Chapter II: Part 2

The manner in which conception takes place has ever been a fruitful subject of inquiry, but we are unable to account for this change precisely. It is, however, pretty evident that the semen of the male is introduced into the uterus, while the semen of the female is discharged from the ovaria by means of the Fallopian tubes, the fimbricated extremity of which closely embraces that organ.

These tubes, by a kind of peristaltic motion similar to the intestines, convey the semen of the female into the uterus, where it unites with the semen of the male; and it is these united fluids which constitute the rudiment of the fœtus, and which often give to the child the appearance and dispositions of their parents. Sometimes one trait is inherited, sometimes another; at other times a new compound or character is formed (like a chemical union), which does not partake of the nature of either of the former.

OF THE MODE BY WHICH PREGNANCY MAY BE DETERMINED.

There are certain signs which a female is taught to regard as essential evidences of pregnancy and it is supposed by most, if not by all women, that their presence is absolutely necessary to the existence of this state. In reference to one or two of these signs, this is far from the fact; for they are not unfrequently absent, although pregnancy exist, and the remainder may be present, although pregnancy be absent. Many a female, I am confident, has, from this very circumstance, experienced much difficulty in attaining certainty as to her state, and suffered months of anxiety and doubt. This has arisen from a want of those clear notions, and that precise information, which a question so important demands.

The object of this chapter is to remove this difficulty, by presenting a short account of those symptoms of conception which the female may herself observe, and to point out to what extent they may be relied on. It will be necessary to notice only _four_ of the signs or symptoms of pregnancy, and they may be considered in the order in which they usually arise; that is, ceasing to be unwell; morning sickness; shooting pains through, enlargement of, and other changes of the breast; and, lastly, quickening.

_Ceasing to be unwell._

The first symptom of pregnancy is the omission of that monthly return, which, in female phraseology, would be described as “ceasing to be unwell;” and it may be adopted as a general rule, that, in a healthy woman, whose menstruation has been established, and continued regular, and who is not nursing, “Conception is followed by a suppression of the menstrual discharge at the next return of its period.” Thus, a female may have been pregnant a week or two already; but she is not aware of it till that period of the month arrives when she is accustomed to menstruate, and then, when she expects to be unwell, she finds that she is not so.

Now this symptom, as a general rule, admits of four exceptions:—

First. A young female shall never have menstruated, and yet conceive.

Secondly. A mother shall conceive while she is nursing, and not menstruating.

Thirdly. A female shall conceive, and yet be unwell during the first three, four, or more months of pregnancy.

Fourthly, and lastly. Occasional conception takes place late in life, after menstruation has apparently ceased for ever.

_First Exception._—Many cases are on record proving this point. I have met with only two cases; one quite a girl, not having arrived at her seventeenth year, and yet was in her sixth month of pregnancy when she applied for a letter for the Finsbury Midwifery Institution; the other was in her nineteenth year. Menstruation was, subsequent to confinement, established in the first; with the result of the latter, I am not acquainted.[9]

Although pregnancy under such circumstances is not of frequent occurrence, still it does now and then take place. A knowledge of the fact may therefore prove useful.

_Second Exception._—It is scarcely necessary to advert to the well known fact that a woman may conceive while she is nursing, without any previous return of the monthly discharge, except to expose the popular error, “that a female will not become pregnant during lactation.” This is very far from being the case. Poor women are much in the habit of nursing their infants eighteen months, two years, and even two years and a half, in order to protect themselves, as they imagine, from becoming pregnant; and many a poor creature have I seen with exhausted frame and disordered general health, arising from protracted nursing, pursued alone from this mistaken notion.

I have large opportunities of investigating this, as well as the several points touched upon in this chapter. On an average, between forty and fifty poor women call upon me every month, with midwifery letters for attendance in their confinement: and the result of my inquiries upon the present question has led me to believe, that more than one third of these women have conceived at least once while nursing, and very many of them oftener.[10]

Mrs. M——, ætat. 30, married six years. Became pregnant three months after her marriage. Having suckled this child for more than two years, became pregnant a second time. This last died in three weeks, and immediately after she proved pregnant for a third time. The third child she brought this morning (being out of health), and assured me that she had not seen anything since she first conceived, that is, three months after her marriage, and six years from the present time.

Mrs. W——, ætat. 25, married five years. Has not been unwell since she first fell in the family way; is now pregnant with a third child, having hitherto fallen pregnant while nursing.

Many other cases illustrative of this fact I might assert, but these suffice to prove the exception.[11]

_Third Exception._—That a female should become pregnant, and yet be unwell during the first three, four, or more months of pregnancy, may appear an extraordinary statement; but it is a fact, that the menstrual discharge sometimes continues in its usual regularity for two, three, or more months after conception, and without any dangerous consequences.

It has been asserted, as an objection, that this discharge is not truly menstruation; but the discussion of that question does not concern us here. We have only to consider, whether there does not frequently, during pregnancy, take place a discharge, so closely resembling menstruation in its periods, quantity, duration, and appearance, that neither the female herself nor her medical adviser shall be able to detect any difference between them; and of this I have no doubt.

It may occur _once_ only after conception, either in diminished quantity or more profuse than usual. It may thus give rise to miscalculation as to the expected time of confinement.

