COMPLICATIONS ARISING FROM MATERNAL DISEASES AND ANOMALIES

Exact observations on a large number of cases have demonstrated beyond doubt that with very rare exceptions a pregnancy exerts a harmful effect upon the course of the disease (tuberculosis). Page 344.

So seriously is the tubercular process affected by a concomitant pregnancy that it seems the duty of the physician to warn every tubercular girl against marriage. Especially deleterious to the patient are pregnancies which follow each other at short intervals. In such instances the patient must be strongly advised against a new impregnation. It hardly can be denied that in some of these cases artificial sterilization may be justified. An additional argument in favor of this procedure is the comparative frequency with which, if not the infection itself, at least a marked disposition to it is transmitted to the fetus in utero. P. 344.

A TEXT BOOK OF OBSTETRICS. Barton Cooke Hirst, M.D., Professor of Obstetrics in the University of Pennsylvania; Gynaecologist to the Howard and Orthopaedic and the Philadelphia Hospitals, etc. W. B. Saunders Co. 1909.

The influence of pregnancy upon tuberculosis is most unfavorable and in women predisposed to tuberculosis, gestation may be the determining factor in lighting up an attack. It is the duty of a physician to advise strongly against marriage and maternity in the case of a woman already infected, or predisposed to tuberculosis. If the patient is pregnant an induction of labor should be considered. P. 427.

THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Jos. B. De Lee, M.D., Professor of Obstetrics at the Northwestern University Medical School; Obstetrician to the Chicago Lying-in-Hospital and to Wesley and Mercy Hospitals, etc. W. B. Saunders Co. 1913.

Women with tuberculosis should not marry, first, because this aggravates their own disease. Second, they may infect the husband, and third, they propagate tuberculous children. Knowing the tendency for a latent tuberculosis to break out in pregnancy, marriage is to be forbidden. If the woman marries, she should avoid conception. P. 481.

If tuberculosis of the lungs is manifested in early pregnancy, if there is fever, wasting, hemoptysis and advancing consolidation, that is, the process seems to be florid, abortion should be induced without delay. Trembley, of Saranac Lake induces abortion in the early months in all cases. Urgent symptoms of cardiac nature, persistent hemoptysis and dyspnea may require emptying of the uterus. Complicating nephritis, heart disease, and contracted pelvis, which is said to be more frequent in the tuberculous, will give early indications for interference. P. 481.

TUBERCULOSIS. Jos. B. De Lee.

The woman should be instructed how to avoid pregnancy in the future. Something must be done until the woman is cured of her tuberculosis, so that she may safely go through a confinement, because every accoucheur recoils with horror from the task of repeatedly doing abortions on these tuberculous women. P. 482.

THE PRACTICE OF OBSTETRICS. Designed for the use of Students and Practitioners of Medicine. J. Clifton Edgar, Prof. of Obstetrics and Clinical Midwifery in the Cornell University Medical College; Visiting Obstetrician to Bellevue Hospital, New York City; Surgeon to the Manhattan Maternity and Dispensary; Consulting Obstetrician to the New York Maternity and Jewish Maternity Hospitals. 5th Edition. Revised. P. Blakiston’s Co., Phil.

The subject of the relationship between tuberculosis and pregnancy has recently attained an increased degree of importance through the agitation in favor of the justification of abortion in the tuberculous pregnant woman. P. 314.

Statistics appear to show, according to Lancereaux, that a considerable number of cases of tuberculosis develop solely as a result of pregnancy. If pregnancy can thus affect health, how much more likely would it be for the disease to assert itself in a woman who is a fit subject for it, or in one who is actually consumptive. In the former class are so called candidates for tuberculosis who have a family history of the disease of much significance under these circumstances. One should strongly dissuade girls with tubercular history and antecedents from early marriage, fearing that repeated childbearing will infallibly light up the dreaded malady. What has been said of the candidate for tuberculosis applies with the same, or greater force in the case of so-called latent tuberculosis and of apparent recovery from the disease. Present sentiment is beginning to dissuade such women from marriage, not less for their own benefit than for the sake of posterity, and all organized movements which are seeking to eradicate tuberculosis from the world lay much stress on discouraging marriage in tuberculosis suspects. Until this view prevails there will necessarily be some justification for interrupting a pregnancy already under way. P. 314.

