Since eclampsia occurs only in connection with pregnancy, and the convulsions usually cease if the fetus dies or is born, one line of reasoning is that the most effective way to treat the disease is to terminate pregnancy. Formerly this was almost always done, and is still practised by some obstetricians. Those who do not agree with this theory contend that the eclamptic woman is a very ill woman whose nervous system is so irritated that the slightest stimulation or irritation works harm. In view of this they feel that manual or instrumental dilation of the cervix, preparatory to delivering the child through that channel, or delivery through an incision in either the abdominal wall or cervix, constitutes a shock that outweighs the advantages of emptying the uterus; therefore, that as a rule, less harm is done by noninterference, quieting the patient and increasing her eliminative functions, than by terminating pregnancy. This line of reasoning also takes into consideration the fact that from 15 per cent. to 20 per cent. of the cases of eclampsia are postpartum, indicating that convulsions may occur even after the uterus has been emptied.

The growing tendency is to adopt a middle course and treat each individual case according to the conditions and indications which it presents. Thus the same doctor will hastily induce labor in a case where the blood pressure and albumen remain alarmingly high, or increase, in spite of all efforts to reduce them, and in another case will go to the extreme of conservatism, doing nothing but quiet the patient with morphia or chloral, or both, and stimulate all of her excretory organs with abundant fluids.

But the nurse’s duties, and I may say her opportunities, for she is privileged to do much, are virtually the same no matter which course is followed, except, of course, the preparation for delivery, if this is performed.

The nurse is concerned with helping to reduce the intake of nitrogenous food, or proteids; diluting the toxines retained in the body; promoting the activity of the kidneys, bowels, liver, lungs and skin; guarding the patient against all avoidable stimulation from without, such as noise, light, ungentle handling and undue resistance to the patient’s convulsive movements; and protecting her from injuring herself by biting her tongue, falling out of bed or striking the wall or head of the bed during convulsions.

By striving to accomplish these general results for her eclamptic patient the nurse will aid immeasurably in saving her life.

A milk diet is the means of reducing the nitrogen intake; or in some cases even that small amount of proteid is deemed too much, and only water is given until 24 to 48 hours after the convulsive seizures have ceased. From three to five litres of these fluids should be given in the course of twenty-four hours, in order to increase elimination by way of both kidneys and skin, and it usually taxes the nurse’s patience and ingenuity to give this amount, for the patient will seldom take large quantities of fluids willingly, even when quite conscious. A surprising amount of water may be given to the sleeping or unconscious patient by dropping it into her mouth from the point of a teaspoon, taking care to give it only at those moments when she is lying quite still. If the nurse attempts to hold the restless patient’s head, or so much as places her hand upon the chin to steady it in order to give water, the irritation, though slight, may be enough to cause a return of the tossing and struggling.

Lithia water and cream-of-tartar lemonade (a teaspoonful of cream of tartar to a pint of water), are frequently given because of their diuretic and diaphoretic action; but whatever the fluid, it must be given persistently, with greatest gentleness and with care that the patient does not choke nor aspirate it into her lungs and thus possibly cause pneumonia. Food even in liquid form is not given while the patient is unconscious, because of this danger of aspiration and subsequent pneumonia.

The bowels are stimulated to greater activity by powerful purges, such as croton oil, in olive oil, dropped on the back of the tongue, or salts or castor oil given by stomach tube.

Copious colonic irrigations, alternating with hot packs so that one or the other is given every six, eight or twelve hours, according to the seriousness of the case, are frequently given and with excellent results. A colonic irrigation may be given by means of the Murphy drip method or through a rectal tube so contrived that a two-way flow of fluid is possible. Water, normal saline (2 drams of salt to a quart of water), or a weak solution of sodium bicarbonate (an ounce of soda to a quart of water), are all used for colonic irrigations, which are given at a temperature of 110° F., very slowly, with the receptacle for the solution placed so low that the flow is under very slight pressure. The patient should lie on her left side, in a comfortable position and be warmly covered. The tube should be introduced from 12 to 18 inches, and the stop cock arranged so that it will take from twenty to thirty minutes for each gallon of fluid to run in and out. About two gallons are usually used for the first irrigation, the amount being increased until five gallons are used each time. The beneficial effects of the colonic irrigations are two-fold, for in addition to removing the toxic material that may be in the colon and rectum, a good deal of fluid is absorbed through the intestinal wall.

