The Matron's Manual of Midwifery, and the Diseases of Women During Pregnancy and in Childbed / Being a Familiar and Practical Treatise, More Especially Intended for the Instruction of Females Themselves, but Adapted Also for Popular Use among Students and Practitioners of Medicine

by Frederick Hollick

SECTION IX.

THE DISEASES OF PREGNANCY.

The diseases which are found during pregnancy are of two kinds; the first kind called Sympathetic, or nervous, consist of various derangements of different parts of the system, produced chiefly by nervous sympathy with the Womb. The second kind, called Idiopathic, are real primary derangements of the Generative Organs themselves, or of those intimately connected with them. Each of these kinds will be treated of separately.

CHAPTER XXVI.

SYMPATHETIC DISEASES OCCURRING DURING PREGNANCY.

SICKNESS AND VOMITING.

Nausea, or sickness, with or without vomiting, is one of the most frequent and troublesome accompaniments of pregnancy. It is so general, in fact, as to be looked upon as one of the earliest and most reliable signs of that state. It is undoubtedly caused, in the earlier stages, simply by the intimate sympathy which exists between the stomach and womb, and which causes one of those organs to be temporarily deranged whenever the other is in any unusual condition. In the latter months it is also produced by the enlarged womb pressing on the lower part of the stomach, as it rises in the abdomen. In many diseases of the womb, particularly in enlargements, and tumors, the stomach will become deranged in precisely the same manner as during pregnancy, and the patient is frequently deceived thereby as to her real condition.

In most cases the sickness does not begin till about the second month, and it seldom lasts beyond the third or fourth. There are some however, with whom it commences almost immediately after fecundation, and others with whom it lasts till the very commencement of labor. I have even known persons who always experienced the nausea at the very moment of conception, and who were thus aware when that event took place. With some persons the trouble occurs only during certain parts of the day, most usually in the morning, while with others it comes on irregularly, or even endures constantly. In most cases it is not very severe, and causes but little distress; occasionally however, it is very serious, and may even lead to fatal results, in spite of all that can be done. Abortion is frequently brought on by it; and so are faintings, and spitting of blood. Many women however, will vomit with violence, during almost the whole period, without either accident or evil effect. The treatment must vary according to the cause of the derangement, its violence, and the effect it produces. In regard to diet but little can be said that will be found generally applicable. Mild and light food is generally recommended, but is not always the best, for some females can only keep on their stomachs the most indigestible articles. Perhaps nothing more can be said, with propriety, than that the patient should take whatever she can retain, particularly if she has become weak from want of nourishment, which is often the case. Some females can only keep down a little broth, or tea, or sweetened water, while others find solid food the best, or fruits. I have known many able to take Gum Arabic, either solid or dissolved in water, and retain it, when nothing else could be borne. This is nourishing, and may often keep up the strength till the sickness abates.

There are many remedies that will sometimes relieve, though frequently they are of no use whatever. A little wine or brandy, or orange flower water;—a few drops of laudanum, or ether, or essence of peppermint, may be tried. One or two ipecac, or cayenne, or camphor lozenges, will sometimes be efficacious, and so will a little Port wine and Peruvian bark, or a seidlitz powder, or even common soda water. A tea-spoonful of powdered charcoal succeeds occasionally, or some very strong bitters, or a cordial, such as a wine-glassful of curacoa. A plaster of opium may also be placed over the stomach, or one of meal wet with laudanum. A mustard poultice over the stomach, will frequently relieve when everything else fails;—sometimes it is more effective however, when placed on the spine, opposite the stomach. As a general rule the bowels should be kept free, either with injections or with mild purgatives, as castor oil, or manna. Regular bathing will often act as a complete preventive or cure, and the vomiting may be frequently stopped by simply dashing cold water over the stomach. Some practitioners recommend emetics, and bleeding if the patient be of a full plethoric habit. Leeches and cups have also been used over the stomach, and sometimes with good effect. Ether and chloroform have also been inhaled, and have operated favorably in a few instances. Plentiful draughts of cold water, or swallowing bits of ice will likewise afford relief to some.

In several instances the vomiting has been so violent, and the patient has suffered so much, and become so exhausted from want of nourishment, that it has been absolutely necessary, after all other means have failed, to cause miscarriage, as the only means of saving the patient's life.

Whenever the trouble can be borne, Patience is the grand specific. The sufferer must recollect that it will surely cease with delivery, and most probably before.

PTYALISM, OR EXCESSIVE SALIVATION.

Some pregnant females will secrete an immense amount of saliva for weeks and months in succession, as if they had been salivated. I have never known a case in which this discharge caused any evil, even when very great, though it is often troublesome. It would probably not be judicious to stop it, even if we could do so, as long as it does no harm, though it may be advisable at times to moderate it. The only treatment proper to effect this is, to keep the bowels free and the body well bathed, and to gargle the mouth with mint or balm teas, or canella water, or a little syrup of poppies.

This discharge, like the vomiting, arises from the sympathetic action of the uterus, and it generally ceases about the fourth month, though with some it will last the whole time.

ODONTALGIA, OR TOOTHACHE.

This is also a very general trouble during pregnancy, and sometimes a very severe one. Like several other sympathetic affections it is very irregular as to its first appearance and duration, some suffering from it most of the time, almost without intermission, while others only have it at intervals, and but slightly.

It sometimes depends upon unsound teeth, but is frequently experienced without any such cause, and is then a true neuralgia. When it arises from a bad tooth, the pain is usually confined more or less to the neighborhood of the tooth, but when it is neuralgic it extends over the greater part or the whole of the jaw and face, and darts about from one part to another. In true toothache there is also usually more or less inflammation and swelling, while in the most agonizing neuralgia nothing of the kind can be seen.

The treatment must be regulated by circumstances. If the pain appears to be kept up by an unsound tooth, it should by all means be extracted, unless the patient be so exceedingly nervous and irritable that abortion is to be feared, in which case the pain must be alleviated as well as it can be, though there is almost as much danger in leaving the tooth in such cases as in extracting it. A few leeches to the gums will sometimes relieve, or a mustard poultice to the cheek, or a blister behind the ear. The stomach or bowels being out of order may also keep up the irritation, and regulating them may materially assist in giving relief. Some persons are relieved by lotions of camphor, or laudanum, and others by washes of cayenne tea, or alum water. In the neuralgic form, when no particular tooth can be found in fault, the treatment must be more general than local. The Carbonate of Iron Pills, which can be purchased at the druggists ready made, have frequently an excellent effect; from two to four may be taken at a dose, twice a day, the bowels being kept open, if necessary, by a little tincture of rhubarb. If the pain comes at regular intervals, or intermits, it may frequently be stopped by quinine. Two of the ordinary quinine pills may be taken every five hours, for two or three days. If the head feels oppressed by their use, the dose must be lessened to one. M. Guillemeau recommends the following to be tried if other means fail, and I have known it to be of decided benefit. Take the whites of two eggs, and two ounces of common black pepper, in powder, and beat them well together. Spread this on some tow or cotton, and lay it on the cheek. It may be kept on till it causes considerable irritation, and sometimes may be used on both sides.

Some females have been relieved by bathing the face in cold water, or keeping ice in the mouth, and others by hot fomentations. It has also been recommended to fill the mouth with cold water, and bathe the cheek with hot at the same time!

Occasionally an abscess, or gum boil will form, and when there seems a tendency to that it may be promoted by keeping a roasted fig in between the cheek and gum, over the part where the abscess points; when full, it should be lanced, as the discharge usually gives relief.

This pain is however very obstinate sometimes, and defies all treatment, but is seldom of such long duration when so severe.

DERANGEMENTS OF THE APPETITE.

The powerful sympathetic action of the womb on the stomach produces not only nausea and vomiting, but various derangements of the appetite and taste also. All of these require notice, and some need attention.

Anorexia.—This means a complete distaste, or even disgust, for food, sometimes of particular articles only, and sometimes for those of every kind. It seldom lasts beyond the fourth month, but occasionally during the whole period. It is remarkable how some females will be affected in this way, and how little they will eat, for several months together. This however is scarcely ever of any consequence, for the system does not seem to suffer in the slightest degree; on the contrary, the mother will remain quite stout, and the child be born fully developed, though the quantity of food taken has apparently been scarcely sufficient to sustain life.

In many cases there is even a decided benefit from this state of things, particularly in those who are of a too full habit.

