After the diagnosis of pregnancy has been satisfactorily established, no further internal examinations are necessary in the absence of special indications, until about the thirtieth week.

At this time a series of complete physical examinations may be required to determine the presentation and position of the child, the presence and rate of foetal heart tones, the diameters of the head, the length and approximate maturity of the child, as well as the condition of the bony and soft passages of the mother.

It is thus that an appreciation of the obstetrical problem is secured and a course laid out for its successful solution.

Pregnancy is not a disease, but a normal function; but the woman is exposed, nevertheless, to many grave risks that are peculiar to her condition and to many complications accidental or otherwise which are more serious on account of her pregnancy.

The ToxÆmias.—The growing ovum brings about changes in the maternal metabolism that are manifested by characteristic symptoms which in other better known conditions are recognized as due to toxÆmia. Therefore, while there is no positive proof as yet that these symptoms, arising during pregnancy, are toxÆmic in origin, the evidence goes to show that they are; and, therefore, should be classified as toxic.

Postmortem findings in eclampsia and pernicious vomiting such as extensive thromboses, cell necrosis, and interstitial hÆmorrhages are very suggestive.

Clinical findings in regard to the excretion of nitrogen (urea, ammonia, uric acid, etc.), the occurrence of acidosis, elevation of blood pressure, fever, diminished excretion, coma and convulsions, all point to toxÆmia.

It is the minor disturbances, however, that the nurse will come in contact with most. They are nearly all toxÆmic in origin, and a brief description of them must be given, together with suggestions for their management.

Salivation or Ptyalism.—In the majority of cases, saliva is not especially noticeable; but at times the secretion shows an enormous increase, and may even demand abortion. Patients will have saliva running constantly from the mouth. The amount may reach a pint or a quart a day, and the skin of the lower lip becomes greatly inflamed.

The only satisfactory treatment is a rigorous milk diet on the theory that the disturbance is an intoxication. In extreme cases abortion may be indicated.

Gingivitis.—The gums may become inflamed, spongy and hÆmorrhagic during pregnancy, usually in patients of low vitality. If a generous diet and astringent mouth washes do not relieve the condition, the milk diet should be considered.

Toothache and Dental Decay.—The patient may be given hypophosphites, and the teeth should be put in good condition by a dentist.

Constipation has already been referred to. Strong cathartics should be avoided lest abortion follow.

Condylomata of pregnancy occur most frequently around the labia, perineum, and anus. They are wart-like growths that develop slowly or quickly and may remain discrete or cover the entire area with masses as small as beans or as large as cauliflowers, which in appearance they much resemble. The etiology is obscure, but they are generally associated with irritating vaginal discharges, such as an old gonorrhoea.

Treatment consists in stopping the discharge or neutralizing it, and in keeping the growths dry with a salicylic acid dusting powder. (See Therapeutic Index.)

Pruritus is often distressing. The itching may be limited to the genitals or appear on other parts of the body. It may be due to the irritation of local discharges or to a condition of the nervous system, arising from toxÆmia. Astringent douches and protective ointments will relieve some cases.

Bromides and milk diet, bran or alkaline baths give good results, and local applications of sedative lotions and ointments containing menthol, carbolic acid or cocaine (cautiously) will aid. The woman in some instances becomes almost frantic, and tears at the vulva with her nails until it bleeds.

The iodine treatment of Hensler is simple and often effective. If no skin changes are visible and but little leucorrhoea, the vulva is thoroughly prepared as for a vaginal operation, dried and painted with a 10 per cent solution of tincture of iodine. Generally one application suffices, but when the leucorrhoea is bad, it may be necessary to repeat the treatment on the third and fifth day thereafter. Between treatments, the vulvar surfaces and even the vaginal walls (by insufflation) are kept dry with zinc oxide powder. If all measures fail and exhaustion is imminent, emptying the uterus may be advisable.

