A System of Midwifery

by Edward Rigby

The vascular system undergoes a considerable change; the actual quantity of blood in the circulation appears to be increased; the pulse is harder, stronger, and more full; in many instances the blood, when drawn, exhibits the buffy coat, as in cases of inflammation; the vagina is more vascular, it is warmer, and the secretion of mucus considerably increased; there is a disposition to headach, and occasional flushing of the face; the animal heat over the whole body is increased. In the nervous system we also observe distinct evidences of a change having taken place: the irritability is increased; there is weariness, lassitude, and a peculiar alteration of taste and disposition; women, who otherwise are of a cheerful disposition, are now gloomy and reserved, and vice versâ; in some the temper becomes fretful and hasty, and in those who are naturally so, a most agreeable change for the better is sometimes observed.[30] Some are liable to spasmodic affections, palpitations, spasmodic cough, vomiting, fainting, headach, toothach, &c.: under this head will come the “morning sickness,” which is so commonly observed during the first weeks; the nature and treatment of which will be considered under the Diseases of Pregnancy; on the other hand, women who are constantly suffering from spasmodic affections, for instance, asthma, &c. are now entirely free from them, and appear to be insensible to causes which, in the unimpregnated state, would induce an attack. To changes in the nervous system must we, in great measure, attribute not only the sickness just mentioned, but also those extraordinary longings or antipathies for certain articles of food or drink, and in some cases, as in chlorosis, for substances which, under other circumstances, would excite disgust. In many, the changes in the function of the digestive apparatus does not amount to actual disease, the stomach merely refusing to digest articles of food which before had agreed with it: but in others, producing severe cardialgia, acidity, or even vomiting. Hence, we not unfrequently observe that women who had hitherto enjoyed a good digestion, now suffer from dyspepsia, and are obliged to be exceedingly careful in their diet; whereas those, in whom the digestion had been previously weak, are now able to digest almost any thing. The secretions of the whole alimentary canal are altered both in quality and quantity; the saliva frequently becomes tenacious, white, and frothy (Dewees,) and at times is so much increased in quantity as to amount to actual salivation; the secretions of the stomach are remarkably altered, as shown by the copious formation of acid in some cases during pregnancy; the mucus is ropy, and frequently vomited up in considerable quantities. The bowels are in some cases much relaxed; in others, constipated. This latter condition, however, may in part be attributed to the pressure of the gravid uterus obstructing the peristaltic motion.

The changes in the appearance of the skin during pregnancy are also worthy of notice. Women, who are naturally pale and of a delicate complexion, have frequently a high colour, and vice versâ; in some the skin assumes a sallow or cadaverous hue; copper-coloured blotches appear on the face and forehead: in others the skin appears loose and wrinkled, giving the patient an aged haggard expression, and destroying her good looks. Mole spots become darker and larger, and these, with a dark ring beneath the eyes and the changes already mentioned, combine to alter the whole appearance of the face. In some women a considerable quantity of hair appears in those parts of the face where the beard is seen in the other sex; it disappears after labour, when the skin resumes its natural functions, but returns on every succeeding pregnancy. In others a similar appearance takes place upon the breasts. The secretions of the skin are more or less altered; women who perspire freely have now a dry, rough skin; whereas those who at other times have seldom or never a moist skin, have copious perspiration, which is not unfrequently of a peculiarly strong odour. Cutaneous affections, also, which have been very obstinate, or had even become habitual, sometimes disappear, or at least are suspended during the period of utero-gestation. Similarly favourable changes are observed for a time in severe structural diseases of certain organs: the fact of well-marked phthisis apparently disappearing whilst pregnancy lasts, is well known.

The breasts become larger, blue veins are seen ramifying beneath the skin, and the circular disc of rose-coloured skin which surrounds the nipples becomes remarkably changed in colour, &c.; appearances, the description of which we shall defer until we come to the consideration of those phenomena produced by pregnancy, which may be looked upon as diagnostic.

The urine undergoes various changes; it is sometimes considerably increased, at others it is very high-coloured, or shows a peculiar milky sediment. A case has been quoted by Dr. Montgomery from Professor Osann’s Clin. Rep. for 1833, p. 27., where the patient in three successive pregnancies was affected with diabetus mellitus, which each time completely ceased on delivery, and again returned when she became pregnant. None of the changes above enumerated excepting of those of the breasts, whether taken separately or conjointly, will enable us to form a correct diagnosis as to the existence of pregnancy. The appearance and feel of the abdomen during the early months afford no sure data: in fact, there is not a single symptom of pregnancy at this period, upon which we can rely with any degree of certainty.

