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Chapter Ten

PREGNANCY

Period of Pregnancy in Human Female—Physiologic Process of Pregnancy—Growth of Embryo from Moment of Conception—Pregnant Woman Provides Nourishment for Two—Her Excreting Organs Must Work for Two.

From the moment the ovum has been fertilized or fecundated by the spermatozoön, the woman is said to be pregnant (or in French enceinte. This term was used very frequently and is still used by prudes, who seem to consider the word pregnant vulgar and disgraceful). Pregnancy, or the period of gestation, lasts from the moment of conception to the moment that the fetus or child is expelled from the uterus. The period of pregnancy differs very widely in different animals,⁶ but in the human female it lasts nine calendar months or ten lunar months—from about 274 to 280 days. We usually count 280 days from the first day of the last menstruation. A pregnant woman generally wants to know the day of the expected confinement—for this purpose a table is appended to this chapter. If you know the first day of your last menstruation, you will see at a glance when the confinement may be expected. There may be a difference of a few days—either before or after the expected date—but for practical approximate purposes the tables serve very well.

A simple way is to count back three months and add seven days. For instance, a woman's last menstruation occurred on April 4th; counting back three months gives you January 4th; add seven days and you get January 11th, the probable date of delivery. The first day of the last menstruation was December 30th; counting back three months gives you September 30th; add seven days and you get October 6th, the probable date of delivery. The presence of a short month like February may be disregarded, as the calculation is not absolutely, but only approximately correct.

The period at which the child's movements begin to be felt by the mother is termed Quickening. It usually occurs at the middle of the pregnancy, between the 16th and 18th week.

Pregnancy is a normal physiological process; but every active physiological process is apt to be accompanied by disturbances, and there is certainly no process in the animal body in which greater activity, greater changes, go on than during the process of pregnancy. Just see what occurs in nine months. The uterus, at first the size of a small pear, reaches a size larger than that of the head of a big man; it does not merely stretch, as some think, but it actually grows enormously in size, the muscular walls of a pregnant uterus being many times thicker than those of a non-pregnant one. They have to be or they would not have the strength to expel the child, when the proper time comes. It is to be borne in mind that the child does not slip out by itself; it is the powerful muscular contractions of the uterus that push it out. If the uterus should refuse to work, if its walls were too thin or too weak, the child could not come out, but would have to be taken out with forceps. Still greater changes than in the uterus take place in the child itself. At the moment of conception it is the size of the head of a pin; at the moment of birth it weighs from seven to ten pounds; at the moment of conception it is a minute, undifferentiated mass of protoplasm, just a single fertilized cell; at the moment of birth it consists of millions and millions of cells, which have become differentiated into numerous harmoniously working organs, and different tissues, such as brain and nerve tissue, muscular tissue, connective tissue, bone, cartilage, etc., etc. A truly wonderful process. And in the meantime this child, which is biologically a parasite (though it is not a nice name to call it by) draws its sustenance from the mother's blood, and the mother has to provide nourishment for two. And, besides providing nourishment, her excreting organs, her kidneys, must work for two, because her system has also to get rid of the child's excretions. No wonder that the pregnant woman, particularly under an artificial unhealthy mode of living, is subject to many troubles and disturbances.

DR. ELY'S TABLE FOR CALCULATING THE DATE OF CONFINEMENT

Explanation.—Find in top line the date of menstruation, the figure below will indicate the date when confinement may be expected, i.e., if date of menstruation is June 1st, confinement may be expected on March 8th, or one day earlier if leap year.

Chapter Eleven

THE DISORDERS OF PREGNANCY

Smooth Course of Pregnancy in Some Women—Pregnancy and Parturition May be Made Normal Processes Through Education in True Hygiene—Morning Sickness and Its Treatment—Necessity for Medical Advice in Pernicious Vomiting—Anorexia—Bulimia—Aversion Towards Certain Foods—Peculiar Cravings—Tendency to Constipation Aggravated by Pregnancy—Dietary Measures in Constipation—Rectal Injections in Constipation—Laxatives—Cause of Frequent Desire to Urinate During First Two or Three and Last Months of Pregnancy—Treatment of Frequent Urination—Cause of Piles During Pregnancy and Their Treatment—Cause of Itching of External Genitals During Pregnancy and Treatment—Cause of Varicose Veins and Treatment—Liver Spots.