As long as the loss of appetite is merely of a sympathetic or nervous character it is not necessary nor advisable to resort to any special treatment. But when it arises from indigestion, or a foul stomach, it is necessary to attend to it. A mild emetic of ipecac or warm mustard and water, may be given, or a dose of Epsom Salts. This state will be recognized by a furred tongue, unpleasant breath, and uneasiness at the pit of the stomach; while in the purely nervous anorexia nothing of the kind is observed. Sometimes it may arise merely from debility of the stomach, and in that case a few of the Carbonate of Iron Pills will be of use. In general the patient is benefited rather than injured by this voluntary fasting.

Boulimia.—This state is the reverse of the former, meaning a ravenous appetite. Some females exhibit it in a most extraordinary degree, and will eat to excess of anything that comes in their way. Many injure themselves in this manner, by causing indigestion, flatulence, heartburn, vomiting, and even inflammation of the stomach. It is of no use reasoning with them, for the appetite is so strong that they will eat let them suffer ever so much.

All that can be done in such cases is, to drink freely of various nourishing liquids, such as soup, broth, rice milk, or chocolate; and by eating jelly, arrow-root, and eggs. These contain much nourishment in a small space, and satisfy the hunger without overloading the stomach. The appetite may also be deadened considerably by eating figs, dates, sugar, or chocolate; and by drinking soda water.

Capricious Appetite.—Sometimes a female is found to have an inordinate desire for some one particular article of diet, which she will eat to excess, but will not touch anything else; this is called malacia. Others will have a craving for some article not proper for food;—this is called Pica. They will devour chalk, cinders, earth, wood, flies, spiders, charcoal, and various other things, sometimes of the most disgusting kind, though ordinarily they may be quite fastidious in their diet. This unnatural desire is also frequently seen in hysteria and chlorosis, and in several uterine diseases.

It does not appear that a moderate indulgence of these unusual tastes is at all injurious, unless the article wished for be of a decidedly hurtful character. On the contrary, it is reasonably conjectured, by many physiologists, that they arise from a real want in the system of the very substances longed for. For instance, there may not be in the mother's blood sufficient lime to form the bones of the child, and this deficiency is intimated by her desire for chalk or plaster; nature having no other mode of making her wants known, or of causing them to be supplied. As a general rule, so long as the indulgence is not obviously improper, it should be allowed to a reasonable extent, both to gratify the patient and to answer to what are probably the demands of nature.

It is seldom that interference is needed in these cases, except when there is danger of the patient doing herself harm; we may then try to alter the condition of the stomach, and so change the taste. A gentle emetic will sometimes do this, or a saline purgative. If these fail use a few of the Carbonate of Iron Pills, or some good strong bitters, or teas, drunk freely, such as Cammomile, Boneset or Centaury.

PYROSIS.

This disease is more frequently called water brash and sometimes heart burn. It is characterized by the raising of a hot acrid fluid into the throat, causing a sensation of burning from the stomach upward, even to the mouth. It is a very frequent attendant upon many forms of dyspepsia, and is generally experienced more or less by most pregnant females, arising either from improper diet or from mere sympathetic derangement. If it arises only from errors of diet, a reform in that particular is all that is needed, but if it is merely sympathetic nothing can be done beyond palliating it, to give temporary relief. For this purpose the patient must take a spoonful of lime water, in half a tumbler of milk two or three times a day, or some carbonate of soda, or magnesia, with a few drops of laudanum if there be any pain. In those cases which resist such remedies a little of the compound iron mixture may be of service, such as can be obtained at the druggists. A nourishing diet should also be observed, and plenty of exercise should be taken in the open air.

DYSPHAGIA.

Difficulty of swallowing, which is meant by this term, is a more troublesome and alarming affection, frequently attendant on pregnancy. There is however nothing dangerous in it, except that it frightens the patient. Some will gasp and be unable to swallow, or even speak, for a considerable time, and will think they have something in the throat. It is however entirely a nervous symptom, arising from uterine irritation, and seldom lasts beyond the third or fourth month. A little cordial, wine, or brandy, will frequently relieve it, or some spirits of camphor rubbed on the neck. M. Colombat d'l'Isere recommends the following ointment, to be rubbed on the neck. Extract of Belladonna forty-seven grains,—Extract of Strammonium fifteen grains,—white wax one ounce,—oil of lemons twelve drops.—These must be warmed and well rubbed together. A dash of cold water on the throat and chest will often succeed better than anything else.

GASTRALGIA.

This is commonly termed cramp at the stomach, or nervous colic. It consists of a severe kind of cramp, with dragging and cutting sensations in the stomach, as if it were being tied in knots and cut to pieces. Sometimes the attack will only last for a few minutes, and then totally pass away, at other times it will remain for half an hour or more, and cause the most intense suffering. The patient will be drawn together, or doubled up, with her hands placed on her stomach, and will groan and exhibit in her features the greatest agony; sometimes even, she will faint away with it.

This affection may, like the others, be merely nervous, and then it is attended by nothing but the pain. It may also arise from real inflammation of the stomach, and then it is attended by fever, excessive soreness and tenderness of the stomach when touched, and by a hot, dry mouth. In the nervous spasm the pain is frequently relieved by pressure, but when inflammation exists the pressure increases it.

Some females always have these attacks whenever the stomach is empty, and they pass away immediately anything is taken to eat or drink. With others they are often brought on by overloading the stomach, or by eating some improper articles.

To relieve the spasm, one of the best things is a tea-spoonful of Compound Spirits of Lavender, taken without water. This nearly always gives relief in ten minutes at most; but if necessary a second spoonful may be taken in a quarter of an hour. A little brandy, or peppermint, or curacoa cordial will also succeed in many instances, or simply drinking freely of any hot tea, or swallowing half a tea-spoonful of common pepper. A mustard plaster put on hot over the stomach will scarcely ever fail, even without anything being taken internally. M. Colombat gives the following recipe as one which he has found efficacious, and it is certainly a pleasant one. Orange and Linden Flower waters each two ounces; Syrup of Ether and of Valerian each one ounce; Syrup of Poppy heads half an ounce. Of this mixture a tea-spoonful may be given every quarter of an hour till the pain abates.

To prevent the return of the attack, the patient must carefully avoid everything that disagrees with the stomach, or creates wind; she must keep the bowels free, and accustom herself to regular bathing or rubbing the body. If the stomach appear weak, which is often the case, some Boneset tea, or Port wine and bark, or a few of the Carbonate of Iron Pills may be advantageous. If there be acid on the stomach, use the means recommended for heartburn.

CONSTIPATION.

This is a very common trouble with pregnant females, and one that may lead to many others. Very frequently it arises merely from the pressure of the expanded uterus upon the large intestine, but it may also arise from a simple want of power, the uterine action having apparently weakened the force of all the neighboring organs. It is advisable to correct it as soon as possible, let it arise how it may, as it is very apt to cause various derangements of the stomach and intestines, and even inflammation of the womb itself. As a general rule, not more than three days should elapse without the bowels being moved, though some will remain a week or more without any apparent inconvenience; but there is always danger in such delay.

Many females do themselves much harm by taking what they call opening medicines, the action of which is often more injurious than the constipation itself. All drastic purgatives, such as aloes, gamboge, colocynth, and jalap should be carefully avoided, as they not only make the costiveness worse after their action is over, but they also frequently produce inflammation, and even abortion, by the violent straining they cause. The best medicines, when they are really needed, are manna, seidlitz powders, or castor oil. Enemas are better however, as a general rule, such as those of thin starch, or molasses and water, to which may be added a little castor oil. The grand aim should be, in all such cases, to stimulate the bowels to an increased action without medicines, by a properly regulated diet! Salads may be eaten when they do not cause derangement of the stomach, and ripe or stewed fruits, particularly figs, dates and prunes. Soups are also good, except they contain rice, or vermicelli, or maccaroni. Bran bread should be eaten regularly, and not white. The only meats should be veal or poultry. As a drink lemonade is excellent, with a little cream of tartar, or tamarind tea, or barley water sweetened with honey. With some patients a cup of coffee, or a glass of beer will always relieve the bowels, especially if a glass of water is also drank after it. I have known persons neglect the bowels so long that they have become completely impacted, by the hard fæces, and could be relieved only by instruments. It is very important to attend to this affection in time, and to persevere with the means of permanent relief regularly.

DYSENTERY AND DIARRHŒA.

It is frequently the case that pregnant females, instead of being constipated are afflicted with severe diarrhœa. This may arise from inflammation, and is then attended by fever, and extreme tenderness and soreness of the bowels. Most usually however it is entirely nervous, and arises from the sympathetic irritation of the womb. There is then no tenderness or soreness, no fever, no derangements of the appetite, nor in fact any other symptom of any consequence. If it remains long unchecked blood will be discharged, from the extreme irritation of the intestines, and it is then called dysentery. This is nearly always accompanied by fever and general irritation. Sometimes there will be a constant and painful desire felt to move the bowels, but with little power to do so, and at the same time a burning heat and unpleasant sensation at the fundus. This is called tenesmus, and the straining from it has frequently produced abortion.