Cessation of the menses. One of the most remarkable changes produced by pregnancy, and one which most constantly appears, is the cessation of the menstrual discharge. From its occurring so uniformly and so soon after conception, it is generally used by women as the best means of reckoning the duration of their pregnancy: still, however, it is very far from being a certain sign, and never can be depended upon by itself in forming our diagnosis. It is well known how many causes produce suppression of the catamenia, independent of pregnancy; and, on the other hand, ample experience has shown that suppressed catamenia are by no means a necessary consequence of pregnancy.

Although the fact has been contradicted by men of experience, still the regular appearance of the menses for the first few months of pregnancy is of such frequent occurrence as to place the matter beyond all doubt: in stating this, we do not allude to occasional discharges of blood from the vagina, but to regular periodical appearances of fluid distinctly bearing all the characters and peculiarities of the catamenia. This fact has been noticed so long ago, as by Mauriceau, who says, “I know a woman who had four or five living children, and who had with every child her menses from month to month, as at other times, only in a little less quantity, and was so till the sixth month, yet notwithstanding she was always brought to bed at her full time.”[31]

It is rare, however, to meet with the catamenia at so late a period, although cases do now and then occur where it lasts throughout pregnancy; more frequently it does not continue beyond the third or fourth month. The source of this discharge appears to be from the vessels of the upper part of the vagina[32] and from the cervix uteri;[33] the gradually shortening of the latter as pregnancy advances may be considered as the reason why, in the majority of instances, the discharge diminishes after the second or third month, and usually ceases by the fifth or sixth. Dr. Dewees supports the same opinion with some excellent observations which are worthy of attention. “We are” says he “acquainted with a number of women who habitually menstruate during pregnancy until a certain period, but when that time arrives it ceases: several of these menstruated until the second or third months, others longer, and two until the seventh month; the last two were mother and daughter. We are certain there was no mistake in all the cases to which we now make reference. First, they (the menses) were regular in their returns, not suffering the slightest derangement from the impregnated condition of the uterus; 2. they employ from two to five days for their completion; 3. that the evacuation differed in no respect from the discharge in ordinary, except that they did not think it so abundant; 4. there were no coagula in any one of these discharges, consequently it could not be common blood of hæmorrhage; 5. in the two protracted cases, the quantity discharged regularly diminished after the fourth month, a circumstance perhaps not difficult of explanation.” (Compendious System of Midwifery, § 235.)

It occasionally happens that the first appearance of the catamenia after conception is more abundant than usual, a circumstance which had been noticed by Dr. W. Johnson in 1769, and confirmed by Dr. Montgomery in his admirable work on the signs of pregnancy, who also confirms the general fact of the menses occasionally appearing during pregnancy by his own experience, and by very ample references. (Op. cit. p. 46.)

The rarest and most extraordinary deviation of this kind from the usual course of things is the appearance of the menses only during pregnancy. Cases of this sort have been recorded by authors of the highest respectability, so that there can be no doubt as to the correctness of their statements. Thus, for instance, Baudelocque says, “I have met with several women, who assured me that they had not had their menses periodically except during their pregnancies; their testimony appeared to me to deserve more credit, because they only applied for an explanation of this extraordinary phenomenon.”[34]

By far the most interesting and detailed case of this nature is one described by Dr. Dewees. “A woman applied for advice for a long standing suppression of the menses; indeed she never had menstruated but twice. She had been married a number of months, and complained of a good deal of derangement of stomach, &c. We prescribed some rhubarb and steel pills; about six months after this she called to say that the medicine had brought down her courses, but that she was more unwell than before. The sickness and vomiting had increased, besides swelling very much in her belly; we saw this pretty much distended and immediately examined it, as we suspected dropsy; but from the feel of the abdomen, the want of fluctuation and the solidity of the tumour, we began to think it might be pregnancy, and told the woman our opinion. On mentioning our impression she submitted to an examination per vaginam; this proved her to be six months advanced in pregnancy. After this she had the regular returns of the catamenial period, until the full time had expired; during suckling she was free from the discharge. She was a nurse for more than twelve months; she weaned her child, and shortly after was again surprised by an eruption of the menses, which as on a former occasion proved to be a sign of pregnancy.” (Op. cit. § 237.)