It is the purpose of this chapter to take up the various complications which may appear in the course of an otherwise normal pregnancy, and offer advice appropriate for their management.

MORNING SICKNESS

About one-half of the expectant mothers that come under our care and observation, experience varying degrees of nausea or "morning sickness." This troublesome symptom makes its appearance usually about the fourth week of pregnancy and lasts from six to eight weeks.

On attempting to rise from the bed, there is an uncomfortably warm feeling in the stomach followed by a welling up into the throat of a warmish, brackish tasting liquid which causes the patient to hasten to rid herself of it; or, as she rides on the train, on the street cars, in a carriage or automobile, she frequently senses the same unpleasant and nauseating symptoms during the second and third months of pregnancy. Normally, this uncomfortable symptom quite disappears by the end of the third month. A number of remedies have been suggested for it, but that which seems to help one, gives little or no relief to another; we therefore mention a variety of remedies which may be tried.

First and most important of all remedies—is to keep the bowels open. Sluggishness of the intestinal tract greatly increases the tendency to dizziness and nausea. During the attack, it is advisable not to attempt to brush the teeth, gargle, or even drink cold water. While you are yet lying down, the maid or the goodman of the house should bring to you a piece of dry, buttered toast, a lettuce sandwich with a bit of lemon juice, or perhaps a cup of hot milk or hot malted milk. Coffee helps to raise the blood-pressure, and all articles of diet that tend to raise the blood-pressure are best avoided during pregnancy. A cup of cocoa may be tried, but, as a rule, women at this time do not relish anything sweet. Oftentimes a salted pretzel is just the thing, or a salted wafer will greatly help. Remain in bed from one-half to one hour and then rise very slowly. There should be plenty of fresh air in the room, as remaining in overheated places is quite likely to produce a feeling of sickness at the stomach.

When the attack comes on during a train ride, open the window and breathe deeply, this, with the aid of a clove or the tasting of a bit of lemon, will usually give relief. In extreme instances the patient should lie down flatly on the back, with the eyelids closed. Go to the rear of the street car, so that you can get off quickly if necessity demands; breathe deeply of the air; resort to the use of cloves or lemons; and thus by many and varied methods will the expectant mother be enabled to continue her journey or finish her shopping errand. We would suggest that, as far as possible, walking should be substituted for riding. I have never heard of a woman being troubled with nausea while walking in the parks, on shady streets, along the country road, or on the beach.

Of the medicines prescribed for "morning sickness" and the nausea of pregnancy, cerium oxalate taken three times a day in doses of five grains each, is probably one of the best.

The persistent or pernicious vomiting which continues on through pregnancy will be spoken of later.

HEARTBURN

Acid eructations are spoken of as "heartburn," and are occasioned by the increased activity of the acid making glands of the stomach. Under certain conditions this acid content of the stomach is regurgitated back into the throat and even belched up into the mouth. In this condition it is well to avoid most acid fruits. Ice cream and other frozen desserts are beneficial. The lowered temperature of cold foods depresses the activity of the acid glands, as also does the fats of the cream, while protein food substances such as white of egg, cheese, and lean meat, help by combining with the excess of acid present in the stomach. Buttermilk or the prepared lactic acid milk, if taken very cold, is often helpful, notwithstanding it is an acid substance, in connection with the dietetic management of heartburn. If the acid eructations be troublesome between the meals, the taking of calcined magnesia (one round teaspoon in a glass of cold water), or, one-half teaspoon of common baking soda in a glass of water, will afford immediate and temporary relief. Simply nibbling a little from a block of magnesia will often give instant relief. These alkalines effectively neutralize the mischievous acids which cause the so-called "heartburn."

IRRITABILITY OF THE BLADDER

The flexing or bending forward of the gravid uterus, by making pressure on the bladder, sets up more or less irritation and consequent disturbance of the urinary function. The capacity of the bladder is actually diminished, and this produces frequent urination. There is usually no pain connected with this annoying symptom—the chief discomfort is the frequent getting up at night. This inconvenience may be lessened by drinking less water after six p. m. These bladder disturbances are most marked in the earlier months, and gradually disappear as the uterus raises higher up into the abdomen; although this symptom may reappear in the last two weeks, as the head descends downward on its outward journey.