Sanatoria for consumptives do not care to admit pregnant women, and this prohibition is equivalent to ranking them as incurable. The fact that a candidate for tuberculosis runs a very great risk of becoming consumptive through childbirth is a most stubborn one, and when in addition to becoming a consumptive herself she also brings into the world an individual who is likely to become tubercular, it readily becomes apparent that the question of the propriety of therapeutic abortion is bound to become an issue in the future in the practice of obstetrics. P. 315.

EXCEPTIONAL CASES

A tubercular woman may go through gestation with no undue acceleration of her malady, only to succumb after delivery to acute general tuberculosis, or acute tubercular pneumonia. P. 315.

Tubercular pregnant women also show no little tendency to abort. P. 316.

TUBERCULOSIS A PREVENTABLE AND CURABLE DISEASE. S. Adolphus Knopf, M.D.; Professor of Phthisio-therapy at the New York Post-Graduate Medical School and Hospital; Associate Director of the Clinic for Pulmonary Disease of the Health Department; Attending Physician to the Riverside Sanitorium for Consumptives of the City of New York, etc. Moffat Yard & Co., 1909. New York.

We have emphasized the fact that tuberculosis is very rarely directly hereditary, but that what is often transmitted by tuberculous parents is a weakened system, or physiological poverty. Nevertheless it is evident that tuberculous individuals ought not to marry, and when tuberculosis develops in a married couple it is best that they should have no children. P. 354.

PULMONARY TUBERCULOSIS. Its Modern Prophylaxis and the Treatment in Special Institutions and at Home. S. Adolphus Knopf, M.D. P. Blakiston’s Sons & Co., Phil., 1899.

If conception has taken place in a tuberculous woman institute treatment, preferably in a sanatorium near the home of the patient. But as Treaudeau says, it is essential that the treatment be continued for a long time afterwards, and I should like to add that a repetition of pregnancy must be prevented. P. 283.

THE TUBERCULOSIS PROBLEM AND SECTION 1142 OF THE PENAL CODE OF THE STATE OF NEW YORK. S. Adolphus Knopf, M.D. Reprinted from the New York Medical Journal for June 12th, 1915.

There seems to be no difference of opinion in the minds of men and women who have studied rational eugenics and sociology concerning the necessity of beginning to work with the preceding generation, and of teaching parents that quality is better than quantity, and that a large number of children, underfed or of mental, moral and physical inferiority, means race suicide, while the reverse means race preservation.

I cannot defend my attitude better than by telling you the conclusions I have arrived at in my study of the tuberculosis situation in the United States. In the families of the poor where there are usually numerous children, it really matters little whether it is the father or the mother who is acutely tuberculous. Since almost invariably they live in close and congested quarters, are underfed and insufficiently clad, it is of relatively rare occurrence when most of the children do not become infected with tuberculosis. In some of our tuberculosis clinics where we insist on an examination of all the children of the tuberculous parents visiting these special dispensaries, we find as many as fifty per cent. of the children to be afflicted with tuberculosis as the result of postnatal infection. In taking the history of a patient in my private consultation work, it is my invariable custom to ask whether he comes from a large family, and if so whether he was among the first or latter born children. As a rule, especially among the poor, it proves to be one of the latter born, (the fifth, sixth, seventh, eighth, ninth, etc.) who contracts tuberculosis, and I believe this to be because when he came to the world there were already many mouths to feed and food was scant, for the father’s income rarely increases with the increase of the family; and the mother, worn out with repeated pregnancies, cannot bestow upon the latter born children the same care which was bestowed upon the first. We know tuberculosis to be a preventable and curable disease, but we also know that it is the disease of poverty, privation, malnutrition, and bad sanitation. P. 4.

I do not know the penalty to be visited upon a physician who offends the majesty of the law as set forth in section 1142 of the penal code, but I for one am willing to take the responsibility before the law and before my God for every time I have counselled, and every time I shall counsel in the future, the prevention of a tuberculous conception, with a view to preserving the life of the mother, increasing her chances of recovery, and, last, but not least, preventing the procreation of a tuberculous race. P. 5.

THE SEXUAL LIFE OF WOMAN IN ITS PHYSIOLOGICAL, BIOLOGICAL AND HYGIENIC ASPECTS. E. Heinrich Kisch, M.D., Professor of the German Medical Faculty of the University of Prague; Physician to the Hospital and Spa of Marienbad; Member of the Board of Health, etc. Translated by M. Eden Paul, M.D. Rebman Co., New York.

