The pernicious influence of pregnancy on
pulmonary tuberculosis has been the object of continual
controversy for centuries, and even today a
conspicuous diversity of opinion still exists with
regard to their relationship, in spite of the voluminous
literature and careful consideration directed
towards the subject.
The intention of this treatise is to provide
a suitable explanation for this unceasing dispute.
In addition, a satisfactory scheme, which has so far
received little attention from the contenders, and by
whose agency, the probable influence of gestation on
a tuberculous individual can be estimated to a thoroughly
reliable degree, is then outlined.
The importance of the relationship cannot
be over -estimated. Tuberculosis reaches a very high
incidence, and exercises a distressing mortality
among women of child-bearing age, and yearly many
tuberculous women become pregnant. Bacon (1915) has
estimated that 32,000 women suffering from pulmonary
tuberculosis become pregnant every year in the United
States. Consequently, obstetricians and phthisiologists
throughout the world are constantly confronted
with the combination.
Its seriousness is equally demonstrated by
the manner in which it involves the personal conscience
of the physician with regard to the practice
of therapeutic abortion. The necessity and indications
for intervention, when the combination exists,
(if the harmful influence of pregnancy is agreed on) ,
has moreover aroused perhaps even more acrimonious
controversy than the original problem of the relationship.
The complexity of the problem is easily
comprehensible. Our knowledge of the physiological
and pathological processes, which are undergone by
the human body when pregnancy and tuberculosis occur,
is fundamentally and totally inadequate to reach a
logical and satisfactory agreement. In addition,
both of these conditions are liable to so many variations
in themselves, that when in combination, and in
different patients, their reactions towards each
other result in a manifold diversity, which defies
all attempts to reduce the prognosis of the disease
to a dogmatic formula.
Consequently, it is not surprising that
perusal of the enormous amount of literature, universal
in its source, on the subject reveals a lack
of unanimity, which prohibits any attempt to formulate
any opinion on the possibilities of this relationship.
The inability to find a satisfactory
answer is in part due to the common sources of errors
when deductions are made from statistics. The
erroneous conclusions may result from an insufficient
number of cases, or insufficient individual data,
when the number of cases is satisfactory. Moreover,
the immense progress made in the diagnosis and treatment
of tuberculosis in later years has rendered the
work of early authors of little significance, and
valueless as the basis of any deduction. Further
explanations for the conflicting conclusions will
become apparent during the following survey of the
literature, and will be stressed at its termination.
It was essential for particular attention
to be directed towards the origin of these fallacies,
in order that their avoidance could be undertaken in
compiling the statistics of this survey. When this
was accomplished, it was discovered that the deductions
resulting therefrom, were in agreement with
the conception towards this combination formulated
in this thesis, namely that the prognosis varies
according to the anatomo- pathological type of pulmonary
tuberculosis, by which the gravid woman is
affected, and gestation per se has very little .influence,
with minor exceptions, on the ultimate course
pursued by this affliction. The statistical and
clinical evidence for this conclusion are furnished
exhaustively.
Other subsidiary factors, especially the
exact moment at which the diagnosis of tuberculosis
is established with regard to the occurrence of
impregnation, whether prior to, during, or consequent
upon pregnancy, the social and financial status of
the patient, multiparity, and age, and their effect
on the eventual outcome of the malady, are next reviewed
in detail. Thereafter, the theoretical
explanations for the clinical observations, accompanying
this association, receive discussion, and their
very apparent inadequacy demonstrated.
Consideration of the modifications of the
treatment of phthisis imposed by pregnancy, and of
the place occupied by the highly controversial procedure,
therapeutic abortion, is then undertaken.
The necessity for the interruption of gestation is
discussed from the three viewpoints meantime upheld,
systematic abstention, systematic intervention, and
elective intervention. The evidence accumulated
from the statistics of this study would point to the
fact that individualisation of each case, an inherent
requisite for the performance of the last- mentioned
policy, is vastly superior to the absolutism expressed
by the other two opinions. The therapeutic procedure
in a pregnant ph thi sic al woman is then summarised in
the general management of such a case.
