a portion of the quinine is absorbed. There is no ground for fearing any untoward effect from quinine. The researches of Chiara of Milan and numerous other observers prove that even the largest therapeutic doses of quinine are not abortifacient in malarial fever or in health. CHOLERA. Pregnant women evince no proclivity to, nor immunity from, cholera. As in variola, the disposition to, and mortality of, the disease grow with the duration of gestation. The prospect of recovery is especially unfavorable during the sixth and seventh months. Pregnancy is usually interrupted when the woman survives the terribly rapid course of the disease. Many women die with the product of conception in the cavity of the uterus. Exceptionally, in the lighter forms of the disease recovery may occur without the interruption of gestation. The causes of premature labor or abortion may be found in the constant hemorrhagic endometritis and the changes in the pressure and constitution of the maternal blood. As the result of the operation of the two latter factors, asphyxia is usually produced. Buhl, Gütterbock, and others are of the opinion that the disease may be communicated by the mother to the foetus. Pregnancy undoubtedly exercises an unfavorable influence on the course of the disease, chiefly from the tendency to uterine hemorrhage. Pregnancy is interrupted in over 50 per cent. of the cases. Premature labor is observed more frequently than abortion. The prognosis with reference to the life of the child is absolutely unfavorable. In very exceptional cases the evacuation of the uterine cavity has seemed to exercise a favorable influence on the course of the disease. Upon this ground the induction of abortion or premature labor has been seriously proposed. The operation, after an extended trial, has fallen into deserved disrepute. SYPHILIS. Syphilis is a frequent complication of pregnancy. Sigmund1 has observed and described the characters of syphilis contracted at the beginning or during the course of gestation. The duration of the stage of incubation is abbreviated. Two weeks is the rule, six weeks the exception. The initial lesions are characterized by an unusual degree of intensity, occasionally involving the vulva, vagina, cervix, nates, and inner surfaces of the thighs. The intensity of the initial lesions is due to the anatomical relations of the genitalia in the pregnant woman and the increased nutritive activity of the parts. The symptoms are marked local reaction, reddening and excoriation of the skin and mucous membrane, swelling, oedema, eczema, follicular abscesses, and necrosis of the connective tissue. Induration is not a characteristic of chancre situated about the genitalia of the pregnant woman. Phagedenic ulceration sometimes attacks the chancre, and then the case may be mistaken for one of phagedenic chancroid. The secondary symptoms are unusually mild. Condylomata appear about the genitalia, and psoriasis is noticeable on the palms of the hands and soles of the feet. Glandular infiltration follows slowly, and alopecia, iritis, laryngitis, and the skin manifestations are observed with comparative infrequency. 1 Wien. Med. Presse, 1873, No. 1, xiv. Constitutional Syphilis.-The influence of constitutional syphilis upon the foetus is marked, and always unfavorable. The foetus may be infected through the medium of the spermatic fluid, the ovum, and by the mother after conception. From an enormous number of carefully-recorded observations it is possible to deduce the following conclusions with reference to the modes of infection and the effect upon the product of conception: 1. When the mother is perfectly healthy, but the father is affected with constitutional syphilis, the foetus is infected by the diseased spermatozoids. The intensity of the foetal disease will depend upon the degree of latency and age of the paternal affection. This mode of infection is observed in the severer forms of hereditary syphilis. Usually the mother is not infected. Occasionally the disease is communicated to her by the foetus in the mode termed by the French syphilographers choc en rétour. 2. When the mother has had constitutional symptoms prior to conception the ovum is infected before its fertilization. The child usually dies in utero, and is expelled in a state of maceration. 3. When the mother is infected during the act of coitus it was formerly believed that the foetus could only be syphilized during its passage through the parturient canal. Sigmund and Vajda have shown that even under these circumstances the infection may be communicated by the mother to the foetus in the course of pregnancy. If the father is affected with constitutional syphilis when the mother acquires the initial lesion, the result sketched in the first proposition follows. 