Herpes is an inflammatory, superficial eruption, characterized by red patches, blisters, or pustules. It is accompanied by burning, itching, and nervous depression. The origin is probably toxic and the termination may be fatal. Milk diet, soothing lotions, and, if necessary, abortion, constitute the means of treatment.

Areas of pigmentation (the chloasmata) are not amenable to treatment. They usually disappear after labor.

Albuminuria of Pregnancy.—Albuminuria is so common as to be almost physiological when the amount of albumin is small. When the amount of albumin in the urine is large, it may be due to pre-existing disease, which is first discovered when the urinalysis is made during pregnancy. (Chronic nephritis?).

If it makes its debut during gestation and continues as a mere trace without casts, it is spoken of as the albuminuria of pregnancy, but the patient must be watched with great care, since the albuminuria may be a premonitory sign of eclampsia.

Albuminuria and eclampsia must be considered together, because, while the two conditions may exist separately, they are most frequently associated, and it is believed that they have a common causation. It is true that most cases of albuminuria terminate favorably, yet the higher the albumin content, the greater the danger of eclampsia.

Albumin appears in the urine in from three to five per cent of all pregnancies. It is more common in the latter half of gestation and the attacks differ greatly in severity.

Symptoms.—In the early stages the urine shows an abundant, pale fluid of low specific gravity.

The seriousness of the case is generally indicated by the amount of albumin, although this is not a reliable guide as to the danger of eclampsia. Casts and red and white blood corpuscles are occasionally found. The output of urea usually remains normal, but diminution usually occurs in connection with eclampsia. AnÆmia and anasarca are common, but it is a hopeful clinical sign that the cases of extensive edema rarely develop eclampsia.

In albuminuria of pregnancy there is a large foetal mortality which, to a degree, is independent of eclampsia. The infant dies in utero or is born feeble, or prematurely.

Eclampsia is the sudden appearance of convulsions in the course of pregnancy. It may precede, follow, or accompany albuminuria. It occurs rarely in the absence of albuminuria in a woman who was apparently in good health. The two phenomena are best explained as a consequence of toxÆmia due to poisons at present unidentified.

Treatment of the albuminuria is treatment for impending eclampsia. Regular examination of the urine is indispensable. The presence of albumin suggests toxÆmia. The daily output of urine and the output of urea must be compared, for a fall in urea is a premonitory sign of eclampsia. The bowels and the skin should be stimulated, respectively, by saline cathartics, hot baths and packs. The digestive organs must be spared as much work as possible, especially the liver. Water is given in abundance, and milk is the staple diet. Koumiss, butter milk and ice cream may be allowed. As the patient improves, vegetables are allowed. The food should be salt-free; and alcohol, as well as rich, indigestible things should be forbidden. In the milder cases boiled fish and a little chicken may be permitted.

The course of the disease and the condition of the patient is determined by frequent examinations of the urine, while in all serious cases an examination of the fundus of the eye must be made to detect a possible albuminuric retinitis.

The treatment of eclampsia will be considered under the complications of labor, where the attack usually begins.

Pyelitis of pregnancy is an acute, and rarely, a chronic infection of the pelvis of the kidney, due to the Bacillus coli. It usually appears after the fourth month (fifth to eighth) and attacks by preference the right side. Extension to the kidney substance, ureters, and bladder is occasionally observed.

Symptoms.—Sudden, acute abdominal pain, at first diffuse, but after a few hours, becoming localized in the right side, and on this account is often confused with appendicitis, especially as vomiting is not infrequent. A chill may mark the onset and the temperature rise to 103° F. or 104° F. The bowels are constipated, the tongue coated, and there is tenderness over the kidney. The urine is scanty, turbid, slightly albuminous and contains pus and epithelium in the urinary canal. A culture reveals the bacillus which has obtained access to the kidney, either by extension of the ureter from the bladder, by direct invasion of the tissues from the adjacent colon, or through the circulation.

