I. SIGNS OF PREGNANCY
Difficulty and importance of the subject.--Diagnosis in the early months.--Auscultation.--Changes in the vascular and nervous systems.--Morning sickness.--Changes in the appearance of the skin.--Cessation of the menses.--Areola.--Sensation of the child's movements.--"Quickening."--Ausculation.--Uterine souffle.--Sound of the foetal heart.--Funic souffle.--Sound produced by the movements of the foetus.--Ballottement.--State of the uterine.--Violet appearance of the mucous membrane of the vagina.--Cases of doubtful pregnancy.--Diagnosis of twin pregnancy.
There is, perhaps, no subject connected with midwifery, which is of such importance, or which, from its difficulty and the serious questions it involves, demands such attentive consideration, and requires so familiar an acquaintance with every part of it, as the diagnosis of pregnancy. The responsibility which a medical man incurs in deciding cases of doubtful pregnancy, and in thus giving an opinion which may not only affect the fortune, happiness, character, but even life itself of the individual concerned, is rendered more painful by the perplexing obscurity of the circumstances under which these cases sometimes occur, being not unfrequently complicated with diseases which add still farther to the difficulty of coming at the truth, and occasionally rendered peculiarly obscure by wilful and determined falsehood and duplicity.
To render this subject more intelligible to our readers, we propose first to consider the general effects which pregnancy produces upon the system, and then to describe those changes and phenomena which are peculiar to this state, and which may therefore be taken as so many means of diagnosis.
Under all circumstances, the diagnosis of pregnancy must ever be difficult and obscure during the early months; the development of the uterus is still inconsiderable, and the effects which it may have produced upon the system, although appreciable and even distinct, are nevertheless too capable of being also produced by other causes, to warrant our drawing any decided conclusion from them.
The effects over the whole animal economy, which result from the presence and advance of this great process, are very remarkable, and show themselves in every portion of it.
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.)
There are other circumstances also connected with the catamenia, which warn us against placing too much confidence in its disappearance as a sign of pregnancy: a woman may become pregnant who has never menstruated, a fact which has been noticed by several authors, and which has been explained as well as confirmed by Levret in his Art des Accouchemens, § 230:--"A woman," says he, "may conceive, although she has not yet menstruated, provided menstruation would otherwise have made its appearance shortly."[35]
Another circumstance, of much more frequent occurrence, is the fact that a woman may become pregnant without having had a return of the menses since her last confinement; hence we occasionally meet with cases where, from a rapid succession of pregnancies, the menstruation has not appeared for several years. From what has now been said, it will be seen, beyond all doubt, that the non-appearance of the menses cannot be looked upon by itself as a diagnostic of pregnancy, or vice versâ: this is more particularly the case when any morbid condition of the system is also present; under such circumstances, little or no confidence can be placed upon it as a guide in forming our diagnosis. In cases where it is an object to conceal pregnancy, the appearance of the menstrual fluid upon the clothes has been imitated in order to deceive. (Montgomery, op. cit. p. 50.) Although, therefore, the cessation of the menses, when taken in connexion with other symptoms, will prove useful in assisting us to a correct opinion, nevertheless, when taken by itself, it will scarcely ever enable us to decide with certainty.
Areola. Among the earliest of those symptoms which must be considered as diagnostic are the changes observed in the appearance of the breasts; "they increase, become full; they are occasionally painful and grow hard: the veins in them are rendered conspicuous from their blue colour; the nipple becomes more bulky and appears inflated, its colour becomes darker, the surrounding disc undergoes a similar change, increases in extent, and is covered with little prominences like so many diminutive nipples."[36] "The several circumstances (says Dr. Montgomery, p. 59,) here enumerated at least ought in all cases to form distinct subjects of consideration, when we propose to avail ourselves of this part as an indication of the existence or absence of pregnancy. One other, also, equally constant and deserving of particular notice, is a soft and moist state of the integument, which appears raised and in a state of turgescence, giving one the idea that if touched by the point of the finger it would be found emphysematous. This state appears, however, to be caused by infiltration of the subjacent cellular tissue, which together with its altered colour, gives us the idea of a part in which a greater degree of vital action is going forward than is in operation round it, and we not unfrequently find that the little glandular follicles, or tubercles, as they are called by Morgagni, are bedewed with a secretion sufficient to damp and colour the woman's inner dress.
These changes do not take place immediately after conception, but occur in different persons after uncertain intervals. We must therefore consider, in the first place, the period of pregnancy at which we may expect to gain any useful information from the condition of the areola. I cannot say positively what may be the earliest period at which this change can be observed, but I have recognised it fully at the end of the second month, at which time the alteration in colour is by no means the circumstance most observable; but the puffy turgescence, though as yet slight, not alone of the nipple, but of the whole surrounding disc, and the development of the little glandular follicles, are the objects to which we should principally direct our attention, the colour at this period being in general little more than a deeper shade of rose or flesh colour, slightly tinged occasionally with a yellowish or light brownish hue. During the progress of the next two months the changes in the areola are in general perfected, or nearly so, and then it presents the following characters: a circle around the nipple, whose colour varies in intensity according to the particular complexion of the individual, being usually much darker in persons with black hair, dark eyes, and sallow skin, than in those of fair hair, light-coloured eyes, and delicate complexion.[37] The extent of this circle varies in diameter from an inch to an inch and a half, and increases in most persons as pregnancy advances, as does also the depth of the colour."[38]
"In the centre of the coloured circle the nipple is observed partaking of the altered colour of the part, and appearing turgid and prominent, while the surface of the areola, especially that part of it which lies more immediately around the base of the nipple, is studded over, and rendered unequal by the prominence of the glandular follicles, which, varying in number from twelve to twenty, project from the sixteenth to the eighth of an inch; and lastly the integument covering the part appears turgescent, softer, and more moist than that which surrounds it; while on both there are to be observed at this period, especially in women of dark hair and eyes, numerous round spots, or small mottled patches of a whitish colour, scattered over the outer part of the areola, and for about an inch or more all round, presenting an appearance as if the colour had been discharged by a shower of drops falling on the part. I have not seen this appearance earlier than the fifth month, but towards the end of pregnancy it is very remarkable, and constitutes a strikingly distinctive character exclusively resulting from pregnancy. The breasts themselves are at the same time generally full and firm, at least more so than was natural to the person previously, and venous trunks of considerable size are perceived ramifying over their surface, and sending branches towards the disc of the areola, which several of them traverse along with these vessels. The breasts not unfrequently exhibit about the sixth month, and afterwards, a number of shining, whitish, almost silvery lines like cracks; these are most perceptible in women, who, having had before conception very little mammary development, have the breasts much and quickly enlarged after becoming pregnant."
In enumerating these various changes which are observed in the breasts, we fully agree with Dr. Montgomery in saying, that the alteration in the colour of the areola is by no means that upon which we can depend with most certainty: in the first place, we frequently meet with so little discolouration during the earlier months as to be altogether inappreciable; we have also already shown that if the patient be a brunette, and has already had children, the colour of the areola cannot be trusted to, as it never entirely disappears after her first pregnancy. On the other hand, we occasionally meet with a considerable change of colour in the unimpregnated state, arising from uterine irritation, as in dysmenorrhoea, &c. Where, however, this is accompanied by the other changes above enumerated, there can be, we apprehend, no doubt as to the existence of the pregnancy. Dr. Smellie, and also Dr. W. Hunter both considered the areola as proof positive of pregnancy. The latter one decided upon a case of pregnancy under very extraordinary circumstances; the body of a young female was brought into the dissecting room, which at the first glance he pronounced to be pregnant, but the accuracy of his diagnosis was not a little doubted when it was ascertained that a perfect hymen was present: to decide the point he had the abdomen opened when the uterus was found to contain a small foetus.
Movements of the foetus. The sensation to the mother of the child moving in the uterus, cannot be looked upon as a certain sign of pregnancy, for even women who have had large families of children are frequently deceived in this respect by the movement of flatus in the intestines, by occasional spasmodic twitchings of the abdominal muscles, &c.; but when the motion of the child can be distinctly felt by the hand of an experienced practitioner, it will no longer admit of any doubt: this, however, is a symptom which can seldom be made use of before the middle of the sixth or seventh month.
Quickening. This leads us to the subject of quickening as a symptom of pregnancy. The very vagueness of the term quickening is of itself a sufficient objection to its use as a source of information on these points. Strictly speaking, it refers to that moment of pregnancy when the woman is supposed to have become quick with child, or in other words, when the foetus becomes endued with life, "an error," as Dr. Montgomery observes, "which the continued use of the term was obviously calculated to foster and to prolong" (p. 75.) As far as we can understand, the word "quickening" at the present day refers to two different events during pregnancy: the one is when the motion of the child first becomes perceptible to the mother; the other consists of those effects which are frequently observed when the uterus quits the pelvis, and rises into the abdominal cavity, viz. fainting, sickness, &c.; in either case it will be evident that no correct conclusion can be formed by this means. It may safely be asserted that until the last twenty years we possessed only three diagnostic marks of pregnancy, viz. the appearance of the areola, a series of changes but little understood; the being able to feel the movements of the child through the abdominal parietes, and the head of it per vaginam. Hence Dr. W. Hunter in describing the uncertainty of the signs of pregnancy says, "I find I cannot determine at four months, I am afraid of myself at five months, but when six or seven months are over, I urge an examination."
In the primipara, the changes which pregnancy produces upon the os and cervix uteri are generally sufficient to lead to an accurate conclusion. The round dimple-like depression which the os uteri forms, the soft cushiony state of the cervix, are changes which we consider as peculiarly the effects of pregnancy, but their distinctness and certainty ceases when the patient has had several children; the irregular shape of the os uteri, its thickened edges, hard here and there, and the os tincæ, itself more or less open, the cervix scarcely, if at all, shortened, even at a late period of gestation, tend not a little to perplex the diagnosis furnished by this mode of examination; and where disease is complicated with pregnancy, the difficulty is greatly increased, and not unfrequently so much, that scarcely a single satisfactory point will be obtained.
Auscultation. Of late years, an immense advance has been made in the diagnosis of pregnancy, by means of the stethoscope. M. Major of Geneva,[39] in 1819, observed the interesting fact that he could hear the pulsations of the foetal heart through the parietes of the mother's uterus and abdomen: he appears, however, to have carried his researches no farther; and little attention was excited to the circumstance until three years afterwards, when a masterly essay on the subject was read before the Académie Royale de Médecine of Paris, by Lejumeau de Kergaradec.[40] In this interesting memoir, the author has described two sounds, which are perfectly distinct from each other in point of character. One of them consists of single pulsations, synchronous with those of the mother's heart, accompanied with the deep whizzing rushing sound, which may be heard over a large portion of the uterus at once; the other of sharp, distinct, double pulsations, producing a ticking sound, and following a rythm, which is not synchronous with that of the maternal circulation. Kergaradec supposed that the former sound was produced by the circulation of the blood in the spongy structure of the placenta, and hence called it the souffle placentaire; later observations[41] have, however, shown that it is not connected with the placenta, but depends upon the increased vascularity and peculiar arrangement of the uterine vessels during the gravid state. The other sound is produced by the pulsations of the foetal heart.
Uterine souffle. The uterine sound, or souffle, may invariably be heard in one or other of the inguinal regions, and usually over a considerable portion of the uterus, extending anteriorly or along the sides of the organ; and according to the observations of Professor Naegelé jun.,[42] there is no part of the uterus, capable of being osculted, in which this sound may not be heard. He considers that the souffle, which is so uniformly heard in the lower parts of the uterus, especially in the inguinal regions, seems to be produced by the uterine arteries before they enter the uterus; these vessels, as soon as they arrive at the broad ligament, assume a different character, become larger than they were on branching off from their original trunk, and are much contorted before entering the parietes of the uterus. Dubois first pointed out the similarity which exists between the sound heard in the gravid uterus, and that of aneurismal varix, where there is a direct passage of blood from an artery into a vein: the sound in this latter condition is produced by the current of blood rapidly issuing from the dilated artery, and mixing with the slower flowing stream of the dilated vein. The circulation of blood in the dilated arteries of the uterus present a considerable resemblance, in many respects, to that of the above-mentioned disease.
That the uterine sound is not confined to that part of the uterus where the placenta is attached, as was supposed by Professor Hohl,[43] is proved by the fact that we can frequently hear it in two different and sometimes opposite parts of the uterus at the same time, which, if his opinion be correct, would indicate the presence of twins; and yet the result of labour has proved that the uterus has contained but one child, and that the placenta had neither been attached in the one or other of these situations. The very circumstance which we have already mentioned, of this sound being invariably heard in one, if not in both, of the inguinal regions, shows that it is independent of the vicinity of the placenta; nevertheless, it must be allowed, that as the uterine vessels undergo the greatest degree of development at this part, the sound will usually be at least as distinct here as in any other portion of the uterus.
The uterine souffle is the first sound which auscultation detects during pregnancy; it may be heard as early as the fifteenth or sixteenth week, but cases now and then occur where it has been even distinguished in the thirteenth or fourteenth week, and Dr. Evory Kennedy, has given some very interesting examples where he was able to hear it with certainty at the twelfth, eleventh, and even in one instance, at the tenth week. (Kennedy, op. cit. p. 80.) During these earlier periods, the sound is weaker, but extends over the whole uterus, from the diminutive size of which it can be heard most readily immediately above the symphysis pubis; in fact, there is every reason to suppose, that the uterine souffle might be detected at a still earlier period, if the uterus were at this time within reach of the stethoscope. As pregnancy advances, it becomes more distinct and powerful, and is occasionally so to a remarkably degree. During the latter periods of pregnancy, it frequently presents considerable modifications of tone, especially where there is general or local vascular excitement, as in cases of fever, or dispositions to hæmorrhage, where the vessels are usually distended, or where (Naegelé, op. cit. p. 86,) the placenta is situated near the os uteri, it assumes a piping, twanging sound of considerable resonance: the same is also observed where, either from the weight of the gravid uterus or any other cause, pressure has been exerted on any of the main arterial trunks: hence, as we shall show more fully when speaking of labour, a remarkable change is produced in the tone of the uterine souffle by the first contractions of that process. The causes of these modifications are not always very easily explained; we sometimes observe the souffle on the same side of the uterus vary rapidly in its degree of intensity, and occasionally even disappear for awhile without our being able to assign any satisfactory reason for such changes.
The uterine souffle taken by itself, although a very valuable sign of pregnancy, can scarcely be looked upon as one which is perfectly certain and diagnostic, since a similar sound may be produced by aneurism of the abdominal aorta and its large branches: there is much reason to think that the uterus, enlarged from other causes than that of pregnancy, and pressing upon the iliac arteries, will produce a similar sound. Professor Naegelé, jun., has also shown that the sounds of the patient's heart may sometimes be heard very low in the abdomen, even as far as the ossa ilii, a circumstance which seems to have depended upon the sound being transmitted through the intestines distended with flatus. Where any of these causes of abdominal souffle have existed in connexion with suppressed catamenia, swelling of the breasts, &c., we might be liable to be deceived if we allowed ourselves to be entirely guided by this sound.
With regard to the foetal pulsations, we find them generally beating at the rate of from 130 to 150 double strokes in a minute, and the age of the foetus appears to have no effect upon their rapidity, for even at the earliest periods at which we can detect these sounds the rate of the pulsation is the same as at the full term of pregnancy.
Although Dr. Kennedy has in a few cases detected this sound even before the expiration of the fourth month, it will not in the majority be possible until a later period. "At the fourth month it frequently requires not only close attention, but considerable perseverence to detect the foetal heart; and at this period it has occurred to us to examine patients whom there was strong reason to suppose pregnant, and after spending a considerable time in endeavouring to detect this sound, we have been on the point of giving up the search as hopeless, when it has been suddenly discovered in the identical spot that had before perhaps been explored without success." (Kennedy, op. cit. p. 101.)