Should the urine at any time become highly colored, take a specimen to your physician at once. Twenty-four hour specimens of urine should be taken by the patient to her physician every two weeks. Do not send it—take it.

LEUCORRHEA

While leucorrhea is an unusual complication of pregnancy, it is often very troublesome and sometimes irritating. Do not take a vaginal douche unless it has been ordered by your physician, and even then make sure that the force of the flow of water is very gentle. The bag of the fountain syringe should be hung only about one foot above the hips. Soap and water used externally, followed by vaseline or zinc ointment, will usually relieve the accompanying irritation.

THREATENED ABORTION

In the third chapter attention was called to the formation of the placenta or "after birth," on the site of the attachment of the cocoon embryo. At this particular time of the pushing away of the embryo from the uterine wall, one of the accidents of pregnancy occurs, in which the embryo becomes completely detached and starts to escape from the uterus, accompanied by varying degrees of pain and hemorrhage. The symptoms of this threatened abortion are:

1. Heavy menstrual pains.
2. Backache.
3. Hemorrhage.

The approach of the calendar date of the third month of pregnancy should be watched for, and all work of a strenuous nature studiously avoided; while at the first signs of the backache or any unusual symptom, the expectant mother should immediately go to bed and send for the physician. One patient who had aborted on four different occasions was able to pass this danger period by adhering to a rigid program of prevention during her fifth pregnancy. Two weeks before the third month arrived she discontinued her teaching and went to bed. She remained there four weeks, thus running over into the middle of the following month. Gradually, she resumed her duties of teaching, carried her precious bundle of life to full term, and is now the proud and happy mother of a splendid baby girl.

Should abortion seem imminent, from one-eighth to one-fourth of a grain of morphine sulphate will greatly reduce all uterine contractions, and this, with the general quieting effect on the whole system, will usually suffice to prevent an abortion. The patient should quietly remain in bed from three days to one week.

If the abortion takes place—if a clot accompanied by hemorrhage is passed—save everything, lie in bed very quietly and send for your physician at once; and when he does arrive, be content if he does not make an internal examination at once, for if he should there is more or less danger of infection. And I repeat—throw nothing away—burn nothing up, save everything that passes until your physician has carefully examined it.

SUDDEN ABDOMINAL PAIN

Sudden or severe pains in the abdomen should be reported at once to your physician, while you should immediately go to bed and quietly remain there until you receive further instruction from your doctor when he calls.

In the later stages of pregnancy any appearance of blood should likewise be noted and reported without delay. These symptoms may not always be serious, but they are also associated with grave complications, and should, therefore, be given prompt attention.

MISCARRIAGE

Abortion is a term used to designate the loss of the embryo prior to or at the third month. Miscarriage applies to the expulsion of the fetus or emptying of the uterus after the third month. It is possible for a miscarriage to occur anytime during the interim between the fourth and ninth months. After the uneventful passing of the third month, if an accident threatens, we instruct the mother to remain quietly in bed three to five days at the calendar date comparable with each menstrual period; and as she approaches the seventh month, we adjure her to be unusually careful and prudent.

The causes of miscarriages are many: Disease of the embryo, imperfect fetal development, some constitutional disease of the mother, a faulty position of the uterus, or it may result from something unusual about the lining of the uterus such as an endometritis—an inflammation of the mucus membrane.

Expectant mothers who manifest symptoms of a threatened miscarriage should studiously avoid such exercises as climbing, riding, skating, tennis, golf, dancing, rough carriage or automobile riding, and such taxing labor as sweeping, lifting, washing, running the sewing machine, window cleaning, the hanging of pictures, draperies, etc.

CRAVINGS

Within reason, a pregnant mother should follow her natural appetite and satisfy her dietetic longings. Should she desire unusual articles of food, as far as possible she should have them. The idea has long prevailed that if the mother does not get what her longing soul supremely desires, that the on-coming baby is going to cry and cry until it is given what the mother wanted with all her heart and did not get. Such an idea is the very quintessence of folly and the personification of foolishness and superstition.

