; that is, at four and a half months. As pregnancy advances these active motions increase in frequency and become more marked. When felt or seen by the physician, as can be done in the sixth month, fetal movements constitute a positive sign of pregnancy.

The Determination of Sex at Will.--Although this has always been a question of great interest, and the subject of much experimentation, no rule can as yet be given by which the parents can know in advance of the birth of the child what the sex will be. Dr. Schenck's theory is that the ruling factor in determining the sex is the food partaken of by the mother.

Furst believes that the differentiation may occur before, during, and a little while after the impregnation; that the chances of the development of one or another sex in one and the same woman may vary before final differentiation occurs. It is impossible to determine the sex of the embryo before the tenth week of fetal life. The cause of the differentiation, he believes, lies largely

in the good or bad state of the health of the parents; in the first instance there being an excess of females, and in the latter an excess of males, relatively speaking. He believes that there is an excess of male children when conception takes place during the post-menstrual anemia. He has investigated one hundred and ninety-three cases carefully in regard to the probable date of conception after menstruation, and there is a notable increase of male births over female in the cases where conception occurred in the first five days after menstruation; that is to say, where the woman is not so well nourished as later.

Dr. J. Griffith Davis gives as the result of her experiments in this direction, that when conception takes place three days before the menstrual period or within forty-eight hours afterward, the child will be a girl; when conception takes place ten days after the period, the child will be a boy.

Although there are a greater number of the female than the male sex in all parts of the world where reliable statistics have been taken, in all civilized countries the proportion of male births is greater than that of females. There is a greater tendency of the male offspring to die earlier, and this is seen even before birth, in the proportion of three to two. For this reason the stronger sex as applied to men has been regarded by some authors as a misnomer. They are physically weaker in early life and succumb more readily to noxious influences.

The relative age of the parents is said to be another

factor in determining the sex of the children. Seniority on the father's side gives an excess of male children; equality in the age of the parents gives a slight preponderance of females; seniority on the mother's side gives an excess of females. Men, and especially scholars, who pass a sedentary life and who exhaust their nervous force to a great extent, beget more girls than boys; so, also, a very advanced age on the part of the man diminishes the number of male offspring.

The Influence of the Male Sexual Element on the Female Organism.--Dr. Alexander Harvey, of Aberdeen, has adopted the theory of fetal inoculation. He believes that the effect is first due to the influence of the male element upon the ovum, which, in consequence of the subsequent close attachment and freely inter-communicating blood-vessels between the modified embryo and the mother, inoculates the condition of the mother with the qualities of the male; and so, on the subsequent impregnation by another male, the offspring resembles the first male and not its real parent. He even goes further, and says that it is conceivable, by successive impregnations effected by him, that the influence may be increased, and if so the younger children begotten by him, rather than the elder, might be expected, ceteris paribus, to bear their father's image. And as regards the mother, he suggests the question, whether there is not something in the popular notion that in the course of years the wife comes to resemble the husband; and that not merely in respect of

temper, disposition, or habits of thought, but in bodily appearance, which may be referable to this influence exerted by the husband on her constitution, through the medium of the fetuses in utero.

Darwin, on the other hand, considers it a most improbable hypothesis that the mere blood of one individual should affect the reproductive organs of another individual in such a manner as to affect the subsequent offspring. The analogy, he says, from the direct action of the foreign pollen on the ovaries and seed coats of the mother plant strongly supports the belief that the male element acts directly on the reproductive organs of the female, and not through the intervention of the crossed embryo.

Dr. John Brown, in reviewing the subject, says it must be conceded that the male element has an influence on the female, over and above its fertilizing influence upon the ovum. The limit of this influence is at present unknown.

Heredity.--Girls are more apt to resemble their fathers in mental traits, disposition, and constitution; while boys take after their mothers. Boys procreated by intelligent mothers will be intelligent; while it does not always follow that the sons of intelligent fathers

are intelligent. The poets Burns, Ben Johnson, Goethe, Walter Scott, Byron, and Lamartine were all born of women remarkable for vivacity and brilliance of language.