The sound of the foetal heart is usually heard at about the middle point between the scrobiculus cordis and symphysis pubis, usually to one side, and that, generally speaking, the left. The extent of surface over which the sound may be heard varies a good deal, and depends, in great measure, on the distance which intervenes between the foetus and stethoscope; hence, when the uterus is distended with a large quantity of liquor amnii, or when the uterine and abdominal parietes are very thick, it is heard over a much larger space, although with diminished intensity; on the other hand, when there is but little liquor amnii in the uterus, it is audible over a small portion only, but is remarkably distinct: this is peculiarly the case during labour after rupture of the membranes. The rapidity and strength of the foetal pulsations appear to be entirely independent of the mother's circulation; violent exercise, spirituous liquors, &c., which will raise her pulse to a considerable degree, have no influence whatever on the foetal pulse. In cases of fever, where the mother's pulse has ranged between 110° and 120°, and even higher, not the slightest change was observable in the sound of the foetal heart; even in acute inflammatory affections, in pneumonia, pleurisy, where there was severe dyspnoea, and also in tubercular phthisis; in cases where the patient has been bled; in cases of menstruation during pregnancy; and even in severe flooding, and when the mother's pulse has been greatly reduced, no perceptible change has been observed in that of the foetus. (Naegelé, op. cit. p. 39.) Dr. Kennedy has observed some remarkable cases where the foetal pulse appeared to vary in accordance with that of the mother (op. cit. p. 91;) but when we bear in mind the frequent changes in point of rapidity, &c., to which the foetal heart is subject, independent of any thing of the kind in the mother's pulse, and that similar changes are constantly observed in the child shortly after birth; and, moreover, that very considerable acceleration of the maternal pulse has decidedly no effect upon that of the foetus in many well-marked instances, we cannot agree with him in supposing that a connexion of the sort to which he has alluded exists. The double pulsations of the foetal heart can only be heard at one point of the uterus at a time, provided there be but one child; but if there be twins, then the sound is heard in two places at once. It has been supposed by some authors (Dubois) that the heart of the second child could not be distinctly heard until labour, when the membranes of the first child had ruptured. Generally speaking, both sounds can be heard pretty distinctly during the last weeks of pregnancy, one of them being low down on one side, and the other high up in an opposite direction. Although in some twin cases there is an evident difference of rhythm between the two foetal hearts, still in many others they are so nearly synchronous as to be scarcely if at all distinguishable in this respect. Hence, therefore, from the known variable character of the foetal pulse, it will be necessary that the sound of each heart should be ausculted at the same moment, minute for minute, by two observers, and thus the slightest appreciable difference between them determined.
Funic souffle. Dr. Kennedy has shown that, where a portion of the umbilical cord passes between the child's body and the anterior wall of the uterus, or crosses any of its limbs or other projections, pulsations are heard synchronous with those of the foetal heart; although not possessing the same characters. "In some cases where the uterus and parietes of the abdomen were extremely thin, I have been able," says Dr. K., "to distinguish the funis by the touch externally, and felt it rolling distinctly under my finger, and then, on applying the stethoscope, its pulsations have been discoverable remarkably strong; and, on making pressure with the finger for a moment on that part of the funis which passed towards the umbilicus of the child, I have been able to render the pulsations less and less distinct, and even, on making the pressure sufficiently strong, to stop it altogether." (Op. cit. p. 121.) In many cases where the umbilical arteries, by their convolutions round a limb, or by any other cause, are subjected to slight pressure, a distinct whizzing sound is produced, which is called by Dr. Kennedy the funic souffle.
The sound of the foetal heart must be looked upon as a sign of the highest value in the diagnosis of pregnancy, since, however complicated and obscure the other symptoms may be, whether from co-existing disease, wilful deception, &c. if this sound be once heard unequivocally, the real nature of the case is satisfactorily established beyond all possibility of doubt.
Another sound in the gravid uterus has been lately noticed by Professor Naegelé, junior, which promises to equal that of the foetal heart, as a certain diagnostic of pregnancy, and must be looked upon as a valuable addition to our means of ascertaining the truth in cases of this sort. The movements of the foetus may be distinguished by the stethoscope at a very early period of pregnancy, long before they are perceptible to the hand of the accoucheur, and in many cases before the patient has been aware of them herself. According to Professor Naegelé's observations, these sounds may usually be heard some little time before the foetal heart is audible, and are sounds which can neither be feigned nor concealed: they can only be heard in the gravid uterus, and under no other circumstances.
Although the sounds of the heart and movements of the foetus are unequivocal proofs of pregnancy, which may be heard at a very early period, still it must, in some degree, remain uncertain at this time, how far their absence can be looked upon as a proof of its non-existence. Under such circumstances, the examinations require to be conducted with the greatest possible care, and to be repeated at favourable opportunities, until no doubt as to the correctness of their results can any longer exist.
The soft cushiony feel of the cervix uteri is a change produced by pregnancy, which, in our opinion, has not received that attention which it deserves; as far as we are able to judge, this condition of the cervix is peculiar to pregnancy, and exists very shortly after conception. We occasionally meet with a soft flaccid state of the os and cervix uteri in certain diseases; but the feel which this communicates to the finger is very different to that above-mentioned, which resembles more the elastic inflated condition of the nipple during pregnancy, than any thing to which we can compare it.
Ballottement. At the beginning of the seventh month we shall be able to feel the head of the foetus upon examination per vaginam. If we direct our finger against the uterus, midway between the os uteri and symphysis pubis, and suddenly exert a slight degree of pressure, we shall become sensible of having struck against something hard within the cavity of the uterus; upon repeating the experiment immediately, we shall probably not feel it, the foetus having risen in the liquor amnii to the upper parts of the uterus; but if hold our finger still for a few moments, it will, by this time, have again descended, and we shall again feel it; at other times, when the foetus is larger and heavier, the head will rest like a light ball, on the tip of the finger, from which circumstance it has received the name of ballottement by the French authors.
Motion of the child. The sensation of the child's movements to the mother is a symptom of very little value, and is liable to mislead the practitioner if he place much reliance upon it; for the passage of the flatus along the bowels, or little spasmodic flickerings of the abdominal muscles, will produce a very similar sensation, and will even completely deceive a patient who has been the mother of several children; but when they become perceptible to the experienced hand of the practitioner, this may also be looked upon as a certain indication that pregnancy exists. The foetal movements can seldom be felt distinctly until the beginning of the seventh month, and even then it requires some caution before we can venture upon a positive opinion. Their activity varies considerably in different cases; in some their nature is almost immediately evident; whereas, in others they are so few and feeble, as to make it very difficult to decide. It has been recommended to put the head in cold water previous to applying it upon the abdomen, as, by this means, a considerable shock is produced which excites these movements more distinctly. We cannot say that we have found this proceeding of any use, since, by this means, the abdominal muscles are rendered so irritable as frequently to obstruct the examination considerably: it is rather desirable to have them in as perfect a state of repose as possible, in order that no movement of the foetus, however slight, should escape our notice. It is in cases of abdominal enlargement from disease; that this means of diagnosis is occasionally very difficult, and where men, even of great experience, have been led to form a very erroneous opinion. The celebrated Peter Franck has related a case of this sort which occurred to himself, where the patient was supposed pregnant, and where he imagined that he had felt the motions of the child: she died shortly afterwards, and the examination of the body showed it to have been a case of ascites complicated with hydatids. Dr. Dewees has given a still more remarkable case of a similar error having occurred to himself. A young lady had her menses suppressed for several months; the abdomen swelled very much, the breasts became enlarged, she had nausea and vomiting in the morning, and other indications of pregnancy; "examining the abdomen carefully, I found it," says Dr. Dewees, "considerably distended; there was a circumscribed tumour within it, which I was very certain was an enlarged uterus. While conducting this examination I thought I distinctly perceived the motions of a foetus. The case proved to be one of accumulation of menstrual fluid in the uterus." (Dewees's Essays on several Subjects connected with Midwifery, p. 337-8.)
In reviewing what has now been stated respecting the diagnosis of pregnancy, it will be observed that we have enumerated four symptoms, which must be looked upon as perfectly diagnostic of this condition, and in the accuracy and certainty of which we may place the fullest confidence: two may be recognised at an early period by means of auscultation, viz. the sounds produced by the movements of the foetus and by the pulsations of its heart; the two others are not appreciable until a later period, and are afforded by manual examination, viz. the being able to feel the head of the foetus per vaginam, and its movements through the abdominal parietes. The next in point of value after these are the changes in the os and cervix uteri, those connected with the formation of the areola in the breasts, and, at a somewhat later period, the sound of the uterine circulation, changes, which, although they cannot separately be entirely depended upon, are nevertheless symptoms of very great importance in the diagnosis of pregnancy.
Two other signs of pregnancy have also been mentioned, viz. the appearance of a peculiar deposite in the urine as described by M. Nauche, or rather by Savonarola (Montgomery, op. cit. p. 157.,) and the purple or violet appearance of the mucous membrane lining the vagina and os externum, as described by Professor Kluge of the Charité at Berlin, and by M. M. Jacquemin, Parent Duchatelet, &c. of Paris. With regard to the first, which is an old popular symptom of pregnancy, there is too much variety in the appearances of the urine, depending on general health, diet, temperature, &c., to enable us to place much confidence in any change of this sort. "I have myself tried it," says Dr. Montgomery, "in several instances, and the result of my trials has been this:--In some instances no opinion could be formed as to whether the peculiar deposite existed or not, on account of the deep colour and turbid condition of the urine; but in the cases in which the fluid was clear, and pregnancy existing, the peculiar deposite was observed in every instance. Its appearance would be best described by saying that it looks as if a little milk had been thrown into the urine, and having sunk through it had partly reached the bottom, while a part remained suspended and floating through the lower part of the fluid in the form of a whitish semi-transparent filmy cloud." (Op cit. p. 157.)[44]
The purple colour of the vaginal entrance appears, from the extensive experience of the above-mentioned authors, to be a pretty constant change produced by the state of pregnancy; it probably occurs at a very early period. How far a similar tinge is produced by the state of uterine congestion immediately before a menstrual period, we are unable to say; at any rate, the character of the examination itself must ever be sufficient to preclude its being practised in this country.
The diagnosis of pregnancy is a subject well worthy of the student's most serious attention; for he will of course be liable, when in practice, to be called upon to give his evidence before a court of justice under circumstances when the responsibility must ever be of the most serious and not unfrequently of the most fearful nature, the more so as the old custom of impanelling a jury of "twelve discreet matrons" to determine whether the woman be quick with child has fallen deservedly into disrepute. He should lose no opportunity of making himself familiar with the various symptoms of pregnancy above enumerated, and of so practising the different senses of hearing, touch, and sight, as instantly and certainly to detect their presence.
Numerous cases are on record, where a false diagnosis in women convicted of capital offences, has led to most lamentable results, and where dissection of the body after death has shown that she was pregnant. Dr. Evory Kennedy has recorded an interesting case of this sort which occurred at Norwich in 1833, when a pregnant woman was on the point of being executed through the ignorance of a female jury. (E. Kennedy's Observations on Obstetric Auscultation, &c., p. 197.) We may also mention a dreadful case of this nature which occurred to the celebrated Baudelocque at Paris, during the horrors of the French revolution.[45] A young French countess was imprisoned during the revolution, being suspected of carrying on a treasonable correspondence with her husband, an emigrant. She was condemned, but declared herself pregnant; two of the best midwives in Paris were ordered to examine her, and they declared that she was not pregnant. She was accordingly guillotined, and her body taken to the school of anatomy, where it was opened by Baudelocque, who found twins in the fifth month of pregnancy.
Equally important is it (and perhaps in some respects even more so) to determine the absence of pregnancy in cases where it has been supposed to exist. In many instances the character and happiness of the individual must depend upon the judgment which the practitioner pronounces; and, painful as will be the task of communicating an opinion which implies guilt and loss of honour, how infinitely revolting and inexcusable must that step be considered, which turns out to have been founded upon an incorrect diagnosis. Hence the importance of separating those symptoms of pregnancy which may be considered certain, and therefore trustworthy, from the crowd of others, which, although collectively they may warrant a suspicion, yet never can justify a decision that pregnancy exists, more especially in cases where so much is at stake. No two symptoms have led more frequently to this cruel error, and therefore to the most unjust suspicions, than the cessation of the menses with swelling of the abdomen, and yet from how many different causes may they arise besides that of pregnancy? Putting even the impulse of common feeling aside, we would ask how a practitioner can dare recklessly to incur the responsibility of injuring a woman's character by hazarding an opinion which involves so much, and is based upon symptoms which, by themselves, prove so little? Whether he exercise his profession in town or country, cases of doubtful pregnancy will constantly come under his notice. We cannot, therefore, too strongly urge the importance of ascertaining how many of the certain symptoms are present, before we allow ourselves to be influenced by those which are uncertain. In speaking of the enlargement of the abdomen as a sign of pregnancy which is extremely equivocal, Dr. Dewees well observes, "But little reliance can be placed upon this circumstance alone, or even when combined with several others; for I have had the pleasure in several instances of doing away an injurious and cruel suspicion, to which this enlargement had given rise. Within a short time, I relieved an anxious and tender mother from an almost heart-breaking apprehension for the condition of an only and beautiful daughter on whom suspicion had fallen, though not quite fifteen years of age: this case, it must be confessed, combined several circumstances which rendered it one of great doubt, and, without having had recourse to the most careful and minute examination, might readily have embarrassed a young practitioner. This lady's case was submitted to a medical gentleman, who, from its history and the feel of the abdomen, pronounced it to be a case of pregnancy, and advised the sorrow-stricken mother to send her daughter immediately to the country as the best mode of concealing her shame. Not willing to yield to the opinion of her physician (a young man,) and moved by the positive denials of her agonized child, the mother consulted me in this case. The menses had ceased, the abdomen had gradually swelled, the stomach was much affected, especially in the morning, and the breasts were a little enlarged. On examination it proved to be a case of enlarged spleen." (Dewees, on the Diseases of Females, p. 178.)
We occasionally, also, meet with cases of self-deception, as to the existence of pregnancy, to an extent which would scarcely seem credible. Women who have been the mothers of several children, will, upon some very slight foundation, suppose themselves with child. Knowing from previous experience many of the symptoms of this state, they will frequently enumerate them most accurately to the practitioner, who, if he rest satisfied with general appearances, may easily be led into a wrong diagnosis. A case of this kind we published in our midwifery reports, where the patient, the mother of two children, came into the General Lying-in Hospital, not only under the supposition that she was pregnant, but that labour had actually commenced; the catamenia had ceased about nine months previously, and the abdomen was considerably enlarged. Examination proved that she was not pregnant. (Med. Gaz. June, 1834.)
In a work solely devoted to cases of doubtful pregnancy by the late W. J. Schmitt, of Vienna, these cases have been very fully discussed. "We occasionally observe certain conditions of the female system, which put on a most striking resemblance to pregnancy, both functionally as well as organically, without at all depending on the actual presence of pregnancy. The abdomen begins to swell from the pubic region exactly in the same gradual manner as in pregnancy; the breasts become painful, swell, and secrete a lymphatic fluid, frequently resembling milk; the digestive organs become disordered; there is irregular appetite, nausea, and inclination to vomit; constipation, muscular debility, change in the colour of the skin, and frequently of the whole condition of the body; the nervous system suffers, and even the mind itself frequently sympathizes; the patient is sensible of movements in the abdomen like those of a living foetus, then bearing down pains running from the loins to the pubes; at last actual labour-pains come on as with a woman in labour, and if by chance her former labours have been attended by any peculiar symptoms, these, as it were, to complete the illusion, appear likewise." (W. J. Schmitt, Zweifelhafte Schwangerschafts-fälle.) A most extraordinary case of the self-deception with regard to pregnancy, has been published by the celebrated Klein of Stuttgardt: it has been quoted in the work of W. J. Schmitt above alluded to, and a brief sketch of it has been given by Dr. Montgomery in his Expositions of the Signs and Symptoms of Pregnancy, p. 172, to which we must refer the reader for much valuable information on this and all other subjects connected with the diagnosis of pregnancy.
Diagnosis of twin pregnancy. Before concluding this chapter, we shall offer a few observations on the diagnosis of twins. A variety of symptoms have been enumerated as indicating the presence of two foetuses in utero, such as the great size of the abdomen, its flat square shape, the movements of a child at different parts of it, &c. The size of the abdomen can never be admitted as a diagnostic mark of twin pregnancy; first, because it equally indicates the presence of an unusual quantity of liquor amnii, or of a very large child; and secondly, because women pregnant with twins are not always remarkable for their size: the flatness, &c., of the abdomen is, we presume, a symptom based on the supposition that there is a foetus in each side of the uterus: this is very far from being correct, as it is well known that the children usually lie obliquely, the one being, perhaps, downwards and backwards, while the other is situated upwards and forwards. The sensation of the child's movements in different or opposite parts of the uterus is no proof whatever that there are twins, because it is constantly observed where there is but one child--a circumstance which is very easy of explanation.
The stethoscope affords us the only certain diagnosis of twin pregnancy; and even here it is limited to the sounds of the foetal hearts; the increased extent and power of the uterine souffle, as remarked by Hohl, arising, as he supposed, from the large mass of the double placenta, is not a proof which can be depended upon. In cases of suspected twin pregnancy the auscultation must be conducted with the greatest possible care, and, generally speaking, a certain diagnosis can only be obtained by two observers ausculting the two hearts at one and the same moment; for, otherwise, the difference between their rhythm is frequently so small as to be inappreciable. The sounds are seldom or never heard at the same level, one being generally heard high up on one side, the other in a contrary direction.
