The Care of Women in Pregnancy. 
CHARLES M. GREEN, M. D. 
BY 
Reprinted front the Boston Medical and Surgical Journal 
of February 25, 1892. 
DAMRELL & UPHAM, PUBLISHERS 
No. 283 Washington Street. 
1892. 
BOSTON: S. J. PARKHILL & CO., PRINTERS 
BOSTON THE CARE OF WOMEN IN PREGNANCY.1 
BY CHARLES M. GREEN, M.D. 
It is probably true that the great majority of preg- 
nant women are not seen by their physician profes- 
sionally until he is summoned to attend them in labor. 
If serious complications arise during the pregnancy, 
such as excessive nausea and vomiting, uterine haem- 
orrhage, unusual pain or convulsions, the doctor is 
necessarily summoned; but the minor ills and discom- 
forts are endured in silence, and no advice is taken 
except that of relatives and neighbors, who love so 
well to fill the ears of the young gravida with accounts 
of their own experiences. In other words, in the great 
majority of cases, no attention is paid to the hygiene 
of pregnancy, and the woman arrives at term in good, 
bad or indifferent condition, as the case may be. 
The reasons for this unsatisfactory state of things 
are not far to seek. Many women believe that preg- 
nancy is a more or less pathological process, and as- 
sume that its ailments must be borne as a necessary 
concomitant of childbearing. They do not know that 
most of the ills of gestation are preventable, or largely 
remediable, by competent medical supervision and 
advice, and that so far from being pathological, preg- 
nancy is indeed a physiological process, except in occa- 
sional instances. Again, probably a large majority of 
women are ignorant of the fundamental laws of health, 
and, while perhaps seldom very sick, are seldom quite 
well. When, in such women, pregnancy supervenes, 
it is not surprising that it is often attended with path- 
1 Read before the Boston Society for Medical ImproxeiHent. De- 
cember 28, 1891. ' 2 
ological conditions. To ignorance, then, both of the 
ways of correct living and of the advantages of proper 
advice during pregnancy, must be ascribed largely the 
unsatisfactory condition in which many women are 
found when labor overtakes them. 
Another reason for the lack of medical supervision 
during pregnancy is the attendant expense. The great 
majority of women are attended in labor by contract, 
so to speak ; that is to say, they expect to pay a cer- 
tain definite fee, usually a small, inadequate one, which 
shall cover the doctor's attendance during the labor 
and his subsequent visits during the convalescence. If 
the woman desires, or feels that she needs, to consult 
her physician during her pregnancy, she usually seems 
to take it for granted that advice at such times should 
involve no additional fees. It is not surprising that 
for the very small fees for obstetric attendance that 
obtain in most suburban and rural districts, medical 
men should be sometimes unwilling to extend their 
advice over the pregnancy as well as to take charge of 
the labor and convalescence. On the other hand, most 
women are unable or unwilling to pay fees for advice 
on matters relating to their pregnancy. 
For one or more of these reasons, to repeat my 
original statement, the great majority of pregnant 
women receive no medical advice or supervision. I 
believe this to be a misfortune, and a detriment to the 
best interests of the race; and it is the object of this 
paper to point out the importance, necessity and ad- 
vantages of proper supervision of pregnancy, how in 
my opinion it should be exercised, and how the obsta- 
cles in its way can be removed. 
There is, supposedly, no question but that pregnancy 
and parturition ought to be, and were in the divine 
plan intended to be, physiological processes : that in a 
large proportion of cases they are not so, a somewhat 3 
extended experience leads me to believe. Making due 
allowance for the congenital and acquired defects of 
general or local character which are certain to make 
these processes pathological, the fact still remains, in 
my judgment, that, in a great majority of cases, preg- 
nancy and labor can be brought quite within physio- 
logical and normal limits. If this opinion is true, 
there is no necessity of dwelling on the importance of 
adopting such measures as will lead to this most de- 
sirable end. 