Hygiene of Pregnancy.--The health and perfection of the child depend largely upon the health and perfection of the parents at the time of its conception, as well as upon the condition of the mother during the pregnancy. Even when both parents possess a strong constitution, but one or both of them is suffering from a temporary exhaustion or malaise, the child will be born below the standard of health it ought to possess. Children born during the first year of married life seldom equal in health the children born of the same parents later; they are not only apt to be sickly, but the liability to premature death is greatly increased. For this reason it is better that the first year of married life should be allowed to pass without conception taking place. A child begotten in an intoxicated or depraved condition of a parent may be depraved itself in the same way, and is apt to be feeble-minded or idiotic.

It must be borne in mind that prenatal culture of some sort begins at the time of conception; and that on the mental as well as on the physical state of the mother, the health as well as the disposition of the child will depend to no slight extent. The prospective mother who constantly gives way to her feelings does a wrong to her unborn child. The mother is at this time more impressionable, more nervous, and more irritable

than is natural to her; and while her family should make a certain allowance for her condition, she, on her part, should not allow herself to give way to her morbid feelings. The prospective mother should not lead a life of self-indulgence, on the one hand, or, on the other, should not be weighed down with cares; she should interest herself in her usual duties, and be relieved of all anxiety possible.

Dress.--The clothing must be loose, and all compression about the waist and abdomen must be especially avoided. If the woman wears corsets, she must take them off at once, and substitute a Ferris or some similar hygienic waist. The corset prevents the proper development of the abdominal muscles, which play so important a role in the expulsion of the child from the womb, as well as in the proper growth and development of the fetus itself. If the woman has already borne children, and toward the end of the pregnancy the abdomen becomes pendulous, she will very materially add to her comfort by swearing a muslin abdominal bandage.

A woolen undersuit, or undervest and drawers, with high neck and long sleeves, must be worn winter and summer; the grade of the wool to be adapted to the season of the year. The especial necessity for wearing wool next the skin during the pregnancy is because of the intimate relation between the skin and the kidneys. Any chilling of the body at this time is apt to lead to the congestion of the kidneys. If there is already any congestion of the kidneys present, or any abdominal

pain, in addition to the undersuit an abdominal bandage should be worn. These bandages come woven in ribbed woolen, and fit the body snugly. This bandage is to be constantly worn, and, of course, changed at night. During the cold weather the stockings should also be of wool. Under no circumstances are garters allowed to be worn, as they form a constriction around the leg and interfere with the return of the venous blood to the heart, and so increase the tendency to the formation of the varicose veins. It is better not to use any means to hold the stockings up; they will be kept sufficiently well in place by the under-drawers. Low shoes should never be worn except in the hottest weather. It is of the greatest importance that the woman should be impressed with the necessity of the avoidance of taking cold, since any lung or kidney trouble is a serious complication of pregnancy.

Diet.--The diet is the same as that at any other time, only it is more necessary to guard against anything which is likely to cause indigestion. In other words, the diet should be plain, simple, and easy of digestion; nutritious and partaken of at regular intervals. In the latter part of pregnancy owing to the pressure of the enlarged uterus on the stomach, the food may have to be partaken of in smaller quantities and at shorter intervals. At this time also the appetite is abnormally large. Where it does not disagree with the patient, milk is the best adjuvant possible to the diet.

Constipation.--Constipation is the rule of pregnancy.