It may continue in its usual regularity for _two_ or _three months_. The following instance of a patient I attended illustrates the fact of its going on to the period of quickening:—

Mrs. R——, ætat. 27, married eight years. Was first unwell when eighteen years of age, and continued to be so regularly until she became pregnant, two years from the time of her marriage. She suckled her first child for eleven months; soon after she became unwell, and continued so until she quickened with her second child; a circumstance which she had not the slightest suspicion of, for there was no perceptible difference either in the quantity or appearance of the monthly discharge. During the remaining months of gestation she did not see anything; she afterwards suckled her little one for ten months; and then was obliged to wean the child, having an attack of the cholera. She continued from this time regular for two years; but meeting with a fall, much to her surprise, two or three days after, miscarried of a four months’ child. She is now pregnant again, having been regular every month till she quickened, and expects to be confined, Feb. 1836.

In this case then, the female was unwell in two pregnancies till the period of quickening; and in the other for four months, when miscarriage took place from accident.

And lastly, it may occur through the _whole_ period of pregnancy.

Mrs. F—— is now pregnant for the third time. In her first pregnancy the monthly returns appeared for three periods, regular as to time, and in quantity and appearance as heretofore. During the second child-bearing, at every month till confinement. During the third—her present pregnancy—for three months only. This patient is always unwell while nursing.

Mrs. J——, now in her eighth pregnancy. Was unwell every month throughout the first six pregnancies; but the quantity always slightly diminished. In the seventh, the same circumstances occurred; but premature labour was this time induced, between the sixth and seventh months, by a fall. During the present pregnancy she has not seen anything. Is always unwell while suckling.

Mrs. P—— is in her fourth pregnancy. In the first three was unwell, at her regular periods, to the time of confinement. The discharge the same in quantity, but rather lighter appearance. Has been unwell in her pregnancy every month up to the present time.[12]

The following case proves how important it is that this fact should be generally known; for up to a very late period, some medical men have even denied the possibility of this occurrence.

The case I refer to was that of a young lady, privately married, the gradual enlargement of whose abdomen was decided by her medical attendant to arise from dropsy; for, although she had most of the symptoms of pregnancy, and the medical man was aware she had been married eight months, still, as _she continued to menstruate_, he declared it impossible that she could be pregnant. Tapping was proposed; and, except that her general health suffered much at this time, the operation would have been performed. The delay saved the patient such unfortunate and mistaken treatment—it might have proved fatal in its results—and she shortly gave birth to a living and healthy male child.

_Fourth exception._—That women late in life have conceived after menstruation had apparently ceased for ever, the following cases prove:—

In September, 1834, I was called to the assistance of a female in labour in her forty-ninth year. She had not been pregnant for twelve years, and supposed she had ceased to menstruate two years previous to that time. She did well, and never afterward saw anything.

Mrs. B——, ætat. 39. Has been married eighteen years, commenced to be unwell very early in life. Has had three children; the last pregnancy seven years since. Is now again pregnant, her menses having left her sixteen weeks prior to conception; before which, she had been very irregular, and supposed she had ceased to be unwell for ever.

Other cases of a similar nature are on record. There can be no doubt they are authentic; but at the same time it must be acknowledged that a female is not unlikely to be deceived, by the irregularity which attends the returns of this discharge, late in life. It so happens, too, that just before the change of life takes place, there appears in the constitution of some females a great disposition to pregnancy; so that many who have ceased to bear children for years, or have been hitherto barren through the whole of their married existence, at this time, to the surprise of their friends and themselves, become pregnant.[13]

A knowledge of these facts must be useful, as they will tend to allay apprehension at what might be supposed disease, both by the mother and by the hitherto childless woman.

A female must not forget, however, that she may mistake her condition, and that such mistakes are not at all unlikely to arise from the circumstance that the symptoms which naturally accompany the _cessation_ of menstruation, much resemble those of pregnancy. She passes over the menstrual period;—she is struck with this. Other symptoms are soon manifested; the size increases—the breasts even become swollen and painful—the stomach disordered, and the appetite capricious;—flatulence collects in the intestines; and while on this account the size still increases, the air moving about the bowels gives an inward sensation which is mistaken by the female for the plunging of the child. Time alone, or the investigation of the medical attendant, detects the mistake; and the symptoms are then to be easily removed by the exhibition of carminative and purgative medicines, the use of active exercise, and bandaging the distended abdomen.

It must be remembered, also, that _suppression_ of the monthly return may arise from a variety of causes, altogether independent of conception. Every female is aware, that exposure to cold, just before the expected period, is a frequent cause. Different forms of disease, hardship, or mental emotions, may produce the same result. It does not follow, therefore, because a woman ceases to menstruate, she _must_ be pregnant; which naturally presents this inquiry: what dependence, then, is to be placed upon the omission of menstruation as a symptom or sign of pregnancy?

When a female ceases to be unwell, and experiences other symptoms of pregnancy, she must consider her situation as yet uncertain, because these signs are common to disease as well as pregnancy. But if toward the third month, while the suppression continues, she recovers her health, and if her appetite and colour return, she needs no better proof of pregnancy; for under other circumstances her health would remain impaired, and even become worse.[14]

_Morning Sickness._

Soon after conception, the stomach often becomes affected with what is called “morning sickness.” On first awaking, the female feels as well as usual, but on rising from her bed qualmishness begins, and perhaps while in the act of dressing, retching takes place.