As regards the marriage of any woman suffering from tuberculosis we must take into consideration a fact that medical experience has conclusively established, namely, that the processes of generation have an unfavorable influence upon pulmonary tuberculosis. P. 259.

During pregnancy tuberculosis advances with such rapid strides that pregnancy and lying-in accelerate the fatal event. In some cases of consumption it is the first pregnancy that is the most perilous, but in other cases a later pregnancy proves more perilous. P. 260.

Dr. S. Adolphus Knopf, M.D., Professor of Medicine, Department of Phthisio-therapy of the New York Post Graduate Medical School and Hospital; Senior Visiting Physician to Riverside Hospital-Sanatorium for the Consumptive Poor of the City of New York, etc.

Reprinted from the Women’s Medical Journal, September, 1915.

Of the 150,000 who it is estimated die annually from tuberculosis in the United States, I venture to say 50,000 have been bread winners. Estimating the value of such a single life to the community at only about $5,000, this makes a loss of $250,000,000 each year. Another third, I venture to say, represents children at school age. They have died without having been able to give any return to their parents or to the community. Making the average duration of their young life only 7.5 years, and estimating the cost to parents and the community at only $200 per annum, the community loses another $75,000,000. The value of lives of little babes, children below and above school age, adolescents not yet bread winners, and men and women no longer able to earn their living can not be estimated in exact figures, but is reasonable to suppose the total annual financial loss from tuberculosis in the United States to be at least half a billion dollars. This does not include the expenditures for hospitals, sanatoria, clinics, dispensaries, colonies, preventoria and other agencies, devoted to the solution of the tuberculosis problem.

In the face of these figures and the suffering, misery and disappointment of parents who lose their children after having tenderly loved and cared for them for some years, I wonder if there can be any doubt in the minds of sane men that it would have been better if these children had never been born. Surely all this is race suicide instead of race preservation.

Not so very long ago I was asked by a young colleague to aid in the diagnosis of tuberculosis in a day laborer. The man earned $12 a week, was thirty-six years of age on the day the examination and diagnosis was made, had been married fourteen years, and his eleventh child had been born on his last birthday; four or five had already died, two of them of tuberculous meningitis. A glance at the rest of the family showed that nearly all of them were predisposed to tuberculosis, if not already infected, and that a few years of continued underfeeding and bad housing would finish their earthly career. With two or three children to provide for the family might have lived in relative comfort; with better food and better home environments the father might never have become tuberculous and none of the children might have contracted the disease. The commonwealth would have been the gainer by two or three mentally and physically vigorous future citizens.

Only a few days ago, while an article for the Journal of Sociologic Medicine was in preparation, an Italian woman presented herself to me for examination. She gave her age as fifty-six, and had married quite young. She had borne her husband seventeen children, of which, however, only four were living. Some had died in infancy, some at school age, and some during adolescence. What useless suffering! What useless economic loss to the individual family and society at large. Upon examination, I found the woman’s mental condition even worse than her physical status. The repeated pregnancies, the frequent diseases in the family, thirteen deaths among her children, had made a mental and physical wreck of her. Yet the woman belonged to the better and well-to-do class of our population of Italian birth. What would her condition have been if she had also had to share in the struggle for the existence of the family, and had had to work in sweatshops or factories, as so many of the poor Italians have to do?

When pregnancy means danger to the life of the mother, or exacerbation of an existant mental or physical ailment, as, for example, tuberculosis, which is always aggravated by child-bearing, every conscientious physician should do his utmost to prevent childbirth in such an invalid.

Where there is tuberculosis or any other serious transmissible disease in one or both of the parents, or there is danger that it may be transmitted to the offspring, it should not only be the right but the sacred duty of the physician to prevent the conception of any physically and mentally handicapped offspring destined to become a burden to the community.

KIDNEY DISEASES

THE PRACTICE OF OBSTETRICS. In Original Contributions by American Authors. Edited by Reuben Peterson, A.B., M.D., Professor of Obstetrics and Gynecology in the University of Michigan, Ann Arbor, Mich. Obstetrician and Gynecologist in Chief to the University of Michigan Hospital. Lea Bros. & Co., Phil. and New York. 1907. Chapter XIX.