The true object of modern medical science is to do 
away with the necessity of medical art : in other 
words, the aim of the true physician is to make the 
further exercise of his profession useless. While the 
force of this statement is admitted in general, it has not 
seemed to me.that the extent to which it is applicable 
in obstetric medicine is fully realized. I believe that, 
accepting the existing states and conditions in which 
women of the present day are found, very much can 
be done by competent supervision during pregnancy to 
bring labor and puerperal convalescence quite near to 
normal, physiological bounds ; whereas experience has 
abundantly convinced me that to the lack or inade- 
quacy of such supervision much unnecessary suffering 
and disaster are due. But to relieve myself of the 
probable criticism that my expectations of preventive 
medicine are altogether utopian, let me hasten to add 
that whatever may be the possibilities of prevention in 
the field of epidemiology and general medicine by meas- 
ures of public and private hygiene, the day is doubt- 
less far distant when the services of obstetric medicine 
and surgery will be found useless. 
Supposing the obstacles in the way of medical super- 
vision of pregnancy, - namely, ignorance of its im- 
portance and necessity on the part of the patient, and 
the question of expense on the part of patient and 4 
doctor, - can .be set aside, let us consider what can be 
done for the welfare of the young pregnant woman 
and her prospective offspring, when free and full op- 
portunities for obtaining medical advice are open to 
her. What are the respective duties of doctor and 
patient in the premises ? Suppose the woman to have 
passed over one or two menstrual periods, and in the 
absence of other probable causes of amenorrhcea pre- 
sumes herself to be pregnant: she consults her physi- 
cian. By a few simple questions he satisfies himself 
that presumably she is pregnant: is it his duty to pro- 
ceed to confirm his presumptive diagnosis by a physi- 
cal examination ? In most cases, certainly not. If 
important plans, as of journeys abroad, of changes of 
residence or manner of living, are dependent on a 
knowledge of the woman's condition, it may be neces- 
sary to determine, if possible, by physical examination 
whether pregnancy actually does exist; but under or- 
dinary circumstances it is proper to proceed with a 
presumptive diagnosis, knowing that time will settle 
the matter beyond question. But at this time it is im- 
portant that the physician should make careful inquiry 
in regard to the patient's general health. Of course, 
if he has been her medical adviser previously, her tem- 
perament, constitution and general condition will be 
known to him; but if not, he should inform himself 
on these points, and adopt such measures as may be 
necessary to promote good general health, and to rem- 
edy, as far as possible, constitutional defects. There 
are some special points, also, on which specific advice 
should be given : these points will be considered in 
detail. 
Nutrition is a process of great importance in preg- 
nancy, both to the mother and to her child: it is de- 
sirable for the mother to be able to put forth all her 
strength in her labor, and to endure its necessary suf- 5 
ferings with the least possible shock to her system. 
To this end attention should be paid to her appetite, 
diet and digestion. Some women during pregnancy 
have inordinate and perverted appetites, which need 
to be moderated and controlled. Some purposely re- 
strict themselves unduly, in the hope of thereby retard- 
ing foetal growth and of thus having an easier labor. 
Others for some reason have an insufficient appetite, 
which needs to be stimulated by proper therapeutic 
measures. The diet of pregnancy needs differ in no 
important particular from that which is proper in 
other phases of hygienic living, unless some special 
condition requires specific modification. Some author- 
ities believe the food should be especially rich in phos- 
phates, to promote the bony development of the foetus ; 
but it seems reasonable that whatever food is best for 
the mother may naturally be expected to be most suit- 
able for foetal development. Simple, nutritious diet, 
in moderate but sufficient quantity, should be advised: 
candy, pastries and fries should be avoided. The use 
of tea, coffee and wine should depend on their effects 
and on the patient's habit. Some women, who habitu- 
ally eat too little, may require forced feeding, - a light 
lunch between meals and at bedtime, of milk, broth, 
egg-nog, malt, or bread and butter. 