If the diarrhœa is not excessive, and the female does not lose her appetite, or strength, it is better let alone, particularly if she be of a full habit, and disposed to fever. If thought desirable to check it a little, this may usually be done by a change in the diet. Rice milk, sago, tapioca, and arrow-root may be taken, white bread may be used, and not much fluid drunk. If such means are insufficient an injection may be thrown up the rectum in the morning, of thin starch, with a tea-spoonful of laudanum. The abdomen may also be well fomented, and a dose of Tincture of Rhubarb taken occasionally. If the tenesmus is very troublesome, an injection of tepid water may be used, and the female should sit occasionally over the steam of hot water: in extremely painful cases a few leeches may be used round the fundament, and a hot flaxseed poultice placed over the abdomen. A warm bath is also an excellent remedy with many. When the diarrhœa still continues notwithstanding the above remedies, resort should be had to tonics and opiates. The patient should take Port wine and Peruvian bark, or some Gentian wine, and use injections of Starch and Laudanum regularly. Cammomile tea may also be freely drunk, and an opium pill may be taken at night. Above all, the patient must endeavor to avoid all mental agitation. When dysentery sets in, every effort should be made to subdue it as early as possible. Half a pint of rice milk, with ten or fifteen drops of laudanum may be taken two or three times a day, and an injection may also be used night and morning of flaxseed, with fifteen or twenty drops of laudanum. M. Colombat recommends the following recipe as seldom failing to cure. Take the whites of six eggs and beat them up in a quart of water; then use one-third as a drink, and the rest as an injection. A neat spoonful should be drunk every ten minutes, and an injection used every two hours, but not more than one small syringeful at a time. A tea-spoonful of syrup of poppies, with some loaf sugar, may also be added to every spoonful that is drunk. Eggs, jellies, and rich soups, with meat and wine, if there be no inflammation, may be taken regularly, in addition to the articles already mentioned.

DYSPNŒA, OR DIFFICULTY OF BREATHING.

There are but few pregnant females who do not complain more or less of difficulty of breathing, and this difficulty may arise from different causes. In the earlier months it is caused by sympathetic irritation only, the same as difficulty of swallowing. In the latter months it is caused by the enlarged womb filling up the abdomen so much that the lungs in the chest are pressed upon and have not sufficient room to play freely. It may also be caused by a plethoric or too full habit, the lungs then being in reality congested.

The temporary difficulty of breathing which is felt in the early months, from nervous sympathy, needs scarcely any kind of treatment, as it passes off naturally in a short time. In severe attacks the same remedies may be used as for difficulty of swallowing before referred to.

That which arises in the latter months, from pressure of the womb, can frequently be relieved only by the patient remaining as long as possible in certain favorable positions. I have known many who could never sleep except when propped nearly upright, by means of pillows and cushions, as immediately they assumed the recumbent position the upward pressure became so great they were nearly suffocated. In such cases the patient should be careful never to eat or drink to excess, nor take anything likely to produce wind, because the least increase in the size of the abdomen adds to the difficulty. The bowels should also be kept free, and nothing tight or heavy in the way of clothing should be worn.

This difficulty is most frequently seen in those who have contracted chests, and in those who have been accustomed to wear corsets and tight dresses. A deformed pelvis may also give rise to it by forcing the womb above its usual position. Many females both create and increase this difficulty by binding themselves tighter than usual during pregnancy, under the mistaken idea that it enables them to support their burden so much easier.

When the dyspnœa arises from a full habit the patient must live low, keep the body regularly bathed and rubbed, and the bowels freely open by an occasional seidlitz powder, or dose of Epsom Salts. If the difficulty becomes at any time suddenly great and alarming, the feet should be placed immediately in hot water, while the patient is upright; a mustard plaster should also be put upon the chest, and an opening injection of starch and Castor Oil administered as soon as possible. The usual practice in such cases is to bleed from the arm, to the extent of eight or ten ounces, and in case no other means give relief, this may be tried.

COUGH.

Like the previous affection cough is most usually produced during pregnancy by sympathetic irritation. It may arise, however from a partial congestion, or inflammation of the lungs or bronchial tubes, produced by a too great determination of blood to them. In the merely nervous cough, there is no expectoration, nor any soreness or pain in the chest, and it will frequently disappear for several days together. No particular attention need be bestowed upon this cough, unless it become so violent as to threaten abortion. In that case a pill, containing one grain of opium, may be taken, or from ten to fifteen drops of laudanum, whenever the attack is severe. Barley water, or gum arabic water, may also be freely drunk, with a large spoonful of Syrup of Poppies added to each pint. A small dose of Hive Syrup, or Paregoric, will also be found sometimes better than anything else. An enema of Starch and Laudanum, as formerly described, will also relieve, in some cases, better than anything taken by the mouth. The body should be kept warm, particularly the feet, and a mustard poultice may be placed over the chest, if the straining at any time becomes too great. Some patients experience relief from an assafœtida pill, or a little musk, and others from a small dram of cordial, or wine.

If there be expectoration, with fever, and tenderness in the chest, or sharp pains when a long breath is drawn, there is reason to fear inflammation of the lungs, or bronchitis. In this case all the above means, except the wine and stimulants, may also be used only more freely, and the mustard poultice must be kept on till it makes a blister. The patient must live low, her feet must be frequently bathed in hot water, and her bowels regularly opened either with saline purgatives or enemas. All that is requisite is to keep the inflammation from extending till after delivery, when it usually subsides without any further trouble. As soon as the womb is emptied, its pressure upon the abdominal aorta ceases, and the blood can then flow freely to the lower extremities, and thus the lungs become relieved and the inflammation goes down.

PALPITATION OF THE HEART.

This is also a frequent accompaniment of pregnancy, and one that is likely to cause alarm sometimes, from its violence. Unless dependant upon organic disease of the heart however, it is in general only a nervous affection, and passes away with delivery. We may always reasonably suppose it to be nervous when it occurs only during pregnancy, and particularly if it is irregular in its frequency and violence. I have known females who were always attacked with it about the same period, and who could therefore always tell when it was coming on, and sometimes even how long it would last. It will sometimes come on during sleep, and so forcibly as to waken the patient instantly. At other times while awake, it will commence so suddenly that she will sink down as if struck by a powerful blow.

The only directions that can be given for alleviating it are, to keep as quiet as possible, use the bath regularly, avoid constipation, and live rather low, particularly if the patient be of a full habit. Exercise should also be taken regularly in the open air, but not of a violent kind. She should also sleep with the head on a high pillow, and never eat late suppers, nor take any food that disagrees with the stomach.

All kinds of stimulants, such as wine, coffee and spices, should be abstained from, and all powerful emotions carefully guarded against. During an attack a few drops of Laudanum, or an Opium pill may be taken, and the feet placed in hot water. An Assafœtida pill is sometimes good, or a little Ether. Bleeding is generally practised in extreme cases, but there is often considerable danger in it.

A too full habit is often the exciting cause of the palpitation, as may be seen by the patient being always liable on the slightest exertion to flushed face, dimness of sight, ringing in the ears, swelling of the limbs, and puffiness of the gums, sometimes to such an extent that the mouth will taste of blood. Such persons should carefully observe a moderate unstimulating and simple diet, and never allow the bowels to remain constipated more than a single day. They should also rub and wash the skin well, and study calmness and quiet.

SYNCOPE, OR FAINTING.

In this condition, which is just the reverse of the former, the heart suspends its action altogether; the breathing ceases, all power of motion and feeling is lost, the face turns ghastly pale, the eyes close, and the individual seems as if actually dead. It seldom lasts however more than five minutes, when the pulse gradually begins to beat, the color returns, and the individual slowly recovers. Some females are liable to such attacks once a month, others once a week, others every few days, and some at irregular periods. They are generally preceded by a dull pain at the pit of the stomach, fullness in the head, yawning, and loss of sight, or ringing in the ears.

The causes that predispose to this fainting are not very well understood, though there is no doubt but it is mainly dependant upon uterine disturbances. In some females it is brought on by the sudden motions of the fœtus, or by their remaining too long in one posture. In others it is produced by straining from constipation, or by sudden fright or anger. In very nervous persons it not unfrequently arises from unpleasant sights, smells, and sounds. In fact it is caused in them much the same as a common hysterical fit, such as is described in my Diseases of Woman. A full habit, and over feeding, or drinking stimulating liquors may also bring it on, and so on the contrary may a state of weakness and exhaustion.