Pephritis. From statistics we find that even excluding the cases of eclampsia, the maternal mortality from nephritis during pregnancy is 33%, and the fetal mortality between 50% and 60%. P. 352.

Women suffering from a chronic nephritis should be advised strongly against marriage, especially in the presence of a cardiac or pulmonary lesion. Married women should be warned against impregnation. P. 354.

Pyelitis. “On account of the increased dangers of pyelitic and especially of a pyelonephritic process during pregnancy, women suffering from these diseases should be warned against marriage. Married women should be warned against a new impregnation, on account of the marked tendency of pyelitis to recur with every pregnancy.” P. 355.

PRACTICAL OBSTETRICS. Thos. Watts Eden. Obstetrician, Physician and Lecturer on Midwifery and Gynecology, Charing Cross Hospital; Consulting Physician to Queen Charlotte’s Lying-in-Hospital; Surgeon to In-Patient Chelsea Hospital for Women. 4th Edition. C. V. Mosby Co. 1915.

Certain of the conditions enumerated form absolute indications for the induction to abortion. These are nephritis, (a form of kidney disease), uncompensated valvular lesions of the heart, advanced tuberculosis, insanity, irremediable malignant tumors, hydatidiform mole, uncontrollable uterine haemorrhage, and acute hydramnios. P. 652.

PRINCIPLES AND PRACTICE OF OBSTETRICS. Jos. B. De Lee, M.D., Professor of Obstetrics at the Northwestern University Medical School; Obstetrician to the Chicago Lying-in-Hospital and Dispensary, and to Wesley and Mercy Hospitals, etc. W. B. Saunders Co. 1913.

All forms of nephritis have a very bad influence on the pregnancy, abortion and premature labor being common. (66% Hofmeier) Seitz found that only from 20% to 30% of the children survived. One of the causes of habitual death of the fetus, abortion, and premature labor is chronic nephritis. P. 497.

“The children of nephritics are usually puny and pale.” P. 497.

Both mother and child are seriously jeopardized by chronic nephritis, the mortalities being about 30% respectively. P. 497.

Women with chronic nephritis should not marry, and if married, should not conceive. P. 498.

Diabetes. Sterility is common. Abortion and premature labor occur in 33% of the pregnancies. The children, if the pregnancy goes to term, often die shortly after birth, the total mortality being 66%. P. 502.

True diabetes has a very bad diagnosis. Offergold found over 50% mortality. Of the children 51% were still born, 10% died within a few days after birth, and 5% more before six months. P. 503.

If a woman comes under treatment with a history of diabetes it is best to terminate the pregnancy at once. P. 503.

THE PRACTICE OF OBSTETRICS. Designed for the use of Students and Practitioners of Medicine. J. Clifton Edgar. Professor of Obstetrical and Clinical Midwifery in the Cornell University Medical College; Visiting Obstetrician to Bellevue Hospital, New York City; Surgeon to the Manhattan Maternity Dispensary; Consulting Obstetrician to the New York Maternity and Jewish Hospitals. 5th Edition, Revised. P. Blakiston’s & Co., Philadelphia.

Statistics appear to show that labors in these women, (diabetes) are quite apt to end unfavorably, in one or another way. When diabetic women become pregnant their disease usually takes a turn for the worse. According to Lecorche, true diabetes who become pregnant, usually succumb to the disease within a short time after delivery. P. 305.

ECLAMPSIA

THE PRINCIPLES AND PRACTICE OF OBSTETRICS. By Joseph B. De Lee, M.D.

Over 20% of women with eclampsia die and statistics show that 10% of such cases developed in the maternities. For the child the chances are not good, nearly one half of the children dying as a result, that is, due to: prematurity, toxemia, asphyxiation by repeated convulsions of the mother, drugs administered to the mother, and injuries sustained during birth, especially forced delivery. Eclampsia is more easily developed in a pregnant woman because the kidneys are carrying an increased burden, and too often diseased through the pregnancy changes. The cause of eclampsia are unknown but in 20% of cases the convulsions begin during pregnancy, in 60% during labor, and in 20% after delivery. Page 365.

The treatment is to stop the gestation at a point before either mother or child, or both, are in danger either to life or to health. Page 1041.