Most women at this early period of their first con- 
sultation with their physician are suffering more or less 
with nausea and vomiting, although some happily es- 
cape this often distressing symptom. It is not my 
purpose to discuss the treatment of this affection, 
which usually disappears spontaneously when the ute- 
rus has become an abdominal organ; but rather to 
express my belief in the importance and wisdom of 
checking or limiting it in its incipiency. The water 
which will quench a small blaze will add to the fury of 
a conflagration; and measures which will control this 6 
symptom in the beginning often prove worse than 
useless when once perverted function has assumed full 
sway. No one can tell to what end an apparently 
physiological nausea may attain. While occasionally no 
therapeutic measure short of induced abortion (and 
sometimes unhappily not even that) will control this 
symptom, in most cases simple remedies will suffice to 
remove it or keep it within due bounds: it is often 
found that attention to diet and digestion is all that is 
necessary. Morning nausea is often proved to be due 
to a want of nourishment, and is prevented by taking 
a lunch at bedtime, and another in the morning before 
raising the head from the pillow. If simple dietetic 
measures do not prevail, the cause should be sought 
for, and perhaps found, in a displacement or impaction 
of the uterus, or in an abnormal condition of the cer- 
vix : in other cases the cause will be found in a per- 
verted innervation or hysteria. But whatever thecause, 
it should be found and removed, if possible, before the 
development of serious results in the patient's condi- 
tion. A return of these symptoms in the later months 
should be given special attention. 
At the first early interview the condition of the 
bowels should receive careful inquiry. Not only are 
most women chronically constipated, but those with 
whom the function of defecation was previously nor- 
mal are often disturbed with sluggishness of the bowels 
in the early months of pregnancy : indeed, constipation 
is considered by some a symptom of pregnancy in 
those previously regular. No speedy resort should be 
had to drugs, but an effort should be made to correct 
the difficulty by hygienic and dietetic measures. The 
woman should be cautioned not to strain at stool ; 
enemata will suffice to ensure an easy movement when 
the failure is due to torpidity of the rectum. Much 
can be accomplished by proper exercise and dietetics ; 7 
but should such measures fail, others must be employed 
to insure a regular, daily movement. 
The skin is also an important organ of elimination. 
The better the functional activity of the skin, the less 
work will be thrown upon the kidneys at a time when 
unusual demands are made upon them. If the patient 
has not the habit of daily bathing, the duty of adopting 
it should be enjoined, the bath to be followed by 
vigorous friction with coarse towels. Apart from the 
benefit of stimulating glandular activity in the skin, 
daily bathing has a sedative effect on the nervous sys- 
tem and tends to promote the functional activity of 
the bowels, and other digestive and eliminative organs. 
Unless the patient has some antecedent affection of 
the kidneys, there is seldom any disturbance of their 
function in the early months. Micturition is some- 
times frequent, owing to the pressure of the enlarged 
and anteverted uterus on the bladder, or there may be 
an irritability of the latter viscus caused by concentrated 
urine. Women proverbially drink too little water to 
properly dilute their urine, which is often high colored, 
of high specific gravity, and excessively acid. This 
condition is not, of course, peculiar to pregnancy; but 
it is liable to be aggravated thereby and should receive 
attention. A glass of water three times a day will 
often suffice to relieve this condition : failing this, lithia 
water or acetate of potash may be advised with bene- 
fit. Throughout the pregnancy the state of the kidney 
should be closely watched. By this is not meant that 
the urine should be examined necessarily at frequent 
intervals. The patient herself, if of average intelli- 
gence, can be taught to do most of the watching, and 
that, too, without exciting her nervous apprehensions. 
In these days when water-closets are to be found on 
every floor of most houses, bedside cabinets and the 
old-time chamber-vessel are seldom used: as a result, 8 
most people rarely see their own urine and are unable 
to give much information concerning it. It is my cus- 
tom, therefore, to direct pregnant women to see their 
urine at least once a day: I instruct them as to the 
average daily amount in health, tell them that it is 
important that this amount should be maintained, and 
ask them to notify me, if they notice any departure 
from normal standards, either in color or amount. I 
also ask to be informed of the occurrence of oedemas, 
puffiness of the eyelids, headaches, disturbances of 
vision, nervousness, and indeed of any symptom of ill- 
feeling. Twice or three times in the later months it 
is well for the physician to examine the urine; but 
even without such examination there is no occasion for 
apprehension of eclampsia so long as the urine is nor- 
mal in amount, so long as the nervous system is in 
stable equilibrium, and so long as there is no appar- 
ent indication of central nervous irritation : the mere 
presence of moderate oedema and albuminuria, without 
other symptoms, does not disturb me in the least, al- 
though it makes me watchful. 
