Prognosis and treatment of pulmonary tuberculosis complicated by pregnancy: a study based on the examination of two hundred and ninety five cases.

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