II. TREATMENT OF PREGNANCY
Sympathetic affections of the stomach during pregnancy.--Morning sickness.--Constipation.--Flatulence.--Colicky pains.--Headach.-- Spasmodic cough.--Palpitation.--Toothach.--Diarrhoea.--Pruritus pudendi.--Salivation.
In the preceding chapter we have enumerated those changes and phenomena which are observed to take place in the system during pregnancy: many of these amount to actual derangements of function, and will, therefore, as such, demand our attention in a practical point of view, for the purpose of alleviating or removing them. Many of these changes are produced by the altered distribution of blood, as well as by the actual increase of quantity which now exists in the circulation; the nervous and also the vascular system of the uterus are now in a state of high excitement and activity--a condition which must necessarily communicate itself to those organs which are supplied by the same nerves; viz. the sympathetic, and by the same portion of the circulation, viz. the branches of the abdominal aorta.
No organ, except the stomach, possesses sympathetic connexions so widely extended over the rest of the system as the uterus; and, we may add, that no two organs are so intimately and reciprocally united as the uterus and the stomach. In the unimpregnated state, we see this manifested in a remarkable degree; if the stomach becomes deranged the uterus sympathizes; thus the states of gastric disturbance, known under the general term of dyspepsia, are frequently followed by leucorrhoea, or some derangement of the menstrual function: on the other hand, uterine disease is invariably accompanied by symptoms of gastric disturbance, and, in many cases, to such an extent as to conceal the real seat of the evil, and mislead the attention of the patient and her medical attendant. In like manner we find that during pregnancy, especially in the early stages of it, the patient is annoyed with a great variety of symptoms more or less indicative of derangement in the functions of the primæ viæ.
Morning sickness. One of the most troublesome, and by no means the least frequent, is vomiting, which, from coming on usually in the morning, is commonly called morning sickness; in some cases the female merely rejects what food or mucus may be present in the stomach, after which she feels relieved; in others she continues to strain violently and ineffectually for some time. In the former case it resembles the common vomiting from a deranged stomach, and cannot be considered as the direct result of sympathy with the uterus: the tone of the stomach has become impaired, and vomiting has followed as a consequence of its being loaded with undigested food and depraved secretions. Hence, in these cases, it is generally preceded by nausea and the other common precursory symptoms of this act: in the latter, however, it appears to be the immediate result of irritation transmitted from the uterus, and assumes rather a spasmodic character; the patient is suddenly seized with involuntary efforts to vomit, which are not preceded by nausea or oppression, and come on independently of the stomach being full or empty.
Morning sickness usually appears during the first few weeks after conception, and continues until the third or fourth month; in some cases it continues throughout pregnancy; in a few it does not begin till much later, and in many it does not appear at all. It scarcely deserves to be called a disease of pregnancy, for it frequently appears as a salutary effort of nature to relieve a cause of much gastric irritation, and, unless it proceeds to a very exhausting degree, must rather be looked upon as a favourable symptom, as it tends to prevent the formation of too much blood, which is so frequent a cause of abortion during the early months. (Hamilton, on Female Complaints.) Hence, therefore, experience verifies the correctness of the old proverb, that a "sick pregnancy is a safe one."
The ejected matter on these occasions, when there is but little or no food upon the stomach, consists of a glairy ropy mucus, sometimes mixed with a considerable quantity of intensely sour fluid, containing a large proportion of muriatic and acetic acid: in some cases more or less bile is vomited.
The treatment of morning sickness will depend in great measure on the severity of the attack: where it is slight, the patient may assist its operation with a little warm water, or chamomile tea: after which the bowels should be briskly opened by a saline laxative, as for instance, a seidlitz powder, sulphate and carbonate of magnesia, &c.: small doses do more harm than good, as, from their slow and ineffective action, they rather tend to increase the irritation and aggravate the symptoms. In severe cases, especially where the pulse is excited, a small bleeding may be used with much advantage, but in most instances the usual treatment of gastric derangement, as it occurs in the unimpregnated state, produces most relief. The bowels should be first opened in the way already mentioned, after which a combination of Pil. Hydrarg. and Extr. Hyosc. or Extr. Humuli, is to be given at night, and a vegetable tonic during the day.
Acids, more especially the mineral, have been very judiciously recommended by Dr. Dewees, and, when combined with any bitter infusion, will be found of great service. Where the constant secretion of acid is very distressing, the nitric acid will be found particularly useful; it allays the irritability of the stomach, and produces a healthy state of its secretion. Opiates are by no means desirable remedies, and rather tend to aggravate the disease by still farther injuring the tone of the stomach and producing constipation. We have known them given in considerable doses and in very powerful forms, but without relief. Hydrocyanic acid, creosote, &c., have also been tried, but with no permanent success; in such cases Dr. Burns has found the application of leeches useful, "especially if accompanied with pain or tension in the epigastric region." On the same principle, we presume, have we found a sinapism of great service. Where the vomiting, in spite of all the above modes of treatment, still goes on unabated, there is nothing which, in our experience, is so useful as covering the epigastrium with a hot flannel, upon which a mixture of camphorated spirits of wine and laudanum has been sprinkled. "We have," says Dr. Dewees, "in several instances, confined patients for days together, upon lemon juice and water with the most decided advantage. We have repeatedly found much benefit from the use of the spirit of turpentine three or four times a day, in doses of twenty drops: this medicine is very easily taken, if it be mixed in cold sweetened water. When the system is not excited to febrile action, and where the stomach rejects every thing almost as soon as swallowed, we have often known a table-spoonful of clove-tea act most promptly and successfully." (Compendious System of Midwifery.)
Heartburn is another form of gastric derangement which frequently occurs to a very distressing degree, and must be looked upon as a modification of morning sickness; in many cases it arises from the presence of acid in the stomach, but in others it is merely a sympathetic result of gastric irritation, without any proof of acidity being present. The treatment of heartburn is much the same as that just described for morning sickness, the main object being to restore the stomach and bowels to a healthy condition. Besides the mineral acids, small quantities of iced water will be found very grateful, relieving the sense of burning in the back of the pharynx, and diminishing, in great measure, that gastric irritability of which it is a symptom.
The frequent, and sometimes almost unlimited, use of antacid absorbents, viz. magnesia or chalk, in this disease, is a practice much to be deprecated: compounds are thus formed in the stomach which are positively injurious, and, beyond the temporary relief procured by removing the acid, they tend to aggravate these symptoms, by increasing the state of gastric derangement. The only chemical antacid which should be given in these cases is the carbonate of soda; by this means a compound is formed (the common muriate of soda,) which of all others is most grateful to the stomach, and which, from its gently laxative effects, is well adapted to keep up a healthy action of the bowels. It is scarcely credible to what extent the use of antacids may be carried to relieve the cardialgia of pregnancy. Dr. Dewees mentions having attended a lady with several children, "who was in the constant habit of eating chalk during the whole term of pregnancy; she used it in such excessive quantities as almost rendered the bowels useless. We have known her many times not to have an evacuation for ten or twelve days together, and then only procured by enemata, and the stools were literally nothing but chalk. Her calculation, we well remember, was three half pecks for each pregnancy. She became as white nearly as the substance itself, and it eventually destroyed her, by deranging her stomach so much that it would retain nothing whatever upon it." (System of Midwifery, § 275.)
The constipation, flatulence, colicky pains, and headach, the spasmodic cough, palpitation, toothach, &c. are symptoms arising from the same cause, a knowledge of which circumstance will influence our treatment of them more or less. Still, however, the indications are the same, viz. to restore and keep up a healthy action of the stomach and bowels. Thus, we frequently find that a severe headach, obstinate cough, or attacks of palpitation, are relieved by aperient medicines; that toothach may be relieved, or even removed, by occasional doses of carbonate of soda, or by blue pill and aperient tonics. Indeed, it is a question in many cases, whether it is proper to extract a carious tooth under these circumstances, for the shock which it produces is sometimes so great as to run the risk of exciting abortion; and in many instances we might extract every tooth on the painful side, and yet not relieve the suffering which arises from nervous pain induced by gastric irritation, and, if carefully examined, the pain will be found to be not confined to a single tooth but to spread over the whole side of the face, darting from the edge of the ear, and extending even to the forehead. The breath is usually sour, and the acid state of the saliva is indicated by the instantaneous reddening of litmus paper laid upon the tongue; in many cases there is at the same time a considerable deposit of lithic acid observed in the urine.
Spasmodic cough, or palpitation, if allowed to continue, may ultimately bring on abortion. The treatment just detailed is equally applicable here, and if the circulation be at all excited blood-letting will prove useful. In bleeding women at this early stage of pregnancy it is not desirable, or even safe, to draw a large quantity suddenly from the system, as it may greatly endanger the life of the foetus, and from the state of the nervous irritability, may even run the risk of bringing on convulsions; syncope is always more or less hazardous to a pregnant woman, and should if possible be avoided. Some caution will be also necessary in our choice of aperient medicines; drastic purgatives, as aloes, colocynth, scammony, &c. are not suited to the state of pregnancy, as they irritate the lower bowels, and thus excite a disposition to uterine contraction; mild, but effectual laxatives, such as castor oil, confectio sennæ, a seidlitz powder, are better adapted; the latter, especially will be found useful, as, from its being taken during effervescence, it is better calculated to quiet the stomach.
Diarrhoea is sometimes an exceedingly troublesome symptom during pregnancy. It not only weakens the patient and thus tends indirectly to induce abortion by destroying the life of the foetus, but it acts also in a more direct manner by exciting uterine contractions, particularly when accompanied, as is frequently the case, with tenesmus. The diarrhoea which is met with in pregnant women is not so frequently, as has been supposed, the result of irritation from the uterus, producing simply an increased peristaltic action of the bowels without any considerable derangement of their functions; by far the most usual form is connected with a very deranged state of the alimentary canal; the evacuations are offensive and generally very acrid; the liver is torbid or secretes an unhealthy bile, so that at length a state approaching to dysentery is produced. Even if the patient go to the full term of utero-gestation, she is much reduced, and is ill able to make those exertions which will be required during labour. If the motions, though frequent, are scanty in proportion to the ingesta, or if scybala are occasionally expelled, one or two doses of castor oil will be required; a few drops of Liq. Opii Sedativ. may be added with advantage to allay the irritability of the bowels, after which, equal parts of blue pill, or Hydr. c. Cretâ, and Dover's powder, will excite the liver to a healthier action, and still farther control their inordinate activity. If the disposition to tenesmus be troublesome, a small injection of starch and opium will afford relief. If the stomach will bear it, a rice-milk diet for a day or two is desirable; it is a gentle demulcent to the irritable intestines, and has a slightly constipating effect.
Pruritus pudendi to a very distressing degree occasionally comes on during pregnancy, and though in most instances a very manageable form of disease, yet if its nature be not properly understood it proves exceedingly obstinate, and much suffering is the result. It appears to be essentially different from the common prurigo, being an aphthous state of the lining membrane of the vagina and skin which covers the perineum and external organs. There is great heat and redness of the parts, which are more or less swollen, and from the scratching which the intense itching demands, the cuticle, where it has been raised by the pustules, becomes abraided, so that severe excoriations, and, where there has not been sufficient attention to cleanliness, even ulcerations may be produced. The pustules on the external parts frequently attain a considerable size, being more distinct than in the vagina, which is usually incrusted with one confluent mass of aphthæ; whereas, on the perineum and margins of the labia we have seen them as large as peas. These cases for the most part yield to the tepid Goulard lotion, or solution of borax.
Where the patient is plethoric, and the system in a state of considerable excitement from the irritation, blood-letting will be necessary, followed by cooling saline laxatives; and if there be much inflammation of the parts, leeches will prove of great service. In every case the bowels ought to be attended to, for constipation will greatly increase the inflammation, and the obstinacy of the disease. It is to Dr. Dewees that we are indebted for first pointing out the real cause and nature of this troublesome affection.[46]
Aphthæ of the vagina are not unfrequently met with in cases of uterine disease, where the discharge is extremely acrid, but the prominent symptom, viz. the intense pruritus, is absent. The aphthous vagina of pregnancy is not a common affection.
Salivation is another affection which is occasionally, though rarely, met with in pregnancy. It is usually attended with morning sickness, constant nausea, and deranged bowels, and may reduce the patient excessively: attention to the state of the bowels, followed by gentle alteratives and tonics, generally gives relief.
III. SIGNS OF THE DEATH OF THE FOETUS
Difficulty of the subject.--Signs before labour.--Motion of the Foetus.--Sound of the foetal heart.--Uterus souffle.--Signs during labour where the head presents--where the face, the nates, the arm, or the cord, present.--Fetid liquor amnii.--Discharge of meconium.
Well has the celebrated Mauriceau observed, "S'il y a occasion où le chirurgien doive faire plus grande reflexion, et apporter plus de précaution aux choses qui concernent son art, c'est en celle où il s'agit de juger si l'enfant qui est dans la matrice est vivant, ou bien s'il est mort." There are few circumstances more painful to the feelings of an accoucheur, than the uncertainty as to whether the child be alive or dead, in a labour where the passage of the head is rendered unusually difficult or dangerous for the mother, even with the aid of the forceps; whether the difficulty be produced by want of proportion between the head and pelvis, unusual rigidity of the os uteri, &c. Could he assure himself that it was alive, he would feel justified in either trusting still longer to the efforts of nature, or in applying the forceps, even although he knows that the delivery cannot be effected without considerable difficulty and suffering: whereas, if he could once feel satisfied that the child had ceased to exist, he would have recourse to perforation, for the purpose of diminishing the size of the head, and thus releasing the mother from the dangers of her situation.
The increasing success which has attended the Cæsarean operation of late years, adds still more to the importance of having the signs of the child's life or death in utero carefully investigated and understood; for, under such circumstances, it becomes a most serious question whether we are always justified in destroying the life of the foetus by perforation, when we might in all probability have saved it by resorting to another means of delivery, which, formidable as it is, is now infinitely less so than it was in former times. It becomes a question whether we ought not, in certain cases to adopt the same indications for performing the Cæsarian operation, as are used upon the Continent, and apply it not only to those cases where the child cannot be delivered par vias naturales, but also in those cases of minor pelvic obstruction, where, if we could feel sure of the child's death, we should have recourse to perforation. Under circumstances of this nature, the question becomes one of fearful responsibility, the painfulness of which is not a little increased by the uncertainty as to whether the child be alive or not. Mauriceau was the first author who devoted a chapter expressly to the consideration of this subject, and those few who have done the same since his time, have borrowed largely from his observations.
A great number of symptoms have been enumerated as indicating the child's death in utero, but for the most part they are deserving of very little confidence, frequently occurring where the result of labour has shown the child to be alive and strong, or vice versâ. The most practical arrangement of these symptoms will, we think, be under the two following heads: those which occur before labour, and those which occur during labour.
The symptoms of the child's death, which are usually enumerated as occurring before labour, are, cessation of the child's movements; the abdomen undergoes no farther increase of size, but rather diminishes; the uterus has no longer the tense elastic feel of pregnancy, but becomes flaccid and moveable; the patient has a sensation of coldness and weight in the abdomen, so that when she turns from one side to the other, she feels as if a heavy weight rolled over to that part of the abdomen which is lowest; the breasts are flabby, and sometimes there is a fetid slimy discharge from the vagina. These changes are accompanied by some or all of the following symptoms: the patient is seized with a sudden shivering, languor, and debility; she loses her appetite and spirits; the stomach and bowels become disordered; the breath is fetid, and the face pale, sallow, and of a dark leaden colour under the eyes. All these symptoms taken collectively will enable us to decide, with a tolerable degree of certainty, that the child is dead: but scarcely any of them alone can be trusted to. The most trust-worthy is the sensation of a heavy weight rolling about the abdomen: when the female turns in bed, rises from her chair, or in any way alters her position, this weight is felt as it were tumbling down to that side which is lowest. A woman who is pregnant with a living child, feels nothing of the sort; she may even dance or jump, and yet she feels no more of a living foetus than she does of her own liver or spleen. The living foetus obeys the laws of organic life; the dead foetus those of gravity. When once the child has ceased to exist, it acts like any other mass of inanimate matter, and pushes the uterus down to that side which is lowest.
In most instances this symptom will be sufficient to make us suspect that the child is dead, but it now and then occurs where the result of labour proves the child to be alive; this must rather be looked upon as an exception to the rule, for it is not of frequent occurrence. We have observed it in two or three cases: it has been also noticed by Dr. E. Kennedy, (op. cit.;) and, therefore, cannot invariably be looked upon as a certain sign of the child's death. We have observed it frequently in cases threatening abortion at an early period: in many it has been followed by premature expulsion, but in others the symptom has gradually disappeared as the health improves, and the patient has eventually been delivered of a living child at the full period.