MATERNAL MORTALITY. Grace L. Meigs, M.D., U. S. Department of Labor. 1917.

Puerperal albuminuria and convulsions, called also eclampsia, or toxemia of pregnancy, is a disease which occurs most frequently during pregnancy but may occur at or following confinement. It is a relatively frequent complication among women bearing their first children. When fully established its chief symptoms are convulsions and unconsciousness. In the early stages of the disease the symptoms are slight puffiness of the face, hands, and feet; headache; albumen in the urine; and usually a rise in blood pressure. Very often proper treatment and diet at the beginning of such early symptoms may prevent the development of the disease; but in many cases where the disease is well established before the physician is consulted, the woman and baby can not be saved by any treatment. In the prevention of deaths from this cause it is essential, therefore, that each woman, especially each woman bearing her first child, should know what she can do, by proper hygiene and diet, to prevent the disease; that she should know the meaning of these early symptoms if they arise, so that she may seek at once the advice of her doctor; and that she should have regular supervision during pregnancy, with examination of the urine at intervals.

DIABETES

THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Joseph B. De Lee, M.D. Page 514.

Without doubt pregnancy has a bad effect on the course of this disease. It may develop a latent diabetes, there being cases where severe symptoms appeared only during successive pregnancies, and others where the disease grew progressively worse each time. Coma occurs in 30% of the cases and is almost always fatal. It may be brought on by a slight shock in pregnancy, but more often during and just after labor. Delivery seems to have a worse effect than most surgical operations, causing collapse, coma, or sudden death. Bronchitis has been noted in the puerperium, and this has been found to eventuate in tuberculosis. True diabetes has a very bad prognosis, authorities finding over 50% mortality, of which 30% died in coma, within two and one half years, and too often the child dies in utero.

PELVIC DEFORMITIES

MATERNAL MORTALITY. Grace L. Meigs, M.D., U. S. Department of Labor, 1917.

Some obstruction to labor in the small size or abnormal shape of the pelvic canal causes many deaths of mothers included in the class “other accidents of labor” and also many stillbirths. If such difficulty is discovered before labor, proper treatment will in almost all cases insure the life of mother and child; if it is not discovered until labor has begun, or perhaps until it has continued for many hours, the danger to both is greatly increased. Every woman, therefore, should have during pregnancy—and above all during her first pregnancy—an examination in which measurements are made to enable the physician to judge whether or not there will be any obstruction to labor. A case in which a complication of this kind is found requires the greatest skill and experience in treatment, but with such treatment the life and health of the mother are almost always safe.

No subject in medicine presents greater difficulties in all its aspects than this one, (treatment of contracted pelves) and none demands such art or practical skill. Science aids little here. P. 709.

Outside factors must also be considered: 1—The environment, whether the parturient is in a squalid tenement, in the country, in a home where every appliance is attainable, or in a well equipped maternity. 2—Whether in the hands of a general practitioner or a trained specialist. 3—If the patient is a Catholic, all medically indicated procedures not being permitted. 4—The age of the parturient, and the probability of her having more children. Even with these enumerations, the possible factors which might influence a labor, or our decision regarding the course to pursue have not all been mentioned. P. 709.

THE PRACTICE OF OBSTETRICS. Designed for the use of Practitioners and Students of Medicine. J. Clifton Edgar, Professor of Obstetrics and Clinical Midwifery in the Cornell University Medical College. Visiting Obstetrician to Bellevue Hospital, New York City; Surgeon to the Manhattan Maternity Dispensary; Consulting obstetrician to the New York Maternity and Jewish Maternity Hospitals. 5th Edition, Revised. P. Blakiston’s & Co., Phila.

A knowledge of the female bony pelvis is the very alphabet of obstetrical science, and the foundation of obstetrical art. This structure is most important since it is from the disproportion between its size and that of the fetus, or from its abnormal shape that many of the difficulties of labor arise.

PRACTICAL OBSTETRICS. Thos. Watts Eden. Obstetrician; Physician and Lecturer on Midwifery and Gynecology, Charing Cross Hospital; Consulting Physician to Queen Charlotte’s Lying-in-Hospital; Surgeon to In-Patient Chelsea Hospital for Women. 4th Edition. C. V. Mosby Co. 1915.