This accident is more alarming than dangerous, except to the child, which may lose its life if the fainting lasts too long.

To recover a person from one of these fainting fits, she should be laid upon her back on a level place, and every part of her dress should be carefully loosed. Some strong odor should then be applied to the nostrils, such as hartshorn, vinegar, burnt feathers, or smelling salts. The body should be well rubbed over the heart and lungs, either with the hand or with a soft, dry napkin. Cold water may also be dashed on the face, and the hands may be well chafed. If the fit still endures, a mustard plaster may be placed on each arm, or the whole body may be placed in a warm bath, if convenient. Care should also be taken to admit the fresh air freely. As soon as she begins to show signs of consciousness, a little wine or brandy may be placed in the mouth, and the body may be elevated a little.

To guard against such attacks, the same precautions as to diet and mode of life must be observed as were directed in the article on palpitation of the heart; and, as this accident is most frequent in those of a hysterical habit, they should carefully follow the advice given in the article Hysteria, in my Diseases of Woman.

HEADACHE AND DIZZINESS IN THE HEAD.

Each of these distressing affections, both of which are very common during pregnancy, may arise either from nervous excitement or from a full habit and determination of blood to the head. Nervous headache is generally met with in the earlier months of pregnancy, and is characterized by being frequently periodical, and often confined to particular spots. It also commences suddenly, from some excitement or depression of mind, and leaves little or no distress when it is gone. The headache, which arises from a too full habit, commences with flushing of the face, heaviness in the eyes, dull pain in the forehead, and a sense of uneasiness, with disposition to sleep or dose. It seldom comes on much till the latter months of gestation. Headache may arise also accidentally, from derangement of the stomach, but this cause is easily ascertained by the furred tongue, loss of appetite, and bitter taste in the mouth; it is also felt most acutely in the back of the head, down by the neck, and passes away immediately the stomach is corrected by an emetic, or by fasting.

Nervous headache during pregnancy often defies all our attempts to alleviate it, though we sometimes succeed in doing so. The best general remedies are warm baths, and, if the bowels are constipated, enemas of starch and castor oil daily. To these may be added occasional small doses of Laudanum, or an Opium pill, or two grains of Camphor. Smelling odors, such as Camphor, Cologne, or Hartshorn, will relieve some, but will make others worse; so that its utility can only be determined by experience. When a severe attack comes on, the patient should put her feet in warm water, or use a warm bath, take a few drops of Laudanum, or a little Musk, or Valerian, and then try to go to sleep. To guard against the attack, she must never overload the stomach, nor take anything indigestible; and never think too much nor allow herself to become excited or depressed.

When the trouble is caused by a too full habit, she must observe the directions given in the articles on palpitation of the heart, and Syncope. The diet must be mild and not too nutritious, the bowels must be regularly moved every day, chiefly by Epsom Salts and Seidlitz Powders, and regular gentle exercise must be taken in the open air.

In the latter months it is especially important to attend to a severe headache immediately, particularly when the pain is seated at the top of the head, because it is very likely, if unchecked, to terminate in convulsions. The means above recommended must be carefully and perseveringly applied; the feet must be kept warm, the bowels freely opened, and the head kept cool by wet clothes, or cold lotions, or ice. It is the general practice in all such cases, if the pain does not abate soon, and the pulse be full and quick, to bleed freely at the arm, and the most eminent physicians of the Allopathic school assure us, that the life of the patient frequently depends upon its being done promptly. I have no doubt, however, but that relief can be generally obtained by the simple means described, if they are used early and perseveringly.

INSOMNIA, OR SLEEPLESSNESS.

There are few affections that cause more real distress during pregnancy than this. Many females will be utterly unable to sleep for many days and nights together, and others can only obtain a few minutes broken and unrefreshing sleep at distant intervals. There is danger, when this state becomes highly aggravated, that it may lead to delirium, or that the want of rest may wear away the strength to such a degree, that the patient will sink from mere exhaustion. There are some females, however, who will remain without sleep, or at most take but very little, for a long time, without suffering any inconvenience.

This affection is essentially a nervous one, and the only means likely to relieve it are those that have a tendency to soothe and calm the nerves. If the patient be surrounded by any irritating circumstances they should be at once removed, or she herself removed from them. Particular attention must be paid to the diet, so that no derangement of the stomach or bowels be kept up, and a regular system of out-door exercise must be practised. A warm bath just before going to bed, with a good rubbing of the skin, will frequently act like magic in procuring rest. As a general rule narcotic drugs should not be used, but in extreme cases they may be resorted to sparingly. A single Opium pill, or a few drops of Laudanum may be taken after the bath. If the patient be thin and delicate, she should eat meat, eggs, and milk, and take a little wine, if it causes no unpleasant symptoms. Indeed a glass of wine will frequently act better than Laudanum, and so will ale with some, and coffee with others. If the patient be of a full habit these things will be improper, and may injure. She should then be kept quiet, and fed sparingly. Music has a powerful effect in many of these cases:—a slow, solemn air, played while the patient is reclining after her bath, seldom fails in inducing sleep.

TEMPORARY AFFECTION OF THE SIGHT, HEARING, AND SMELL.

These disorders are quite common during pregnancy, particularly in the latter months. Some females will be utterly unable to distinguish any odors, even the most powerful; others completely lose their taste, and others again become deaf or blind. When they are caused only by the sympathetic action of the womb, such deprivations are seldom of long duration, though they may recur at frequent intervals. In some cases they remain a considerable time, and great fear is felt that they may become permanent, but there is little danger of such a result. I knew a lady who suddenly lost her sight when about two months gone, and who remained totally blind till about three hours after her delivery, when her sight returned in a moment as perfect as before. The same thing has frequently been observed of the other senses. In some cases the vision will not be lost but perverted, and the patient will then see everything double, or larger or smaller than natural, or always of a wrong color. In like manner some will hear imaginary conversations, or will fancy everybody is shouting, or perhaps only whispering, though they are all the time speaking in their natural voice.

These perversions, when thus produced, need occasion no alarm, and seldom require attention, unless accompanied by other urgent symptoms. They may arise however, from a fullness of blood in the head, in which case they are accompanied by a flushed face and drowsiness, and are preceded by bright sparks flashing before the eyes, or by ringing in the ears.

The treatment of all these affections should be the same as that recommended for most of the previous derangements, particularly for Headache, Syncope, and Palpitation of the Heart. If there be nervous excitement merely, it must be calmed in the same way as recommended in the articles referred to, and also in the last one on sleeplessness. If the female be of a full habit, and there is evidently a pressure of blood on the brain and nerves of the special senses, the same means should be adopted to reduce the system, and draw the blood to the extremities, that have already been described.

In such cases these sudden deprivations of sight and hearing sometimes indicate the commencement of Convulsions, or Apoplexy, particularly if they occur during labor, when every means should be resorted to instantly to relieve the pressure on the brain. If no simpler means succeed in a reasonable time, it is the general custom to bleed freely from the arm, and there is no question but this frequently removes the difficulty at once, whatever objections may be made to the practice. It is also proper to say that many eminent practitioners, who are not advocates of the lancet in general, strenuously urge that it should be used immediately if the sight or hearing suddenly disappear in this way at any time. And I certainly have myself known these accidents sometimes followed by a fit of Apoplexy, or Convulsions, and even death. Such was the case with a friend of one of my patients. She found one day, quite suddenly, that she could only see half of any thing she looked at, and at times it even disappeared altogether. Nothing was done for her, and in about five hours after the first attack she fell speechless and died before they could lift her upon the bed. It will therefore be a necessary precaution, in all pregnant females of a full habit, to attend rigidly to the advice that has been given, because simple means, used in time, and regularly, may prevent the necessity of stronger ones altogether. In purely nervous cases of this kind no apprehension whatever need be felt, and no such practice as bleeding is required.

DISORDERED JUDGMENT, INCLINATIONS, AND PROPENSITIES.

The sympathetic irritation of the uterus, in some females produces extraordinary phenomena of this kind, from simple desire to the most furious craving, and from mere caprice to actual insanity. There is no doubt but that many of these unusual desires, or longings as they are called, are either produced or much aggravated by the imagination of the patient, and frequently would never be experienced at all, if the idea was not suggested by other people having had the same. Custom and imitation are very powerful in such cases, particularly when the nervous sensibility is much exalted. Still the most singular aberrations of this kind will often arise without any such adventitious aid, and the fact should be borne in mind, so that these temporary vagaries may be regarded with proper charity and forbearance.