The function of the lungs may be promoted by using oxygen and by keeping the air in the patient’s room fresh and constantly moving, but moving so gently that there is no perceptible draft. The nurse must remember that the skin also is an excretory organ whose function is being stimulated, and this necessitates its being kept warm.

Some obstetricians feel that it is as important to increase the excretions of the skin as of the kidneys, and that inability to induce perspiration is an unfavorable sign. Others, who disagree on this point, believe that the skin is of minor importance but that the bowels are of equal consequence with the kidneys. However, the nurse will do no harm, and will err on the safe side if she takes care to keep her patient warm and constantly protects her from being chilled, that is from exposure or changes in the temperature of her surroundings. A flannel nightgown or dressing gown will help to this end, or if neither is available, at least the patient’s chest and arms may be protected by warm bed jacket, or sweater, put on backwards and fastened at the back of the neck. This protection, together with a number of blankets, with or without hot water bags between them, will often induce a slight but constant perspiration, particularly if fluids by mouth are being forced at the same time. This may be all of the stimulation that the skin needs, and has the advantage of not greatly disturbing the patient, a point that cannot be too constantly borne in mind.

If something more is needed, the hot dry pack is a widely used and usually efficacious method of producing a sweat and can be given easily in the patient’s home with no more equipment than the average family possesses or can obtain. The articles needed are two rubber sheets or two heavy quilts; four blankets; three, four or five hot water bags; an ice cap or a basin with ice and two cloths for the patient’s head; a pitcher of the fluid that she is taking, and a feeding cup, drinking tube, small pitcher or a spoon with which to give it. One rubber sheet (or one of the quilts), and two blankets should be slipped under the patient, after the regular bedclothes have been loosened at the foot. If the patient is having convulsions it is better to leave on her a warm garment with sleeves to insure against her arms and chest being uncovered, otherwise the nightgown may be removed.

The patient is covered with one blanket which is tucked between her legs and around her body with her arms out, so that no two surfaces of the skin come in contact. The blanket on which she lies is brought up about her; another blanket should be laid over this and tucked in well about the neck, shoulders and entire body, while the fourth blanket is next wrapped around her from below. One long or two short hot water bottles should be placed on each side of the patient and one at her feet, all being placed outside the four blankets. The second rubber sheet, or quilt, is thrown over the whole and the ice cap, or cold compresses (changed every four or five minutes) placed on her forehead. (Fig. 48.)

A patient may usually be left in such a pack as this from half an hour to an hour, but since any sweat bath is more or less depressing, she must be watched constantly for evidence of exhaustion, such as a weak, rapid, irregular pulse and increased weakness, or the sudden relaxation of an active eclamptic patient.

In some instances the hot-water bags may be inadvisable, because of supplying more heat than the condition of the patient warrants; but if they are used, the nurse must remember how easily an unconscious or ill person is burned. She must watch the bags, move them frequently and take care that one of them does not slip under the patient. And while the pack is in progress, an even greater effort than ever should be made to force the fluids.

If the blankets are wrapped snugly about the patient, alternately from below and above as described, they will frequently provide all of the restraint that is necessary should she have a convulsion while in the pack. The importance of protecting her against exposure and chilling while in the pack cannot be too insistently stressed.

If I have seemed to dwell at surprising length upon rudimentary nursing details, in this connection, it is because the patient’s life literally depends upon the nurse’s conscientious and painstaking attention to these same details. The doctor may study the case ever so earnestly and order the treatment ever so wisely, but if every detail of that treatment is not thoughtfully and skilfully carried out, it may do the patient more harm than good. And on the other hand, I can think of no circumstance that gives the nurse deeper gratification than the almost miraculous improvement in an eclamptic patient, sometimes only overnight, after she has taxed to the utmost all of her ingenuity to make her ministrations effective.