The general course of labor is modified by pelvic contractions in various ways. 1—Abnormal presentations are three or four times commoner in contracted than in normal pelves. 2—Prolapse of the cord is much commoner than in normal pelves. 3—When natural delivery occurs labor is prolonged and the mechanism is modified. 4—Unless the true conjugate is at least 3¼ inches, even with artificial aid the survival of the child is seriously jeopardized. 5—The maternal risks are increased by the greater length and difficulty of the labor and by the frequent necessity of employing artificial methods of delivery. 6—The fetal risks are increased in natural delivery by severe compression of the head during its passage through the narrow pelvis, and other circumstances by the operations required to effect delivery, some of which involve the destruction of the fetus. P. 409.

THE PRACTICE OF OBSTETRICS. In Original Contributions by American authors. Edited by Reuben Peterson, A.B., M.D. Lea Bros. & Co., Phil. and New York. 1907.

Labor complicated by anomalies of the Bony Pelvis. John F. Moran, M.D.

The frequency with which pelvic contraction occurs can only be determined with relative accuracy. There is in existence a comparatively large amount of statistical data on this subject, but the reports of different investigators vary within wide limits, and these variations are naturally not to be explained entirely on the assumption of racial conditions, or geographic distribution. Between these wide limits are arrayed the figures of about 20 modern observers in different parts of the civilized world who have reported statistics of cases. The combined figures of 19 observers include a total of over 150,000 cases examined for pelvic contraction. In these cases the average of contraction is found to be about 10%. Williams concludes that contracted pelves occur in from 7% to 8% of the white women of this country. P. 658–659.

HEART DISEASE

THE SEXUAL LIFE OF WOMAN IN ITS PHYSIOLOGICAL, BIOLOGICAL AND HYGIENIC ASPECTS. E. Heinrich Kisch, M.D. Professor of the German Medical faculty of the University of Prague; Physician to the Hospital and Spa of Marienbad; Member of the Board of Health, etc. Translated by M. Eden Paul, M.D. Rebman Co., New York.

These are cases (severe heart disease) in which, in my opinion, it is the physician’s duty to concern himself with the subject of the use of preventive measures, and having regard for the preservation of a woman’s life, and uninfluenced by any false delicacy, but with simple earnestness to inform his patient with respect to the needful prophylactic measures. The artificial termination of pregnancy, which unquestionably is often justified in women suffering from heart disease, but which unfortunately is apt to have very unfavorable results, will rarely need to be discussed if by the proper employment of preventive measures care is taken that pregnancy does not recur too frequently. P. 255.

OBSTETRICS. A Text Book for the use of Students and Practitioners. Whitridge Williams, Professor of Obstetrics, Johns Hopkins University; Obstetrician in Chief to the Johns Hopkins Hospital; Gynecologist to the Union Protestant Infirmary, Baltimore, Md. D. Appleton & Co., 1912.

Some authorities recommend that women suffering from heart lesions should be dissuaded from marriage, or if married, from becoming pregnant. This, however, appears to be an extreme view, though of course when the lesion is serious and the compensation faulty the dangers of child-bearing should be carefully explained. P. 498.

THE PRACTICE OF OBSTETRICS. In Original Contributions by American authors. Edited by Reuben Peterson, A.B., M.D., Professor of Obstetrics and Gynecology in the University of Michigan, Ann Arbor, Mich.; Obstetrician and Gynecologist-in-Chief to the University of Michigan Hospital. Lea Bros. & Co., Phil. and New York. 1907. Chapter XIX.

“Leyden claims that about 40% of all women with serious heart lesions meet their death in connection with childbirth. Still greater than the demands upon the heart during pregnancy are those made by labor. The strain, mental excitement, and especially the sudden changes in the blood pressure, conditions which are well recognized as extremely harmful to every patient with a chronic heart lesion, and which cannot be avoided in the course of labor, make the situation extremely dangerous.” (Hugo Ehrenfest, M.D.) P. 357.

“The prognosis for the fetus is unfavorable. Fellner, whose figures undoubtedly are low, places the frequency of premature, spontaneous interruption of pregnancy as 20%, other writers at from 40% to 60%.” P. 358.

“No marriage for the unmarried, no pregnancy for the married, no nursing for the confined,” is a statement which has been made by a French author, and has been accepted by many writers. It is incompatible with the results of recent investigations. It would be too harsh and unjustifiable to deny marriage to a woman who has a well compensated valvular lesion. She should be informed of the risks of impregnation, but should be warned against marriage only where there exist distinct evidences of incompensation, especially in cases of mitral stenosis. P. 359.