This symptom may occur almost immediately after conception; but it most frequently commences for the first time between two or three weeks after. Now and then it is experienced only the last six weeks or two months of pregnancy, when it is attended, generally, with much distress and discomfort. And lastly, it is not unfrequently absent altogether.

It continues, more or less, during the first half of pregnancy, and subsides about the time when the movements of the child begin to be felt.

Irritability of the stomach, however, may arise from a variety of causes totally independent of pregnancy, and connected with disease or disordered function. Of what avail, then, it will be asked, is this symptom as a sign of pregnancy? It is so far available:—

The nausea and vomiting of pregnancy are not accompanied by any other symptom of ill health; but, on the contrary, the patient feels as well as ever in other respects, and perchance takes her meals with as much relish as formerly; but while doing so, or immediately after, she feels suddenly sick, and has hardly time to retire, when she rejects the whole contents of her stomach, and very shortly after is quite well again. Not so with sickness arising from disease, or disordered condition of the stomach.

_Shooting pains through—enlargement of—and other changes of the breast._

When two months of pregnancy have been completed, an uneasy sensation of throbbing and stretching fulness is experienced, accompanied with tingling about the middle of the breasts, centring in the nipple. A sensible alteration in their appearance soon follows: they grow larger and more firm. The nipple becomes more prominent, and the circle around its base altered in color and structure, constituting what is called “the areola.” And, as pregnancy advances, milk is secreted.

The period of gestation at which these changes may occur, as well as the degree in which they become manifested, varies very much. Sometimes, with the exception of the secretion of the milk, they are recognised very soon after conception;—in other instances, particularly in females of a weakly and delicate constitution, they are hardly perceptible until pregnancy is far advanced, or even drawing towards its termination.

_Enlargement of the Breast._—The changes in the _form_ and _size_ of the breast may be the result of causes unconnected with pregnancy. They may enlarge in consequence of marriage, from the individual becoming stout and fat, or from accidental suppression of the monthly return. There are, however, these differences: enlargement from pregnancy may in general be distinguished from that produced merely from fat, by the greater firmness of the breast, and its knotty uneven feeling—it is heavier; and the tension and enlargement from suppressed menstruation, by its subsiding in two or three days, whereas that caused by pregnancy continues to increase. Nevertheless, the dependence which may be placed upon the enlargement of the breast only, as an evidence of pregnancy, is not very great, and considered alone, but a doubtful sign.

_The Nipple._—Not so the changes which take place in the nipple, and around its base. These alterations, if present, are of the utmost value, as an evidence of pregnancy. The changes referred to are these:—

About the sixth or seventh week after conception has taken place, if the nipple be examined, it will be found becoming turgid and prominent, and a circle forming around its base, of a colour deeper in its shade than rose or flesh-colour, slightly tinged with a yellowish or brownish hue, and here and there upon its surface will be seen little prominent points, from about ten to twenty in number. In the progress of the next six or seven weeks, these changes are fully developed; the nipple becoming more prominent and turgid than ever: the circle around it of larger dimensions, of an extent of about an inch or an inch and a half; the skin being soft, bedewed with a slight degree of moisture, frequently staining the linen in contact with it; the little prominences of larger size, from the sixteenth to the twelfth of an inch perhaps; and the colour of the whole very much deepened, but always modified by the complexion of the individual, being darker in persons with dark hair, dark eyes, and sallow skins, than in those of fair hair, light-coloured eyes, and delicate complexions.

Such are the essential characteristics of the true areola, the result of pregnancy, and, I believe, of that condition only.

This, then, is a most valuable sign; but, unfortunately, it is frequently absent; and how often it is present, although I have examined many hundred cases for it, I cannot determine, as unfortunately no note was made upon this point. It should also be observed, that both in dark and fair women, the change of colour, without the other appearances, may be present, and yet pregnancy exist; and I have also seen frequently the dark circle alone, where pregnancy did not exist; but I never saw an instance where these prominences were truly developed, without the presence of pregnancy.

This fact has been more particularly noticed of late years by an eminent physician-accoucheur, and the attention of the author has, in consequence, been much directed to it; and, as a striking illustration of its truth, he may mention, that, called upon very recently to visit one of the Institution patients, the third day after her delivery, and having occasion to examine the breast, I pointed out to the gentleman in attendance the presence of these little prominences around the base of the nipple; upon which the patient, to my great surprise, immediately observed, “Ah, sir, I always know when I am pregnant by them, for they appear about ten days or a fortnight after its occurrence, and subsequent to delivery diminish gradually, as my milk leaves me.”

It has occurred to me during the past year to be consulted in five cases of doubtful pregnancy. In _two_ of them, circumstances forbade the probability of its occurrence; but in both the true areola was distinctly and fully developed. It decided my opinion; and the result proved its correctness: both became mothers. _Two others_ had made themselves patients of the Lying-in-Institution, having obtained letters for attendance from governors of the charity, and upon which was marked, by their own calculation, the month of their expected confinement. But I was led to believe, from observing two or three symptoms, that pregnancy did not exist.