In these cases, we should rather attribute the source of this symptom to a loss of the firmness and tone peculiar to the uterine parietes during pregnancy, and which depends upon the increased activity of the circulation in them at this period: when this is considerably diminished, the uterine parietes will necessarily become more flaccid, and, therefore, less able to withstand the influence of gravity, or sustain the uterus in its proper situation. The embryo itself during the first two or three months is too small and too light to produce this symptom itself.
The sensation (to the mother) of the child's movements is as fallacious an indication of the child's life as it is of pregnancy; nor can the absence of this sensation be looked upon as a proof of its death. Women are very liable to be misled in this respect; so much so, that it will be much safer for the practitioner never to allow his diagnosis to be at all influenced by their statements; the more so, as it applies equally to mothers of large families as to primiparæ. Thus cases every now and then occur where the patient declares her conviction that the child is dead; that she has not felt it move for several days before labour; that she feels altogether differently to what she did in any of her former pregnancies, and yet she is delivered of a healthy living child. On the other hand, we as frequently meet with cases where, up to the very commencement of labour, the patient asserts that she has distinctly felt the motion of the child, and yet she brings forth a child in such a state of decomposition as proves beyond all doubt that it must have been dead some eight, ten, or more days.
As the sound of the foetal heart is the surest sign of pregnancy, so it is an equally certain proof of the child's life: but is the absence of this sound, a certain symptom of its death? at the best it is a negative evidence, and the value of it must entirely depend upon the skill of the ausculator and the care with which he makes his examination. If, after repeated and careful auscultation of the abdomen, the well-practised ear can no where detect a trace of the foetal pulsations, it may be asserted on very safe grounds that the foetus has ceased to live. This is more particularly the case during the last weeks of pregnancy, when the pulsations are stronger, and the bulk of the child, in proportion to that of the liquor amnii being absolutely, as well as relatively, greater. The distance between the heart and surface of the abdomen is less during the last weeks of pregnancy also; the child's movements are not so free as at an earlier period; and hence, if the foetal heart is beating, it will be more easily discovered.
The uterine souffle affords us little aid in the diagnosis of the child's death: it is frequently very distinct when the child is evidently alive; and where it has been heard previous to its death, it will continue for some hours afterwards, although with diminished strength and over a smaller space.
During labour there are a variety of symptoms, by the aid of which we can pronounce, with a very tolerable degree of certainty, whether the child is alive or not; if alive, the foetal heart can invariably be detected; and, for the reasons above stated, will be heard more distinctly than in the earlier months of pregnancy. If, from the violence or duration of the labour, or any other cause, the child is becoming exhausted, the pulsations become weaker and slower until they stop; so that by the aid of auscultation we possess distinct evidence of the child's life being endangered, and of its complete extinction.
If the head presents during labour, a firm elastic swelling (caput succedaneum) will rise on that portion of it which first enters the vagina: this is produced by the circulation in the presenting part of the scalp being obstructed by the pressure which the os uteri and vagina exert upon it, an effect which can only be produced upon the head of a living child: where, on the other hand, the child is dead, the scalp will be felt to be soft, flabby, and without swelling. This may be looked upon as a very certain proof of the child's death in primiparæ, where the head is advancing slowly, and where it is tightly encircled by the distended vagina. But in multiparæ, where the soft passages have been dilated by repeated labours, the pressure upon the head is so slight, and its passage through them so rapid, that little or no swelling is produced: even in these cases the finger of the accoucheur will easily distinguish the head of a dead child by the loose yielding flabby feel of its integuments; the cranial bones are more moveable, and overlap each other at the sutures more than usual; their edges feel sharp, as if no longer covered by the scalp; and frequently communicate a grating sensation when they rub against each other. The great fontanelle is flaccid and loose; the bones, which form it, appear falling together, from a want of sufficient contents to keep them asunder, a circumstance which probably arises from the circulation in the brain having ceased; and in those cases where the child has already been dead some time, a crackling or crepitous sensation is communicated to the finger from emphysema, the result of decomposition.
The only case in which the swelling of the head is capable of misleading us, is in lingering difficult labours, where the child has been alive at the beginning, the swelling has formed, but from the duration and severity of the labour the child has died: wider such circumstances, a dead child may be born with the usual swelling of the cranial integuments which is observed in a living child. This can only happen where it has been expelled almost immediately after its death, for in two or three hours the swelling loses its former firm tense feel, and becomes so soft and flaccid, as not to be easily mistaken.
If the face presents during labour, the flabby state of the lips will instantly lead us to suspect that the child is dead: the tongue is also flaccid and motionless. Whereas, in a living child the lips are firm and full; if the face be approaching the os externum, a considerable swelling will be felt on that side which presents; the tongue is firm, and frequently moves upon the finger.
If the nates present, the state of the sphincter ani will be a sure guide in ascertaining whether the child be alive or not. If it be alive, it will be found closed, and will contract distinctly upon the finger; whereas, if dead, it will be relaxed, and insensible to the stimulus of the finger.
In an arm presentation, where the child is alive, the arm will swell, and grow livid or nearly black; but if it be dead, no swelling will be observed, the arm will be very flabby, and where it has been dead some time, the epidermis will peel off. In this case, as in head presentations, the date of the child's death will more or less modify these appearances; if it has not taken place until some time after the commencement of labour, a dead child may be born exhibiting the swelling and discolouration above-mentioned. The pulse in the wrist of the prolapsed arm is no guide, as the very degree of pressure, which produces these changes in its appearance, will be generally sufficient to render it imperceptible.
In cases where the cord has prolapsed, we have certain evidence with respect to the child's life: if alive the cord is firm, turgid, and distinctly pulsating; if dead, it is flaccid, empty, and without pulsation.
Fetid liquor amnii, and the discharge of the meconium, have also been enumerated as signs of the child's death, which occur during labour. The first affords no proof whatever, as cases not unfrequently occur in which the liquor amnii is excessively fetid, and of a thick slimy consistence, and yet the child is born alive and healthy.
The appearance of meconium during labour is a suspicious sign where the nates do not present, and will at any rate justify the supposition, that if the child be not actually dead, it is very weakly; in nates presentations, however, this will not hold good, for the meconium is constantly discharged during labour, where the child is in this position, and yet it will be born alive and well.
IV. MOLE PREGNANCY
Nature and origin.--Varieties.--Diagnostic Symptoms.--Treatment.
When any cause has occurred to destroy the life of the embryo during the early weeks of pregnancy, one of two results follows, either that expulsion takes place sooner or later, or the membranes of the ovum become remarkably changed, and continue to grow for some time longer, until at length they form a fleshy fibrous mass, called mole, or false conception.[47]
It is well known that the venous absorbing radicles of the chorion, which give it that shaggy appearance during the first months of pregnancy are the means by which the embryo is furnished with a due supply of nourishment at this period: if the embryo should die from any cause, and the uterus show no disposition to expel the ovum, the nourishment which has been collected by the absorbing power of the chorion appears now to be directed to the chorion itself, which therefore puts on a fleshy growth and increases very rapidly in size. (Roederer, Elementa Artis Obstetricæ, p. 738.)
In other instances, the thick fleshy character of the ovum is not produced by a growth of substance, but is the result of hæmorrhage from rupture of some of the vessels which run between the uterus and the ovum. In this case, if the placental cells be already formed, they become distended with the blood of the hæmorrhage which solidifies by coagulation; and not only render the chorion or incipient placenta much thicker and more solid, but give it also a lobulated tuberculated appearance: from the same reason, the little funis, which is probably not an inch long, is greatly distended, being in some cases as thick as the body of the embryo itself, the blood having penetrated from the placental cells into the cellular tissue of the chord. This is by no means an uncommon form of mole; externally it is covered by the decidua, which appears to be in a natural condition, and the inner surface of the cavity is lined by a fine membrane, having all the usual characters of the amnion. The lobulated appearance is chiefly seen from within, the amnion being raised by a number of irregular convexities.
"When the blood is poured out from its containing vessels into the substance or cells of the placenta, or between the membranes, gradually coagulates, and assumes a very dark purple, and sometimes almost a melanotic black colour: after a time, however, it begins to lose this tint, the colouring matter gradually becomes removed, and the coagulum successively assumes a chocolate brown, a reddish or brownish yellow hue; and latterly, if time sufficient be allowed, it presents a pale yellowish white or straw-coloured substance, the fibrinous portion of the coagulum being then left alone."[48] This form of mole, as far as our own observation goes, seldom attains any considerable size, rarely exceeding four inches in length, and is usually expelled between the eighth and twelfth week. The size and condition of the foetus varies a good deal; in some cases it appears nearly healthy, although the cord is much thickened and distended; this is probably owing to its having been expelled shortly after its death, or to its having gone on to live a short time after the injury which had caused hæmorrhage: in this way alone can we explain why we occasionally meet with cases where the parietes of the ovum are much thickened and solidified, and yet the embryo is in such a state of integrity as to prove that its death must have been very recent. The extravasation of blood between the ovum and uterus does not appear to be sufficient to annihilate immediately the nutrition of the embryo, so that the blood has had sufficient time to solidify before the ovum was expelled. At other times the embryo exhibits evident marks of having been dead some time: it is much smaller and younger in proportion to the size of the ovum; sometimes it has disappeared entirely, a short rudiment of the funis merely remaining to mark its previous existence.
"Should the embryo die (suppose in the first or second month) some days before the ovum is discharged, it will sometimes be entirely dissolved, so that when the secundines are delivered, there is nothing to be seen. In the first month the embryo is so small and tender, that this dissolution will be performed in twelve hours; in the second month, two, three, or four days will suffice for this purpose." (Smellie.)
Where the growth of the ovum proceeds after the destruction of the embryo, it increases very rapidly in size, much more so than would be the case in natural pregnancy, so that the uterus, when filled with a mole of this sort, is as large at the third month as it would be in pregnancy at the fifth.
Another form of mole is where the uterus is filled with a large mass of vesicles of irregular size and shape like hydatids, which appear to be the absorbing extremities of the veins of the chorion distended with a serous fluid; it is difficult to distinguish these from real hydatids; the more so, as Bremser asserts that he has occasionally met with real hydatids among them. Perhaps the mode of their attachment will in some degree assist the diagnosis: these vessicles, or hydatids of the placenta, as they have been called, are attached over a large portion of the uterus,--an arrangement we believe, not generally seen in real hydatids, which are mostly attached to a single stalk or pedicle. Indeed, it may be doubted if the masses of vesicles which are occasionally expelled from the uterus are ever true acephalocysts, as they are invariably connected with a blighted ovum, and are, therefore, formed as before observed, by a dropsical state of the venous radicles of the chorion.
A variety of other molar growths have also been enumerated by authors; in fact, "the term mole has been rather vaguely applied to almost every shapeless mass which issued from the uterus, whether this proved to be coagulated blood, detached tumours, or a blighted conception." (Churchill, on the Principal Diseases of Females, p. 153.) Thus a fibrinous cast of the uterus, which has been formed by a coagulum of blood, from which the colouring matter has been drained, has been called a fibrous mole: these, however, may easily be distinguished from real moles, which are invariably the product of conception: from inattention also to this circumstance, fungoid, bony, and calcareous tumours have been described as so many species of moles.[49]
Diagnostic symptoms. The diagnosis of a mole pregnancy is exceedingly obscure; in fact, for the first eight or ten weeks we know of no symptom by which we can distinguish it from natural pregnancy. As the death of the embryo is intimately connected with the first morbid changes in the condition of the ovum, and in most cases precedes them, the earliest symptoms which can excite our suspicions are those which indicate this event: thus we shall find that the face becomes pale and chlorotic, the digestion deranged, the breasts flaccid, with unusual lassitude, debility, and depression of spirits; many of the sympathetic affections which belong to early pregnancy, such as the morning sickness, nausea, &c. cease suddenly; in some cases, an attack of hæmorrhage comes on, and may be repeated several times, causing much loss of strength and exhaustion, and attended with a good deal of pain, more especially if the uterus be about to throw off its contents. In that form of mole where the parietes of the ovum have been thickened and lobulated by masses of coagulated blood, the uterus undergoes little or no more increase of size, but the mole, especially the hydatic, continues to grow rapidly; and the unusual increase in the size of the abdomen, as already mentioned, will be an additional reason for suspicion. In all cases, hæmorrhage sooner or later makes its appearance, the patient's health still farther declines, leucorrhoea comes on, followed by oedema of the feet, general breaking up of the health, and even incipient cachexia. Occasionally the discharge is excessively putrid and offensive. Where it is of the hydatic species, we can frequently ascertain its character by the expulsion of two or three hydatids which have separated from the main mass, or by the escape of some limpid colourless water resulting from the rupture of one or more of them. The expulsion of the mole itself clears up all doubts.
The amount of hæmorrhage will chiefly depend upon the extent of surface by which the mole is attached to the uterus: hence it is observed to be greatest in cases of hydatic mole, from the large size of the mass to be expelled: indeed, under these circumstances, it is frequently more profuse than hæmorrhage from detachment of the placenta. The process of the expulsion itself resembles that of an abortion: pain in the back, groins, and lower part of the abdomen comes on, with more or less discharge of blood; at length bearing down pains succeed, and the mass is expelled.
We cannot better describe the symptoms produced by the presence of a hydatic mole, and the mode of its expulsion, than by quoting a case from the work of Dr. Gooch, on some of the most Important Diseases peculiar to Women.
"I was sent for to ----, a few miles from London, to see a lady, who, having ceased to menstruate for one month, and becoming very sick, concluded that she was pregnant. The next month she had a slow hæmorrhage from the uterus, which had continued incessantly a month when I saw her: she kept nothing on her stomach. On examining the uterus through the vagina, its body felt considerably enlarged, and there was a round circumscribed tumour in the front of the abdomen, reaching from the brim of the pelvis nearly to the umbilicus. I saw her several times at intervals of a fortnight, during which the hæmorrhage and the vomiting continued unrelieved: the peculiarity about the case was the bulk of the uterus, which was greater than it ought to be at this period of pregnancy; it felt also less firm than the pregnant uterus, more like a thick bladder full of fluid. Eleven weeks from the omission of the menstruation, she was seized with profuse hæmorrhage; towards evening there came on strong expelling pains, during which she discharged a vast quantity of something which puzzled her attendants. The next morning I found her quite well--her pain, hæmorrhage, and vomiting, having ceased. I was then taken into her dressing-room, and shown a large wash-hand basin full of what looked like myriads of little white currants floating in red-currant juice. They were hydatids floating in bloody water."
The treatment previous to the expulsion of the mole should be gently alterative and tonic; the chylopoietic functions should be kept in regular action, and the strength sustained. When hæmorrhage comes on, we must be guided a good deal by the quantity lost, and by the effect which it has upon the pulse. Generally speaking, when the pulse has been a good deal reduced in strength and volume, we shall find the os uteri relaxed and dilated, and in all probability a portion of the mass protruding into the vagina, which may be hooked down by the fingers, and thus the expulsion of the whole mass facilitated. For farther details regarding the management of such cases, we must refer to the chapter on premature expulsion of the ovum, between the symptoms and treatment of which, and of mole pregnancy, there is a close analogy. The after treatment will always be a matter of considerable importance, and will, in a great measure resemble that in abortion or mis-carriage.
Patients who have suffered from a mole pregnancy generally have their strength seriously reduced and their health much broken: hence, they are liable to leucorrhoea, menorrhagia, or dysmenorrhoea, which entail a long series of troublesome and even dangerous affections, the recovery from which will be slow and difficult, requiring a long course of tonic medicines, and removal to the sea-coast or some watering-place where there are chalybeate springs.
V. EXTRA-UTERINE PREGNANCY
Tubarian, ovarian, and ventral pregnancy.--Pregnancy in the substance of the uterus.
The ovum when impregnated does not always quit the ovary and pass along the Fallopian tube into the uterus. It may remain in the ovary and become here developed; it may pass into the Fallopian tube and remain there; or from some defect in the action of the fimbriated extremity of this canal, it may escape into the cavity of the abdomen, and become attached to some of the viscera. Hence, extra-uterine pregnancy has been divided into three species, viz. graviditas tuberia, ovaria, and ventralis, according to the situation which the ovum takes. A fourth has been also described by M. Breschet, which he has called graviditas in substantia uteri, a modification probably of tubarian pregnancy.