Many a precious babe has suffered as a victim of this notion of "craving" and "marking." One mother gave her baby a huge mouthful of under-ripe banana because "she knew that was just what he wanted, because, when pregnant, she had craved and craved bananas and for some reason or another she did not get them." The soft, smooth piece of banana slipped down the baby's throat—on into the stomach and intestines—caused intestinal obstruction and finally the end came; and we registered one more victim to the fallacies of fear and the superstitious belief in "cravings" and "markings." Occasionally some cravings are unusual and freakish, for instance, egg shells, leather, candles, chalk, and other abnormal tastes are developed. Of these we have only to say, "Rise above them, become mistress of the situation and change your longings." If such abnormal cravings come to you in the kitchen, don your bonnet and go at once out of doors and take a walk. Don't be foolish just because somebody told you foolish stories about these things.

CONSTIPATION

Bowel hygiene is an important part of the management of pregnancy. Constipation often proves to be very troublesome. In another chapter this subject is treated at some length. Here, we pause only long enough to say that habit has much to do with this difficulty. A regular time should be set apart each day for attending to this important matter.

HEMORRHOIDS

Of all the maladies that the human family falls heir to, hemorrhoids are among the commonest and, we may add, the most neglected. Any woman who enters pregnancy, suffering from hemorrhoids, is going to have her full share of suffering and pain before she has finished with her labors. Taken early, they may be greatly helped, if not entirely relieved, by the daily use of the medicated suppository (See Appendix). The bowel movements should never be allowed to become hard, the dietetic advice of another chapter should be carefully followed and the oil enema, as described in the appendix, should be used if necessary. For immediate relief, hot witch-hazel compresses may be applied; or, in the case of badly protruding piles, the patient should immerse the body in a warm bath and by the liberal use of vaseline they can usually be replaced. The physician should be called and he will advise any further treatment the case may require.

VARICOSE VEINS

Varicose veins or the distension of the surface veins of the legs are very common among women in general and pregnant women in particular. The legs should be elevated whenever the patient sits, while in bad cases they should be bandaged while standing. There are many elastic surgical stockings on the market today that, if put on before rising in the morning, will give much relief and comfort all during the day. Any large medical house or physician's supply house can furnish them according to your measurements—which should be taken before getting out of bed in the morning. These measurements are taken according to instructions and usually are of the instep, ankle, calf of leg, length of ankle to knee, etc.

CRAMPS

Cramps are sharp, exceedingly painful muscular spasms occurring in the muscles of the calf of the leg, the toes, etc. The expectant mother in the later months of pregnancy awkwardly turns in bed, is suddenly awakened and without a moment's warning, is seized with a most excruciating pain in her leg or toe. The most effectual treatment for these cramps is quickly to apply a very cold object to the cramping muscle. Extremes of either heat or cold usually relieve as well as the vigorous grasping or kneading of the muscle. A hot foot bath on going to bed will often prevent an attack. A long walk in the latter months of pregnancy should invariably be followed by a short hot bath or a foot bath. Many attacks may be avoided by this procedure.

SWELLINGS

All swellings should be taken seriously by the pregnant mother to this extent, that she save a twenty-four hour specimen of urine and that she personally take it to her physician, with a report of her "swellings." This symptom may or may not indicate kidney complications. The blood-pressure together with chemical and microscopical analysis of the urine will determine the cause.

Slight swelling of the feet is often physiological and is due to pressure of the heavily weighted uterus upon the returning veins of the legs. The progress of the veinous blood is somewhat impeded, hence the accumulation of lymph in the tissues of the legs, ankles, and feet.

Never allow yourself to guess as to the cause of swellings, always take urine to the physician and allow him definitely to ascertain the true cause. All tight bands of the waist and knee garters must be discarded at this time. The same general treatment suggested for varicose veins holds here.

GOITRE

The enlargement of the thyroid gland—goitre—is physiological during pregnancy, and is believed to be caused by the throwing into the maternal blood stream of special protein substances derived from the fetus. As just stated, this is more or less physiological, will usually pass away after the babe is born, and, therefore, need give the mother no particular concern. Tight neck bands should be replaced by low, comfortable ones. The bowels should move freely every day, and water drinking be increased as well as sweating of the skin encouraged by a short, hot bath, followed by the dry blanket pack, while the head is kept cool by compresses wrung from cold water. In this manner the elimination of these poisons is increased through both the skin and the kidneys.