Appliances for giving hot packs and hot-air baths are usually found in all hospitals, and the nurse will use them as directed, which obviates any necessity for describing them here. But in addition to correctly adjusting and using the appliance itself, she must watch her patient for evidence of exhaustion or shock; protect her from burns; keep cold applications on her head and give her as much fluid as possible. And when the hot pack is over, the patient must be taken from it gradually; one blanket at a time, or the heat slowly reduced, and then the greatest care taken that she is not chilled while being put into dry clothing, for she must be kept warm and perspire slightly even after the sweat is finished.

Restraint during convulsions should be as mild as possible, for resistance only increases the patient’s excitement, and sustained effort should be made to reduce it instead. To this end there are innumerable details to be considered. Every act must be performed as quietly as possible. The nurse must walk lightly and if her tread will be made softer by wearing bedroom slippers, she should wear them. She should consciously guard against kicking or striking the bed. All talking should be in low tones; doors opened and closed quietly; papers should not be rustled nor furniture scraped on the floor. The room should be as dark as is feasible and the source of light screened from the patient’s eyes.

She should be saved from biting her tongue by having placed between her teeth something that will serve as a mouth gag and still not cut nor bruise the mucous membranes. In a private home, one will find that a cork answers admirably; or the handle of a wooden spoon well wrapped with gauze or a clean handkerchief; or a small roll of bandage or clean cloth tightly rolled. Another method is to take a fresh handkerchief, or napkin, in the fingers by opposite corners, twist it slightly into a roll and force it between the teeth and tie the two corners firmly together at the back of the neck.

Venesection. The large intake of fluids tends to dilute and eliminate the toxins which are giving so much trouble, but another very prompt and efficacious measure is to withdraw from 500 cubic centimetres to 1000 cubic centimetres of blood by venesection, according to the condition of the pulse. In preparing for a venesection the nurse will slip a small rubber, covered with a towel, under the arm that is to be opened, and scrub the inner surface of the elbow with soap and solutions according to the wishes of the doctor in charge, and cover the cleaned area with a dry sterile towel or one wet with a disinfecting solution. A sterile towel should be slipped under the patient’s arm, one laid over the arm above and one below the cleaned area so that the entire surrounding field is protected by sterile towels.

For the puncture there will be needed a sterile canula, or infusion needle, with a piece of rubber tubing attached; a sterile receptacle for the blood, usually a 1000 cubic centimetre, graduated measuring-glass; both dry and alcohol sponges or cotton pledgets; adhesive plaster, or a bandage to hold in place the small dressing which is applied after the needle is withdrawn; and a tourniquet for tight application to the upper arm to impede the return of the venous blood and thus distend the large vein to be seen near the surface of the inner curve of the arm. This vein usually may be easily pierced, without incising the skin, the canula pointed toward the hand to meet the blood stream, after which the tourniquet is removed. Sometimes it is necessary to incise the skin in order that the vein may be exposed and the needle inserted into it directly. In this case the doctor will need, in addition to the articles already mentioned, a scalpel, a pair of tissue forceps, three or four artery clamps, a needle holder, skin needles and sutures.

A venesection is practically always followed by a drop in the blood pressure and a marked improvement in the general condition.

Infusions, or subcutaneous injections of saline solutions, are also frequently given to eclamptic patients with beneficial results. About 1000 cubic centimetres at 105° F. is introduced slowly into the tissues, and the solution may be normal saline, consisting of two drams of common salt to a litre of distilled water, filtered and sterilized; or possibly one containing five grains each of sodium bicarbonate and sodium chloride to the litre.

The articles necessary, in addition to the soap and solutions for cleaning up the skin, are a small rubber to protect the bed; three or four sterile towels; a flask of the solution at 105° F.; sterile infusion bottle, or can, with rubber tubing fitted with a piece of glass tubing at some point in its length, through which the flow of the solution may be watched, a stopcock, and an infusion needle (I cannot refrain from cautioning the nurse to be sure that the tubing does not leak; is not collapsed and stuck together at any point along its length, and that the needle is sharp, free from rust and contains a wire as evidence of not being clogged); two hot water bottles about half full, with air expelled; a pole or stand upon which to hang the bottle; a package of gauze sponges, or squares, and narrow strips of adhesive.