We saw that in some women menstruation runs a perfectly smooth course, free from any disagreeable symptoms. The same is true of pregnancy. It is remarkable how smooth and easy the entire course is with some women. Many women know that they are pregnant only because of the non-appearance of the monthly periods; and even in the later months they feel no discomfort, attending to all their work and pleasures as usual; and even childbirth is a trifling matter with them. Unfortunately the number of such women is not very large, and, because of our confined, unnatural, often exhausting way of living, is becoming smaller and smaller. There is no question that the civilized, refined woman has a harder ordeal in pregnancy and childbirth than has her primitive sister. We confidently hope that this will not be so in the future; we expect the time to come when true hygiene will be an integral part of the education and the life of every girl, and then pregnancy and parturition may become even easier processes than they are in the primitive races. But the time is not yet; and in the meantime our young women have a good deal to go through.

Morning Sickness. One of the commonest disorders of pregnancy is the so-called morning sickness. This consists in a feeling of nausea and vomiting, which comes on soon after getting up. The morning sickness makes its first appearance in the third, fourth or fifth week of pregnancy and lasts usually until the end of the third or fourth month. In some women, however, the morning sickness comes on in a few days after impregnation has taken place, and those women diagnose their condition unmistakably by the feeling of slight nausea which they experience on getting up. Medicines are as a rule of little use in treating morning sickness. The "disease" can be relieved but not cured. The patient should stay in bed later than usual, should have her breakfast in bed, and then not get up for about half an hour afterward. If the patient is anemic, a good iron preparation may prove useful.

Pernicious Vomiting. The vomiting of pregnancy sometimes becomes so severe and uncontrollable that it has been given the name pernicious. The patient is unable to retain any kind of food, not even liquids, vomits almost incessantly, and may become very much run down and exhausted. The vomited matter may contain blood. For this condition a competent physician must be consulted, for in some cases the patient's life may be in danger and an abortion has to be performed.

Capricious Appetite. A capricious appetite is very common in pregnancy. The capriciousness may express itself in four different directions: (1) The patient may lose her appetite, almost altogether, partaking only of very little food, and that with effort. This condition of loss of appetite is called anorexia. (2) The patient may develop an enormous appetite—what we call bulimia—eating several times as much as she does ordinarily. (3) She may develop an aversion towards certain articles of food. Thus many women develop an aversion towards meat, the mere sight of or talk about meat causing in them a sensation of nausea. (4) She may show a craving for the most peculiar articles of food and for articles which are not food at all. The craving for sour pickles or sour cabbage is well-known; but some women will eat chalk, sand, and even more peculiar things (for the chalk there may be a reason: the system needs an extra amount of lime and chalk is carbonate of lime).

Constipation. Constipation is very common among women in the non-pregnant condition; but in the pregnant it is much more common and much more aggravated. Constipation must be guarded against, but the measures must be of a mild nature. If we can relieve the constipation by dietary measures alone, so much the better. The dietary measures should consist in eating plenty of fruit—prunes, apples, figs, dates, etc., and coarse bread and bran. Constipating articles, such as cheese or coffee, should be eliminated. Where dietary measures alone are insufficient, the patient should take an enema—a rectal injection—twice or three times a week. The enema should consist of about 8 ounces (half a pint) of cold or lukewarm water containing a pinch of salt, and should be retained about ten minutes. Instead of water, we may advise an occasional enema of two to four drams of glycerin. Or instead of a glycerin enema, a glycerin suppository may be used. If internal laxatives are to be used, only the mildest and non-griping preparations should be employed The best are: a good mineral oil—one or two tablespoonfuls on going to bed, or fluid extract of cascara sagrada, one-half to one teaspoonful on going to bed. It is very important, whatever we use, not to use the same thing for a long time. If the same drug or measure is used without any change, the bowels get used to it and cease to respond and we have to use larger and larger doses. In fighting constipation we must therefore constantly change our weapons: one night we use mineral oil, the next night cascara sagrada, the third night an enema, the fourth night a glycerin injection or suppository, the fifth night perhaps nothing at all, the sixth night a blue mass pill, the seventh morning a Seidlitz powder, then a rest for a day or two, then a repetition of the same measures. But always remember: first try to get along without any drugs at all. Many cases can get relieved of their constipation by a proper change in diet alone. And where this is impossible, then use mild laxatives and use them interchangeably.