This is due to the great pressure that the enlarged uterus makes on the bowel; and as important as it is at all times to keep the bowels regular, it is at this time more necessary than ever that the woman should have the bowels well evacuated every day. A retention of fecal matter in the body causes the reabsorption into the blood of the toxic matters, with the resulting headaches, dizziness, loss of appetite, and intense nervousness. To obviate this tendency to constipation, plenty of fruit and vegetables should be eaten, as well as cereals if the woman is taking a good deal of outdoor exercise, otherwise the latter had better be omitted. The woman should drink plenty of water--at least three pints a day; this acts as a laxative as well as to flush out the kidneys. If, in spite of all these measures, constipation still persists, as it probably will, a seidlitz powder can be taken the first thing on rising in the morning; or from one teaspoonful to one tablespoonful of the effervescing granules of the phosphate of soda in a glass of water, also to be taken on rising in the morning; or one-half grain of the solid extract of cascara sagrada night and morning. The object of these is to keep the bowels open, but purgation must always be avoided.

Bladder Symptoms.--If there is any irritability of the bladder, any scalding on urination, or a very great frequency of emptying the bladder in the early months of pregnancy, a physician should be consulted at once; in the last months of pregnancy there is a desire to evacuate the bladder frequently, and sometimes at the

last there is an incontinence of urine, which is due to the descent of the uterus and the great pressure on the bladder; this condition disappears with the confinement.

Leucorrhea.--If this is present to any marked degree, the vaginal douche should be continued throughout the pregnancy; the temperature of the douche should be from 110 degrees to 112 degrees F.; it must never be taken very hot or very cold. The fountain syringe should be used, and the bag should not be hung more than three feet above the bed, so that there shall not be too much force to the stream of water.

Baths.--Warm tub-baths may be taken throughout the pregnancy, but never oftener than twice a week, and the woman should never stay in the tub longer than is absolutely necessary for the bath, as otherwise the bath is too enervating. A daily sponge-bath of cool or cold salt water at a temperature of from 80 degrees to 70 degrees F., and in the proportion of a pint of rock or sea salt to a gallon of water is most invigorating, and counteracts many of the nervous symptoms and promotes sleep and good digestion. The temperature of the room in which this bath is taken should be 72 degrees F. Shower-baths cause too great a shock to the nervous system, and they as well as foot-baths must be prohibited. Sitz-baths at a temperature from 110 degrees to 90 degrees F. may be taken just before retiring throughout the pregnancy. The frequency and duration of the bath as well as the temperature should be regulated by the attending physician. In

cases of intense nervousness and insomnia these baths have an excellent sedative effect. A pregnant woman must never under any circumstances take ocean baths, since there is always great danger that the shock of the waves will cause an abortion. Sea-voyages should be avoided because of the severe nausea and vomiting, as well as the danger that the lurching of the vessel may cause miscarriage.

The sewing-machine is a tabooed thing for the pregnant woman, because of the jarring of the pelvis which it produces. Sweeping of heavy carpets is also injurious. There must be no lifting of heavy pieces of furniture, and especially no lifting from the floor, as it interferes with the circulation in the uterus and is apt to produce miscarriage.

Driving in an easy carriage over smooth roads is permissible; dogcarts, or any conveyance which produces much jolting, must be avoided; and while driving is good, the woman should not do her own driving, on account of the danger of the jars that would be caused by the sudden pulling of the horse upon the lines. Horseback-riding and bicycling are, of course, forbidden, as are also golf, tennis, and dancing.

Exercise.--Exercise in the open air should be taken every day, when the weather is suitable, and walking is the best form of exercise. The amount will be regulated to some extent by what the woman has been accustomed to taking, and it should always stop short of fatigue. The woman should live as much as possible in

the open air, and she should attend to her ordinary duties about the house. Long railway journeys are always objectionable.

Hemorrhoids or piles are very often troublesome toward the close of the pregnancy. To overcome this, the patient should lie down immediately after the bowel movement, and remain in the recumbent position for ten or fifteen minutes. In addition, care should be taken to secure a loose movement of the bowels. Should the piles come down, applications of cloths wrung out of hot water, and held well pressed against the bowel, should be made; the piles should then be pressed back until the finger feels that the mass has been pushed above the second constriction of the bowel, which is felt to exist at about two inches above the sphincter ani muscle. Should these means not suffice, the physician must be consulted at once.