Their cases were examined, and at last the breast; in both the true areola was wanting: the review of symptoms decided all doubts. Had, however, the true areola been present in either, it would at once have reversed, instead of confirming my first suspicions.

The _fifth_ was pregnant, but the true areola was wanting; and I was obliged to refer to those signs which can alone be recognised by a medical man.

The absence, then, of this sign, except in combination with other circumstances, proves nothing, but, if present, I believe it conclusive.

_The Presence of Milk._—With regard to the presence of milk in the breasts, as this is a symptom which may arise, and does very generally, in the latter months of gestation alone, when the existence of pregnancy has been long determined, it is only mentioned here to refute the popular error, that “the presence of milk in the breasts is an infallible proof of pregnancy.” It is no such thing; and many well-recorded instances could be brought forward to prove the possibility of its formation under circumstances totally independent of pregnancy.

Belloc speaks of a servant girl, who being obliged to have sleeping with her an infant who was being weaned, and which by its crying disturbed her rest, bethought her of giving it her breast to appease its clamour; and the result was, that in a short time she had milk enough to satisfy the child.[15]

The following case is related by Mr. George Semple: Mrs. B——, wife of John Breward, Simpson Green, near Idle, aged forty-nine, the mother of nine children, the youngest of whom is twelve years old, lost a daughter-in-law about a year ago, who died in about a fortnight after giving birth to her first child. On her death, Mrs. B. took charge of the infant, a little puny sickly baby. The child was so fretful and uneasy, that Mrs. B. after many sleepless nights, was induced to permit the child to take her nipple into its mouth. In the course of from thirty to thirty-six hours she felt very unwell; her breasts became extremely painful, considerably increased in size, and soon after, to her utter astonishment, milk was secreted, and poured forth in the same abundance as on former occasions, after the birth of her own children. The child, now a year old, is a fine, thriving, healthy girl, and only a few days ago I saw her eagerly engaged in obtaining an apparently abundant supply of healthy nourishment, from the same fountain which, nearly twenty years ago, poured forth its resources for the support of her father.”[16]

_Quickening._

There is only one other symptom which I think it useful to notice, that is quickening; by which is meant, the first sensation experienced by the mother of the _life_ of the child within her womb.

The first time this motion of the child occurs, the sensation is like that of the fluttering of a bird within her, and so sudden that she frequently faints, or falls into an hysterical paroxysm. A day or two passes by when it recurs. It afterwards increases both in frequency and degree, until the movements of the child are fully recognised.

It is proper that a female should be informed that the _period_ when quickening takes place is very uncertain; for an impression is popularly prevalent that it always occurs _exactly_ at the end of four calendar months and a half. This is not the case; it varies in different women, and in the same women during different pregnancies, as the following one or two instances will prove:—

Mrs. F——. Quickened with her first child at four months: quickened with the second at fourteen weeks: and is now in her third pregnancy, and reckons from the fourteenth week again.

Mrs. B——. Has had seven children, and with all felt the motion of the child for the first time at the third month.

Mrs. Mc M——. Has been several times pregnant; seldom feels movements of the child at all until the sixth month, and not strongly till the eighth.

The annexed table of the periods of quickening of seventy cases taken in the order in which they have been entered in the author’s note-book, will forcibly stamp the truth of these opinions:

9 Quickened at the 3d month.
11 Quickened at 3½ months.
21 Quickened at the 4th month.
16 Quickened at 4½ months
8 Quickened at the 5th month.
1 Quickened at 5½ months.
4 Quickened at the 6th month.
——
70
——

In a few of these cases, for the sake of convenience I have used round numbers, when two or three days before or after was the exact time; and for the sake of correctness, have omitted several cases, in which there was the slightest doubt in the patient’s mind of the exact time.

It appears from this table, that this symptom takes place more frequently between the twelfth and sixteenth week, than before or after these periods; and that subsequent to the 4½ and the expiration of the sixth month, it may occur in the proportion of more than one case out of every five.—Before the third month, quickening seldom arises.

This symptom may not be felt by the mother at all, and yet pregnancy exist. This is rare, but the fact is confirmed by many writers; and I have met during the last seven years with two instances, and in both the mothers gave birth to living and healthy children.

Now comes the question, how far this symptom is of value, as a sign of the pregnant state?

If it has been experienced in former pregnancies, it is invaluable, for I believe it is not to be mistaken. If it is a first pregnancy and doubtful, it removes all obscurity, provided the sensation grows stronger and stronger, until the movements of the child are distinctly felt.

Four only of the symptoms of pregnancy have been noticed, because the remainder are not recognisable, except by the accoucheur, although to him of the greatest value when pregnancy is complicated and doubtful from the presence of disease.

The nature of these symptoms has been described as plainly, and yet as briefly, as possible, because of the importance of their being clearly understood by married women.

I have also endeavored to point out their real value as evidence of pregnancy—how they are sometimes absent in patients who are pregnant, and some of them present in those who are not so—because of the doubt and obscurity which arise from these variations.

And lastly, in bringing these observations to a conclusion, I venture to say, that if the married female will only take the trouble to make herself familiar with this little detail, she will not regret the time as lost or misspent, because it will generally guide her aright, and I trust save her many moments of anxiety and discomfort.

ON THE
DISEASES OF PREGNANCY,
AND HINTS FOR THEIR
PREVENTION AND RELIEF.