Some females will entirely change in their dispositions at these times, the most amiable and mild becoming positively ill-natured and malicious;—the gentle will turn headstrong, the haughty and proud will become humble, and the gay will become melancholy, or the sad will madly seek every kind of gaiety. Such things however should never be remembered, nor be brought up against them afterwards, for truly at such times they know not what they do!

Women have been known while in this state, to become thievish, or to have an irresistible propensity to burn or kill. Some have even been known to exhibit great talents for music or poetry, though ordinarily without any capacity for such things. Some will suddenly exhibit a most extraordinary intellect, while others will become quite silly. A medical writer tells us an instance of one female who always had an excellent sound judgment while pregnant, but no memory, while in her ordinary state she had a poor judgment but a most extraordinary good memory. The celebrated Baudelocque gives an account of another who could scarcely eat anything but what she stole, while going to market; and another writer mentions a lady who longed till she was almost delirious to bite a piece out of a baker's shoulder, who worked opposite her window. There is even an account of one who longed to eat some of her husband, whom she dearly loved, and who actually killed him to satisfy her appetite, and then salted pieces of the body to keep for future use. A writer named Vives also tells us of a female whose husband paid a large sum of money for her to be allowed to bite a young man's neck, it being evident that she would be nearly certain to miscarry unless so gratified. In the year 1816, at Mons, in France, an unfortunate woman in this condition was seized with an irresistible impulse to destroy her children, and actually drowned three of them, and herself afterwards. She had previously sent a poisoned cake also to one at school, but fortunately it was not eaten.

Generally speaking all these things pass away with delivery, if not before, unless it be actual insanity, which sometimes remains. All that can be done is to attend strictly to the general health, keep the skin, bowels, and stomach, in good action, and remove all depressing or irritating circumstances. If there be a propensity to anything decidedly injurious or dangerous, the patient must be strictly watched, but without its being perceived or known by her, for fear of exciting suspicion in those who would be disposed to be cunningly secret or revengeful. Proper diet, regular bathing, and out-door exercise often correct many of these things.

HÆMOPTYSIS, HÆMATEMESIS AND EPISTAXIS.

These three terms mean spitting of blood, vomiting of blood, and bleeding from the nose, all of which frequently occur during pregnancy.

Spitting of blood is most usually observed in nervous women, and in those of a full habit. It is caused partly by sympathetic irritation, and partly by the womb pressing upwards against the diaphragm and lessening the size of the chest, which deranges the circulation in the lungs, and causes rupture of their blood vessels. The premonitory symptoms are pains round the waist, cold extremities, creeping of the skin, and a sensation of anxiety or depression round the heart. The attack begins by difficulty of breathing, heat in the chest, and dry cough, followed by spitting up more or less bloody frothy mucus; all which symptoms are much increased by violent exercise, or a hot atmosphere. In ordinary cases a mere spitting of blood need occasion no great alarm, unless attended by symptoms of inflammation, or unless the patient has had cough, and other indications of pulmonary derangement before conception.

In hæmatemesis the blood is vomited from the stomach, and is in black clots, frequently mixed with the food, or bile, while that which comes from the lungs in spitting on the contrary is bright red, and quite fresh. In vomiting of blood also, there is seldom any cough or exertion of any kind.

The treatment of spitting of blood must be nearly the same as for many other derangements already described. When there is a full habit, the patient must live low, keep the bowels free, and the skin in good order, and avoid all agitation of mind or over exertion of body. An Opium pill occasionally will be useful, or a few drops of laudanum. The cough must be combatted in the way recommended in my previous article on Cough. Lemonade or tamarind tea, with some Syrup of Poppies added, may be freely drunk, or some of the black currant root tea. The treatment of Hæmatemesis is precisely the same. Occasionally however the blood will pass into the intestines and occasion colic, and then it must be removed by administering an enema of starch and castor oil, or a little manna may be taken.

Epistaxis, or bleeding from the nose, is much more frequent than either of the preceding, but is seldom of much consequence. In many cases in fact it is highly beneficial, as it relieves the head from pressure, and thus obviates many inconveniences. If it continue too long, or becomes excessive, it may generally be arrested by putting cold wet cloths between the eyes, and on the cheeks, while the head is kept elevated. The feet and hands should be kept warm, and the air breathed should be as cold as possible. In extreme cases, the nostrils may be plugged with bits of sponge, or cotton, or some powdered alum may be snuffed up them. The best plan is to raise the hands above the head and put something very cold, as a lump of ice for instance, or a piece of cold iron, between the shoulders; this seldom fails.

VARICOSE VEINS.

Very often in pregnant women the veins in different parts, but particularly of the thighs and legs will swell out in knots, either singly or in bunches, sometimes like strings of beads, or like the links of a chain. These are called Varices, and occasionally they attain a large size, and extend to various other portions of the body, as the external lips, vagina, and mouth of the womb. Some women in fact have them over nearly the whole body. They are caused by the pressure of the womb on the large abdominal veins, preventing the return of the blood and disturbing the balance of circulation between the veins and arteries. In the majority of cases, unless very large, they cause but little inconvenience, and may be let alone, but sometimes they cause pain, or become so full that there is danger of their bursting, and then it is necessary to interfere.

The first thing to be done is to relieve the abdominal veins from the pressure of the womb, and this may be done by the patient keeping more or less the horizontal position, and carefully avoiding all violent exertion. The swelling is always worse during the latter part of the day, particularly if the woman has been much on her feet, she should therefore apply a cloth roller round the limbs before she rises in the morning. If this be carefully put on, just tight enough not to interfere with the motion of the limbs, nor totally obstruct the circulation, it will prevent the varices to a great extent, if not altogether. Brisk friction with the hand will disperse the swelling in many persons, or warm fomentations, but sometimes cold bathing answers better. It is advisable always to disperse them as soon as possible, for if they remain too long that part of the vein becomes permanently weakened by being overstretched, and will be always liable to swell again from any slight cause. It is particularly advisable in these cases to avoid constipation, and also to keep the skin in good action by bathing and frictions.

If at any time one of these varices should burst, it need occasion no alarm, unless it be seated on a large vein, and the bleeding becomes profuse. To stop it, bind on firmly over the rent any firm cold body, as a flat stone, or a large silver coin, passing the bandage several times round. In slight cases a simple cold compress will be sufficient, or a little powdered alum, or some vinegar and water. In short any of the usual remedies for stopping bleeding from wounds. The female must be quite still till it is stopped, and must be careful when she begins to move about again, because it is liable to break out afresh. Those of a very full habit must live low, and avoid all stimulants, so as not to increase the quantity of blood in the body more than is necessary. It is advisable to remove the varices, as much as possible, before labor comes on, particularly if they are situated on the lips, or in the vagina, because they may burst during delivery and cause considerable inconvenience, or even danger. It is rare that these swellings continue after delivery, but if they should do so, the same treatment must be persisted in as before.

HÆMORRHOIDS, OR PILES.

These are troublesome annoyances at any time, but particularly during pregnancy, and unfortunately they are very common at that time. They are, no doubt, chiefly caused in the same way as varicose veins, that is by the enlarged womb preventing the proper flow of the blood in the small veins, and so causing them to swell, and form tumors. They may in fact be called varices, as truly so as those on the limbs. In many persons however they are undoubtedly brought on merely by Constipation, which will undoubtedly either cause them or make them much worse when otherwise produced. In general they become worse as the pregnancy advances, because the womb becomes larger and the bowels are more apt to be confined.

As long as they only cause inconvenience, without any particular distress or urgent symptom, they may be let alone, or be slightly treated in the way of palliation, till after delivery, when they will disappear. Occasionally however, they grow to a large size, so as to hinder the passage of the bowels, and prevent the patient from sitting down or walking. They may then cause inflammation, and bring on falling of the intestine, or abortion, by the straining which they necessitate when the bowels are moved. And even if these extreme results do not follow, there may be serious derangements of the general health, indicated by difficulty of breathing, sleeplessness, headache, and fever. In short there are few of the derangements incident to pregnancy so annoying as this, and unfortunately, from its nature, the sufferer dislikes to speak of it and seek the necessary assistance. Many prefer undergoing the most excruciating agony for months, rather than complain, which shows the necessity for females knowing how to treat themselves, when possible.

The bleeding which sometimes takes place from Piles is more often beneficial than otherwise, unless it becomes excessive, from rupture of a large vessel, in which case, if the wound is external, it may be treated the same as the ruptured varicose vein; if it be internal, the remedies must be injected with a syringe, or a large roll of lint or cotton may be soaked in alum water and passed up the rectum. Frequently bathing the thighs and perineum with cold water will be sufficient.

