Part 7 (1/2)

_Motion of the child._ The sensation of the child's movements to the mother is a symptom of very little value, and is liable to mislead the pract.i.tioner if he place much reliance upon it; for the pa.s.sage of the flatus along the bowels, or little spasmodic flickerings of the abdominal muscles, will produce a very similar sensation, and will even completely deceive a patient who has been the mother of several children; but when they become perceptible to the experienced hand of the pract.i.tioner, this may also be looked upon as a certain indication that pregnancy exists. The foetal movements can seldom be felt distinctly until the beginning of the seventh month, and even then it requires some caution before we can venture upon a positive opinion. Their activity varies considerably in different cases; in some their nature is almost immediately evident; whereas, in others they are so few and feeble, as to make it very difficult to decide. It has been recommended to put the head in cold water previous to applying it upon the abdomen, as, by this means, a considerable shock is produced which excites these movements more distinctly. We cannot say that we have found this proceeding of any use, since, by this means, the abdominal muscles are rendered so irritable as frequently to obstruct the examination considerably: it is rather desirable to have them in as perfect a state of repose as possible, in order that no movement of the foetus, however slight, should escape our notice. It is in cases of abdominal enlargement from disease; that this means of diagnosis is occasionally very difficult, and where men, even of great experience, have been led to form a very erroneous opinion. The celebrated Peter Franck has related a case of this sort which occurred to himself, where the patient was supposed pregnant, and where he imagined that he had felt the motions of the child: she died shortly afterwards, and the examination of the body showed it to have been a case of ascites complicated with hydatids. Dr. Dewees has given a still more remarkable case of a similar error having occurred to himself. A young lady had her menses suppressed for several months; the abdomen swelled very much, the b.r.e.a.s.t.s became enlarged, she had nausea and vomiting in the morning, and other indications of pregnancy; ”examining the abdomen carefully, I found it,” says Dr. Dewees, ”considerably distended; there was a circ.u.mscribed tumour within it, which I was very certain was an enlarged uterus. While conducting this examination I thought I distinctly perceived the motions of a foetus. The case proved to be one of acc.u.mulation of menstrual fluid in the uterus.” (Dewees's _Essays on several Subjects connected with Midwifery_, p. 337-8.)

In reviewing what has now been stated respecting the diagnosis of pregnancy, it will be observed that we have enumerated four symptoms, which must be looked upon as perfectly diagnostic of this condition, and in the accuracy and certainty of which we may place the fullest confidence: two may be recognised at an early period by means of auscultation, viz. the sounds produced by the movements of the foetus and by the pulsations of its heart; the two others are not appreciable until a later period, and are afforded by manual examination, viz. the being able to feel the head of the foetus per v.a.g.i.n.am, and its movements through the abdominal parietes. The next in point of value after these are the changes in the os and cervix uteri, those connected with the formation of the areola in the b.r.e.a.s.t.s, and, at a somewhat later period, the sound of the uterine circulation, changes, which, although they cannot separately be entirely depended upon, are nevertheless symptoms of very great importance in the diagnosis of pregnancy.

Two other signs of pregnancy have also been mentioned, viz. the appearance of a peculiar deposite in the urine as described by M. Nauche, or rather by Savonarola (Montgomery, _op. cit._ p. 157.,) and the purple or violet appearance of the mucous membrane lining the v.a.g.i.n.a and os externum, as described by Professor Kluge of the Charite at Berlin, and by M. M.

Jacquemin, Parent Duchatelet, &c. of Paris. With regard to the first, which is an old popular symptom of pregnancy, there is too much variety in the appearances of the urine, depending on general health, diet, temperature, &c., to enable us to place much confidence in any change of this sort. ”I have myself tried it,” says Dr. Montgomery, ”in several instances, and the result of my trials has been this:--In some instances no opinion could be formed as to whether the peculiar deposite existed or not, on account of the deep colour and turbid condition of the urine; but in the cases in which the fluid was clear, and pregnancy existing, the peculiar deposite was observed in every instance. Its appearance would be best described by saying that it looks as if a little milk had been thrown into the urine, and having sunk through it had partly reached the bottom, while a part remained suspended and floating through the lower part of the fluid in the form of a whitish semi-transparent filmy cloud.” (_Op cit._ p. 157.)[44]

The purple colour of the v.a.g.i.n.al entrance appears, from the extensive experience of the above-mentioned authors, to be a pretty constant change produced by the state of pregnancy; it probably occurs at a very early period. How far a similar tinge is produced by the state of uterine congestion immediately before a menstrual period, we are unable to say; at any rate, the character of the examination itself must ever be sufficient to preclude its being practised in this country.

The diagnosis of pregnancy is a subject well worthy of the student's most serious attention; for he will of course be liable, when in practice, to be called upon to give his evidence before a court of justice under circ.u.mstances when the responsibility must ever be of the most serious and not unfrequently of the most fearful nature, the more so as the old custom of impanelling a jury of ”twelve discreet matrons” to determine whether the woman be _quick with child_ has fallen deservedly into disrepute. He should lose no opportunity of making himself familiar with the various symptoms of pregnancy above enumerated, and of so practising the different senses of hearing, touch, and sight, as instantly and certainly to detect their presence.