Treatment.—The diet should be fluid and mostly milk, the bowels should be moved freely and frequently. The urine is alkalinized with sodium citrate, since the Bacillus coli lives only in an acid medium. As the symptoms subside, urotropin may be administered. If the patient does not improve within two weeks, abortion must be seriously considered. Nephrotomy is not to be thought of unless abortion has failed.

Hyperemesis Gravidarum.—The nausea and vomiting of pregnancy is so usual as to be regarded as normal. It usually ceases from the fourth to the fifth month spontaneously; has no ill effect upon the ovum, and may respond readily to treatment.

Hyperemesis comes on at the same period and exhibits all stages of violence, from the mild form above described, to cases that end fatally.

Three classes of this serious disorder may be distinguished as associated (Eden), neurotic, and toxÆmic vomiting.

Associated vomiting is the vomiting that comes with gastric ulcer or cancer, chronic gastritis, cirrhosis of the liver, and cerebral disease. These conditions must be excluded in diagnosis.

Neurotic vomiting—severe and persistent nausea and retching—is common in pregnant women of the nervous type. It does not lead to loss of flesh ordinarily; the urine is somewhat diminished in quantity from the lack of fluids, but the amount of nitrogen excreted remains normal. This is important.

ToxÆmic vomiting includes a small but very important class of cases, for all are severe and intractable and some end in death.

Clinical Features.—The normal nausea and vomiting may seem unusually severe. It persists and gets worse. Then vomiting occurs when no food is taken and nothing is held on the stomach. The vomit is stained with bile or blood. The tongue remains clean, and the general condition is good.

Next, weight is lost and the pulse quickens. A persistent pulse of over 100 is serious. The tongue becomes coated, sordes develops, sleeplessness and muscular twitching appear, and the patient complains of epigastric pain. Abortion may now occur and the condition clear up.

In its final stage, the urine becomes scanty and albuminous, icterus may appear and the temperature rise to 100° F. or more, though sometimes it is subnormal. The pulse may go to 120. Delirium and coma supervene, and emptying the uterus is of no value. Fifty per cent of these bad cases die.

The especially prominent points to be noted are the urine, which shows acetone, albumin and blood, either one or all, as well as an increased amount of ammonia. A persistently rapid pulse, marked loss of flesh, coated tongue, jaundice and delirium are regularly present.

Treatment.—Organic disease must be excluded and a diagnosis of pregnancy strongly evident.

For the neurotic type, the patient must be segregated from her friends, and a competent, cheerful nurse put in charge. A cool, darkened room is best. If the patient can be transferred to a hospital, the results are more satisfactory. Here the isolation from external interests and irritations can be made complete. The patient does not talk, even the nurse comes with food, attends to the obvious necessities, and departs in silence. Once a day a sedative bath is given (see Baths, p. 325) and medication in kind and frequency as the conditions demand.

In any case, the patient should be put to bed and fed carefully every two or three hours on milk, peptonized food or barley water. If this is not retained, albumin water may be given for twenty-four hours at regular intervals, or rectal alimentation may be tried after stopping all foods by mouth. Iced champagne, seltzer or Vichy, either alone or with milk, may be tried. A dry diet is sometimes effective, rusk, toast, toasted shredded wheat biscuit, crackers, etc., taken early in the morning, as one eats cheese. No exercise is permitted except such muscular and nervous excitation as may be derived from massage or the sedative bath.

Drugs are sometimes of great value—the bromides, in full doses, or 1 m. doses of tincture of iodine, well diluted, every hour; or bismuth with hydrocyanic acid; or cocaine or oxalate of cerium. Occasionally good results are reported from a capsule of pepsin, 2 gr. and ¼ gr. silver nitrate given just before meals; and adrenalin in 10 drop doses may be considered. Extract of corpus lutea has been tried by Hirst with favorable results.

Sinapisms to the epigastrium and ice bags to the spine have been found useful, and washing out the stomach is efficient at times. In washing out the stomach, be sure the stomach tube is iced before it is introduced.