The fluid is usually introduced between the breast tissues and underlying muscles; the area to scrub up in preparation being just below the breast, where the curve begins, and toward the axilla. The bottle which contains the solution should be stoppered with sterile cotton, or, if a can, covered with a sterile towel, and hung between the hot water bottles, to keep the fluid warm, and held in place with a towel pinned around them, top and bottom. (Fig. 49.)

If the nurse is to give the infusion, she should grasp the end of the needle, to which the tubing is attached, with her right hand, pierce a piece of sterile gauze; open the stop cock and allow the air and cold fluid to escape, leaving a drop on the point of the needle; lift the patient’s breast with her left hand and quickly plunge the needle in just under it. The direction of the needle should be parallel to the chest wall to insure its running below the breast tissue, and above, not between the ribs. The needle, and the gauze through which it runs, may be held in place by means of narrow strips of adhesive plaster. The stop cock should be so adjusted that the warm fluid will flow into the tissues very slowly, about an hour being required to introduce 1000 cubic centimetres. During this time the patient must be kept well covered and the solution kept at about 105° F. as some of the heat is lost in its course through the tubing. A hot water bag placed upon the bed, over a coil of the tubing, is another means of maintaining the desired temperature, but it must be watched and moved from time to time, to guard against burning the patient. In hospitals where the infusion apparatus is equipped with a heater, hot water bags are, of course not needed, but they are of practical service in a patient’s home.

Termination of pregnancy is resorted to much less frequently than formerly, because it is believed that an eclamptic patient is particularly susceptible to infection and also that the shock of an induced labor is serious to so ill a woman.

The method of terminating pregnancy, when this is finally deemed necessary, depends upon the condition of the cervix; the size of the child; and upon the patient’s general condition. The method may be simple induction of labor, by the introduction of a bougie, if haste is not imperative; introduction of a bag; manual dilation of the cervix, if it is soft and partly obliterated; vaginal hysterectomy, or even cesarean section.

Chloroform is not used as an anesthetic, in eclampsia, nor to relieve the labor pains nor control the convulsions because of its tendency to increase the liver necrosis which is incidental to the disease.

Recovery is comparatively rapid, when it occurs. The blood pressure drops to normal; the albumen and casts disappear from the urine and all symptoms subside in from two to four weeks. (Chart 1.) And, happily, since one attack confers an immunity, the patient who recovers from eclampsia need not fear a recurrence of the disease.

Nephritic Toxemia is a serious toxemia, sometimes complicating pregnancy, and though it may occur at any time during the period of gestation, it usually develops during the latter months. As a rule, it is simply an exacerbation and accentuation of a previously existing, chronic nephritis, of which the patient may, or may not, have been aware; though in some instances the disability of the kidneys may arise during pregnancy. In many cases, so far as the kidneys are concerned, the patient is entirely normal in the non-pregnant state, and even during pregnancy, up to a certain point; then her kidneys prove to be unequal to the added metabolic strain of pregnancy, and signs of renal insufficiency appear.

Such a patient will suffer from toxemia, with each recurring pregnancy, the symptoms almost always appearing earlier, and with increased severity, with each pregnancy, as the permanent damage to the kidneys is increased by each successive attack.

Symptoms. The symptoms in nephritic toxemia are practically the same as those in chronic nephritis: lassitude, headache, visual disturbances, edema, high blood pressure and casts and large amounts of albumen in the urine. In some instances, the patient suffers such slight discomfort that the increased blood pressure and urinary symptoms are the only precursors of coma, and possibly convulsions which cannot be distinguished from an eclamptic seizure.

As the patient may die in the coma, no matter how suddenly it develops, the value of regular urinalyses and observations upon the blood pressure, which are included in prenatal care, must once more be mentioned.

In severe, chronic cases infarcts (hemorrhagic or necrotic areas) appear in the placenta. These may be extensive enough to interfere with the nourishment of the fetus, which, being already weakened by the toxic effects of the disease, is unable to survive. As a result, nephritic toxemia is second only to syphilis in causing premature deaths. When the child dies, the symptoms usually begin to subside in a week, or possibly two, and the dead fetus is expelled.