In describing the diseases which are incident to the whole period of pregnancy, my design is to take a general popular survey of the subject. I wish simply to communicate that kind of information, which every married and well-educated woman should certainly possess, and can usefully employ. To advance further than this, to those points upon which the assistance of the medical adviser ought to be sought, would be on every account improper, and productive rather of evil than of good.

There is no organ in the body, with the exception of the stomach, that exercises a more extensive control over the female system than the womb. Hence, when in the condition of pregnancy, it affects, directly or indirectly, various parts of that system. The effects of pregnancy, however, vary much according to the constitution of the female.

Sometimes a very salutary change is produced, so that the individual enjoys better health during gestation than before. The delicate and frequent-ailing girl, for instance,—the propriety of whose marrying was a matter of doubt among her friends—becoming pregnant, instead of realizing the apprehensions and fears of those most dear to her, will sometimes acquire new life and vigor from the altered circumstances of her condition. On the other hand, speaking generally, it is sometimes the case that harassing and painful symptoms will arise. These are designated the “diseases of pregnancy.”

_Morning Sickness._

Nausea or vomiting, is one of the most common and distressing affections of pregnancy. It is chiefly troublesome in the earlier months of gestation, continuing until the period of quickening, when it decreases or ceases spontaneously;—or it does not occur until the latter months of pregnancy, when it subsides only upon delivery. I shall consider these states separately; and—

_First_, of sickness during the _earlier_ months. This arises solely from sympathy with the newly commenced action, and irritable condition of the womb. This is evident from the fact, that, as the novelty of the pregnant state ceases, and the stomach becomes accustomed to it, the sickness subsides gradually, and is rarely troublesome afterwards.

It occasionally commences immediately after conception; and it is a remarkable fact, that a pregnant woman scarcely ever feels sick, until she first gets upon her feet in the morning. Hence it is called the “morning sickness.” She awakes refreshed and well, arises from her bed, and while dressing begins to feel qualmish. At the breakfast table she has no appetite, or if she takes anything, is shortly obliged to leave for her dressing-room, where she returns what she has taken; or, if she has been unable to take anything, ejects a fluid, limpid, thin and watery; and if the vomiting increases in severity, bile is thrown up at the same time. After the lapse of three or four hours, she feels quite well again, and by dinner time sits down with an appetite to her meal.

If there is merely nausea or vomiting _without the presence of bile_, it is evident that it arises solely from irritability of the stomach, and is not connected with a disordered condition of the digestive organs, which latter circumstance is not unfrequently the case. The best means that can be employed to relieve this irritable state will be found in a draught taken twice a day for several days, composed of fifteen grains of magnesia, one drachm of tincture of columba, and an ounce and a half of distilled peppermint water.[17]

Medicine sometimes is hardly called for; and I have known a tumbler of warm chamomile tea, or even warm water only, taken immediately after nausea was felt, by inducing immediate vomiting, tranquillize the disturbed stomach, and thus abridge the morning attack. It is sometimes attended with advantage to take the chamomile tea before the female rises from her bed. I advised this with the most marked success very lately in the case of a lady who was very much reduced by the morning sickness. It had continued for several weeks, and with so much violence and straining, as to cause blood to be ejected with the fluid. In less than one week, when all other means had previously failed, the above suggestion was successful.

It frequently happens that the acidity is very great, in which case fifteen or twenty grains of magnesia should be taken in a wine-glass of milk[18]—or, if it is preferred, a small tumbler of soda water; but the latter must not be persevered in for any great length of time, as it will then become injurious. The presence of acidity, however, is sometimes so difficult to overcome by alkalies, that these medicines must be given up, and acid remedies employed. Lemonade may first be taken, but lemon juice and water is still better.

The state of the bowels must not be forgotten, and if any of the latter remedies are resorted to, the most marked benefit will be derived from a gentle dose of Epsom or Cheltenham salts every second morning, if so often necessary.[19]

The diet in such a case must also be carefully attended to; but as this point will be referred to more particularly presently, it is only necessary now to say that the quantity of food taken must bear some proportion to the slightly diminished powers of the digestive functions, and that it will be well, when the sickness is very obstinate and distressing, to take no food at all for several hours after rising. If, after a few hours, the mouth is much parched, it may be moistened with a little broth, or weak beef-tea; but let nothing more be taken for five or six hours, and it is most probable that the sickness which has resisted all other means, will thus be relieved.

If this irritable state of the stomach is connected with a _disordered condition_ of the _digestive organs_, the sickness will be accompanied with the presence of bile in the matter vomited, a furred tongue, confined or irregular action of the bowels, and occasionally with what is termed “a sick headache.” These symptoms are to be relieved by medicines which thoroughly clear out the bowels, allay the irritability of the stomach, and afterwards by those which restore tone to both. But it is to be observed that the following directions are only intended to apply to those simple cases, in which, whether necessary or not, no one ever thinks of consulting their medical adviser, and for which it is certainly desirable that they should have some judicious directions, rather than be left entirely without them. If these symptoms become at all aggravated, it is requisite that they should make immediate application for professional advice.

The bowels will need in the first instance a draught composed of infusion of senna and Epsom salts—the common “black draught,”—with half a drachm of the tincture of henbane in addition. This, with five grains of blue pill, most probably effects the object desired; the bowels will be well purged, and the tongue become clean.