To relieve the pain and swelling, the female should sit over the steam of hot water, and use the warm bath. If the piles are external, they should be bathed with hot milk and Laudanum, or rubbed with any soothing ointment, particularly the Cucumber Ointment, mentioned in my Diseases of Woman, or with Stramonium Ointment. If they are internal the milk and Laudanum should be injected if possible, or some thin starch and Laudanum, and a stiff roll of cloth may be smeared with the ointment and introduced. In general, ointments or other greasy matters are not so good as the milk or starch. In conjunction with this, the bowels must be kept free, either with enemas or castor oil, or by using a seidlitz powder in the morning. This is indispensable, for if constipation exists, no applications can render much service. The patient must also avoid fatigue, and not remain too long upon her feet, nor sit long, particularly on a hard seat, and if she be of a full habit she must live low, to avoid making too much blood. It is also important, at all times, to avoid using drastic purgatives, such as Aloes, Colocynth, or Gamboge, as they always make piles much worse, or even cause them.

ŒDEMA, OR WATERY SWELLINGS.

This affection also appears, like the preceding, to arise from obstructed circulation, but instead of the blood accumulating it is merely the serum, or watery portion of it. The swellings are generally whitish, and spread about, and a small pit remains in them when pressed with the finger. They are found on various parts of the lower limbs, and on the groin or abdomen, and also upon the external lips, in which place they are often exceedingly troublesome. As a general rule these swellings are of small account, and as they disappear with delivery, but little attention need be bestowed upon them. Sometimes, however, they become very extensive, and so engorged that they inflame and are extremely painful. They have even been known to mortify, and cause considerable sloughing, particularly when chafed and afterwards wet with the urine. In these extreme cases there may be serious disturbance of the general health, from the constant irritation, and from the patient being unable to walk about. I have often known the limbs and vulva covered with patches of Erysipelas from this cause. Sometimes the swellings even become so large that they interfere with the process of delivery.

The treatment of this affection consists in rest, particularly lying down, saline purgatives, regular, and frequent washing the parts with cold milk and Laudanum, or with a solution of Borax, half an ounce to a pint of water, to be used cold and with a tea-spoonful of Laudanum added to it. Simple cold water is frequently quite sufficient. In general all kinds of ointments are injurious, but if other means fail to give relief, the Cucumber Ointment may be tried. The wash should always be used after urinating, and the parts must not be rubbed, but lightly dried with a piece of soft linen. Fullers earth is often an excellent application when there is chafing.

If the patient be of a full habit, she must carefully diet herself, and bathe regularly. If she be thin and weak, a generous diet will be advisable, with meat and even a little wine.

HYDRORRHEA, OR PROFUSE DISCHARGE OF WATER.

This consists in a discharge of water, more or less profuse, from the vagina, at various periods during pregnancy. Some females will only discharge a small quantity, at intervals, others will have a constant dropping, and others again will pour out an immense quantity, sometimes several pints, or even quarts, in the course of a few days. In general this water is quite limpid and colorless, but sometimes it contains much mucus, and at other times it is tinged with blood. It does not appear that this discharge leads to any evil result, even when excessive, and I only refer to it to relieve anxiety. The origin of this water is not yet ascertained, but it is generally thought to be secreted between the membranes and the womb, and to be quite distinct from the liquor amnii.

PUSTULES, AND MUCOUS DISCHARGES.

Occasionally the external lips will be covered with pustules during pregnancy, and frequent discharges of mucus will occur from the vagina. They are both however caused by the unusual action of the uterine system, and merely require frequent bathing of the parts with milk and Laudanum, and regular action of the bowels. The most important thing to remark in connection with them is that they have often been mistaken, even by medical men, for the effects of syphilitic disease, and much distress has resulted from such mistakes.

DERANGEMENTS OF THE URINARY ORGANS.

Several derangements of the urinary organs are liable to occur during pregnancy, partly from sympathetic irritation, and partly from mere pressure. Some of these may be partially relieved, others have to be borne as patiently as they can be till delivery removes them.

The swollen womb often presses on the neck of the bladder, and hinders the passage of the urine, or even obstructs it sometimes altogether, and thus causes straining, burning heat, and great distension of the bladder. In some instances this passes off as the pregnancy advances, owing to the womb rising higher in the abdomen, but in other cases it remains more or less, during the whole term. It is particularly important, in such cases, that the female should not let the difficulty remain too long unremedied, for if the bladder be very full it may become utterly impossible to empty it by natural effort. Sometimes the difficulty is much lessened by lying on the back a short time before attempting to urinate, or by raising up the abdomen with the hand at the time. Many females can urinate with tolerable comfort while lying on the back or abdomen, and others are much relieved by constantly wearing a bandage. Constipation always makes this difficulty worse, and sometimes even causes it, by keeping the rectum full and thus increasing the pressure. In all such cases it will be readily seen, that forcing medicines are not only useless, but liable to cause injury. The change of position, rest, and supporting the abdomen are the means to be relied upon. If these fail, and the urine accumulates, the catheter must be used. A warm bath, or fomentation with warm water and Laudanum, will assist, and sometimes relieve alone. To ease the burning and distress the patient must drink freely of gum water, or barley tea, with a little Syrup of Poppies.

There is one manœuvre which, if practised aright, will nearly always allow the female to urinate with ease, and fortunately she can practise it herself. It consists in introducing two of the fingers into the vagina, and raising up the womb, as if practising the ballotment. This removes the pressure from the bladder, and the urine then escapes by natural effort. A few trials will soon enable any one to do this, particularly if they notice well the form and position of the parts, as shown in the plates of this work. A lady who heard me mention this in one of my Lectures, afterwards stated that the knowledge of it enabled her to dispense altogether with the catheter, which she was previously necessitated to use during most of her pregnancy.

When there is merely a nervous irritation causing the difficulty, the warm bath, or fomentation with warm water and Laudanum will be sufficient, or a little Belladonna Ointment may be rubbed over the meatus urinarius, while some starch and Laudanum is injected carefully into the vagina.

CRAMPS.

These arise from the womb pressing on the nerves of the sacrum, and are therefore not under the control of medicine. All that can be done is to change the position of the body as much as possible, from lying down to standing up, and by turning from one side to another. Brisk rubbing with the hand will also assist in giving relief. The cramps however usually disappear after delivery, and must therefore be borne as patiently as possible till that takes place.

PRURITUS, OR ITCHING OF THE EXTERNAL PARTS.

Having treated this affection fully in my Diseases of Woman, I cannot do better than extract the article from that work on the subject.

"This disease, though not so immediately dangerous as some others, is perhaps the most distressing that can be met with.

"It consists in an intolerable and incessant itching of the parts, which nothing seems to allay. Sometimes it is so bad that the female is almost tormented to death; she cannot see company, or walk out, and often shuts herself up alone in her agony. Many have fainted from it, and some have even become delirious. I have seen patients whose hands it was necessary to tie, to prevent them tearing themselves to pieces.

"The causes of pruritus appear to be most of those that produce simple inflammation, which it very frequently accompanies or precedes. Pregnant females are very liable to it, and in some it will continue, in spite of all that can be done, till after delivery, when it usually disappears. I have known it produce abortion. Some females always have it at the menstrual period, and others during nursing. Occasionally there is a little eruption attending it, but not always, though the parts are generally swollen and red. Parasites are sometimes the exciting cause, and should always be destroyed immediately.

"The treatment consists in first attending strictly to the diet, which must be light and unirritating, and to the regular action of the bowels and womb; and in using the cooling washes and lotions before mentioned. If the itching still continues, use either of the following washes to the parts:—Sub. carbonate of potash three drachms, water four ounces; put a tea-spoonful of this into a quart of warm water, and use it three times a day.—A tea-spoonful of Eau de Cologne to a pint of warm water.—Sulphate of Zinc, half a tea-spoonful to a quart of warm water. Both these may be used many times in the day.—Borax half an ounce, Sulphate of Morphia six grains; pure water half a pint. This last seldom fails of giving relief. It should be applied three or four times a day, with a piece of soft linen, the parts being first washed with warm soap and water. A tea-spoonful of laudanum will sometimes answer as well as the six grains of Sulphate of Morphia.

"Caustic has been employed, and blisters to the inside of the thighs, but such violent remedies are seldom either necessary or serviceable. I have known the parts to be deeply scarified with the lancet, and even burnt with a red hot iron, without at all alleviating the pruritus.

"In young persons it seems to be often produced by constipation, worms, and gravel; but it most probably depends, essentially, on some impurity, or irritating quality, in the blood, or in the natural secretions of the parts, which should therefore never be allowed to remain long unwashed.