This singular deviation from the usual course of conception is fortunately of rare occurrence, for few cases terminate favourably. If it be in the Fallopian tube or ovary, these become immensely distended into a species of sac or cyst, to the sides of which the placenta adheres: as the ovum increases, this at length gives way from excessive distension, and the patient usually dies from internal hæmorrhage. In ventral pregnancy, the sac is attached to the abdominal viscera, and is usually imbedded among the convolutions of the intestines: hence the duration of extra-uterine pregnancy will depend upon its situation; thus, if it be in the Fallopian tube, it rarely lasts beyond two months; whereas, ovarian pregnancy will continue for five or six months; on the other hand, in ventral pregnancy the foetus will not only be carried to the full term, but far beyond that period, amounting to several years.[50]
Although the uterus does not receive the ovum into its cavity as it does in natural conception, it nevertheless undergoes many of those changes which are known to take place in regular pregnancy. The layer of coagulable lymph, which is effused upon its internal surface, and which forms the membrana decidua of Hunter, is present, and the uterus undergoes a slight increase of volume. As the ovum increases, excruciating pains are felt in the lower part of the abdomen, coming on at irregular intervals, and of irregular duration; in some cases lasting for a short time, in others continuing for twenty-four hours. These attacks of pain are generally accompanied with very painful forcing and tenesmus, and not unfrequently with a discharge of bloody mucus from the vagina. In tubarian pregnancy, however, the case generally follows a much shorter course: the patient is suddenly seized with an acute pain in the lower part of the abdomen, followed by nausea and vomiting; she becomes faint and weak; the abdomen evidently increases in size (from effusion of blood into the cavity;) the debility becomes more alarming, and death quickly follows.
In ovarian pregnancy the fatal termination is merely postponed till a later period, during which the patient has to undergo attacks of most terrible suffering: at length, after a paroxysm more than usually severe, and frequently attended with the sensation of something giving way in the abdomen, faintings come on, speedily followed by death. During the attacks there is obstinate constipation, which is attended with painful and fruitless efforts to evacuate the bladder and rectum; the face is pale, and expressive not only of the most acute suffering, but of great anxiety and mental depression; nevertheless, in the intervals of the attacks she feels easy, and appears well and cheerful.
The termination of a ventral pregnancy is very different; after a time the foetus dies, and may either remain enclosed in the cyst for life, or it may be discharged in portions by means of an abscess, either through the intestines, uterus, vagina, or abdominal parietes. Cases have occurred where it has come away by the bladder; in the former case, where it is retained, it diminishes more or less in size, becomes hard and closely packed together, and, in some instances, encrusted with a layer of calcareous matter.
It is to our venerable friend, the late Dr. Heim, of Berlin, that we are indebted for much curious and interesting knowledge respecting extra-uterine pregnancy. Although the symptoms in the very early stages are so obscure as to render it nearly impossible to detect its presence, he has nevertheless observed some facts connected with it, which are peculiar, and deserve to be noticed. No morning sickness has been observed in cases of extra-uterine pregnancy, a circumstance which can easily be accounted for, if we bear in mind the causes of morning sickness in natural pregnancy: the patient could only lie on the affected side, and the abdomen was observed to swell irregularly, not in the same manner as in regular pregnancy.
In tubarian and ovarian pregnancy, the pain was in the pelvis, but in ventral pregnancy it occupied more or less the whole abdomen, the parietes of which were very tender upon pressure. In cases where the foetus died at an early period, the symptoms gradually disappeared after a time, especially when followed by the bursting of an abscess through the rectum or any other part. One of the most remarkable facts which Dr. Heim observed, was a peculiar whining tone of voice, with which the patient expressed her sufferings during a paroxysm of pain; so peculiar, that when once heard, the sound can never be mistaken. On several occasions Dr. Heim was enabled by means of this symptom alone to decide confidently as to the nature of the case the moment he entered the room, a fact which would appear scarcely credible had not the results of the cases proved the correctness of his assertion. A most interesting case of this sort occurred, which he pronounced to be ventral pregnancy, and when it had gone the full term gastrotomy was performed, a living child was extracted but the unfortunate mother perished: she could not be induced to submit to the operation until inflammation had come on, and she died in two days after.
It must always remain a matter of great obscurity as to the immediate causes of extra-uterine pregnancy, more especially of the ovarian and ventral species; and the more so as we are still ignorant of the mechanism by which the fimbriated extremity of the Fallopian tube grasps the ovary immediately over the impregnated vesicle of de Graaf at the moment of conception. In many cases we are inclined to think that this function of the Fallopian tube is destroyed by adhesions between it and the ovary, a circumstance of not uncommon occurrence; but from the alteration in the shape and size of these parts, as also from the extensive adhesions which are usually found after death, in such cases it will ever be difficult, and perhaps impossible, to prove it.
The treatment of extra-uterine pregnancy must be chiefly guided by the prevailing symptoms: where any portion of the abdomen is very tender to the touch, leeches and warm fomentations will be required; the pain during the attacks can only be alleviated by frequently repeated opiates; and constipation must be carefully guarded against by laxatives and enemata between the paroxysms. Where an effort is made by nature to discharge the foetus by means of an abcess, the case will require all our care to sustain the powers of the system through a long protracted struggle. Portions of the foetus come away from time to time, and if the exit afforded them be by way of the intestine, the suffering produced is very great, particularly when any of the larger bones are passing. The presence of such a mass of semi-decomposed animal matter in the abdomen is of itself sufficient to injure the general health materially: hence it is that patients, during the process of expulsion, suffer greatly from severe attacks of fever, which recur from time to time. Where the abscess opens through the abdominal parietes, the whole is completed with much greater ease and safety to the patient: in some instances the tumour has been opened, and a foetus with a large quantity of putrid pus has been removed. (Medical Obs. and Inquiries, vol. ii. p. 369.)
A case of ventral pregnancy has recently come under our care, a short account of which will enable the reader to understand the subject better than a mere enumeration of symptoms; the more so as we believe it to have been the first case of extra-uterine pregnancy in which the stethoscope has been used.
The patient, æt. 32, and the mother of four children, was admitted, May 26, 1837, into St. Bartholomew's Hospital, under Dr. Latham, who kindly consigned her to our charge. She considers herself to be six months advanced in pregnancy; is continually suffering from attacks of acute pain in the lower part of the abdomen, both at the sides and front, causing her to moan from its great severity; this is accompanied with a constant dragging pain on the right side, and in the loins: the attacks of abdominal pain go off at intervals, leaving her comparatively easy. She is pale, with an anxious expression of face. Pulse 120, and firm. Tongue moist. Bowels very constipated.
The abdomen is as large as in common pregnancy at the sixth month, but does not present the same uniform distension, being irregularly shaped. At the left hypogastrium is a soft tympanitic prominence of considerable extent, and appears, from its feel and also from auscultation, to consist of a large portion of the intestines pushed over to that side: at the inner edge of this tumour a solid mass, as large as the head of a six months' foetus, can be felt. Between this and the median line of the abdomen, and half way between the pubes and umbilicus, a small hard knob-like and moveable prominence is felt immediately beneath the abdominal parietes, and intensely painful to the touch. From this point, quite to the right side, the abdomen has a solid irregular feel; below this to the symphysis pubis, a very loud souffle is heard, synchronous with the mother's pulse, having all the characters of the uterine souffle in common pregnancy except its extraordinary loudness. Its limits, superiorly, are remarkably defined; below a transverse line, drawn half way between the umbilicus and pubes, it is heard in full strength, whereas, immediately above it the sound ceases: it is also heard some way to the right side. At the upper part of the right iliac region two ridge-like prominences, like the extremities of a child, may be felt close beneath the abdominal parietes. No trace of foetal pulsation can be heard over any part of the abdomen, although it has been carefully ausculted round to the loins: it was however distinctly heard the day before we saw her, by two gentlemen who are proficients in the use of the stethoscope, and whom we consider fully capable of judging in such a case.
On examining per vaginam, the os uteri is found high up and backwards, barely within reach. Its edges are thick, soft, and closed; the cervix is short, and seems less than half an inch. The anterior portion of the inferior segment of the uterus feels somewhat firm and full, as if there was something in the uterus. We were confirmed in this respect by our friend, Dr. Nebel, jun., of Heidelberg, who was on a visit to this country at the time, and who examined the case with us. He was at first induced to suppose that it was the head. We considered that it was the uterus more or less anteverted, the fundus being pressed forwards and downwards, and the os uteri backwards, by the extra-uterine cyst above; farther examinations tended to confirm this view.
She states that the catamenia appeared last in November, during the middle of which month she was attacked with inflammation of the bowels, for which she was treated, and soon afterwards began to have the violent attacks of pain of which she now complains. She felt the child move at the usual time; it evidently formed the mass which occupies the lower part of the abdomen, and its movements appeared unusually close to the surface. During the last few days they have ceased altogether. The above-mentioned attacks of pain have continued to recur ever since at short intervals and with increasing severity.
As leeches had been applied without relief, and as the pulse was quick and hard, she was ordered to be bled to eight ounces, and to take half a grain of morphia immediately.
June 2.--Has been in constant suffering, in spite of leeches and morphia; bowels obstinately constipated, but moved at length by repeated injections and doses of house medicine. Has not felt the motions of the child since the intestines have become tympanitic: still, however, the mass can be felt lying across the abdomen, half-way between the pubes and umbilicus, commencing from about three inches to the left of the median line, and extending to about four inches on the opposite side. On the left side it feels firm and rounded, and so superficial, that it can almost be grasped through the abdominal integuments. Face very pale and anxious. Pulse 120.
June 10.--Was easy and free from pain when we first saw her: the souffle is heard over a smaller extent; in the centre of the space where it is heard it is as remarkably loud as ever, but it gradually becomes indistinct towards the circumference. As she was able to rise we examined her standing: the os uteri is exceedingly high up to the left sacro-iliac symphysis, so that it can scarcely be reached; the cervix is short, the lips somewhat larger than usual, and the whole very firm and immoveable. The anterior portion of the uterus, to be felt through the vaginal parietes, is somewhat firmer and larger than usual: on pressing the tumour in the left hypogastrium, this appeared to lie altogether anterior to the uterus. Little motion is communicated to the os uteri when this is moved.
June 20.--Has been in much suffering since last report; much emaciated; complains of a fetid taste in the mouth; bowels inclined to be purged; stools of a whitish purulent appearance; tongue clean; pulse tolerably natural; has continued to pass portions of fibrinous matter from the vagina, mixed with bloody mucus, since last report. The hard globular swelling at the left side of the abdomen is more distinct at times: the hand can almost pass round it: it has the precise feeling of the head; the mass which lies across the abdomen is also more distinct: the souffle is heard over a much smaller space and is diminished in strength.
June 27.--Much the same, except that, after severe bearing down and tenesmus, she has passed a considerable quantity of blood from the rectum and vagina. The little prominences on the right side, presumed to be the extremities, are remarkably distinct, like two heels or knees.
July 18.--No material change has taken place since last report; she has suffered from irregular attacks of pain, and has had repeated discharges of blood from the vagina, which always give relief; is weaker than usual, and feels exhausted from the continued character of the pain; abdomen less swollen; the globular mass on the left side is lower and much nearer to the median line; the little prominences on the right are also lower, and nearer the median line; the whole mass appears much more compressed together and nearer to the pubes; it is extremely painful on the left side, and at the most painful spot the skin is red and inflamed; the bowels, appetite, &c. are natural; pulse feeble, but regular; scarcely any trace of souffle to be heard.
Shortly after this she left the hospital, and for some time continued to enjoy tolerable health, occasionally suffering from severe paroxysms of abdominal pain; the abdomen diminished considerably in size, and the various prominences became indistinct.
In May, 1839, she was again admitted in a state of great exhaustion from constant severe pain. The abdomen had diminished still more, and a portion of the mass had descended between the uterus and rectum; the constipated bowels were moved with great difficulty, but with much relief. The symptoms gradually diminished, and she was discharged in the first week of the following August.
In January, 1840, she returned to the hospital, all her former sufferings being greatly aggravated. The abdomen had subsided still farther; early in February she passed a quantity of putrid purulent matter from the rectum, after which the abdomen diminished considerably. The pain appeared to be chiefly situated in the upper part of the rectum, accompanied with severe bearing down, and on examining per vaginam the mass was felt deep at the posterior part of the pelvic brim: the debility and emaciation increased, and she died early in February. Our notes of the post mortem examination were as follows:--
Much emaciated, abdomen concave, but on pressing it the tumour can be felt at the brim of the pelvis. On opening the abdominal cavity, the mass was found adhering firmly to the neighbouring intestines, and on the right side to the soft linings of the pelvis: it was of an irregular form, with spots of livid vascularity in different parts: on the upper and left side of it, fetid purulent matter was seen exuding from a small orifice. The uterus was below, its fundus pushed over to the left side. On separating its adhesions, and attempting to raise the sac from the pelvis, the half-softened parietes gave way, and the decomposed putty-like mass of the foetus became visible; the cranial bones were at the left side; the feet were still distinct on the right side; the whole was immersed in a quantity of thick fetid pus, and there were no traces either of umbilical cord or placenta.
Cases of ventral pregnancy have been recorded where the child has remained in the mother's abdomen without producing any dangerous symptoms, and where she has again become pregnant in the natural way. The earliest instance of this sort was recorded so long ago as by Albucasis. A very interesting case of this nature is described by Dr. Bard of New York. (Med. Obs. and Inquiries, vol. ii. p. 369.) It was the patient's second pregnancy; at the end of nine months she had pains, which after a time went off; the tumour gradually diminished somewhat, and in about five months after she conceived again, and in due time was delivered, after an easy labour, of a healthy child. "Five days after delivery she was seized with a violent fever, a purging, suppression, pain in the tumour, and profuse fetid sweats:" an abscess formed in the abdomen, which was opened, and a vast quantity of extremely fetid matter was discharged; the opening was enlarged, and a foetus of the full size was extracted. Dr. Bard "imagined the placenta and funis umbilicalis were dissolved in the pus, of which there was a great quantity."
It becomes a question of deep interest whether it be really possible to save the patient and the child in cases of ventral pregnancy, by performing gastrotomy. The separation of the placenta from the walls of the cyst can only be effected with much difficulty and hazard; indeed, we are at a loss to conceive how it can be removed with any degree of safety, where the child has been found alive. The attachment in these cases was more than usually firm, and it has been left to undergo that process of solution which has been described in Dr. Bard's case. In all the cases where gastrotomy has been performed some time after the child's death, little or no trace of the placenta has been found, but in its place a quantity of ill-conditioned purulent matter, which was excessively fetid.
The fourth species of extra-uterine pregnancy, which M. Breschet has described as taking place in the substance of the uterus, is of very rare occurrence, four cases only having been recorded by him. (Med. Chir. Trans. vol. xiii.) M. Breschet has attempted a variety of explanations of this singular anomaly, but without success; and from the circumstance of the cyst having always been found situated in the fundus to one side, the Fallopian tube of which was closed at its uterine extremity, we think that there can be little doubt of its having been a modification of tubarian pregnancy, where the ovum had been obstructed at that portion of the Fallopian tube where it passes obliquely through the wall of the uterus: in one case the tube appears to have given way at this part, and the ovum to have insinuated itself between the uterus and peritoneum. In these cases the sac ruptured at about the same period as in tubarian pregnancy, except in one instance, where she went five months. A rather inexplicable case of extra-uterine pregnancy has been recorded by Mr. Hay, of Leeds (Med. Obs. and Inquiries, vol. iii.,) where a full grown foetus was found enclosed in a large sac, which filled the abdominal cavity, and which communicated inferiorly with the uterus. On tracing the umbilical cord, "we were led," says Mr. Hay, "to a large aperture in the right side of the inferior globular sac already mentioned, from which that which contained the foetus seemed to have its origin. This inferior sac we now found to be the uterus, containing a very thick placenta, which adhered very firmly to about three-fourths of its internal surface, having the navel string attached to its centre, and this centre corresponded nearly with the centre of the fundus uteri. The placenta filled up the greatest part of the aperture of communication between the uterus and sac. The Fallopian tube on the left side was very small; the place of that on the right was occupied by the beginning or orifice of the sac." (Op. cit.)
This would seem to have been a case of pregnancy in the substance of the uterus, and where a portion of the ovum had burst its way into the cavity of the uterus lined with decidua, to which it adhered; the other portion, containing the embryo, distended the uterine parietes in a contrary direction, and thus formed the large sac which communicated with the cavity of the uterus.
VI. RETROVERSION OF THE UTERUS
History.--Causes.--Symptoms.--Diagnosis.--Treatment.--Spontaneous terminations.