A TEXT BOOK OF OBSTETRICS. Barton Cooke Hirst, M.D.; Professor of Obstetrics in the University of Pennsylvania; Gynecologist to the Howard and Orthopaedic, and the Philadelphia Hospitals, etc. 7th Edition. W. B. Saunders Co., Philadelphia and London. 1912.

Abortion is induced in about 25% of all cases, as the result of placental apoplexies, or of the stimulation of the uterus to contraction by the accumulation of carbondioxid gas in the blood. Pregnancy distinctly increases the danger of the heart lesion. In 58 serious cases, 23 died after premature delivery of the child. In milder cases prognosis is not grave, yet the woman’s condition is by no means free from danger. If the disease be of long standing and serious in character, it appears from statistical studies that about half the women die. P. 423.

PRINCIPLES AND PRACTICE OF OBSTETRICS. Jos. B. De Lee, M.D.; Professor of Obstetrics at the Northwestern University Medical School; Obstetrician to the Chicago Lying-in-Hospital, and to Wesley and Mercy Hospitals, etc. W. B. Saunders Co. 1913.

Abortion and premature labor, especially the latter, occur in cases of dis-compensation, in from 20% to 40%, and stillbirth in 29% to 70%, giving figures collected from various sources by Fellner. P. 489.

THE PRACTICE OF OBSTETRICS. Designed for the use of Students and Practitioners of Medicine. J. Clifton Edgar, Professor of Obstetrics and clinical midwifery in the Cornell University Medical School; Visiting Obstetrician to Bellevue Hospital, New York City; Surgeon to the Manhattan Maternity and Dispensary; Consulting Obstetrician to the New York Maternity and Jewish Maternity Hospitals. 5th Edition, Revised. P. Blakiston’s & Co., Philadelphia.

Acute Endocarditis not only has an injurious influence upon pregnancy, but it is also apt itself to become extremely grave. Regarding treatment, induced labor will be demanded. P. 310.

TOO FREQUENT PREGNANCIES

BEING WELL BORN. An Introduction to Eugenics. Michael F. Guyer, Ph.D., Professor of Zoology, University of Wisconsin. Bobbs-Merrill Co. Indianapolis. 1916.

Too short an interval between childbirths would also seem to be an infringement on the rights of the child as well as of the mother. Thus Dr. R. J. Ewart, (“The Influence of Parental Age on Offspring,” Eugenic Review, Oct., 1911) finds that children born at intervals of less than two years after the birth of the previous child still show at the age of six a notable deficiency in height, weight and intelligence, when compared with the children born after a longer interval, or even with first-born children. P. 166.

FREQUENT PREGNANCIES. The Contributions of Demography to Eugenics. Dr. Corrado Gini, Professor of Statistics at the Royal University of Cagliari, Italy.

If the possibility of generation at any season of the year cannot, as has been shown, have any deleterious effect on the vitality of human offspring, it can none the less have indirect deleterious consequences, in so far as it allows pregnancies to succeed each other at too short intervals. P. 323.

“The deleterious consequences which too short a period after the preceding birth have upon the vitality of the child are indisputable, at least during the first year of life.” P. 323.

THE SEXUAL LIFE OF WOMAN IN ITS PHYSIOLOGICAL, BIOLOGICAL AND HYGIENIC ASPECTS. E. Heinrich Kisch. Rebman Co., N. Y.

“Frequently recurring pregnancies and childbirth, according to Kronig, act as the predisposing cause in the production of neurasthenia.” P. 257.

NEO-MALTHUSIANISM AND RACE HYGIENE, IN “PROBLEMS IN EUGENICS.” Vol. 2. Dr. Alfred Ploetz, President of the International Society for Race Hygiene. London, 1913.

Malthusianism further affects the quality of the offspring by increasing the intervals between single births. In families in which the parents intend to have only a few children, the mother is usually exempt from so frequent child-bearing, and she has ample time for regaining her strength. The greater interval between births has evidently a favorable effect upon the expectation of life of the children that are born. Westergard has stated that in 21,000 births, if the interval between birth is:—

	The percentage of deaths before five years of age is
Less than one year	20%
One to two years	14%
More than two years	12%

That means a difference in the mortality between first and last class of 40% in favor of the longer interval. P. 186.