Numerous cases are on record, where a false diagnosis in women convicted of capital offences, has led to most lamentable results, and where dissection of the body after death has shown that she was pregnant. Dr.

Evory Kennedy has recorded an interesting case of this sort which occurred at Norwich in 1833, when a pregnant woman was on the point of being executed through the ignorance of a female jury. (E. Kennedy's _Observations on Obstetric Auscultation_, &c., p. 197.) We may also mention a dreadful case of this nature which occurred to the celebrated Baudelocque at Paris, during the horrors of the French revolution.[45] A young French countess was imprisoned during the revolution, being suspected of carrying on a treasonable correspondence with her husband, an emigrant. She was condemned, but declared herself pregnant; two of the best midwives in Paris were ordered to examine her, and they declared that she was not pregnant. She was accordingly guillotined, and her body taken to the school of anatomy, where it was opened by Baudelocque, who found twins in the fifth month of pregnancy.

Equally important is it (and perhaps in some respects even more so) to determine the absence of pregnancy in cases where it has been supposed to exist. In many instances the character and happiness of the individual must depend upon the judgment which the pract.i.tioner p.r.o.nounces; and, painful as will be the task of communicating an opinion which implies guilt and loss of honour, how infinitely revolting and inexcusable must that step be considered, which turns out to have been founded upon an incorrect diagnosis. Hence the importance of separating those symptoms of pregnancy which may be considered certain, and therefore trustworthy, from the crowd of others, which, although collectively they may warrant a suspicion, yet never can justify a decision that pregnancy exists, more especially in cases where so much is at stake. No two symptoms have led more frequently to this cruel error, and therefore to the most unjust suspicions, than the cessation of the menses with swelling of the abdomen, and yet from how many different causes may they arise besides that of pregnancy? Putting even the impulse of common feeling aside, we would ask how a pract.i.tioner can dare recklessly to incur the responsibility of injuring a woman's character by hazarding an opinion which involves so much, and is based upon symptoms which, by themselves, prove so little?

Whether he exercise his profession in town or country, cases of doubtful pregnancy will constantly come under his notice. We cannot, therefore, too strongly urge the importance of ascertaining how many of the certain symptoms are present, before we allow ourselves to be influenced by those which are uncertain. In speaking of the enlargement of the abdomen as a sign of pregnancy which is extremely equivocal, Dr. Dewees well observes, ”But little reliance can be placed upon this circ.u.mstance alone, or even when combined with several others; for I have had the pleasure in several instances of doing away an injurious and cruel suspicion, to which this enlargement had given rise. Within a short time, I relieved an anxious and tender mother from an almost heart-breaking apprehension for the condition of an only and beautiful daughter on whom suspicion had fallen, though not quite fifteen years of age: this case, it must be confessed, combined several circ.u.mstances which rendered it one of great doubt, and, without having had recourse to the most careful and minute examination, might readily have embarra.s.sed a young pract.i.tioner. This lady's case was submitted to a medical gentleman, who, from its history and the feel of the abdomen, p.r.o.nounced it to be a case of pregnancy, and advised the sorrow-stricken mother to send her daughter immediately to the country as the best mode of concealing her shame. Not willing to yield to the opinion of her physician (a young man,) and moved by the positive denials of her agonized child, the mother consulted me in this case. The menses had ceased, the abdomen had gradually swelled, the stomach was much affected, especially in the morning, and the b.r.e.a.s.t.s were a little enlarged. On examination it proved to be a case of enlarged spleen.” (Dewees, _on the Diseases of Females_, p. 178.)

We occasionally, also, meet with cases of self-deception, as to the existence of pregnancy, to an extent which would scarcely seem credible.

Women who have been the mothers of several children, will, upon some very slight foundation, suppose themselves with child. Knowing from previous experience many of the symptoms of this state, they will frequently enumerate them most accurately to the pract.i.tioner, who, if he rest satisfied with general appearances, may easily be led into a wrong diagnosis. A case of this kind we published in our midwifery reports, where the patient, the mother of two children, came into the General Lying-in Hospital, not only under the supposition that she was pregnant, but that labour had actually commenced; the catamenia had ceased about nine months previously, and the abdomen was considerably enlarged.

Examination proved that she was not pregnant. (_Med. Gaz._ June, 1834.)

In a work solely devoted to cases of doubtful pregnancy by the late W. J.

Schmitt, of Vienna, these cases have been very fully discussed. ”We occasionally observe certain conditions of the female system, which put on a most striking resemblance to pregnancy, both functionally as well as organically, without at all depending on the actual presence of pregnancy.