During the earlier months of pregnancy the uterus is liable, although rarely, to a peculiar species of displacement, called retroversion, in which the fundus is forced downwards and backwards into the hollow of the sacrum, between the rectum and posterior wall of the vagina, and its os and cervix are carried forwards and upwards behind the symphysis pubis.
Retroversion of the uterus appears to have been known to the ancients, as we find it alluded to by Hippocrates (De Nat. Mulieb. sect. 5.) and Philumenus (Histoire de la Chirurg. par Dujardin and Peyrhille, t. ii. p. 280.) Oetius, who has quoted the works of the celebrated Aspasia, describes this displacement of the uterus very exactly, and gives rules for introducing two fingers into the rectum, in order to remedy it. Rod. a Castro, who wrote in the sixteenth century, in his work on the diseases of women, quotes what Hippocrates had written on the subject of this displacement; and it is astonishing that no farther notice was taken of it until the eighteenth century, when it excited considerable attention among accoucheurs. (Martin le Jeune, p. 137.) Gregoire appears to have been the first who gave a good description of it; his pupil, Mr. W. Wall, on his return to England, met with what he considered to be a case of this displacement, and not being able to restore the uterus to its natural position, requested the advice of Dr. W. Hunter. On passing his finger between the os uteri and symphysis pubis, and thus removing, in some degree, the pressure upon the neck of the bladder, a considerable quantity of urine was discharged, but he was unable to return the uterus to its natural situation, and the patient gradually sunk. The bladder was found immensely distended; the lower part of it, "which is united with the vagina and cervix uteri, and into which the ureters are inserted, was raised up as high as the brim of the pelvis by a large round tumour, (viz. the uterus,) which entirely filled up the whole cavity of the pelvis. The os uteri made the summit of the tumour upon which the bladder rested, and the fundus uteri was turned down towards the os coccygis and anus." (Medical Obs. and Inquiries, vol. iv. 404.)
Causes. This displacement may also occur in the unimpregnated state, either from the fundus being pushed into that position by some morbid growth, or where this effect has been produced by the violent pressure of the abdominal muscles in lifting heavy weights, under circumstances where the uterus has been larger and heavier than usual;[51] but it is in the early months of pregnancy that it is most likely to happen, because now the fundus is both larger and heavier than before, and, therefore, more liable to be affected by the pressure of the intestines and abdominal muscles, and has not yet attained a sufficient size to prevent its undergoing this displacement in the pelvis: this period is about the third or fourth month, often before it, but never after it. (Burns's Anatomy of the Gravid Uterus, p. 17.)
It has been supposed by many authors, especially Dr. Burns, that distension of the bladder is, in many instances, the immediate cause of retroversion, owing to the intimate connexion which exists between the lower part of the uterus and this organ, inasmuch, "that whenever the bladder rises by distension, the uterus must rise also." In the later editions of his work on the principles of midwifery, he has considerably modified this opinion, and from careful examination of the parts in situ, in the third month, is not disposed to consider the distension of the bladder as the cause, but the effect of retroversion. In every case which has come under our own observation, the bladder has not been distended until the retroversion had taken place, in consequence of which the os and cervix uteri had been tilted up behind the symphysis pubis, and having thus compressed its neck had caused the difficulty in passing water.[52] Whenever any force is applied to the fundus uteri at this period of pregnancy, either from external violence, or the action of the abdominal muscles pressing the intestines and bladder against it, it will be pushed against the rectum, in which case the rectum will be flattened at that part against which the fundus rests; and if any mass of fæculent matter be passing along the intestine, its course will be obstructed at this point, and the rectum quickly become distended with an accumulation of fæces above, by which means the fundus will not only be prevented from rising, but in all probability be forced still lower down. If the force which has originally pushed the fundus backwards be of sufficient degree and duration to carry it past the promontory of the sacrum, the increase of space which it will meet with in the hollow of the sacrum, and the straining efforts which are induced by the displacement itself, contribute powerfully to complete the mischief, and to bring the fundus so low into the pelvic cavity as at length to turn it nearly upside down.
As soon as the fundus of the uterus is pressed with any degree of force against the posterior parietes of the pelvis, its os and cervix will be directed forwards and upwards against the symphysis pubis, and from the pressure which they exert against the neck of the bladder, the patient either experiences complete retention of urine, or, at any rate, considerable difficulty in passing it; hence, therefore, we find, that where retroversion has come on suddenly, the patient is generally sensible of the pain produced by the displacement, before she has experienced any difficulty in evacuating the bladder.
A modern French author of great experience, (Martin le Jeune, p. 178,) in enumerating the causes of retroversion, appears to take a similar view of the subject, and places retention of urine very far down in his list. "Sudden and violent contractions of the abdominal muscles and diaphragm in attempting to vomit, to evacuate the bowels or bladder, or to lift heavy weights; the throes during an abortion at an early period of pregnancy; strong mental emotions; retention of urine; tumours in the neighbourhood of the fundus, which by their weight or pressure force it backwards towards the sacrum, are the causes which may produce a retroversion of the uterus."
Retroversion may also come on gradually, from "the uterus remaining too long in that situation which is natural to it when unimpregnated, namely, with its fundus inclined backwards. This may depend on various causes; such as too great width of the pelvis, or the pressure of the ileum full of fæces on the fore part of the uterus. In this case the weight of the fundus must gradually produce a retroversion, and she will be sensible of its progress from day to day." (Burns's Anat. of the Gravid Uterus. p. 18.)
It will thus be seen how peculiarly liable the uterus is to retroversion during the early months of pregnancy. At this time, the fundus is not yet free from the weight of the superincumbent coils of intestine; and if from any cause its ascent out of the pelvis be delayed beyond the usual time, its liability to retroversion is still farther increased; for, not only does the size of the fundus press it still farther backward, but any sudden contractions of the abdominal muscles, or external violence, act upon it with increased effect.
The symptoms of this displacement are as follow:--the patient is seized with violent pain, bearing down, and sense of distension about the hollow of the sacrum, with a feeling of dragging and even tearing about the groins, produced by the violent stretching of the broad and round ligaments; the bearing down is sometimes so severe and involuntary as to resemble labour pains, and cases have occurred where it has been mistaken for labour. With all this she finds herself unable to pass fæces or urine, from the pressure of the fundus upon the rectum and of the os uteri upon the neck of the bladder. Upon examination per vaginam, the altered position and form of this canal instantly excite our suspicion: instead of running nearly in a straight direction backwards and somewhat upwards, it now takes a curved direction upwards and forwards behind the symphysis pubis; the hollow of the sacrum is occupied with the globular and nearly solid mass, (the fundus uteri,) which is evidently behind the vagina, the posterior wall of this canal being felt between it and the finger; behind the symphysis pubis, the vagina is more or less flattened, and its anterior wall put violently upon the stretch, so much so that, according to Richter, the orifice of the urethra is sometimes dragged up above the pubic bones, (Anfangsgründe der Wundarztneikunst, vol. ii. p. 45:) the os uteri is found high up behind the symphysis pubis, and in most cases can be reached, although with much difficulty; sometimes we shall be able to reach the posterior lip only, which is now the lowest: but "if the retension of urine has been of some duration, it will be impossible to reach the os uteri above the pubic bones with the finger. On examining per rectum, we shall feel the same tumour pressing firmly upon it, and preventing the farther passage of the finger, thus proving that the tumour is situated between the rectum and the vagina; for, in such cases, the bladder forms a considerable swelling below it, and prevents the finger from passing up." (Op. cit.)
"The uterus being situated in the centre of the pelvis, between the rectum and bladder, its retroversion cannot take place without deranging the functions of these organs: the symptoms thus produced come on rapidly when the displacement is sudden, slowly when it is gradual. Their severity is in proportion to the size of the uterus, the degree of retroversion, its duration, and the various circumstances which increase the impaction of the uterus in the cavity of the pelvis: they also determine the degree of inflammation and gangrene of this organ and the neighbouring parts." (Martin le Jeune, p. 178.) Hence we frequently observe in the earlier stages of retroversion, before the displacement has become complete, that the patient is able to relieve the bladder to a certain extent, although very imperfectly, and that with some difficulty; a slight dribbling of urine continues to a very advanced stage, when the bladder is enormously distended, and upon the point of bursting: this is not so much the case with the rectum, the passage of fæces being generally completely obstructed at an early period, partly from the pressure of the fundus against it, and partly from the solid nature of its contents. "When such suppressions once begin they aggravate the evil, not merely by causing pain, but by occasioning a load of accumulated fæces in the abdomen above the uterus, which presses it still lower into the cavity of the pelvis, at the same time that the distension of the bladder in this state draws up that part of the vagina and cervix uteri with which it is connected, so as to throw the fundus uteri still more directly downwards." (Dr. W. Hunter, Med. Obs. and Inquiries, vol. iv. p. 406.) These conditions of the bladder and rectum, and the retroversion of the uterus, act reciprocally as cause and effect; for the continuance of the distension of the bladder and the descent of the fæces from the part of the intestine above the obstruction, must elevate still more the os uteri, and depress to a still greater degree the fundus. The retroversion, on the other hand, increases the affection of the bladder and rectum, from which the principal danger of the disease arises. (Burns's Anat. of the Gravid Uterus.)
The diagnosis of retroversion is, generally speaking, not very difficult, the os uteri tilted up behind the symphysis pubis, and the fundus forced downwards and backwards between the vagina and rectum, are sufficiently characteristic of this displacement. We cannot agree with Dr. Dewees that it can easily be mistaken for prolapsus uteri; in cases of sudden prolapsus which has been caused by great violence, there will be, it is true, intense pain in the pelvis, with sensation of forcing and tearing in the direction of the broad and round ligaments; there will also, probably, be inability to evacuate the rectum and bladder; but then the examination, per vaginam, will present such a totally different condition of parts as to preclude all possibility of mistake: the vagina merely shortened, neither altered in direction or form; the os uteri at the lower part of the tumour, which is in the vagina; the mobility of the tumour itself, all conspire to show that the case is one of prolapsus not retroversion.
We occasionally meet with cases of retroversion where the os uteri, although carried more or less upwards and forwards, is not forced, to that extreme height behind the symphysis pubis as is usually observed. Instead of looking towards, or rather above, the symphysis, the os uteri itself looks downwards, the neck or lower part of the body of the uterus being bent upon the fundus like the neck of a retort.[53] If, under such circumstances, we cannot satisfy ourselves as to the existence of pregnancy, we might easily be led to form an erroneous diagnosis, and to conclude that some tumour had forced itself down into the hollow of the sacrum, between the rectum and vagina, and had thus pushed the uterus upwards and forwards, above the brim of the pelvis. An extra-uterine ovum of the ventral species may occupy this situation, but its slow and gradual growth, its greater softness and elasticity, and the slight degree of uterine displacement produced in its early stages, would enable us to ascertain its real character. The same would hold good to a certain extent with an ovarian tumour, although in all probability this would produce more or less displacement of the uterus to one side.
The danger in retroversion of the uterus chiefly arises from the distension or rupture of the bladder, and from the gangrenous inflammation which may then take place, not only in it, but also in the uterus and neighbouring parts. The very displacement itself is sometimes immediately attended by alarming symptoms, such as faintness, vomiting, cold sweats, weak irregular pulse, as seen in cases of inversion or strangulated hernia. In some cases the suffering at first is but trifling, and only increases in proportion to the degree with which the bladder is distended.
Retroversion not reduced may experience a spontaneous termination in two ways, either by abortion being excited, after which the uterus, now diminished in size, returns to its natural situation, or it may go on to increase in this position until a more advanced period of pregnancy, when if it be not capable of being replaced by the action of the pains, sloughing takes place in the fundus, and the foetus is discharged, either by the rectum or vagina, as in a case of ventral pregnancy.
In the treatment of retroversion of the uterus, our object should be, first, to remove the accumulated contents of the bladder and rectum, and secondly, to endeavour to restore the uterus to its natural position. The relief of the bladder must be our first aim, for here is the greatest source of danger. The elastic catheter should always be used in these cases, and greatly facilitates the operation of drawing off the water. The altered direction of the urethra must be borne in mind; in many cases we must pass the catheter nearly perpendicularly behind the symphysis pubis: by pressing the uterus backwards, we shall diminish its pressure upon the urethra, and thus enable the catheter to pass with great ease.[54]
"The catheter should be employed occasionally, and the bowels emptied daily, either by medicines of a mild kind, or by injections: if this plan do not succeed in restoring the fundus, we should then consider the propriety of mechanically replacing it. To aid us in our judgment, we should consider, first, the period of gestation; secondly, the degree of development the uterus has undergone; thirdly, the nature and severity of existing symptoms. The period of gestation ought almost always to influence our conduct in this complaint, and we may lay it down as a general rule, the nearer that period approaches four months, the greater will be the necessity to act promptly in procuring the restoration of the fundus: the reason for this is obvious, every day after this only increases the difficulty of the restoration from the continually augmenting size of the ovum. The degree of development should also be taken into consideration, as some uteri are much more expanded at three months, than others are at four. The extent or severity of symptoms must ever be kept in view; as, for instance, where the suppression of urine is complete, and not to be relieved by the catheter, in consequence of the extreme difficulty and impossibility to pass it: here we must not temporize too long, lest the bladder become inflamed, gangrenous, or burst; for the bladder, from its very organization, cannot bear distension beyond a certain degree, or beyond a certain time, without suffering serious mischief." (Dewees, Compend. Syst. of Midwifery, 6th Ed. § 276.) Our next step should be to relieve the rectum of its contents by emollient enemata; this is not always very practicable, owing to the flattened state of it: hence a glyster pipe of the ordinary sort is too large, and meets with much resistance; in such cases it will be desirable to use a common elastic catheter, or thin elastic tube without an ivory nozzle, which will, therefore, better adapt itself to the form of the bowel. A few doses of a saline laxative should be given to render the contents of the bowels more fluid, and the enemata repeated until a sufficient evacuation has been effected. Where the retroversion is not of long standing, and the patient not far advanced in her pregnancy, these means are generally sufficient; and the uterus, in the course of a few hours, will return to its natural position, either spontaneously or with very slight assistance. Where, however, the uterus is large and firmly impacted, where it has already been displaced more than twenty-four hours, where the suffering from the very beginning has been acute, independently of that produced by the distended bladder, we cannot expect that the spontaneous replacement will follow the mere removal of the accumulated urine and fæces; nor must the uterus be suffered to remain in the state of retroversion, as not only will its pressure on the neighbouring parts produce serious mischief, but from the increasing growth of the ovum, every day will add to the difficulty of moving it out of the pelvis. In determining upon the artificial reposition of the uterus, it must be borne in mind that the chief difficulty is to raise the fundus above the promontory of the sacrum, for if we can once succeed in gaining this point, the rest will follow of itself; our object, therefore, will be to raise the fundus upwards and forwards, in a direction towards the umbilicus of the patient. To effect this purpose various methods have been proposed: some have recommended that, with a finger in the vagina, we should hook down the os uteri, while with one or two fingers of the other hand passed into the rectum, we endeavour to push the fundus out of the hollow of the sacrum. Some object to any attempt being made through the rectum. (Naegelé, Erfahrungen und Abhandlungen, p. 346.) We agree with Richter in the utter inutility of attempting to bring down the os uteri; in most instances we can barely reach it with the tip of the finger, and even were we able to lay hold of it, we should run little or no chance of moving it so long as the fundus is impacted in the hollow of the sacrum. The fingers which are in the vagina must endeavour to raise the fundus, and in doing so may be assisted by one or two fingers in the rectum according to circumstances; the very effort to press per vaginam against the fundus, necessarily puts the anterior wall of the vagina upon the stretch, and thus tends of itself to bring the os uteri downward.[55] In all cases where the reposition of the uterus is at all difficult, Professor Naegelé recommends the introduction of the whole hand into the vagina, by which we gain much greater power. Under such circumstances it is desirable to place the patient upon her knees and elbows, as in a difficult case of turning, because now the very weight of the fundus will dispose it to quit the pelvis. The only difficulty which we shall meet with in thus using the whole hand, is the violent straining and efforts to bear down, which the patient is involuntarily compelled to make, from the presence of the hand in the vagina. Dr. Dewees in such cases very judiciously recommends bleeding to fainting, not only to obviate these efforts which would have prevented our raising the fundus, but also to relax the soft parts as much as possible. In our attempts to replace the uterus we must not be discouraged by finding that at first no impression is made upon it; by degrees it will begin to yield, and with a little more perserverance we shall be enabled to push the fundus above the promontory of the sacrum. (See Mr. Hooper's Case, Med. Obs. and Inquiries, vol. v. p. 104.)