THE LIFE INSURANCE EXAMINER. A Practical Treatise by Charles F. Stillman, M.S., M.D., Medical Examiner for the Mutual Life Insurance Co.; Clinical Professor of Orthopaedic Surgery in the Women’s Medical College of the N. Y. Infirmary; Orthopaedic Surgeon to the N. Y. Infant Asylum; Member of the Am. Orthopaedic Association; Permanent member of the American Medical Association; Fellow N. Y. Academy of Medicine, etc. 3rd Edition. Spectator Co., N. Y., 1890.

“Postpone (as dangerous insurance risks) all cases of pregnancy; all instances where the mother seems, in the judgment of the Examiner, to have been bearing children too fast.” P. 186.

RASSENVERBESSERUNG. Translated from the Dutch of Dr. J. Rutgers. 2nd Edition. Dresden, 1911.

The combatting of self-induced abortion is one of the problems of Sexual Hygiene. The two causes of most weight in this situation are syphilis and too frequent pregnancy. It is quite evident that both of these causes would be favorably influenced by the use of contraceptive measures. P. 81.

THE MALTHUSIAN, May 15, 1914. Sexual Ethics. A Study of Borderland Questions. Robert Michels, (Review).

Prof. Michels perceives that race control has two aspects; it may be an urgent duty, and it is in any case an inalienable human right. It may be regarded as a duty to actual or potential children, in view of either bad economic conditions,—such as affect the bulk of all European populations,—or defective heredity, and it may also be considered as an obligation of humanity towards the wife and mother. Prof. Michels here speaks with no uncertain voice: “The type of woman continually engaged in child-bearing is a primitive one, out of harmony with the needs and ideas of modern civilized life. Even as few as six pregnancies that go to full term rob a woman of about ten years of her life, and these the best. It is evidently far easier to provide a clear-sighted affection and a wisely conceived and individualized upbringing for two or three children than it is for eight or nine.”

MR. SIDNEY WEBB, in The Times of October 16, 1906.

Assuming, as I think we may, that no injury to physical health is necessarily involved (in the volitional regulation of the marriage state); aware, on the contrary, that the result is to spare the wife from an onerous and even dangerous illness for which in the vast majority of homes no adequate provision in the way of medical attendance, nursing, privacy, rest, and freedom from worry can possibly be made, it is, to say the least of it, difficult on any rationalist morality to formulate any blame of a married couple for the deliberate regulation of their family according to their means and opportunities.

PERNICIOUS VOMITING

THE PRINCIPLES AND PRACTICE OF OBSTETRICS. By Joseph B. De Lee, M.D.

Among diseases incidental to pregnancy must be counted pernicious vomiting. Page 370.

Statistics are uncertain, but out of 118 cases there were 46 deaths. Page 357.

The keynote of treatment is to stop the gestation at a point before either mother or child, or both, are in danger to life or to health. Page 1041.

THE PRACTICE OF OBSTETRICS. By J. Clifton Edgar, M.D., Professor of Obstetrics and Clinical Midwifery in the Cornell University Medical College; Visiting Obstetrician to Bellevue Hospital, New York City; Surgeon to the Manhattan Maternity and Dispensary; Consulting Obstetrician of the New York Maternity and Jewish Maternity Hospitals, New York City.

Under certain circumstances labor may be much disturbed by pernicious vomiting. The causes comprise actual organic disease of the stomach and functional disturbances from errors in diet. The determining cause of a paroxysm of vomiting is a severe labor pain. The coincidence of labor and vomiting is not unusual in anemic primiparae. Mental emotion is also a cause. As this vomiting may presage the development of eclampsia or some other affection it is best to terminate labor at once. Page 648.

CHAPTER VI
HARMFUL METHODS PRACTICED TO AVOID LARGE FAMILIES

In this chapter it is shown that ignorance of scientific means of preventing conception involves women in harmful practices. The most common is coitus interruptus which results in nervous disorders. Long continued celibacy or unnatural continence leads to sex inversions. When, in spite of these unscientific practices, pregnancy follows, abortion, the greatest disgrace of modern civilization, is the only resort of the harassed mother, unless she will bear unwanted offspring.