Treatment and Nursing Care. The treatment and nursing care are virtually the same as for pre-eclamptic toxemia; rest in bed, milk diet, forced fluids, purges, and in addition, observations upon the intake and output of fluids. The output of urine will not equal the amount of fluid which the patient takes in, at first, but in those patients who improve, the amount of urine gradually increases until it equals the amount of fluid ingested. The edema and other symptoms improve, except the high blood pressure and the albumen in the urine, which sometimes persist for months. (Chart 2.)

If the patient has coma or convulsions, the treatment is the same as in eclampsia.

A patient with inadequate kidneys who has never been able to carry a child to term may sometimes achieve this coveted end by going to bed a few weeks before the period in her pregnancy when the toxic symptoms have usually appeared, taking only milk for food, drinking large amounts of water, and keeping her bowels moving freely.

It is impossible to distinguish between eclampsia and nephritic toxemia during an attack, but this is of no importance at the time, as the treatment of the two diseases is the same.

But during the puerperium, the differential diagnosis may be made, for in eclampsia the blood pressure falls rapidly to normal and the casts and albumen disappear from the urine in from two to four weeks. In nephritic toxemia, on the other hand, although the blood pressure falls somewhat, and the albumen decreases in amount as the patient’s general condition improves, by the end of the puerperium the blood pressure is still elevated and casts and albumen are still present in the urine.

In eclamptic cases that come to autopsy, there is a typical, peripheral necrosis of the liver, but in nephritic toxemia there is no liver lesion.

Acute Yellow Atrophy of the Liver is one of the grave but very rare toxemias of pregnancy and though it may occur at any stage it usually appears during the latter part of pregnancy or during the puerperium. This complicating condition is not peculiar to pregnancy alone, although from forty to sixty per cent. of the cases which occur are in pregnant women.

The symptoms, which sometimes come on suddenly in a woman who previously has been entirely well, may suggest phosphorus poisoning. They are abdominal pain, headache, vomiting, and diarrhea followed in some cases by coma and convulsions, and in others by violent delirium. With these symptoms are jaundice and a diminished amount of urine, which contains albumen, casts, and usually a good deal of blood. The picture is practically that of pernicious vomiting plus jaundice and pain.

Little is known of the ultimate cause of the disease, but it produces rapid atrophic and degenerative changes in the liver, and though mild cases sometimes recover, the outcome is usually fatal. It was formerly thought that the termination of pregnancy virtually cured the condition, but the present belief is that delivery produces little or no effect. The tendency now, therefore, is simply to employ the same kind of eliminative treatment that is used in eclampsia.

Among the more serious complications of pregnancy, which are not due to that condition, but which it is important to recognize and treat early, may be included syphilis, heart lesions, pulmonary tuberculosis, thyroidism, gonorrhea and pyelitis.

“Syphilis is one of the most important complications of pregnancy,” in the opinion of Dr. Williams, “as it is the most important single cause of fetal death.”

In support of this contention, Dr. Williams reports upon a series of 10,000 consecutive deliveries which took place under his observation, and in which syphilis caused 26.4 per cent. of the deaths among 705 babies who died after the seventh month of pregnancy or during the first two weeks after birth. Furthermore, nearly as many more babies who were discharged alive, at the age of two weeks, died in a short time or gave evidence of having syphilis later on in life.

Believing in the importance of diagnosing and treating this disease during pregnancy, Dr. Williams subsequently made observations upon 4,000 cases in which Wassermann tests were given, and to which 421 women gave positive reactions. In this series of 4,000 deliveries, 302 babies died during the last two months of uterine life, or the first two weeks of extra-uterine existence. The relative frequency of the various causes which worked destruction in these 302 little lives is given by Dr. Williams in the following table:—

It will be seen from these figures that syphilis caused almost as many deaths as the three causes, next in order, combined.

The effect upon the child’s chances for life, of treating the expectant mother for syphilis, is suggested by comparing the results among the 421 syphilitic women who were not treated at all; those treated insufficiently by receiving but two or three doses of salvarsan and no after-treatment of mercury (because of the patient’s lack of cooperation or because treatment was instituted too late in pregnancy); and those treated satisfactorily, which meant the administration of from four to six doses of salvarsan followed by mercurial treatment continued sufficiently long to result in a Wassermann reaction that was negative, and remained so.