Where the pain in the pelvis indicates considerable pressure of the uterus upon the surrounding parts, arising probably from swelling and engorgement with blood, the result of vascular excitement, a smart bleeding will afford great relief; the size and firmness of the tumour are diminished, the soft parts in which it is imbedded are relaxed, the general turgor and sensibility are alleviated, and if the moment of temporary prostration which it has produced be seized upon by the practitioner, he will find that the reposition of the uterus, which was before nearly impracticable, is now comparatively easy.
Where, however, the circumstances of the case are so unfavourable, and the fundus so firmly impacted in the hollow of the sacrum as to resist the above-mentioned means, Dr. Hunter proposed, "Whether it would not be advisable, in such a case, to perforate the uterus with a small trocar or any other proper instrument, in order to discharge the liquor amnii, and thereby render the uterus so small and so lax as to admit of reduction." (Med. Obs. and Inq. vol. iv. p. 406.) Dr. Hunter did not live to see this plan carried into execution. In latter years, several cases of otherwise irreducible retroversion have thus been successfully relieved: the remedy, it is true, necessarily brings on premature expulsion of the foetus sooner or later. Under such circumstances, this result cannot be made a ground of objection. In cases of such severity as to require paracentesis uteri, there can be little or no chance of the foetus being alive; and even if it were, of what avail would this be, when almost certain death is staring the mother in the face, unless relieved by this operation?[56] Puncture of the bladder has also been tried where the urine could not be drawn off.[57]
Cases have now and then been met with where the retroversion of the uterus has continued to an advanced period of pregnancy without producing serious injury to the patient: Dr. Merriman has even recorded some, where the uterus has continued in this state up to the full term. Some of these had been actually published as cases of ventral pregnancy; but for their history he has shown that they evidently were cases of retroversion: the patient had been subject to occasional suppressions of urine and difficulty in passing fæces; these symptoms had gradually diminished as pregnancy advanced; the os uteri could not be felt, or, if it were capable of being reached, was found high up behind the pubes, the head of the child forming a large hard tumour between the rectum and vagina. The condition of the vagina afforded strong evidences of the nature of the complaint: on introducing the finger in the usual direction, it was stopped, as if in a cul-de-sac: but on passing it forwards, the vagina was found pulled up behind the symphysis pubis. In some of these cases the uterine contractions gradually restored the fundus to its natural position: the os uteri descended from behind the symphysis, and the child was born after long protracted suffering; in others, which have been mistaken for ventral pregnancy, the fundus has inflamed and ulcerated, and the child has been gradually discharged by piecemeal.
VII. DURATION OF PREGNANCY
There are few questions of great importance and interest respecting a subject under our daily observation, about which such uncertainty and so much diversity of opinion exists, as the duration of human pregnancy; and yet, as is the case with the diagnosis of pregnancy, upon a correct decision frequently depend happiness, character, legitimacy, and fortune. In like manner it frequently happens, that the data upon which we have to found our opinion are exceedingly doubtful and obscure; and to increase the difficulties of the investigation still farther, we have not uncommonly to contend with wilful deception and determined concealment.
The duration of pregnancy must ever remain a question of considerable uncertainty so long as the data and modes of calculation vary so exceedingly. "Some persons date from the time at which the monthly period intermits; others begin to calculate from a fortnight after the intermission; some reckon from the day on which the succeeding appearance ought to have become manifest; some are inclined to include in their calculation the entire last period of being regular; and others only date from the day at which they were first sensible of the motions of the infant."[58]
"A good deal of the confusion on this point seems to have arisen from considering forty weeks and nine calendar months as one and the same quantity of time, whereas, in fact, they differ by from five to eight days. Nine calendar months make 275 days, or if February be included, only 272 or 273 days, that is thirty-nine weeks only instead of forty. Yet we constantly find in books on law, and on medical jurisprudence, the expression "nine months or forty weeks." Another source of confusion has evidently had its origin in the indiscriminate use of lunar and solar months, as the basis of computation in certain writings of authority."[59]
It is owing to this uncertainty that a considerable latitude has been allowed by the codes of law in different countries for the duration of pregnancy, in order to prevent the risk of deciding where the data are so uncertain.
Experience has shown that the ordinary term of human pregnancy, wherever it has been capable of being determined with any degree of accuracy, is 280 days or forty weeks; and this period seems to have been generally allowed even from the remotest ages. As, however, it is so difficult to fix the precise moment of conception, it has been customary in different countries to allow a certain number of days beyond the usual time; thus the Code Napoléon ordains 300 days as the extreme duration of pregnancy, allowing twenty days over to make up for inaccuracy of reckoning. In Prussia it is 301 days, or three weeks beyond the usual time. In this country the limit of gestation is not so accurately determined by law, and therefore gives rise occasionally to much discrepancy of opinion.
The grand question which this subject involves, is, whether a woman can really go beyond the common period of gestation. A great number of authors have considered that the partus serotinus, or over-term pregnancy, is perfectly possible; but by far the majority use such an uncertain mode of reckoning that little confidence can be placed in them.
Two questions here arise, the determining of which will greatly assist us in forming a correct view of this intricate subject, viz. first, what has been the duration of those cases of pregnancy where the moment of conception has been satisfactorily ascertained? secondly, what are the causes which determine the period at which labour usually comes on?
The circumstances under which it happens that we are able to ascertain the precise date of impregnation occur so rarely, that it is nearly impossible to collect any considerable number of such cases. Three have occurred under our own notice, in which there could be little doubt as to the accuracy of the information given, and in each of these the patient went a few days short of the full period. One, a case of rape, was delivered on the 260th day; in the two others, sexual intercourse had only occurred once; in one case she went 264, in the other, 276 days. We could have mentioned several others, but where even the slightest shadow of doubt as to their accuracy has existed, we have rejected them as inconclusive.
The mode of calculating the duration of pregnancy, which is ordinarily adopted, viz. by reckoning from the last appearance of the catamenia, although the chief means which is afforded us for so doing, is nevertheless much too vague and uncertain to ensure a decided result; for although it is a well-known fact, that conception very frequently takes place shortly after a menstrual period, there can be no doubt that it is liable to occur at any part of the catamenial interval, and particularly so shortly before the next appearance: hence, by this mode of reckoning, we are not more justified in expecting labour in nine months time from the last appearance of the catamenia, than at any part of the interval between this and what would have been the next appearance.
Dr. Merriman, who has devoted much attention to this intricate but important subject, says, "When I have been requested to calculate the time at which the accession of labour might be expected, I have been very exact in ascertaining the last day on which any appearance of the catamenia was distinguishable, and having reckoned 40 weeks from this day, assuming that the two hundred and eightieth day from the last period was to be considered as the legitimate day of parturition" (Synopsis of Difficult Parturition, p. xxiii. ed. 1838;) and gives a valuable table of "one hundred and fifty mature children, calculated from, but not including, the day on which the catamenia were last distinguishable." Of these,
5 were born in the 37th week, 16 --- in the 38th, 21 --- in the 39th, 46 --- in the 40th, 28 --- in the 41st, 18 --- in the 42nd, 11 --- in the 43rd;
so that about one-third were born three weeks after the 280 days from the last appearance of the catamenia; a circumstance which is perfectly easy of explanation, from what we have just observed, without the pregnancy having overstepped its usual duration: in other words, it would appear that 28 of these cases had conceived one week, 18 two weeks, and 11 three weeks after the last appearance of the catamenia.
The question therefore of the partus serotinus; as far as these data are concerned, remains still undecided: of 10 cases which have occurred under our own immediate notice, where the patients determined the commencement of their pregnancy from other data than the last appearance of the catamenia, a similar variation was observed, viz. that nearly one-third went beyond 280 days, six of these individuals reckoned from their marriage, and four from peculiar sensations connected with sexual intercourse, which convinced them that impregnation had taken place: of these, seven did not go beyond the 280th day, two having been delivered upon that day, and three went beyond it, viz. to the 285th, 288th, and 291st days: the two former reckoned from their respective marriages; the latter, who went 291 days, from her peculiar sensations.
The calculation from the date of marriage is liable to the same objections as that taken from the last appearance of the catamenia; for if it had been solemnized (as is usually the case where it is possible) shortly after a menstrual period, and if conception did not take place until a fortnight or three weeks afterwards, the patient's pregnancy would thus have appeared to have lasted so much longer than the natural term. The case, however, which is stated to have gone 291 days, does not come under this head, for here the pregnancy really appears to have lasted 10 or 11 days beyond the full period, which cannot be accounted for in the way above mentioned: we should not have ventured to quote this, if a similar instance had not been recorded by Dr. Dewees. "The husband of a lady, who was obliged to absent himself many months, in consequence of the embarrassment of his affairs, returned, however, one night clandestinely, and his visit was only known to his wife, her mother, and ourselves. The consequence of this visit was the impregnation of his wife; and she was delivered of a healthy child in 9 months and 13 days after this nocternal visit. The lady was within a week of her menstrual period, which was not interrupted, and which led her to hope she had suffered nothing from her intercourse; but the interruption of the succeeding period gave rise to the suspicion she was not safe, and which was afterwards realized by the birth of a child."[60]
Although it is to be regretted that this case has been calculated in the ordinary vague manner of calendar months, yet it is perfectly evident that the pregnancy was longer than the ordinary duration. We shall, therefore, endeavour to investigate the possibility of over-term pregnancy still more closely by a consideration of the second question, viz. what are the causes which determine the period at which labour usually comes on?
It is now ten years ago since we first surmised that "the reason why labour usually terminates pregnancy at the 40th week is from the recurrence of a menstrual period at a time during pregnancy when the uterus, from its distension and weight of contents, is no longer able to bear that increase of irritability which accompanies these periods without being excited to throw off the ovum."
Under the head of PREMATURE EXPULSION, we shall have occasion to notice the disposition to abortion which the uterus evinces at what, in the unimpregnated state, would have been a menstrual period: for some months after the commencement of pregnancy, a careful observer may distinctly trace the periodical symptoms of uterine excitement coming on at certain intervals, and it may be easily supposed that many causes for abortion act with increased effect at these times. Where the patient has suffered from dysmenorrhoea before pregnancy, these periods continue to be marked with such an increase of uterine irritability as to render them for some time exceedingly dangerous to the safety of the ovum. Even to a late period of gestation, the uterus continues to indicate a slight increase of irritability at these periods, although much more indistinctly; thus, in cases of hæmorrhage before labour, especially where it arises from the attachment of the placenta to the os uteri, it is usually observed to come on, and to return, at what in the unimpregnated state would have been a menstrual period. We mention these facts as illustrating what we presume are the laws on which the duration of pregnancy depends, and also as being capable of affording a satisfactory explanation of those seeming over-term cases which are occasionally met with.
From this view of the subject it will be evident, that the period of the menstrual interval at which conception takes place, will in great measure influence the duration of the pregnancy afterwards; that where it has occurred immediately after an appearance of the menses, the uterus will have attained such a dilatation and weight of contents by the time the ninth period has arrived, that it will not be able to pass through this state of catamenial excitement without contraction, or, in other words, labour coming on: hence it is that we find a considerable number of labours fall short of the usual time, so much so that some authors have even considered the natural term of human gestation to be 273 days or 39 weeks: for a somewhat similar reason we can explain why primiparæ seldom go quite to the full term of gestation, the uterus being less capable of undergoing the necessary increase of volume in a first pregnancy than it is in succeeding ones.
On the other hand, where impregnation has taken place shortly before a menstrual period, the uterus, especially if the patient has already had several children, will probably not have attained such a volume and development as to prevent its passing the ninth period without expelling its contents, but may even go on to the next before this process takes place: it is in this way that we would explain the cases related by Dr. Dewees and Dr. Montgomery. We are aware that, under such a view of the subject, the duration of time between the catamenial periods of each individual should be taken into account, some women menstruating at very short, and others at very long, intervals; but although this will affect the number of periods during which the pregnancy will last, it will not influence the actual duration of time, as this will more immediately depend upon the size and weight of contents which the uterus has attained.
The valuable facts collected by M. Tessier respecting the variable duration of pregnancy in animals, which have been quoted by some authors in proof of the partus serotinus, are scarcely applicable to this question in the human subject; the absence of menstruation, and the different structure of the uterus, prevent our making any close comparison.
VIII. PREMATURE EXPULSION OF THE FOETUS
Abortion.--Miscarriage.--Premature labour.--Causes.--Symptoms.-- Prophylactic measures.--Effects of repeated abortion.--Treatment.
The uterus does not always carry the ovum to the full term of pregnancy, but expels it prematurely. This expulsion of its contents may occur at different periods, and is characterized accordingly: thus, among most of the Continental authors, it has been divided under three heads; those cases which occur during the first sixteen weeks coming under the head of abortion; those which occur between this period and the twenty-eighth week are called miscarriages; and when they take place at the latter period, until the full term of utero-gestation, they receive the name of premature labours.
It is perhaps useful to distinguish those cases of premature expulsion which occur before from those which occur after the fourth month, inasmuch as they seldom prove dangerous before that time, from the diminutive size of the ovum and from the slight degree of development which the uterine vessels have undergone; whereas, after this period the hæmorrhage is more severe, and the general disturbance to the system greater. In other respects it will be more simple to divide premature expulsion of the ovum under two heads only; those cases which happen before the twenty-eighth week, or seventh month, being termed abortions, and after this period (as before) premature labours. This division is highly important in a practical point of view, since it marks the period before which the child has little chance of being born alive; whereas, after this date it may with care be reared.[61] A foetus may be expelled, at a very early stage of pregnancy, not only alive but capable of moving its limbs briskly for a short time afterwards, but it is unable to prolong its existence separate from the mother beyond a few hours. Cases do occur now and then where a child is born in the sixth month, and where it manages to struggle through, but these are rare, and must rather be looked upon as exceptions to the general rule.
Abortions usually occur from the eighth to the twelfth week, a period which is decidedly the least dangerous for such accidents. "The liability to abortion is greater in the early than in the later periods of pregnancy; for as the union between the chorion and decidua is not well confirmed, as the attachment of the latter to the internal face of the uterus is proportionably slight, and as the extent of surface which the ovum now presents is very small to that which it offers in the more advanced state of pregnancy, and as it can of course be affected by smaller causes, it will be seen that a separation will be more easily induced, and prove much more injurious to the well-being of the embryo, than a larger one at another stage." (Dewees, Compendious System of Midwifery, § 929.) Abortions coming on at a later period, viz. from the sixteenth to the twenty-eighth week, which corresponds to the second division, or miscarriages, of the continental authors, are not only more dangerous than abortions at an early stage, for the reasons above-mentioned, but also than premature labours, as in this last division the uterus has attained such a size as to make the process rather resemble that of natural labour at the full term.
Causes. Premature expulsion may be induced by a great variety of causes, which may be brought under the two following heads: those which act indirectly, by destroying the life of the embryo, and those which act directly on the uterus itself. These various causes may be general or local; the process of nutrition for the growth and development of the embryo may be defective and scanty, from general debility or disease: hence, whatever depresses the tone of the patient's health renders her liable to abortion by causing the death of the embryo. Thus, dyspepsia and derangement of the chylopoietic viscera; debilitating evacuations; depressing passions of the mind; bad or insufficient nourishment; intense pain, as in toothach; severe suffering from existing disease, especially where the health is much broken down by some chronic affection; syphilis, and febrile attacks, all act as indirect causes of abortion.[62] Salivation from mercury not unfrequently has a similar effect; in some instances, however, febrile affections appear to act much more directly, stimulating the uterus to powerful contractions and rapid expulsion of its contents. The symptoms which indicate the death of the child have already been detailed in the chapter upon that subject.
The period which may elapse between the death and the expulsion of the embryo varies exceedingly: in the early months the one usually follows the other pretty quickly, owing probably to the slight attachment of the ovum to the uterus; during the middle third of pregnancy the interval may be of considerable duration, and cases every now and then occur where the foetus is retained, not only several weeks, but even some months after its death; whereas, during the latter third of pregnancy, expulsion follows the death of the child after a short interval, seldom exceeding two or three days; for now the weight of the dead foetus speedily irritates the uterus to contraction, and, as has been observed by Smellie, the membranes, running gradually into putrefaction, and being now unable to bear the weight of the liquor amnii, burst, and expulsion soon follows.
Among the causes which act locally in inducing premature expulsion by first destroying the child, may be enumerated external violence applied to the abdomen, such as blows, falls, and other violent concussions; these act indirectly by producing separation of the ovum from the uterus, and thus destroying the life of the child. Under the same head may be classed all violent exertions, as lifting heavy weights, straining to reach something high above the head, &c. The mere act of walking, when carried to such an extent as to induce exhaustion, will suffice, in weakly delicate females, to bring on expulsion; sudden and violent action of the abdominal muscles, when excited by a half-involuntary effort to save herself from falling, or receiving any other injury, may produce a similar effect: if the foetus be so young that its movements cannot be felt by the mother, she feels from this moment more or less pain in the pelvis, with a sensation of weight and bearing down; and this, in all probability, will be followed by a discharge of blood from the vagina: where pregnancy has sufficiently advanced for the motions of the foetus to be perceptible, the mother will frequently feel them in an unusually violent degree for a short time immediately after the injury, and then they cease entirely.