As may be inferred from the last paragraph, the 
condition of the nervous system should receive special 
attention throughout pregnancy. Making due allow- 
ance for a poor inheritance, most women can be 
brought into a state of nerve equilibrium by a skilful 
guidance on the part of the physician into ways of cor- 
rect living. There is no better medicine for unstable 
nerves than a plenty of sound sleep. If, therefore, it 
is found that the patient's sleeping habits are unsatis- 
factory, the cause should be sought for and removed. 
Suitable exercise, and a warm bath and a lunch at 
bedtime are often efficacious-; but sometimes a course 
of bromides may be advisable. In the later months 
the woman sometimes fails to sleep because she cannot 
lie comfortably in bed. She may be accustomed to 9 
sleeping on her side, but finds herself unable to lie 
comfortably on her side when the abdomen is much 
enlarged. In such cases I have found that the use of 
a small pillow, upon which the abdomen can rest as 
upon a shelf, has been productive of comfort and 
repose. A pregnant woman's nervous system is often 
grieviously upset by the injudicious conversation of 
her friends and relatives. Some people are singularly, 
nay criminally, indiscreet in their talks with pregnant 
women. Accounts of appalling haemorrhages, of con- 
vulsions, and of the graver obstetric operations are 
certainly not conducive to nerve quietude in the preg- 
nant state. Neither is it judicious for the gravida to 
read all about it in the family medical books: such 
books are responsible for much harm. The more 
ignorant of the act of parturition a woman can be kept, 
the better: I would not have her know that there is 
such a thing as a placenta even. 1 always advise 
against any reading or any conversation with friends 
on the whole subject, and warn against listening to 
what may be well meant in the way of lay advice, 
promising that I will answer any question, if it be 
proper. 
If a women dresses properly at other times, she 
need make no changes during pregnancy, except to 
provide for the gradually enlarging uterus. Most 
women, however, still cling to the garter and the corset, 
both of which are more than usually deleterious during 
pregnancy. 11 is sometimes difficult to induce a woman 
to lay aside these abominations even in the later 
months ; but such a course should be advised, and the 
reasons why should be explained. It is gratifying to 
know that some women are substituting a comfortable 
waist for the corset; and are suspending the skirts 
from the shoulders, instead of buttoning them tightly 
around the waist. Garters are also to some extent 10 
giving way to tapes attached to the corset-waist. It 
will be the better for all women, when they follow the 
advice of physicians in these matters of dress. 
How much exercise ought a pregnant woman to 
take ? It is often difficult to prescribe the exact amount 
that is suitable for any given person. Most women 
obtain all needed exercise in the. pursuit of their usual 
affairs; some, however, in the leisure class, need more 
than their habitual activity. Walking is probably the 
most suitable exercise in pregnancy, not carried, how- 
ever, to the point of fatigue: the august lady at the 
court of St. James set her subjects a good example in 
this respect. In the latter weeks, when walking may 
have become difficult, driving may well take its place. 
One might hesitate to prescribe gymnasium exercise 
for the pregnant; yet I recall one patient, habituated 
from early childhood to gymnastic exercise, who con- 
tinued her training during nearly the whole of her 
gestation, omitting only the heavier work, and she hqd 
a most rapid and easy labor and an uneventful con- 
valescence. Fortunately, most women are engaged in 
house-keeping duties, and except for the want of the 
open air, housework is probably the healthiest occupa- 
tion a woman can have. It is difficult sometimes to 
induce women to take sufficient open-air exercise; but 
there is no question that most women are greatly bene- 
fited by it during pregnancy, and have easier labors in 
consequence. Women should be willing to train them- 
selves in some degree for their labor, as an athlete 
would train himself for a race. 
Pregnant women should be cautioned against indis- 
creet exertion at the times which would be menstrual 
periods were they not pregnant. I have too often seen 
the unfortunate results of indiscretions at these times. 
When miscarriage occurs, it is usually at the time of a 
menstrual epoch. Some women are made aware of the 11 
approach of these epochs during pregnancy by certain 
unmistakable sensations and feelings of malaise ; but to 
avoid oversight in those not so warned, they should be 
advised to mark off on their calendars the days when 
menstruation would ordinarily occur. In these days 
no undue exertion should be made, and exercise 
should be somewhat restricted: above all at such times 
nervous excitement should be avoided. 