The next thing is to allay the irritability of the stomach, which is to be accomplished by the means already pointed out—the effervescing draught of soda, magnesia, chamomile tea, &c.; but in connexion with this, two or three grains of the purified extract of aloes, with an equal quantity of the extract of henbane, must be taken two or three times a week, at bedtime. This will keep the tongue still clean, and the bowels in order.

After a little time, the sickness having subsided, tonic medicines may be used: and a fourth part of the following mixture, taken three times a day, will, under the present circumstances, be the best means of restoring the tone of the stomach and bowels: sulphate of quinine, six grains; diluted sulphuric acid, half a drachm; infusion of columba, five ounces and a half; simple syrup, half an ounce.

Having pointed out the means for mitigating sickness in the early months, there only remains one additional suggestion to make, and it is, that all the remedies for relief detailed may, in some cases, fail. The sickness continues most obstinate; every time the female takes food, or even sometimes when abstaining from it, she vomits; and at last, from this excessive irritability and long-continued violent action of the stomach, symptoms threatening miscarriage will manifest themselves.[20] There is generally in such a case, pain and a sensation of tension about the pit of the stomach, increased after every attack of sickness. If symptoms of miscarriage are not present, the application of nine or twelve leeches to the stomach, and pieces of soft linen rag well soaked with laudanum, constantly applied and renewed, will give the most decided relief. If, however, there is pain in the loins and hips, increasing in frequency and power, becoming at last slightly bearing down, I strongly advise the patient to consult her medical adviser, as the loss of a little blood from the arm, perfect rest in the recumbent position, and other directions which he alone can give, will, in such a case, be absolutely necessary, and I may add, if perseveringly acted up to by the patient herself, be certainly followed by success.

_Secondly_, of sickness coming on at the _conclusion_ of pregnancy.

This arises from the distended state of the womb affecting mechanically, by its pressure, the coats of the stomach, and certain parts of its neighborhood.

This form of vomiting but rarely occurs; for do not let me be supposed to refer to the sickness which sometimes immediately precedes, and generally accompanies, the early part of labour. I am speaking of that irritability of the stomach which may arise about the sixth, seventh, or eighth month, and from which the female has been entirely free during the previous months of gestation, and now producing vomiting of an exceedingly troublesome form.

A lady suffering from sickness thus late in pregnancy, ought to seek medical advice at once. From this cause, if severe, premature labour might be brought on, and judicious medical treatment is always decidedly necessary to mitigate this form of sickness. The patient must lose a little blood, she must keep strictly to her sofa, and the bowels ought to be gently acted upon by small doses of Cheltenham or Epsom salts. A grain of the extract of opium may be given to allay the irritability at night, and cloths dipped in laudanum frequently applied to the pit of the stomach.

In all forms of sickness arising from pregnancy as its cause, the diet must be light, mild, and nutritious, taken in moderate quantities of three or four meals a day. It should consist of mild animal food, boiled or roasted. Chicken, white game boiled, mutton or beef roasted, are the viands most nutritious and easily digested. Stale pure bread untoasted, or pilot bread, mealy potatoes, or well-boiled rice, in moderate quantities, may be taken with animal food for dinner. A glass of port wine with warm water at the conclusion of the meal, is the best kind of beverage.

Advantage has often been derived from always taking brown bread, and Jamaica sugar in the morning’s coffee. The healthy operation of the bowels has thus been promoted; although a system of regular exercise by walking, apportioned to the strength, and not continued so long as to fatigue, will generally effect this purpose, while at the same time it gives tone to the general health. Fatigue of body is sedulously to be avoided. Slow and moderate walks, exercise in an open carriage (if the patient has sufficient strength), should be taken daily between breakfast and dinner; always avoiding to sit down to the latter meal tired, and, therefore, probably, with a blunted appetite.[21]

_Heartburn._

This is a very distressing symptom, and occurs early after conception; sometimes, however, not till after the fourth month; and occasionally is absent altogether. It is produced by an acid forming on the stomach, which rises into the throat, and, from the sensation it occasions, is called _heartburn_.

It is a very common complaint of pregnancy, and every female knows that she finds relief by taking a little magnesia or chalk, or lime-water and milk, with the occasional use of magnesia; but, although these means generally mitigate this symptom, occasionally it is very severe and almost intractable, and they fail. Under such circumstances, a draught composed of 15 grains of magnesia, 10 drops of the solution of the subcarbonate of ammonia, and 1½ ounce of mint or peppermint water, taken three times a day, and continued for three or four days, will remove the complaint.

If the bowels are confined, as is frequently the case, mild doses of Epsom or Cheltenham salts will be the best aperients. The use of these must be regulated by circumstances,—taken every second, third, or fourth day; that is, resorted to with sufficient frequency and perseverance to guard against costiveness.[22]

The _diet_ must also, in every case, be strictly attended to, and regulated upon the plan already stated.

_Costiveness._

A costive state of bowels is one of the most common and, at the same time, troublesome of the diseases of pregnancy. It arises partly from the increased activity which is going on in the womb, and which induces a sluggish condition of the bowels, and partly from the pressure of the now enlarged and expanded womb on the bowels themselves.