Among those mothers who were not treated, 52 per cent. of the babies were born dead or had syphilis; among those treated incompletely, 37 per cent. and among those treated until cured, syphilis caused the death of or was demonstrable in but 6.7 per cent. of the babies.^[5]

The deductions to be made from these dramatic figures is, that although syphilis seems to have about the same effect upon the pregnant, as the non-pregnant woman, it constitutes a serious menace to infant life and health.

Accordingly, it is very important that every pregnant woman be given the Wassermann test as early as the third or fourth month, and any woman who gives a positive reaction should be urged to submit to intensive treatment until cured. Her compliance will apparently multiply by seven or eight her expected baby’s chances for life.

Heart Lesions sometimes present grave complications during pregnancy, or at the time of labor, because the damaged or weakened heart is unable to meet the greatly added strain put upon it at these times. Spontaneous, premature labor sometimes results from serious heart trouble, while in some cases labor is artificially induced to relieve the overworked organ of the strain that is evidently exhausting it. Quite obviously it is an important step toward the prevention of both these deplorable occurrences to have the difficulty recognized early. Rest in bed and the same kind of medical treatment that would ordinarily be given for a poorly compensating heart will sometimes enable the disabled organ to carry its load throughout pregnancy. But care is necessary.

Pulmonary Tuberculosis is so common under all conditions that it is not surprising to find it fairly often among pregnant women. Since the treatment for this disease consists largely of effort to conserve the patient’s forces and build up the bodily resistance, the drain which pregnancy makes upon the system is likely to be inimical to the tuberculous patient’s improvement. It is the general opinion, therefore, that the tuberculous patient grows worse during pregnancy, and is still further weakened by the ordeal of labor and the drain of nursing her baby.

Some women with tuberculosis improve during the period of pregnancy, but decline after delivery. The disease may advance rapidly in such cases and the patient succumb very early.

There is great reluctance to terminate pregnancy in tuberculous patients, except in extreme cases as a last resort, to save the mother’s life, or when, after the child is viable, its chances for life would seem to be better if it were brought into the world, because of the mother’s possible death.

Certain it is that the care which is given to the non-pregnant tuberculous person is needed to an even greater degree by the expectant mother who is suffering from this disease. And under such care, it not infrequently happens that the patient will go through pregnancy safely, and if the care is continued after delivery, and her baby not allowed to nurse, her ultimate recovery does not seem to be retarded by the experience.

Tuberculosis is sometimes, though not frequently, transmitted from the mother to the fetus; but babies born of these mothers are not likely to be robust, particularly as they must be deprived of that bulwark of early infancy—maternal nursing.

Thyroidism in pregnancy has been, and still is, so widely discussed and studied that the nurse will do well to at least take cognizance of that fact, even though no definite conclusions seem to have been generally accepted.

The toxemias of pregnancy are so shrouded in mystery, and knowledge of the functions and inter-relations of the ductless glands is still so meagre, though it is known that one, the ovary, is inevitably concerned with pregnancy, that one is not surprised to find certain investigators considering these two problems together. Nor is it surprising that directly opposite views are held concerning the relation of thyroidism to toxemia.

Since the nurse will sometimes care for toxemic patients who are treated for thyroidism, either by means of gland therapy or operative procedure, she should understand the rationale of such treatment when she meets it.

Dr. Williams says, for example, “A considerable amount of work has been done in this direction, but the consensus of opinion is that abnormalities of the thyroid secretion play no part in the causation of eclampsia.”

On the other hand, it will be remembered that the thyroid gland is usually somewhat enlarged during pregnancy, and in this connection Dr. Edgar observes that “The normal enlargement of this organ in the gravida has been wanting in certain cases of eclampsia.”

Dr. Edward P. Davis summarizes his opinions on the subject as follows: “Hyper-thyroidism in pregnancy produces a toxic condition in the mother, which exposes her to the danger of the toxemia of pregnancy and her child to the dangers which accompany that condition. During pregnancy, the patient has a rapid pulse, often with high tension, and attacks of breathlessness and syncope, and intense nervousness. When uterine contractions begin, the action of the heart becomes exceedingly rapid; there is difficulty in breathing and the patient is brought into great distress. It is often necessary to give prompt assistance in labor, and this may require the performance of cesarean section. The child is exposed to the risks of rapid delivery, although, if section be performed, the risk to the child is reduced to the lowest point. When the placenta is examined, it is found that certain changes have taken place in its structure which interfere with the circulation of the blood through the placenta, and may indirectly bring about the death of the fetus. The child is also subject to the same toxic conditions which the mother has had and may die from failure of the liver and kidneys or in convalescence.