Toothache is not uncommon in pregnancy, and a pregnant woman should have her teeth put in first-class condition.

Difficulty in Urination. Pregnant women often suffer with frequency and urgency of urination. Some have to urinate, while they are on their feet, every few minutes. This is due to the fact that during the first two or three months of pregnancy the uterus is not only enlarged but is also anteverted, that is turned forward and presses down upon the bladder. When the woman is lying down the pressure on the bladder is relieved, and she does not have to urinate frequently. This pressure lasts only the first two or three months, because after that the growing womb lifts itself out of the pelvis, rising into the abdominal cavity; it is no longer anteverted and the pressure on the bladder is relieved. During the last months of the pregnancy there is again frequent urination, because then the heavy uterus sinks again into the pelvic cavity and presses upon the bladder. The treatment for this frequent urination consists in wearing a well fitting abdominal belt or corset, which raises the uterus and prevents pressure on the bladder. Sometimes a pessary which prevents the anteversion is efficient. In all cases lying down and resting is useful. In short, keeping off one's feet is the most efficient remedy for the treatment of frequent urination in pregnant women.

Hemorrhoids (Piles). On account of the pressure of the womb on the rectum, and also on account of the constipation which is so frequent during pregnancy, hemorrhoids or piles are quite frequent among pregnant women. The treatment of hemorrhoids consists in removing the cause: wearing a well-fitting abdominal belt, and relieving the constipation. Injecting into the rectum about half a pint of cold water three times a day is very useful. For the intolerable itching sometimes present in hemorrhoids the following ointment will be found very grateful: menthol, 5 grains; calomel, 10 grains; bismuth subnitrate, 30 grains; resorcin, 10 grains; oil of cade, 15 grains; cold cream, one ounce. The piles (the hemorrhoids) are to be well cleansed with hot water, and this ointment is to be well smeared over; a little is pushed into the rectum, and a piece of cotton is put over the anus. This protects the clothes from soiling and keeps the medicine in place for a longer time. Instead of ointment a cocoa butter suppository may be used. A suppository of the following composition is good: powdered nutgalls, 3 grains; oil of cade, 3 drops; resorcin, 1 grain; bismuth subnitrate, 5 grains; cocoa butter, 20 grains. One such suppository to be inserted three times a day. The ointment and the suppository given above, if used in conjunction with the proper regulation of the bowels, will not only relieve but will cure most cases of hemorrhoids caused by pregnancy.

Itching of the Vulva. Pruritus Vulvæ. Itching of the external genitals during pregnancy is not uncommon. This may be due to the fact that the vulva is generally congested and swollen during pregnancy or it may be caused by an increased leucorrheal discharge. The itching is sometimes very severe, and if the patient scratches with her nails and produces bleeding, she may cause an infection of the parts. The patient should be cautioned against scratching; she should try simple measures to relieve the itching. A small towel or gauze compress wrung out of boiling water and applied to the vulva several times a day, followed by a free application of stearate of zinc powder is often efficient. If it is not, the following salve may be tried: carbolic acid, 10 grains; menthol, 5 grains; resorcin, 15 grains; zinc oxide, 1 dram; and white vaseline, one ounce. In very severe cases the vulva should be painted with a solution of silver nitrate, 25 grains to 1 ounce of distilled water.

Varicose Veins. In most women during pregnancy the veins in the legs become somewhat enlarged. This is due to the pressure of the womb, which interferes with the circulation. If the veins become very prominent, swollen and tortuous, they are called varicose. This condition should be prevented, because it often and to some degree always persists permanently even after the pregnancy is over. The best precautionary measure is for the woman to wear a well-fitting abdominal belt or maternity corset, which supports the womb and does not permit it to sink too low into the pelvis. If varicose veins have been permitted to develop, the woman should wear well-fitting rubber stockings, or at least have the legs bandaged with woven elastic bandages. The bandage must be applied by a competent person, uniformly and not too tightly. Constipation has also a bad effect in making varicose veins worse; the bowels should therefore also be looked after. In some severe cases all measures are of little value unless the patient at the same time stays in bed or on a couch for a few days, with the legs elevated.

Swelling of the feet should be at once attended to. It may be a trifling matter due only to pressure of the womb; then again it may be due to some kidney trouble. The physician will determine the true cause and prescribe the appropriate treatment.