A confined state of bowels is the frequent source of many serious evils; it therefore behoves the female to be vigilant and guard against it.

_First_,—Because, as before stated, pregnancy itself predisposes to constipation.

_Secondly_,—Because it is much more easily prevented than removed, when, after several days’ confinement, an accumulation of hardened fæces has collected in the lower bowel.

_Thirdly_,—Because such an accumulation may give rise to inflammation of the bowel itself, and, in the earlier months of pregnancy, to miscarriage; and,

_Lastly_,—Because, if a female falls into labor with her intestinal canal so loaded, it will of itself be sufficient to render, what would otherwise have been a quick, easy, and safe labor, a long, painful, and difficult one; and may be the cause also of very serious and alarming symptoms some forty or eight-and-forty hours after her labor is over.

The first and leading symptom of this affection is a costive or more consistent state than usual of the fæcal excretions, with a less frequent call for evacuation than is customary with the individual when in health. If this is not attended to, and several days, perhaps a week, pass by without the bowels being relieved at all, pain in the head, a foul tongue, and an increased degree of fulness and tension of the abdomen, are experienced. These symptoms are followed, in all probability, by thin watery evacuations, attended with pain, weight, and pressure about the lower bowel; they become frequent; and the female at last, finding that the bowels are not only open again, but even loose, takes chalk mixture. She is not aware that this very looseness is nothing more than increased secretion of the lining membrane of the bowel, caused by the pressure of the accumulated mass of hardened fæces, which it passes and leaves unmoved. The chalk mixture relieves the irritation upon which the looseness depends, but the disease is not removed, and, instead of its being a case simply of costiveness, it has now become one of constipation; an accumulation of hardened stool is distending and irritating, by its pressure, the lower bowel and the womb, and the serious consequences before enumerated may follow.

Very often have I been consulted by a female far advanced in pregnancy for what she supposed mere looseness of bowels, which has already been found to originate under circumstances like these. It is of the highest importance that the patient should endeavor to guard against such a result; and without doubt she may avoid it, and regulate her bowels with great comfort to herself, throughout the whole period of pregnancy, if she will only use the means.

In pointing out a plan to accomplish this desirable object, the first prescription I have to offer is by far the most valuable,—“prevention is more easy than cure.”[23] If the bowels are sluggish to-day,—that is to say, if they are not as freely relieved as usual,—and you do not assist them by medicine, depend upon it, to-morrow they will be confined, and there will be no relief at all. If, then, the bowels, are _disposed_ to be costive, I would recommend one large tablespoonful of castor oil—if it does not nauseate the stomach,—and advise that the dose be repeated in four hours, if the desired effect has not been produced, or a wine-glass of beaume de vie at night; and early the next morning, before leaving the dressing-room, let the lavement be used, the injection consisting merely of a pint of blood-warm water;—or the following pills will be found useful to be kept in the patient’s bedroom:—Two scruples of the compound extract of colocynth and one of the extract of henbane divided into twelve pills. Two or three of these may be taken at bedtime, when the bowels have not been, during the day, satisfactorily relieved. These are always ready in the bedroom, and, as they generally answer the object efficiently, and with comfort to the patient, are the most convenient form of aperient.

It will now and then happen, however, that the female has let the day slip. When this is the case, in combination with medicine, the use of the lavement is desirable. Medicine alone will not answer the purpose, unless it be taken in doses so strong as will not only move the bowels but irritate them too. With the exhibition of the warm water, mild aperients never fail. Females, generally, are averse to the use of the lavement, and it is a prejudice which is most deeply to be regretted. I have known purgative medicines so often resorted to, and, in time, so increased in power and quantity, because they began to lose their effect, that, by their continual irritation, disease of the lower bowel has been produced, and death has, at last, been the consequence. If, then, the bowels have been one or two days confined, the lavement in the morning will render much less medicine necessary, and frequently have an effect when medicine alone would not. Many ladies use the warm water every second or third morning, during the latter weeks of pregnancy; and by this means they regulate their bowels—which would otherwise be confined—with great comfort to themselves, and need no medicine at all.

I will only add one word, in conclusion, upon this subject. Let it be remembered, that if the bowels have been confined several days, and diarrhœa comes on, that this is not a natural relief, but the effect of irritation, caused by the presence of a loaded state of the lower bowel, which must be quickly removed by the medical attendant, or it may give rise to some one of those serious evils already enumerated.

_Diarrhœa._

An affection very opposite to that which has just been discussed, may occur during pregnancy. We have seen how diarrhœa may arise as a symptom of costiveness. It will manifest itself, however, independently of such a cause. The intestines may participate in the irregularity of the womb, and, their vermicular action becoming morbidly increased, diarrhœa is the consequence. It is a disease which varies very much in different individuals, and may clearly be divided into two kinds.

One, in which the motions are more loose and frequent than in health, but not otherwise much altered in their appearance. The tongue is clean, or only slightly white, and the appetite is pretty good. No medicine is required here; a careful diet will correct the evil.

_In the other case_, the stools are liquid, dark-coloured, and very offensive, accompanied with a coated tongue, bad taste, offensive breath, loss of appetite, and more or less disorder of the digestive organs. In these latter circumstances, your medical adviser should be consulted; in case you do not see him, I have found at first the following draught, given every three or four hours, very useful—rhubarb, eight grains; ipecacuanha, one grain; dill water, one ounce.