"Sitting in cold water, and the application of ice to the parts, has given relief. I have also effected many cures, almost instantaneously, by means of a small Galvanic plate, so constructed as to be worn just within the vulva.

"All remedies must of course be applied with caution during pregnancy; and it must be recollected that sometimes the disease will continue, more or less, till after delivery, though the distress from it may be much alleviated."

CHAPTER XXVII.

IDIOPATHIC, OR PRIMARY DISEASES INCIDENT TO PREGNANCY.

FLOODING, OR HEMORRHAGE.

Flooding is one of the most dangerous accidents that occur during pregnancy, its consequences being often of the most serious character. The causes that lead to flooding are very numerous, some of them predisposing to it, and others immediately exciting it. Among these may be mentioned a too full habit, violent exertion, falls, coughing, vomiting, straining from costiveness or violent purgatives, forcing medicines, criminal attempts at abortion, overwalking, blows on the abdomen, too much dancing, or running up stairs, strong mental emotions, fright, or anger, and certain excesses. The immediate cause is the separation of the membrane in which the fœtus is inclosed from the walls of the womb. Flooding may however result from the placenta growing over the mouth of the womb, and being torn as that opens—usually about the sixth or seventh month.—(See the article Flooding during Labor.)

In most cases flooding is preceded by dull pain in the loins and groins, and a sensation of weight and dragging. Similar sensations however are often produced by other causes, which makes it difficult to predicate, with any degree of certainty, whether the patient is about to flood or not. The very first appearance of blood from the vagina must therefore be watched for carefully, as that removes all doubt, and warns us to be prompt with the proper remedies. Sometimes a female will flood internally, the blood being retained by the passage being closed or plugged up by clots, or by its passing behind the membranes, or under the centre of the placenta. These internal or concealed hemorrhages are very dangerous, as the patient may lose much blood before her condition is suspected. It is therefore necessary to bear this in mind, and carefully use every means to ascertain whether such an accident has occurred or not. In general the indications are pretty plain, the patient suffering from deep seated and distressing pains in the back and groins, with great weakness in the limbs, faintness, weak pulse, dimness of sight, ringing in the ears, coldness of the hands and feet, swelling of the abdomen, and finally fainting, particularly if the retained blood suddenly escapes, which it usually does.

In the early months there is more danger to the child from flooding than there is to the mother, because it is nearly certain to lead to abortion. In the latter months, on the contrary, the mother runs the greatest risk, as the child may then live if it be expelled, while the mother may sink and die from excessive loss of blood. There are many females of a very full habit, who suffer but little from hemorrhage, unless it be excessive, indeed some seem to be benefitted by it, and are thus relieved from headache and convulsions. It should, however, be carefully watched, and its effects duly noted.

The treatment of flooding must depend materially upon its severity, and the time when it occurs. In the early months, when the discharge is slight, and when it causes little distress, simple means will answer. The patient must lie on her back, on a hard mattress, with the pelvis raised, by means of a pillow, higher than the rest of the body. The air must be kept fresh and cool around her; she must keep herself quiet in body and mind, live rather low, and drink freely of cooling drinks, such as soda water, lemonade, tamarind tea, or ice water. [The fullest directions for making and using all these drinks will be found in my "Diseases of Woman.">[

If the flooding does not stop with these simple means, external applications must be made, of cold, wet cloths, or even ice, over the abdomen, and inside the thighs. Finally, if further treatment is still needed, cold astringent injections may be carefully thrown into the vagina. Cold water is perhaps as good as anything for this purpose, and I have frequently known a most severe flooding checked immediately by injecting cold water into the vagina and rectum, and applying cold wet cloths over the abdomen, and inside the thighs. Some astringent drink may also assist, such as a little syrup of comfrey, or extract of Rhatany, and particularly a tea made of the root of the black currant, as recommended in my "Diseases of Woman."—[A handful of the root may be boiled in two quarts of water, for twenty minutes; it should be sweetened to taste and drunk freely. The common blackberry, or the dew berry, is also excellent, though not so good as the black currant.]—If the patient be nervous and irritable, or suffer much from pain, an opium pill may be taken, or from ten to twenty drops of laudanum.

The general practice in these cases is to bleed freely and give opium! And as this practice certainly does succeed in many extreme cases, I should certainly recommend, if the simpler means fail, to resort to it at once. I dislike bleeding very much, in any cases, and here it seems particularly inappropriate; I should therefore say try almost anything and everything first, but never obstinately refuse to do it if nothing else succeeds.

In some cases a plug or tampon is used, to fill up the vagina. It may be made of a roll of cloth, cotton, or a piece of sponge. This practice, however, is useless in the latter months of pregnancy, and very often fails even at other times. When it succeeds it causes the blood to coagulate, and thus closes up the mouths of the vessels. Quite as often, however, it only keeps it in, and makes it accumulate in the womb till it all rushes away at once; still it may be tried.

If the hemorrhages should occur so frequently, or be so excessive, in spite of all treatment, as to endanger the safety of the patient, there is no other resource left to save her life but to produce abortion, because the presence of the fœtus and its appendages is evidently then the irritating cause which keeps up the discharge, and it cannot be expected to stop till the womb is emptied.

ABORTION, OR MISCARRIAGE.

When the fœtus is prematurely expelled before it can survive, it is called an Abortion, but if its expulsion take place so late that it can live, it is called Miscarriage. Both these are serious accidents. In abortion the child is lost, as a matter of course, but in miscarriage it may live, after the seventh month. The danger to the mother is considerable from both, though greatest probably from abortion. It is probable that many very early miscarriages take place unperceived, the female suffering but little from the accident, and the embryo being too small to be seen, unless carefully looked for.

The most frequent periods for such accidents are found to be six months, five months, and three months; and what is very singular, a much greater number of male children are aborted than females, the proportion being about sixteen to eleven.

These accidents are so intimately connected with flooding, that many writers always treat of them together, considering the flooding merely as the most frequent cause and symptom of miscarriage or abortion. In speaking therefore of the immediate causes of premature expulsion of the fœtus, we place hemorrhage first, and the causes before enumerated which produce that as being its most frequent remote ones.

A full habit, with tendency to local congestion, seems to predispose a female very much to miscarriage; every one so constituted should carefully avoid luxurious living and an inactive life. Violent bodily exertion, falls, or blows, or strong mental excitement are most usually the immediate causes, though with some it will come on spontaneously without any such exciting agencies. Some females will miscarry many times in succession, and always so near the same period, that they can tell to a day or two when it will happen. It seems to become a habit of the womb with them to contract at that particular time, and the only way to break through the habit is for them to avoid becoming pregnant for some considerable time, say two or three years after, they may then go the full time, but will seldom do so if they conceive immediately after having miscarried. In some persons miscarriage is caused by a too eager gratification of certain desires; but in others it may arise from the opposite cause.

There is a disease of the womb also by no means unfrequent, though but little understood, which undoubtedly causes much miscarriage, and that is Rheumatism of the Womb! This mostly exists before the pregnancy however, and should be then treated according to the plan laid down in my "Diseases of Woman."

Miscarriage also arises in many females from a rigid state of the muscular fibres of the womb, which not relaxing sufficiently to allow that organ to expand become irritated by the pressure they experience, and begin to contract. This contraction of the womb of course soon leads to the expulsion of its contents, the same as in real labor. Women with their first children are more liable to miscarriage than others on this account, the womb not having become habituated as it were to the necessary relaxation.

And this is the reason also why some females, after suffering from this accident many times in succession at last escape it. In general they miscarry early the first time, from the womb not relaxing sufficiently, but go a little longer the next time, and longer still the next, and so on till they reach the full period. The fibres of the womb have gradually become accustomed to relax, and have borne the irritation longer and longer each pregnancy, till at last they have forborne to contract till the proper time. I knew one female who miscarried twenty-one times in succession, getting gradually nearer to the full period each time, till at last she reached nine months, and was rewarded with a living child.

Sometimes the accident may be produced by a uterine tumor, by a great quantity of water in the womb, or even by there being more than one child, because in either of these cases there is required more room than ordinary; and of course from the greater expansion required, the liability is increased. Various womb diseases may also be mentioned as causes, or adhesions of its walls or ligaments to the walls of the abdomen, and also a diseased state of the placenta. The pressure of corsets and tight dresses also not unfrequently lead to the same result. Some general diseases undoubtedly often cause miscarriage, such as measles, jaundice, scarlet fever, consumption, and probably many others, particularly those in which the quality of the blood is much altered, or the nervous power much exalted or depressed. Convulsions have already been mentioned as being frequent causes of miscarriage, and all strong mental or moral impressions. Indeed these last causes operate more than is suspected, and make it necessary for a pregnant female to be kept as calm in her mind as it is possible for her to be. I have even known one to miscarry from a fright in a dream.