This leads me to speak of the propriety of sexual 
intercourse during pregnancy. To many women I 
believe coitus during pregnancy is distasteful, to many 
even obnoxious, to all, in my opinion, it is more or 
less injurious. Aside from the mechanical disturbance 
of the uterus by impact, the sexual act injuriously con* 
gests the pelvic vessels, excites and then depresses the 
nervous system, and is often a cause of miscarriage, 
especially when practised at a menstrual epoch. So 
far as my knowledge of the animal creation goes, the 
pregnant female will not suffer the sexual approach of 
the male, but will fight, if necessary, to protect her- 
self. Certainly among enlightened human beings, men 
who have at heart the welfare of wife and children 
should be willing to forego sexual indulgence during 
the time when the wife needs all her vital powers for 
her own well-being and that of her expected offspring. 
Many men and women err through ignorance, and are 
grateful for advice on this subject. 
It is believed by some that the pelvis should always 
be carefully measured in the early months of preg- 
nancy with a view to anticipating some serious com- 
plication in labor at full term. In women who have a 
history of difficult and pathological labors, such a 
course is wise; but in primigravidte it has never 
seemed to me warrantable to subject them to a routine 
examination unless there was a reasonable suspicion 
of some deformity in the parturient canal. Marked 12 
forms and degrees of pelvic deformity are likely to be 
suspected during pregnancy, if the patient is under ob- 
servation, and in such cases pelvimetry should be made. 
The minor degrees of pelvic contraction, on the other 
hand, even if suspected and ascertained to exist, would 
not warrant obstetric interference before full term in 
a woman pregnant for the first time. In such cases 
the child is often proportionally small, and is safely 
delivered either by nature or by art. If, however, the 
first labor proves disastrous, and the woman demon- 
strates her unfitness to give birth to a full-term child, 
premature labor can be induced in subsequent preg- 
nancies. I do not, therefore, include pelvimetry among 
the necessary duties of the medical attendant, as a 
matter of routine. 
With a view to successful lactation the breasts should 
receive some attention. They should be relieved from 
injurious pressure by corsets and tight clothing early 
in the pregnancy; no other care except cleanliness is 
necessary until after the seventh month when it is ad- 
visable to begin to prepare the nipple. The old-time 
custom of applying a decoction of green tea and brandy 
in equal parts is familiar to all, and doubtless this mix- 
ture is very efficacious in toughening the nipple: I 
have found, however, that absolute alcohol, diluted 
one-half with water, is quite as satisfactory and less 
troublesome. I am accustomed to advise the use of 
this lotion morning and evening during the last two 
months. If the nipple is flat or inverted, it is well to 
draw it out by gentle suction with a heated bottle 
before applying the alcohol. With proper preparation 
in pregnancy and suitable care during lactation, sore 
nipples need rarely occur. 
As the abdomen enlarges in the later months, and 
the skin is tightly stretched, much comfort is imparted 
by inunction with sweet oil or lanoline. I have 13 
thought, too, that the skin is thereby softened and 
made more elastic, and that there is not so much tear- 
ing in the deeper layer and consequently not so much 
disfiguration by scars. Some women are oppressed 
with the weight of the uterine tumor and are unable 
to go about with comfort: a well adjusted abdominal 
support is a great comfort in such cases, and often 
enables the woman to walk and drive until she is 
brought to bed. 
It is well known that a species of anaemia is a phy- 
siological condition in pregnancy : the red corpuscles, 
albumen, iron, and the salts of the blood are diminished ; 
while the white corpuscles, fibrin, and water are in- 
creased. Robust, well-nourished women may have 
sufficient reserve power to sustain the demands which 
pregnancy makes upon their vital energy without arti- 
ficial assistance ; but this type of women is not com- 
mon in my experience. 1 have already spoken of the 
importance of careful attention to nutrition during 
pregnancy, as a means of preventing undue impover- 
ishment of the blood; and it has seemed to me that 
most women are benefited by the administration of 
iron, especially in the last two months. Apart from 
the general benefit of iron as a tonic, there' is 
ground for belief that post-partum hmmorrhage is less 
likely to occur in those whose blood has not been too 
much impoverished by the unsupported demands which 
pregnancy makes upon it. It has long been my custom 
to prescribe Queveune's iron in the last two months of 
pregnancy, with great apparent benefit. 