As the tongue cleans, the stool becomes more natural, a wine-glass, three times a day, of some bitter infusion, such as cascarilla, orange peel, or gentian, may be taken with advantage. If the diarrhœa continues for any length of time, it is always wise to have the surface of the body kept warm with flannel; and this is best accomplished by a flannel roller bound gently round the abdomen.

But in either form of this disease, whatever remedies are proposed, there is one mode of treatment applicable to both, and which is the most important of all; a proper system of _diet_. The food must be sparing in quantity, of the mildest quality, and such as to leave, after the process of digestion, as little excrementitious matter as possible.

In a recent attack, the _first_ day, the patient should only take mild drinks, containing a small quantity of unirritating nutriment; such as barley water, or arrowroot made with water. Irish moss will be found palatable. During the _next_ day or _two_ the same diet must be continued, but may be given in larger quantity, and of greater strength. Tapioca, sago, and rice-gruel might be added to the list. When the irritation is somewhat allayed, on the _third_ or _fourth_ day, perhaps, broth may be taken; but no solid food of any kind, least of all solid animal food, until the disease is removed or greatly allayed. As soon as this is the case, a small quantity of the lightest animal food may be taken; such as the animal jellies, made from calves’ head or feet, chicken with well-boiled rice, white game boiled, roast mutton and beef may follow; but lamb and veal for the future should be avoided.

It may be observed, that in some cases, where the diarrhœa has been of long standing, a _drier_ diet is best, the liquid food appearing to keep up the disease. Rice well boiled, and merely moistened with a little broth, is the best and one of the most desirable articles of diet in such cases.

_Piles._

Pregnant women are very subject to piles. Both with costiveness and diarrhœa they are a frequent attendant, but particularly with the former. They will usually disappear, if they are slight, as soon as the bowels are restored to a healthy action; but they may not, and then will give rise to great suffering.

The pregnant woman recognises piles under two forms: 1, where they exist as little tumours within or without the bowel, becoming, very soon after their exclusion, more solid and firm, unless they early break and bleed; and 2, where they present, without the bowel, a tumour, large in circumference, separable in lobes, altogether like a piece of sponge coloured, and bleeding occasionally from the surface.

Of all the _causes_ which operate in the production of piles, habitual constipation is the most frequent. The excrementitious matter is delayed in the bowel, becomes hard and knotty, and a source of great irritation: this irritation induces a determination of blood to the part, and the gradual dilatation of its vessels takes place as a consequence, which eventually forms the tumours known under the appellation of _piles_. Now, as in pregnancy there is a greater disposition to costiveness than at any other time, and as piles are a consequence of this disordered function, so this disease is much more prevalent during the pregnant state than at any other period; another argument, and a very powerful one, why costiveness should be diligently guarded against.

The _symptoms_ of this complaint are well known. There will be weight, heat, and a sense of fulness about the lower bowel, a frequent desire both to relieve the bowels and bladder; all of which symptoms are removed for a time if a discharge of blood takes place.

If the piles be without the bowel, they are constantly irritated by the friction of the parts in the ordinary motion and erect position of the body, and that to a painful degree during the period of the evacuation of the bowels. If exercise be taken in a carriage, the pain is much aggravated; and if the irritation produce inflammation, the piles will become swollen, red or purple, and excessively painful.

The _treatment_ of this disease, when it occurs during pregnancy, is two-fold—general and local. We must remove the _cause_ by such means as excite a brisker action of the bowels; and our choice of aperients must be directed to those which act efficiently but mildly, and without irritating the lower bowel itself.[24] Next to small and repeated doses of castor oil—say a tablespoonful,—the most desirable form of aperient that can be employed is the confection of senna, that is, lenitive electuary, combined with sulphur and magnesia. Of the following form, a dessert-spoonful or more should be taken, at first, twice daily:—Confection of senna, two ounces; flowers of sulphur, one ounce; carbonate of magnesia, two drachms and a half. In conjunction with this medicine, much benefit may be derived by the injection of half a pint of warm or cold water—whichever soothes most—as a lavement; but it must be administered very cautiously, to avoid irritating the parts with the pipe of the instrument.

It is important that medicine, in frequent use, should be so taken as to act upon the bowels in the evening only; for if the bowels are acted upon in the morning, the patient being obliged to move about all day, will suffer considerable distress and local irritation; whereas, if the bowels are not evacuated till the evening, the horizontal position, and the perfect rest of a long night, will obviate all inconvenience.

Great assistance may be afforded in the cure, and also in alleviating pain, by external applications to the tumours themselves. If, however, the piles are swollen and inflamed, and the pain experienced great, half a dozen leeches, or from half a dozen to a dozen, should be first applied in their immediate neighbourhood, the parts fomented, and then warm bread and water poultices renewed every three hours.

These remedies will afford very considerable relief; and, when the inflamed state is subdued, an ointment must be applied to the tumours and around them night and morning, composed of two drachms of powdered galls, half a drachm of camphor, and two ounces of lard; or composed of one drachm of powdered black hellebore root, rubbed down in one ounce of lard. The latter preparation will, for some time after its application, give much pain, but proportionate relief will follow.