Liver Spots. Chloasma. In some cases irregular brownish patches or splotches develop on the skin around the breasts, on the sides, or on the face. These patches are known popularly as liver spots or in medical language as chloasma. Nothing can be done for them, but they generally disappear after the pregnancy is over. A few patches here and there may remain permanently.

Chapter Twelve

WHEN TO ENGAGE A PHYSICIAN

Necessity for the Pregnant Woman Immediately Placing Herself Under Care of Physician and Remaining Under His Care During Entire Period.

The disorders and disturbances described above are, with the exception of pernicious vomiting, of a minor nature. They are annoying, may cause considerable discomfort and suffering, but they do not endanger the life of the woman or of the child. Occasionally, however, fortunately not very often, the kidneys become affected, and for this condition treatment by a physician is absolutely necessary. In fact, the correct and safe thing for a woman to do is to consult a physician as soon as she knows she is pregnant, and have him take care of her during the entire pregnancy. Some women engage a physician during the eighth or ninth month and this is decidedly wrong, because it may then be too late to correct certain troubles which if taken at the outset could have been easily cured; while many troubles in the hands of a competent physician can be prevented altogether. I must therefore reiterate: every woman should engage a physician from the beginning of her pregnancy, or at least during the third or fourth and certainly not later than the fifth month. He will examine the urine every month and make sure that the kidneys are in order, he will make sure that the child is in a normal position, and will prevent a host of other ills.

Position of the Child in the Womb.

This is not a special treatise on the management of pregnancy, and therefore minute details are out of place. Besides, to the details the physician will attend. But some hints regarding diet and general hygiene will prove useful.

If everything is satisfactory, if there is no severe vomiting, kidney trouble, etc., the usual mixed diet may continue. The only changes I would make are the following: Drink plenty of hot water during entire course of pregnancy: a glass or two in the morning, two or three glasses in the afternoon, the same at night. From six to twelve glasses may be consumed. Also plenty of milk, buttermilk and fermented milk. Plenty of fruit and vegetables. Meat only once a day. For the tendency to constipation, whole wheat bread, rye bread, bread baked of bran or bran with cream.

As to exercise, either extreme must be avoided. Some women think that as soon as they become pregnant, they must not move a muscle; they are to be put in a glass case, and kept there to the day of delivery. Other women, on the other hand, of the ultramodern type, indulge in strenuous exercise and go out on long fatiguing walks up to the last day. Either extreme is injurious. The right way is moderate exercise, and short, non-fatiguing walks.

Bathing may be kept up to the day of delivery. But warm baths, particularly during the last two or three months, are preferable to cold baths.

Chapter Thirteen

THE SIZE OF THE FETUS

Approximately Correct Measurements and Weight of Fetus at End of Each Month of Pregnancy.

Men and women are always interested to know how large the fetus is and how far it is developed during the various months of pregnancy. Absolutely exact measurements cannot be given, but the following approximate measurements are correct:

1. Embryo Between One and Two Weeks Old.

2. Embryo About Four Weeks Old.

3. Embryo About Six Weeks Old.

At the end of the first month (lunar) it is about the size of a hazelnut. Weighs about 15 grains.

At the end of the second month it is the size of a small hen's egg. The internal organs are partially formed, it begins to assume a human shape, but the sex cannot yet be differentiated. Up to the fifth or sixth week it does not differ much in appearance from the embryos of other animals.

At the end of the third month it is the size of a large goose egg; it is about two to three and a half inches long. Weighs about one ounce.

At the end of the fourth month the fetus is between six and seven inches long and weighs about five ounces.

At the end of the fifth month the fetus is between seven and eleven inches long, and weighs eight to ten ounces.

At the end of the sixth month it is eleven to thirteen inches long and weighs one and one-half to two pounds. If born, is capable of living a few minutes, and it is reported that some six months' children have been incubated.

At the end of the seventh month the fetus is from thirteen to fifteen or sixteen inches long and weighs about three pounds. Is capable of independent life, but must be brought up with great care, usually in an incubator.

At the end of the eighth month the length is from fifteen to seventeen inches, and weight from three to five pounds.

At the end of the ninth month the length of the fetus is from sixteen to seventeen and one-half inches, and weight from five to seven pounds.

At the end of the tenth lunar month (at birth) the length of the child is from seventeen to nineteen inches and the weight from six to twelve pounds; the average is seven and a quarter, but there are full term children weighing less than six pounds and more than twelve; but these are exceptions.