The abdomen begins to swell from the pubic region exactly in the same gradual manner as in pregnancy; the b.r.e.a.s.t.s become painful, swell, and secrete a lymphatic fluid, frequently resembling milk; the digestive organs become disordered; there is irregular appet.i.te, nausea, and inclination to vomit; constipation, muscular debility, change in the colour of the skin, and frequently of the whole condition of the body; the nervous system suffers, and even the mind itself frequently sympathizes; the patient is sensible of movements in the abdomen like those of a living foetus, then bearing down pains running from the loins to the p.u.b.es; at last actual labour-pains come on as with a woman in labour, and if by chance her former labours have been attended by any peculiar symptoms, these, as it were, to complete the illusion, appear likewise.” (W. J.

Schmitt, _Zweifelhafte Schw.a.n.gerschafts-falle_.) A most extraordinary case of the self-deception with regard to pregnancy, has been published by the celebrated Klein of Stuttgardt: it has been quoted in the work of W. J.

Schmitt above alluded to, and a brief sketch of it has been given by Dr.

Montgomery in his _Expositions of the Signs and Symptoms of Pregnancy_, p.

172, to which we must refer the reader for much valuable information on this and all other subjects connected with the diagnosis of pregnancy.

_Diagnosis of twin pregnancy._ Before concluding this chapter, we shall offer a few observations on the diagnosis of twins. A variety of symptoms have been enumerated as indicating the presence of two foetuses in utero, such as the great size of the abdomen, its flat square shape, the movements of a child at different parts of it, &c. The size of the abdomen can never be admitted as a diagnostic mark of twin pregnancy; first, because it equally indicates the presence of an unusual quant.i.ty of liquor amnii, or of a very large child; and secondly, because women pregnant with twins are not always remarkable for their size: the flatness, &c., of the abdomen is, we presume, a symptom based on the supposition that there is a foetus in each side of the uterus: this is very far from being correct, as it is well known that the children usually lie obliquely, the one being, perhaps, downwards and backwards, while the other is situated upwards and forwards. The sensation of the child's movements in different or opposite parts of the uterus is no proof whatever that there are twins, because it is constantly observed where there is but one child--a circ.u.mstance which is very easy of explanation.

The stethoscope affords us the only certain diagnosis of twin pregnancy; and even here it is limited to the sounds of the foetal hearts; the increased extent and power of the uterine souffle, as remarked by Hohl, arising, as he supposed, from the large ma.s.s of the double placenta, is not a proof which can be depended upon. In cases of suspected twin pregnancy the auscultation must be conducted with the greatest possible care, and, generally speaking, a certain diagnosis can only be obtained by two observers ausculting the two hearts at one and the same moment; for, otherwise, the difference between their rhythm is frequently so small as to be inappreciable. The sounds are seldom or never heard at the same level, one being generally heard high up on one side, the other in a contrary direction.

CHAPTER II.

TREATMENT OF PREGNANCY.

_Sympathetic affections of the stomach during pregnancy.--Morning sickness.--Constipation.--Flatulence.--Colicky pains.--Headach.-- Spasmodic cough.--Palpitation.--Toothach.--Diarrhoea.--Pruritus pudendi.--Salivation._

In the preceding chapter we have enumerated those changes and phenomena which are observed to take place in the system during pregnancy: many of these amount to actual derangements of function, and will, therefore, as such, demand our attention in a practical point of view, for the purpose of alleviating or removing them. Many of these changes are produced by the altered distribution of blood, as well as by the actual increase of quant.i.ty which now exists in the circulation; the nervous and also the vascular system of the uterus are now in a state of high excitement and activity--a condition which must necessarily communicate itself to those organs which are supplied by the same nerves; viz. the sympathetic, and by the same portion of the circulation, viz. the branches of the abdominal aorta.

No organ, except the stomach, possesses sympathetic connexions so widely extended over the rest of the system as the uterus; and, we may add, that no two organs are so intimately and reciprocally united as the uterus and the stomach. In the unimpregnated state, we see this manifested in a remarkable degree; if the stomach becomes deranged the uterus sympathizes; thus the states of gastric disturbance, known under the general term of dyspepsia, are frequently followed by leucorrhoea, or some derangement of the menstrual function: on the other hand, uterine disease is invariably accompanied by symptoms of gastric disturbance, and, in many cases, to such an extent as to conceal the real seat of the evil, and mislead the attention of the patient and her medical attendant. In like manner we find that during pregnancy, especially in the early stages of it, the patient is annoyed with a great variety of symptoms more or less indicative of derangement in the functions of the primae viae.

_Morning sickness._ One of the most troublesome, and by no means the least frequent, is vomiting, which, from coming on usually in the morning, is commonly called morning sickness; in some cases the female merely rejects what food or mucus may be present in the stomach, after which she feels relieved; in others she continues to strain violently and ineffectually for some time. In the former case it resembles the common vomiting from a deranged stomach, and cannot be considered as the direct result of sympathy with the uterus: the tone of the stomach has become impaired, and vomiting has followed as a consequence of its being loaded with undigested food and depraved secretions. Hence, in these cases, it is generally preceded by nausea and the other common precursory symptoms of this act: in the latter, however, it appears to be the immediate result of irritation transmitted from the uterus, and a.s.sumes rather a spasmodic character; the patient is suddenly seized with involuntary efforts to vomit, which are not preceded by nausea or oppression, and come on independently of the stomach being full or empty.