“A minute discussion of the subject would be occupied largely by the question of exactly what are the poisons which cause this condition, and this question has not yet been definitely answered.

“So far as neutralizing the results of excessive action of the thyroid, it is best accomplished by rest, a diet from which meat and other heavy proteins are excluded, regulation in the action of the bowels and the avoidance of nervous excitement or undue exertion. If the action of the heart is excessively disturbed, those drugs which control cardiac action must be used. In extreme cases, morphine and atropine are given.”

Pyelitis is a fairly common, and sometimes a very painful and serious complication arising during the latter half of pregnancy. It is an inflammation of the pelvis of the kidney, most frequently the right, caused by a damming back of urine, because of pressure of the enlarged uterus on the ureter where it crosses the pelvic brim; and by infection, which may travel up from the bladder or be conveyed by the lymph and blood streams, frequently from the intestines. The colon bacillus is the commonest offender, though the streptococcus, gonococcus or even the tubercle bacillus may be the cause.

Frequently the patient will be entirely well, aside from a slight irritability of the bladder causing frequent micturition, and suddenly have paroxysms of acute pain in the region of the kidney, which may be swollen and very painful on palpation. She will have fever and sometimes chills and a catheterized specimen of urine will contain pus and bacteria. The kidney may suddenly empty itself of pus after which the pain and swelling will subside, only to recur when the pus accumulates again.

The treatment is rest in bed, a bland diet and an abundance of milk and water to drink. As the infection is often of intestinal origin, drugs are usually given to prevent intestinal fermentation and keep the bowels moving freely. Sometimes, though rarely, when the patient does not improve under treatment, pregnancy is terminated to relieve the pressure on the ureter and thus drain the diseased kidney by permitting an unobstructed flow of urine.

The tendency of the disease is to subside spontaneously, but sometimes it is necessary to incise and drain the kidney, or even to remove it; while in others the infection is so virulent that the patient dies of septicemia.

Gonorrhea during pregnancy may cause great discomfort in the shape of irritation and itching of the vulva, or even excoriation of the mucous membrane, and sometimes abscesses of the vulvovaginal glands. Occasionally the infection reaches the decidua and causes an abortion. But the chief danger in gonorrhea is that, after delivery, if the disease has remained uncured, the organisms may travel up from the vagina to the uterine cavity and tubes, and there set up an inflammation, or possibly cause a general postpartum infection. The greatest danger to the child is that its eyes may become infected during the passage of the head through the birth canal. This is the reason for the very great care that is taken of the eyes of the newborn, which will be described in a later chapter.

It is very important, therefore, for the sake of both mother and child, that gonorrhea be discovered early, for treatment started at this stage is often attended by very gratifying results, as the disease may be entirely cured before it is able to invade the uterus and tubes. This is because the closure of the internal os, by the membranes, converts the vagina and cervix into more or less of a cul-de-sac, to which the infection is restricted. Being thus localized, it may often be eradicated with relatively little trouble.

The yellow vaginal discharge, characteristic of gonorrhea, may become profuse and purulent. It is removed by means of low, very gently given douches. Tampons and vaginal suppositories are sometimes used, while abscesses and abrasions are given appropriate surgical treatment.

The nurse must observe the strictest technique while caring for these patients because of the danger of infecting herself and others with the discharges. She should wear a gown and rubber gloves when giving douches or dressing diseased vulva, and because of the possibility of contamination by splashing fluids, she should hold her head well to one side in addition to protecting her eyes with goggles. All utensils for each patient should be isolated and they should also be washed and boiled after each time that they are used.

“Lying-in is neither a disease nor an accident, and any fatality attending it is not to be counted as so much per cent. of inevitable loss. On the contrary, a death in child-bed is almost a subject for an inquest. It is nothing short of a calamity which it is right that we should know all about, to avoid it in future.”