It is also a fact, though not generally known, that there are certain diseases of the father that may produce miscarriage, and unfortunately they are of that kind that often remain for a long time in the system without much external manifestation, so that many persons think they are perfectly free from them even while they are working such mischief.

The death of the child also is sure to produce miscarriage, and this may result from various causes, such as external injuries and violence, or from remaining too long in the warm bath and thereby causing congestion of blood in the womb. Small pox and syphilis in the mother may also cause the death of the child, though not always. Many having been born at full term with these diseases upon them.

In general the fœtus is expelled very soon after it dies, but occasionally it is retained for a considerable time, and may not pass away till it is completely decayed. It has even been known to become almost fluid, and several months elapse before it was entirely expelled. Most women know when it dies, by its seeming to fall down to the bottom of the abdomen, like a dull weight, and also by its feeling very cold. Very often, however, there is no indication of its death whatever. M. Chailly mentions a case where the embryo died, probably when about fifteen days old, but the placenta continued to grow, and the lady was delivered when about six months and a half gone of the dead embryo, only about a quarter of an inch in length, though the after-birth was nearly large enough for one of the usual size. In this case it had died but not decayed, and remained in the womb six months and a half. In cases of twins also, one will sometimes die at an early period, but remain till the other is born at full term.

The growth of the placenta over the mouth of the womb, and shortness of the chord, have already been referred to as causes both of flooding and miscarriage; and to these may be added monstrous or deformed fœtuses, which rarely reach the full term.

It is probable that there are many constitutional and individual peculiarities predisposing to miscarriage, with which we are not much acquainted, and which may account for the constant occurrence of that accident in many females, notwithstanding all we can do. A scrofulous taint is with good reason supposed to be one of these, and it is probable that the disease of the placenta, and its consequent separation from the womb, before referred to, is mostly caused by a taint of this kind. In many instances, where a female has miscarried from no apparent cause, if the placenta be carefully examined it will be found dotted here and there with diseased spots, sometimes like scrofulous sores! It is advisable always to ascertain this, and to carefully examine the fœtus and its appendages. In all cases the advice I gave to keep from being pregnant for some time, will be found most likely to succeed in averting the accident, both because it gives the womb time to regain its strength and break through its habit, and also because it gives us time to operate upon the constitutional taint, if there be reason to suppose it exists.

It is a curious fact, but one often observed, that living in certain localities even predisposes to miscarriage. There is a certain district in France where the females are so liable to it, that all who can do so leave the place when they become pregnant, and thus escape the greater risk. Miscarriage also becomes epidemic at certain times, and prevails like contagious diseases; several instances of this are recorded in history.

Bleeding is also supposed to be a cause of abortion, and probably it may lead to it in certain states of the system, but by no means so certainly as many suppose. Instances have been known of pregnant females being bled from ten to twenty times without any evil result, even though carried so far as to make them faint. Mauriceau tells us of one who was bled ninety times, and yet was delivered of a healthy living child at full term. In like manner many other ordinary causes of abortion will often fail entirely of their usual effects. Thus Mauriceau informs us that a female seven months gone fell upon the hard pavement from a three story window and broke her arm, but yet did not miscarry. Madame Lachapelle also tells us of a young pregnant woman who threw herself down stairs purposely, from fear that she should have to submit to the Cesarean operation, she having a deformed pelvis. The fall caused her death soon after, but did not make her miscarry. Certain powerful medicines are also taken by some, a very small quantity of which, in most cases, produces abortion immediately, but without effecting what they desire, though it sometimes poisons themselves.

Indeed the power which the womb sometimes exhibits to retain its contents in spite of the most violent disturbing agencies, is truly astonishing. Cases have been known even where the womb itself has been severely wounded, and yet miscarriage did not take place; as in the case of a poor country-woman whom I heard of, who accidentally fell upon a sharp wooden stake, and run it far into the body, injuring the womb in a terrible manner, but strange to say, though far advanced in pregnancy, she recovered and went safely through her full time. I have often known women begin to flood and suffer from dreadful pain, with other common symptoms of abortion, as early as the second month, and yet they went safely the full time, though these signs continued the whole time. In some cases the waters have even been partially discharged, and yet abortion did not result. M. Velpeau tells us of an instance where the bag of waters broke, in a female six months gone, and one arm of the child even came down into the vagina, and yet the arm returned, the discharge ceased, and she went her full term.

The progress of a miscarriage varies according to the time at which it occurs, and the causes from which it arises. When it results from any violence or accident, it usually takes place in a short time, and is preceded by abundant flooding, which comes on immediately. The discharge of blood however, is lesser the nearer we approach the full term, so that a female six months gone is not in nearly so much danger from flooding as one only two or three months gone. The reason is this, in the early months nearly the whole of the fœtal membranes are attached to the womb, so that in case of their being separated, it bleeds from nearly all its internal surface, but in the latter months the only point of attachment is the placenta. In the latter months also the womb contracts vigorously, and so closes its vessels, but in the early months its contractions are comparatively feeble. In those cases also, where the child has been dead a considerable time before its expulsion, there is seldom much flooding, the connection between it and the mother having been more or less destroyed by decay of the parts. The same result mostly follows a miscarriage from internal disease, particularly of the placenta. Indeed in some of these cases, the blood-vessels connecting the fœtus with the mother have been so completely destroyed, that no blood whatever could escape from them.

In regard to the probable consequences of premature delivery, it has already been remarked that it is more dangerous in the early months than the latter. It may also be added that it is much more dangerous, at any time, when caused by violence of any kind, or by forcing medicines, than when it occurs naturally. The danger is much increased if it occurs during fever, or any eruptive disease, or if the patient be suffering from diarrhœa or convulsions. As a general rule we may say, in all cases, that miscarriage or abortion is always more dangerous to mother and child than natural labor, both in its present and in its future consequences. During an attack of jaundice an abortion may terminate fatally in a few hours; and very frequently the trouble with the after treatment is very great and long-continued.

The treatment in an accident of this kind must vary according as we are required to prevent it, or to remedy the evils that follow when it has occurred.

If an abortion be threatened from any cause, the same general practice must be adopted as recommended for flooding, the indications being the same. I believe myself that in most cases, except from accidental violence or internal disease, miscarriage may be averted. I knew a lady who had miscarried many times, always at the same period, who avoided it at last by simply preventing constipation from the first commencement of pregnancy, and by using an enema every evening of warm starch and water, pretty thick, with about thirty drops of laudanum. This was administered by means of a common injection pipe, just before going to bed, and continued till after she had quickened, and repeated occasionally after that, if she felt any premonitory symptoms of uterine disturbance. If the patient be of a full habit, she should also, from the very beginning, live low, keep the bowels free, and the skin in good action, and take gentle regular exercise in the open air.

When all the means used are found of no avail, and it becomes evident that the fœtus must be expelled, every endeavor should be used to assist nature in its removal as early and as safely as possible. For this purpose the same treatment, as far as practicable, must be pursued as in a real labor. If the hand can be conveniently introduced, without undue force, it may be so, to remove clots, or to take hold of any part of the fœtus which may present, and assist in its extraction. In the early months considerable help may be given, sometimes by introducing the finger into the mouth of the womb, with a little extract of Belladonna, to promote its relaxation, but no force must be exerted in doing so. If any part of the after-birth can be laid hold of it should be withdrawn, but no extraordinary effort must be used to reach it. Frequently it happens that a portion of the after-birth remains in spite of all attempts to take it away, and there is a possibility that it may produce inflammation of the womb, but no very serious apprehensions need be felt of such a result, providing the patient is properly attended to in other respects. The retained portion gradually decays, and passes away, merely occasioning inconvenience and being very offensive. The danger from leaving it except at a very late period, is generally thought to be less than that from using any forcible means to remove it.

The best means for correcting the offensive discharge are cleansing and antiseptic injections. Warm soap suds are very good, or a decoction of Peruvian bark in water. Strong coffee is also excellent, or a weak solution of chloride of lime. The bowels must be kept free, and the skin carefully cleansed and well rubbed. On all occasions when the hand can be introduced with moderate and safe efforts it should be so, and the after-birth removed.

In conclusion it should be remarked, that the tendency to miscarry, like many female diseases, is undoubtedly owing, in great part, to the general debility and weakness which characterizes so many women at the present day, and which is brought on chiefly by neglect of their physical education when girls, and by their artificial mode of life afterwards.