4. Infection of the foetus may occur during its passage through the parturient canal. Weil' records a case of this nature. 5. When both parents are affected with constitutional syphilis the disease will be communicated to the foetus. The intensity of the foetal syphilis will depend upon the degree of latency and age of the parental affection. When both parents have passed through the tertiary forms an apparently healthy child may be born. Evidences of hereditary syphilis, however, are usually developed before puberty. According to the intensity of the poison the foetus dies in utero, causing the interruption of pregnancy; is born, alive, with manifestations of hereditary syphilis, seldom acquired; or may give evidence of the inheritance of the disease after a variable interval of from weeks to months. TREATMENT.-Fortunately, syphilis as a complication of pregnancy is a very tractable affection. The interruption of pregnancy may be prevented and the effect of the syphilitic poison upon the foetus favorably modified in the large majority of cases by appropriate specific treatment. Mercurial inunctions are preferable to the exhibition of the remedy by the mouth. Iodide of potassium must be used with care, on account of its tendency to provoke uterine contractions. Attention must be paid to local primary or secondary lesions, since the child may be infected during its passage through the parturient canal. Cardiac Diseases. The mutually unfavorable relations between acute and chronic cardiac diseases and pregnancy depend largely upon the seat and character of the affection. 1 Deutsch. Zeitsch. f. prakt. Med., 1877, No. 42. ACUTE ENDOCARDITIS, occurring in the course of gestation, evinces a distinct tendency to the malignant, ulcerative form. This disposition is much more marked during the puerperium. The dangers of the detachment of particles of valvular vegetations, giving origin to the processes of thrombosis and embolism, are obvious. The PROGNOSIS of acute endocarditis during pregnancy and the puerperium is much more unfavorable than in the non-gravid state. CHRONIC HEART DISEASES. The mode in which pregnancy, parturition, and puerperium exert an unfavorable influence on chronic heart diseases is still the subject of controversy. Spiegelberg accounts for the disastrous results attending aortic insufficiency observed in the second half of pregnancy on the ground of the inadequacy of the compensatory hypertrophy of the left ventricle. The intercalation of the placental circulation, the increase of the total blood-mass, the increase in arterial tension, throw an extra amount of work upon the left heart, which it is not able to perform. Irregular heart-action and dyspnoea, sometimes leading to the interruption of pregnancy, are the results. After labor the placental circulation is eliminated, arterial blood-pressure is lowered, venous blood-pressure is elevated, and the right heart is threatened. In case of mitral insufficiency and dilatation of the left ventricle, without compensatory hypertrophy of the right heart, the effect of these sudden variations in vascular tension is obviously serious. Dyspnoea, pulmonary catarrhi, general œdema, albuminuria, ascites, pleural effusions, occur. Fritsch is of the opinion that these phenomena, sometimes observed in the course of mitral disease after labor, are due to the sinking of intra-abdominal pressure, the accumulation of blood in the great abdominal vessels, and cardiac paralysis from insufficient blood-supply. During parturition Spiegelberg thinks the chief danger in all forms of valvular defects consists in pulmonary edema as the result of circulatory disturbances. 3 Löhlein and Kleinwächter believe that the chief danger of chronic valvular disease occurs during the puerperium, and lies in the tendency to the recurrence of endocarditis. TREATMENT.-The treatment of acute and chronic heart disease is not materially modified by the coexistence of pregnancy. In threatened asphyxia the induction of premature labor is indicated in the interest of the child. During labor the timely performance of version or application of the forceps lessens the bearing-down efforts, and may prevent alarming complications. Diseases of the Lungs. ACUTE LOBAR PNEUMONIA. This is a rare affection in women at all times, and is a very infrequent complication of pregnancy. Occurring with greatest relative frequency 1 Arch. f. Gyn., viii. p. 373; x. p. 270. 2 Lehrbuch d. Geburtshülfe, 1882, p. 248. 