When the case gets worse in spite of treatment and acidosis supervenes, bicarbonate of soda may be given in sixty grain doses every four hours, by rectum, if necessary, until the urine gives an alkaline reaction.

Glucose as a readily assimilable carbohydrate may be given in doses up to 10 oz. of a 6 per cent solution (Eden) or sugar infusions by rectum, 1000 c.c. in twenty-four hours by drop method.

The obstetric treatment is the emptying of the uterus. To be effective the abortion must be done before the condition of the patient is desperate. It is most favorable before the febrile stage. If the vomiting persists in spite of treatment and is accompanied by emaciation, a pulse of over 100, albumin in the urine, with an increase of the ammonia output, the pregnancy should be terminated at once. If the patient can not go to a hospital, the nurse should prepare the room as described for operations.

After emptying the uterus, the vomiting usually ceases but much labor is thrown upon the nurse in supplying nourishment and caring for an exhausted and whimsical patient.

The back must be inspected daily for decubitus (bed sores) and her position changed frequently. A daily rub with alcohol and water (50 per cent) followed by an oil inunction will be valuable. The teeth and gums should be cleaned with gauze, wrapped around the finger and dipped in solution of boric acid. No brush should be used.

Multiple Pregnancy.—Twins occur about once in ninety labors, triplets, once in seven thousand.

Heredity and multiparity seem to be the only recognized predisposing factors. The more pregnancies a woman has, the more liable she is to have twins.

Twins may occur through a division of the primitive cell through the fertilization of two ova from the same or different ovaries, or by fertilization of a single ovum having two nuclei. (See Fig. 13). The former are called binovular twins, and may or may not be of the same sex. The latter are called uniovular twins and are always of the same sex. Twins are usually somewhat smaller than a single child, and frequently associated with hydramnios. Binovular twins have separate placentÆ and uniovular twins have one placenta, with separate cords.

Twin pregnancies usually go into labor earlier than the single child, possibly on account of the over-distention of the uterus.

The diagnosis is occasionally difficult and at other times easy. Two sets of heart tones must be distinguished and differentiated by their variation in frequency, heard at the same time by different observers. The presence of twins may be strongly suspected also when the external measurements of child and uterus greatly exceed the average. In such cases a systematic and persistent search must be made for the two foetal heart tones.

The delivery is generally uncomplicated, unless the chins become locked.

Displacements of the Uterus.—In most cases displacements of the uterus are a consequence of conception in organs that are previously retroflected or retroverted. They rarely produce symptoms until the end of the third month, when the attention is directed to the bladder. There may be absolute retention or a constant dribbling from a full bladder (ischuria paradoxa), possibly associated with pain. If recognized early, an attempt should be made to replace the uterus by posture (knee chest) and when replaced, to hold it by pessary or tampon. The prone position in bed will aid.

After retention has occurred, the patient should be put to bed and the bladder catheterized regularly every eight or ten hours for three or four days. As a rule, the organ will rise spontaneously into the abdomen. If it does not, it is probably incarcerated under the promontory, and the physician must try to replace the uterus by manipulation or by continuous pressure, but in bad cases, he will empty the uterus before the condition of the patient becomes too serious.

In multiparas with weak abdominal walls, or women with spinal curvature or contracted pelves, the uterus may fall forward and, passing between the recti muscles, continue to drop until the fundus lies lower than the symphysis pubis.

Management, until labor occurs, may be made more effective by using a strong, well-fitting abdominal bandage.

Malformation of the uterus may possess an obstetric interest at times. The double uterus (uterus didelphys) and the uterus with a rudimentary horn (uterus bicornis) are examples. These are congenital conditions, due to imperfect development, and pregnancy may take place in one or both sides. If in one side only, the other half will also exhibit the softening and other changes as in normal cases. Binovular twins may be the result of a pregnancy in each side.