BACKACHE

The backache of the later months of expectancy is very annoying and often spoils an otherwise restful night's sleep. This is probably also a pressure symptom, if the physician's analysis of the urine proves that the kidneys are not at fault. If you have electric lights in the home, a very useful contrivance can be made which will give you great relief. The light end of an extension cord, five to seven feet in length, is soldered into the center of the bottom of a bright, pressed tin pail about twelve inches in diameter at the top and nine or ten inches deep. With the bail removed, screw in a sixteen or thirty-two candle power bulb and attach the extension cord to a nearby wall or ceiling socket. This arrangement supplies radiant heat and is called a photophore (See Fig. 3). Apply this twofold remedial agent—light and heat combined—to the painful back (underneath the bed clothing) and our restless mother will go to sleep very quickly. This may safely be used as often and as long as desired.

PERNICIOUS VOMITING

Persistent, prolonged, and very much aggravated cases of morning sickness are termed pernicious vomiting. The patient emaciates because of the lack of ability to keep food long enough to receive any benefits therefrom.

In treating these cases the sufferer should be put to bed in a room with many open windows, or, if the weather permit, should be out of doors on a comfortable cot. She should remain in bed one hour before the meal is served and from one to three hours afterward. The mind should be diverted from her condition by good reading, friends, or other amusements. The utmost care and tact should be used in the preparation of her food, and art should be manifested in the daintiness of the tray, etc. We found one mother was nauseated even at the sight of her tray and so we planned a call that should bring us to her home at the meal hour. The tray came in with the attendant in unkempt attire, who said, as she placed it carelessly down on a much-loved book our patient had been reading: "I heard you say you liked vegetable soup so I brought you a big bowl full." As I gazed at the tray, I saw a large, thick, gravy bowl running over with the soup. I usually like vegetable soup, but at the sight of that sloppy looking bowl—well, I thought I should never care for it again.

After installing a new maid who had a sense of service and daintiness, and who took real pleasure in the selection of the dishes for the tray, as well as the quality and quantity of food served in them, our patient made speedy recovery, went on to full term and became a happy mother.

There is no doubt that the mind has very much to do with this vexing complication of pregnancy. One mother immediately stopped vomiting everything she ate when told by her husband that "the doctor said he was coming in the morning to take you away from me to the hospital if you didn't stop vomiting." Everything known should be tried for the relief of these patients and in extreme cases, when the mother's life is endangered, pregnancy should be terminated.

INSOMNIA

The neutral full bath, temperature 97 F., maintained for twenty minutes to one-half hour, should be taken just on going to bed. The patient must not talk—must rest in the bath—absolutely quiet. The causes of insomnia should be determined if possible, and proper measures employed to remove them. They may consist of backache, cramps, frequent urination, pressure of the uterus on the diaphragm or pressure against the sides of the abdomen. The bed should be large, thus giving the patient ample room to roll about.

The following procedures may be tried in an effort to relieve the sleeplessness:

Rubbing of the spine, alcohol or witch-hazel rubbing of the entire body, the neutral bath, or the application of the electric photophore—described a few pages back—may be made to the painful part. Do not resort to drugs, unless you are directed to do so by your physician.

HEADACHE

Headaches should not be allowed to continue unobserved by the attending physician. Measure the daily output of urine, which should be at least three pints or two quarts. In case of daily or frequent headaches, notify your physician at once and take a twenty-four hour specimen of urine to him. Headache is an early symptom of retained poisons and if early reported to the physician quick relief can be given the patient and often severe kidney complications be avoided by the proper administration of early sweating procedures. Water drinking should be increased to two quarts (about ten glasses) a day. Less food and more water are the usual indications in the headaches of pregnancy.

HIGH BLOOD-PRESSURE

Blood-pressure is called high when the systolic pressure registers above 150 to 160 millimeters of mercury. Pressure above 165 should be taken seriously and the patient should keep in close touch with her physician. Tri-weekly examinations of the urine should be made, while eliminating baths should be promptly instituted. The subject of blood-pressure in relation to pregnancy will be fully dealt with in the next chapter—in connection with toxemia, eclampsia, etc.