Swelling and pain of the external genitals and of the lower limbs are best relieved by the recumbent position. Should the veins of the legs be much enlarged or the feet swollen, the patient should have compression made by the wearing of elastic stockings. Or in some cases a bandage is sufficient; in this case the bandage may be made of muslin; it should be three inches wide, and, beginning at the toes, should extend up as high as the enlargement of the veins continues. This bandage should be freshly applied every morning before rising.

Pain caused by the stretching of the skin may be relieved by the inunction of the skin with cottonseed or

cocoanut oil. For severe pain in the small of the back, rubbing with soap liniment or alcohol will be found useful.

Mental Occupation.--Important as this always is, it is doubly so now. The mind should be constantly and pleasantly occupied, but no severe study should be indulged in. The emotional susceptibility is generally somewhat increased. The pregnant woman, quite excitable and irritable, readily responds to influences by which in the non-gravid condition she could not be affected. Sometimes she feels unusually well, is intellectually brightened and more active, and says she is positively happier. At other times she is despondent and morose.

Physiologists admit and observation proves that maternal emotions do affect the development and the exterior of the fetus; likewise the mental organization of the fetus may be affected. All unpleasant news, frights, and physical shocks, also scenes of suffering and distress, must be avoided, as the mind is particularly impressionable at this time. Around the patient should be thrown a gentle and protective care, and she should be treated with the considerate kindness which her condition demands. Theatres and all places where there will be a large assemblage of people should be avoided, as the close air and general bad ventilation are apt to produce vertigo and sometimes attacks of fainting.

Sleep.--During pregnancy a large amount of sleep is

required; there should be eight hours spent in sleep at night, and one hour every afternoon. Pregnant women should never do any night watching. There is unusual necessity for good ventilation during sleep at this time.

The Marital Relation.--Coitus is, as a rule, distasteful to pregnant women. It is for the best interest of the wife as well as for that of the child that all marital relation should be suspended at this time. Even uncivilized nations have condemned the privilege of sexual intercourse during pregnancy, and have visited punishment on the offender. If these relations are not wholly suspended, they must at least be at those periods which correspond to the time at which the woman would have been unwell had she not been pregnant. To the continuance of these relations throughout the pregnancy is due much of the suffering of the wife, not only then, but at the time of the labor as well; and the nourishment of the child is interfered with.

Causes of Miscarriage.--Hemorrhoids; straining at stool; excessive intercourse in the newly married; nursing; ocean-bathing; overexertion; overexcitement; a fall; any violent emotion; anger; sudden or excessive joy; a fright; running; dancing; horseback-riding; riding in a heavily built carriage over rough roads; great fatigue; lifting heavy weights; the abuse of purgative medicines; disease or displacements of the womb; and a general condition of ill health.

The danger of miscarriage is greatest during the first

three months of pregnancy. Miscarriage is a fruitful source of disease and often of danger to wives; it is said that thirty-seven out of every hundred pregnant women miscarry. Miscarriage is most apt to occur during the first pregnancy; and great care should be taken to prevent this, as the habit is easily established, and after one miscarriage has occurred, another is likely to follow, so that it is sometimes with the greatest difficulty that the woman can be made to carry the fetus to full term. Artificially produced abortions are not an infrequent cause of sterility; the young wife becomes pregnant, and has an abortion produced because she is not yet ready to give up all her pleasures; and eventually when she does become very anxious to have a child such an extent of uterine disease has been produced by the abortions that she cannot conceive.

To Prevent Miscarriage.--The life must be free from all excitement, and must be as quiet as possible without becoming monotonous; especial care must be exercised at the return of the dates for the menstrual periods.

The symptoms of miscarriage are a show of blood, more or less profuse, with intense abdominal pain; on the slightest show of blood the patient should go to bed at once and the physician should be sent for.