Pressure Symptoms.—Edema of legs and sometimes of the vulva occurs during the last trimester. It is due to increased intraabdominal pressure and to direct interference with the return circulation by the pressure of the heavy uterus on the iliac veins at the brim of the pelvis. The urine should be examined for albumin and the patient put in the horizontal position if the edema is troublesome.

Varicose veins of legs and vulva may cause much distress. The limbs should be bound with flannel spirals or with rubber bandages in the recumbent position, or elastic stockings may be obtained. Operation during pregnancy is not to be considered. The vulva can only be relieved by a double bandage, which is sewed at the point where it crosses the vulva, and buckled or tied to a waistband above the hips, both before and behind. This brings support to the vulva. If the veins rupture, the part should be elevated and compressed with an aseptic pad.

HÆmorrhoids may either appear or grow worse late in pregnancy. If they protrude, they should be replaced. Ointments and iced applications may be used and the bowels kept loose.

Cramps may occur in the muscles of the legs, due sometimes to the varicose veins and sometimes to pressure on the lumbosacral plexus.

Moles.—Mole is the name given to an ovum which is destroyed by disease of its coverings during the early months of gestation. Two kinds are known, the blood mole (carneous mole, fleshy mole, or hÆmatoma mole) and the hydatidiform mole (vesicular mole).

The blood mole results from progressive or recurrent slight hÆmorrhages during the first three months of pregnancy, but hÆmorrhages insufficient in quantity to produce an abortion. The blood forms a clot, which may be retained for several months and become solidified.

Hydatidiform mole is a disease of the young chorionic villi, characterized by the growth of an immense number of irregular clusters and chains of grape-like cysts from the very minute to bodies four-fifths of an inch in diameter. The causation is unknown.

Both forms occur in the first half of the pregnancy and are characterized by undue enlargement of the uterus and hÆmorrhagic discharge.

Diseases of the Membranes.—Hydramnios, or polyhydramnios, is the name applied to the condition where an excess of liquor amnii is formed. The amount normally present varies, but anything in excess of four pints could be called hydramnios. Six gallons have been reported. Since the source of the liquor amnii is not positively known, the etiology of hydramnios must be equally obscure.

It is occasionally associated with morbid conditions of the mother, such as hepatic or cardiac dropsy, but more frequently with developmental anomalies of the foetus.

Since the mother is usually healthy and the foetus frequently deformed, the theory is advanced that the disease is foetal in origin. It frequently occurs with twin pregnancies, and in the first months it is most plausible that the liquor amnii is in some way derived from the foetus.

The disease is more common in multiparas. It is generally slow in onset, but it may be acute, and an immense amount of fluid may be formed in a few weeks.

The symptoms are those due to pressure from the extremely large uterus.

The treatment, if interference with heart or lungs becomes pronounced, is puncture of the membranes. The child need not be considered for it is usually dead or deformed.

Oligohydramnios is the condition where the liquor amnii is deficient in amount. It gives no maternal symptoms, but it is the cause of many birthmarks and foetal deformities (club-foot, spinal curvature, wry-neck, ankylosis of joints).

Amniotic adhesions are usually associated with oligohydranmios and cause deformities by amputation of limbs, strangulation of cord, and production of six fingers.

The placenta may show anomalies of size and shape. Thus, there may be two lobes, or three. There may be the main placenta and a small out-lying mass connected by membrane and vessels with the larger segment. The cord may be inserted in the middle or at the edge and yellowish-white masses called infarcts may be found in its substance.

Unusual size and weight of the placenta are suggestive of syphilis.

Abnormal conditions of the foetus may arise from primary or transmitted disease or from errors of development. The developmental errors may be monsters, hydrocephalus spina bifida, etc., which may not influence the pregnancy. The most commonly transmitted disease is syphilis, which may produce abortion, premature labor, or a child born with syphilitic skin changes on palms and soles, as well as internally.