3 Kleinwüchter's Grundriss d. Geburtshülfe, 1881, p. 190. * Carl Braun, Lehrb. d. g. Gynaek., 1881, p. 708. in the early months of pregnancy, the unfavorable character of the prognosis grows with the duration of pregnancy. Interruption of pregnancy may occur as the result of a variety of causative agencies. The elevation of maternal temperature, insufficient oxygenation of the maternal blood, placental anæmia from inadequate supply of blood to the left heart, are of chief etiological moment. The PROGNOSIS with reference to mother and child is always grave. The TREATMENT is that of pneumonitis in the non-gravid state. Parturition exerts a prejudicial influence by overtaxing the failing heartpower and increasing the hydræmia. The induction of premature labor is therefore strongly contraindicated. In the event of labor every effort must be made by operative procedure to save the mother's strength. ACUTE PLEURITIS is nearly as fatal a complication of pregnancy as pneumonitis, and for the The danger is especially great during labor. same reason. CHRONIC PLEURISY, EMPHYSEMA, AND EMPYEMA are dangerous complications of pregnancy, limiting respiratory space and producing cardiac complications. The induction of premature labor may be indicated by these conditions in the interest of mother and child. PULMONARY TUBERCULOSIS. Pregnancy exerts a prejudicial influence on hereditary or acquired tuberculosis as a rule. Latent tendencies to the disease are developed, and the progress of the existing affection is hastened. These effects upon the course of phthisis, Lusk says, are most frequently observed between the ages of twenty and thirty years, although of not infrequent occurrence between the ages of thirty and forty years. To these general propositions there are occasional rare exceptions. The disease is sometimes very rarely-observed to make no progress during gestation and the patient may decidedy improve during the lying-in period. puerperal phases, says Spiegelberg, exercise such varied influences upon the development and course of tuberculosis that it is an imperative necessity to individualize in every case. The When the disease progresses during pregnancy, abortion or premature labor may take place, or the woman may die undelivered. Infants born of tuberculous mothers are usually weak and sickly, and perish during the first months of life. For these reasons it is an established rule in practice to inform women of the tuberculous diathesis of the dangers entailed by the marital relation. A woman affected with tuberculosis ought never to nurse her own child. As a rule, however, there is seldom any necessity for such a warning, as the function of lactation is rarely established under these conditions. FUNCTIONAL DISORDERS IN CONNECTION WITH THE MENOPAUSE. By W. W. JAGGARD, M. D. DEFINITION AND TERMINOLOGY.-The time of life in a woman when the natural cessation of ovulation and menstruation occurs has received a variety of appellations more or less descriptive of the phenomena which are supposed to precede, attend, and follow that event. Change of life, Turn of life, Critical time, Climacteric, in English; Das klimacterium, Das aufhören menstrualer Ausscheidung, Das aufhören der Weiblichen Reinigung, in German; Ménopause, Âge de retour, Âge critique, Temps critique, in French; Cessatio mensium, Climacterium, in Latin; Menolipsis, in Greek,-are terms used to mark out a certain period of time commencing with the functional and organic disorders connected with the cessation of ovulation and menstruation in a causal relation, and terminating with the permanent resettlement of health. DATE OF CESSATION OF MENSTRUATION, AND DURATION OF THE CHANGE OF LIFE.-The function of ovulation, as far as we know, ceases with the discontinuance of menstruation, although immature ova still exist in the ovaries. The date of natural cessation of menstruation and ovulation is variable in different women. It is difficult to determine an average date, because the menopause may be gradually ushered in, and then women are apt to interpret any genital hemorrhage as menstruation. In certain cases the menstrual flow may cease between the ages of thirty and forty years, or even at an earlier period. On the other hand, the function has been noted by competent observers' to continue up to and beyond the sixtieth year. According to tradition, Cornelia, the mother of the Gracchi, was confined in her seventieth year. Parvin' has recently called attention to another historical instance of alleged late menstruation, recorded in a note to the fifty-sixth chapter of the Decline and Fall of the Roman Empire. On the authority of D'Herbelot's great work, Bibliothèque orientale, 1777, Gibbon mentions the case of Asima, the mother of Abdallah. When the tidings of the death of her son were borne to Asima her menses reappeared at the age of ninety as the physical effect of her grief. The historian informs us that the flow proved fatal in five days. These anomalous cases of so-called protracted menstruation are frequently examples of pathological hemorrhages dependent upon structural changes, sometimes of a malignant character. Even admitting the 1 Tilt, The Change of Life, 4th ed., 1882, p. 24. |