There remains fur me to speak of one more subject 
of great importance to both patient and physician, the 
selection of the nurse. Too often this duty is at- 
tended to by the patient without consultation with her 
medical adviser; such, indeed, is the custom. While 
some men may be indifferent, most physicians would 14 
prefer to select the nurse who is to be their lieutenant 
and assistant, as much as the commanding officer to 
choose his adjutant, as indeed it is his prerogative to 
do. It is only right that he who is to have the re- 
sponsibility of the case -should select or approve the 
nurse who is to carry out his orders: no man can do 
his best work, if handicapped with an assistant in whom 
he has not confidence. There is need, I think, of 
some educational work on this point among the laity : 
women engage their nurse long before their physician, 
and without consultation with him, because they have 
not a correct understanding of the relation of the nurse 
to the physician. In most cases when the patient's 
means allow her to employ a training-school graduate, 
the nurse may be entirely satisfactory to the physi- 
cian; yet it is unnecessary for me to assert in this 
presence that there is room for choice among trained 
nurses. And when we pass without this circle to the 
greater field of the old-time monthly nurse, we find 
them good, bad or indifferent, septic or otherwise, ac- 
cording to circumstances. I have long since declined 
to attend cases unless I could select, or approve of, the 
nurse, and my own results and peace of mind have 
greatly benefited thereby: it is needless to add that 
the patient's welfare is promoted, quite as much as 
the physician's, by thus allowing the doctor to give his 
patient the benefit of his own better knowledge as to 
the relative fitness of nurses. He surely can choose 
more wisely than his patient. 
I hope it will not be supposed, from the length of 
this paper, that under ordinary circumstances much 
time or money must be spent in the exercise of suitable 
supervision over pregnancy. When the woman is in 
good general health two or three interviews with her 
physician will usually suffice: at these consultations, 
distributed through the pregnancy, all needed advice 15 
can be given, and the physician can assure himself that 
his patient continues well. If, however, at any time 
the pregnant woman is not well, it is needless for me 
to emphasize the importance of bringing her as near 
as possible to normal standards. 
It has often seemed to me that the physician's visits 
came at the wrong time: in most cases he does not see 
the patient during pregnancy, when he might be of 
great service, but makes numerous visits during the 
lying-in period which ought to be for the most part 
unnecessary. If the paiient approaches her labor in 
good physical condition, in the best possible physical 
strength and with stable nerves, - if then the labor is 
skilfully conducted and she is delivered without septic 
infection and left in the hands of a competent nurse, 
there is little or nothing to require the subsequent at- 
tention of the physician: his care and advice can be 
much more profitably bestowed before the baby is 
born. If the physician's visits could be transferred in 
part from the puerperal to the pregnant period, there 
would be in my opinion fewer abnormal labors, less 
suffering, more rapid convalescence and better obstetric 
results. 
How can this desirable state of things be brought 
about ? How can the two chief obstacles be removed ? 
Ignorance of the advantages of supervision among the 
laity can only be removed by active missionary work 
by the medical profession : when it comes to be under- 
stood in any community that the leading physicians 
will not attend obstetric cases unless women place 
themselves under observation early in their pregnancy, 
the lesson will soon be learned. Already among the 
more enlightened and well-to-do classes of this com- 
munity, it is quite generally the custom for women to 
inform their physician as soon as they have passed 
over one or two periods and to place themselves in 16 
his care. And among those less well-circumstanced 
the lesson could soon be taught by well-directed effort 
in the circle of each physician's influence. The ques- 
tion of expense ought not to be an obstacle in the way 
of all necessary supervision of the pregnant: it is not, 
among those pecuniarily well situated. Indeed, it has 
seemed to me that less expense is incurred on the 
average when the patient has received adequate atten- 
tion during pregnancy, for the reason that fewer visits 
are necessary during the puerperal period. Among 
those who by force of circumstances or by custom are 
attended by contract, where the physician's services 
must be unrequited, if given during pregnancy, selfish 
motives alone would seem sufficient to induce him to 
give all needed attention to prevent complications and 
disasters which more or less affect his reputation, often 
give him much additional work and disturb his peace 
of mind. But appeals to such motives are unworthy 
of a liberal profession: the true physician is ever 
willing to give freely of his time and ability to pro- 
mote the best interests of those who are placed in his 
care. THE BOSTON 
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