Premature expulsion may also be induced immediately without the previous death of the child, by causes which directly excite the uterus to action: thus, various violent mental emotions, as rage, joy, horror, may act in this manner, although they may also act more indirectly; sudden exposure to cold, as sudden immersion in cold water, will occasionally produce it instantly. Irritation in the intestinal canal will directly excite uterine contraction; hence an attack of dysentery is frequently a cause of abortion, and we not unfrequently meet with patients who are liable to this affection in every pregnancy: a similar effect may be produced by the improper use of drastic purgatives, which irritate the lower bowels, viz. aloes, scammony, savin, &c.; or the uterus may, in some cases, be excited to contract from the peculiar action of secale cornutum. On the other hand, a loaded state of the bowels equally predisposes to abortion, by impeding the free return of blood from the pelvis. A state of general plethora acts in the same manner; and this is more particularly the case if it takes place at what would, in the unimpregnated state, have been a menstrual period; for, occurring in conjunction with the increased vascular action which prevails at these periods in the uterine system, it produces, as it were, an apoplectic state of the uterine sinuses, which form the maternal portion of the placenta; blood is extravasated between the ovum and uterus; their connexion is more or less destroyed, and the death of the foetus becomes unavoidable: hence, in these cases the expulsion may result either from this latter circumstance, or from the uterus being irritated to contract by the effused blood between itself and the membranes.
In patients who have suffered from attacks of dysmenorrhoea in the unimpregnated state, the irritable uterus, when pregnant, is very apt to contract upon its contents and expel them. This usually happens at what would have been a menstrual period, and not unfrequently takes place so soon after impregnation as merely to be looked upon as an unusually severe attack, the little ovum having been imperceptibly expelled among the discharges. Under this head must be brought those cases of spasmodic affection of the uterus, which Dr. Burns has described, and where, from the diminutive size of the ovum, the case has rather resembled one of menorrhagia. Cases of abortion are also mentioned by authors where the uterus is stated to be incapable of undergoing the necessary dilatation and increase of size which pregnancy requires; but we are strongly disposed to refer them to the above head of great uterine irritability, as we neither know of any diagnostic marks which will enable us to detect this condition during life, nor are we aware of any physical condition of the uterus short of actual disease, to be detected after death, which can produce this inability.
The uterus may be also excited to expel the foetus, without its previous death by local causes, as acute leucorrhoea, or other inflammatory affections of the vagina, by inflammation and other affections of the bladder, as calculus, &c. Too frequent sexual intercourse during the early months of pregnancy is peculiarly liable to excite abortion: this is especially observed among primiparæ of the better ranks, where, from luxurious living, &c., there is but little physical strength in proportion to the great irritability of the system: hence we find that a fifth, or even a fourth, of these females abort in their first pregnancies. In conclusion we may briefly state that the same circumstances which in the unimpregnated condition produce menstrual derangement and other disorders of the uterine system, now act as so many causes of abortion.
The sudden cessation of the breeding symptoms, with sense of weight and coldness in the lower part of the belly, flaccid breasts, pain in the back and loins, and discharge of blood from the uterus, are pretty sure signs of abortion: they are those which are "produced by separation of the ovum and contraction of the uterus," (Burns;) the one is attended by hæmorrhage, the other by pain. Although these are two chief symptoms which characterize a case of threatened abortion, and although they must necessarily be present more or less in every instance where premature expulsion actually happens, still neither of them, either separately or conjointly, can be considered as a certain proof that the uterus will carry its contents no longer. Cases not unfrequently happen where patients have repeated attacks of hæmorrhage during the early months of pregnancy, and sometimes to a considerable amount, without any apparent disturbance to the process of gestation, and are delivered of a living healthy child at the full term: on the other hand, we have known instances where the pain of the back was severe, and where, on assuming the erect posture even for a minute, the sense of weight and bearing down in the lower part of the abdomen was so great as to make the patient fear that the ovum was on the point of coming away; still even these threatening symptoms have gradually subsided, and the pregnancy has continued its natural period. Puzos considered that neither pain nor hæmorrhage were necessarily followed by expulsion. (Mém. de l'Acad. de Chir. vol. i. p. 203.) When, however, both occur together, and to a considerable extent, the case must be looked upon as one of at least doubtful if not unfavourable termination. Where pain comes on at regular intervals, with hardness of the uterus, and dilatation of its mouth, this is a serious symptom, for it shows that the uterus will no longer retain its contents, but is evidently preparing to expel them.
The part of the ovum at which the separation of it from the uterus has taken place, not only determines which of the above symptoms will appear first, but also the probability of expulsion. "When a considerable separation takes place, as must be the case when it commences at the upper parts of the uterus, pain will more likely occur than when it happens near the neck; hence we sometimes have pain before the blood issues externally. The uterus in this instance suffers irritation from partial distension from the blood insinuating itself behind the ovum; contraction ensues; the blood is thus forced downwards, and is made to separate the attachment between the ovum and the uterus in its course, until it finally gains an outlet at the os tincæ. In consequence of the uterus being excited to contraction, the friendly coagula which may have formed from time to time are driven away, and the bleeding each time is renewed and accompanied most probably with increased separation of the ovum, until at last from its extent the ovum becomes almost an extraneous body, and is finally cast off. Hence a separation at or near the os uteri will not be so dangerous, and in all probability there will be hæmorrhage without pain, which is the contrary when it takes place near the fundus." (Dewees, Compend. System of Midwifery, § 981, 982.) The pain during the abortion is sometimes exceedingly severe, and not unlike that of dysmenorrhoea: this is probably owing to the violent contractions of the uterus, which are required to dilate the os and cervix before the ovum can pass: they are frequently attended with nausea, vomiting, and fainting, and sometimes with more or less general fever and local inflammatory action; the pain is generally attended with much irritability of the bladder, and frequent desire to pass water; the pulse is mostly quick and small, and where there is arterial excitement, it is sharp and resists the finger.
Treatment. The treatment of premature expulsion consists in, 1, that which is intended to guard the patient against its occurrence, or prophylactic; and 2, in that which is required during an attack.
A knowledge of the various causes of premature expulsion will materially assist us in the prophylactic treatment; under all circumstances, even where there is not the remotest fear of such an accident coming on, it is nevertheless highly important to pay strict attention to the state of the stomach and bowels, for these are almost always more or less influenced by the presence of pregnancy; the vomiting and sickness must be relieved in the manner already pointed out under the chapter on the TREATMENT OF PREGNANCY; the bowels, if constipated, must be moved by the mildest laxatives, such as castor oil, Confect. sennæ, or a Seidlitz powder; and thus all sources of irritation in the primæ viæ prevented as far as possible. The patient must carefully avoid every thing which may excite the circulation, such as violent affections of the mind, rich indigestible and stimulating food, violent exertion, &c. The diet should be light, nourishing, and moderate; heavy meals must be forbidden, and especially suppers; she should keep early hours, take gentle and regular exercise, and in fact, endeavour by every means in her power to raise her health to a full degree of tone and regularity. In those patients who have already miscarried in their previous pregnancies, these precautions must be enforced with double vigilence; for the system becomes exceedingly irritable, and the uterus soon acquires, as it were, a habit of retaining its contents only to a certain period, and then prematurely expelling them. When this is the case, it becomes exceedingly difficult, and is often actually impossible, to make it carry the ovum to the full term of utero-gestation, and, despite of the greatest care, the symptoms of premature expulsion will come on at about the same time at which they occurred in former pregnancies, and sometimes to the very same week.
In the treatment of such cases, where there is so much liability to abortion, we must first examine the precise condition of the circulation, and ascertain whether it be above or below the natural standard of strength; for as abortion may arise from very opposite conditions of the circulation, our treatment must consequently vary. If there be signs of arterial excitement, a small bleeding may be necessary; it unloads the congested vessels, diminishes the force of the circulation, and therefore also the chance of an extravasation of blood between the uterus and ovum; the bowels must be kept open by cooling saline laxatives, and the circulation may be still farther controlled, by the use of nitre two or three times a day. The diet must be spare; she must take regular exercise in the open air, wear light clothing, dress loosely, and sleep upon a hard mattress.
In these cases we are often warned that congestion of the uterine vessels is present, by pain and throbbing, and sense of fulness in the groins; leeches applied to these parts give much relief, and frequently render venesection unnecessary. Tight lacing ought to be strictly prohibited in all cases of pregnancy, particularly where there is a disposition to plethora: among other bad effects, it prevents the proper development of the breasts, the nipples are pressed so flat as to be nearly useless, the child being unable to get sufficient hold of them: this may in some degree be avoided, by putting thick ivory rings upon the breasts, and thus shielding the nipples from injurious pressure. It will, however, be much better to have the dress made loosely, to allow for the development of the breasts, which takes place during pregnancy; for there can be little doubt, that irritation of these glands is very liable to be followed by a corresponding state in the uterus.
The common but erroneous notion that it is necessary to take an extra quantity of nourishment for the support of the child as well as of the mother must be strenuously opposed. Nature contradicts it in the most striking manner; for, by the nausea and sickness which most women experience during the first half of their pregnancy, she raises an effectual obstacle to any error of this kind. "It certainly cannot be intended for any other purpose, since it is not only almost universal, but highly important when it occurs, as it would seem to add much to the security of the foetus; for it is a remark as familiar as it is well grounded, that very sick women rarely miscarry; while on the contrary, women of very full habits are disposed to abortion, if exempt from this severe, but as it would seem, important process." (Dewees, on Children, § 45.)
Where the case has become one of habitual abortion, the patient's only chance will be by living separate from her husband for twelve or more months: the uterus, not being exposed to any sexual excitement during this period, becomes less irritable, and it gradually loses the disposition which it has acquired of expelling its contents prematurely. In such a case, when pregnancy has again commenced, it requires to be watched most narrowly; every possible source of irritation must be removed by the strictest attention to diet and regimen, and the patient must make up her mind to be entirely subservient to the rules laid down by her medical attendant. Although the chances are against her escaping without premature expulsion, still we are not to despair, experience showing that cases every now and then occur where the patient has gone the full term of pregnancy in safety, in spite of repeated previous abortions. Dr. Young of Edinburgh, in his lectures on midwifery, describes a case where the patient actually miscarried thirteen times, and yet bore a living child the fourteenth time.
On the other hand, where the condition of the patient evinces a state of strength considerably below the natural standard, we find a very different set of symptoms to those which have been just described, requiring opposite treatment: the face is pale and even sallow; the pulse is soft, small, and irritable; the tongue pale and flabby; the digestion impaired; the bowels torpid; and the extremities cold: fatigue, or rather a sense of exhaustion, is induced by the slightest exertion, and this is attended with dull, heavy, dragging pain about the pelvis and loins, and a feeling as if the contents of the abdomen required more support, and were disposed to prolapse either by the rectum or vagina, on her maintaining an upright posture for any length of time.
Even at a very early period of pregnancy, there is the sensation of a weight in the lower part of the abdomen, falling over to that side which is lowest, as we described among the signs of the death of the foetus at a later period, resulting in all probability from a loss of tone and firmness in the uterus. In this state, if nothing be done to restore the mother's strength, the embryo will inevitably perish, and expulsion follow, sooner or later, as a necessary result.
In all cases where pregnancy occurs, in a weakly delicate woman, measures should be taken to increase the general tone of health, in order to fit her for going through this process safely, by removing her to the country, or to the sea-side, or to some watering place, where she will have the opportunity of drinking a mild chalybeate, and enjoying a purer air. Where it is even hazardous to move her, she should be put upon a course of mild chalybeates. The food should be light and nourishing, and a glass or two of wine or mild ale, may generally be taken with advantage. Where she can bear it, tepid salt-water bathing, or sponging, will have the best effects.
"For a number of years, (says Mr. White of Manchester,) I have been convinced of the good effects of cold bathing, not only in preventing miscarriages when every other method has been likely to fail, but other disorders which are incident to pregnant women, and generally attendant upon a weak lax fibre. I don't mean the cold bath in the greatest extreme, but such as that of Buxton or Matlock, or sea-bathing, or bathing in a tub in the patient's house, with the water a little warmed. I have frequently advised my patients to bathe every other day, at a time when the stomach is not overloaded, and not to stay at all in the water; to begin this process as early as possible, even before they have conceived, as there will be then no danger from the surprise, and continue it during the whole term of pregnancy; and several have bathed till within a few days of their delivery." (White, on Lying-in Women, p. 70.) Where exercise can be taken without fear, it should be done regularly but cautiously, so as not to induce fatigue or exhaustion, which is the very effect we must be so careful to avoid; in fact, every means and opportunity should be used of recruiting the powers and the vigour of the system. In proportion as the strength increases, so does the irritability diminish; the uterus becomes less sensitive to external impressions, and can, therefore, bear its gradual development without being excited to contraction; the foetus receives its due supply of nourishment; the feeling of relaxation and deficient support of weight, and bearing down, go off as health returns; and by thus keeping up the powers of the system to the proper standard, it will be enabled to continue the process of pregnancy to the full term.
Although some women recover very quickly after an abortion, and appear for the time to suffer but little from its effects, they seldom escape with impunity, more especially if it has been repeated more than once: anæmia, with its varied train of anomalous symptoms and concomitant gastric and cerebral disturbance, profuse leucorrhoea, menorrhagia, and dismenorrhoea, are some of the more direct results of repeated abortion; we may also enumerate prolapsus uteri, inflammation of the cervix, with induration and scirrhus, as the more remote effects.
In the treatment of a case where expulsion is threatened, our object will be either to stop that process in time to save the life of the foetus, or if this cannot be attained, to carry it through, in such a manner, as to expose the mother to as little danger and injury as possible.[63] In the first instance, we must be guided nearly by the same rules as in the prophylactic treatment: if there be considerable arterial excitement, and evidence of general plethora, a small bleeding will be useful in restoring a calm to the circulation; the most perfect quiet of body and mind must be insisted upon; the patient should lie upon a hard mattress, and be covered with as little clothing as is consistent with safety; she must refrain from all exertion, and strictly maintaining the horizontal posture for a considerable time. The indications for our treatment will be, 1. to remove every thing which may, in any degree excite the circulation, and, 2. to prevent the contraction of the uterus. Stimulants of every description, and animal food must be forbidden; the bowels must be opened by gentle saline laxatives; and if the pulse still betrays any sharp or resisting feel to the finger, small doses of nitre may be taken as already recommended. When the circulation has become perfectly calm, and every trace of excitement allayed, opiates will prove of inestimable value: they stop any disposition to uterine contraction, and remove the pain in the back and loins which this will cause. The form which we prefer is the Liquor Opii Sedativus, as being more sure in producing a sedative effect than common laudanum, while at the same time, it produces less irritation and derangement in the stomach and bowels.
A moderate discharge of blood from the vagina, although showing that a separation has taken place between the ovum and the uterus, cannot be looked upon as an unfavourable sign, for it relieves the pelvic vessels, diminishes the pain in the back, and makes the patient feel more light and comfortable; but if it be at all brisk, and continues so after the employment of the above remedies, if also there be heat and throbbing in the region of the uterus, it will be necessary to apply cloths wrung out of cold water to the lower part of the abdomen and vulva, and to the groins and sacrum; and this treatment must be continued in full force until the symptoms of congestion have abated, and the discharge lessened or stopped.
If the hæmorrhage be really profuse, it shows that the separation of the ovum from the uterus must be of considerable extent; and as there will be no chance of preserving the life of the foetus under such circumstances, the expulsion of the ovum is no longer to be avoided, but rather to be promoted; our attention therefore must now be directed to assist the uterus in the evacuation of its contents, with as little injury and danger to the mother as possible. It is, however, no easy matter to decide with certainty when we must give up all hope of preserving the ovum, for a large quantity of blood may be lost without expulsion being a necessary consequence. Uterine contractions may have even taken place, and yet by careful management the mischief may be sometimes averted, and the patient be enabled to go her full time. Even where they have been of sufficient force and duration to dilate the os uteri, we are not justified in discontinuing remedial measures unless the flooding has seriously affected the patient's strength, and the ovum be actually projecting through the os uteri. "We might often prevent abortion (says Baudelocque) if we were perfectly acquainted with its cause, even when the labour is already begun. A very plethoric woman felt the pains of childbirth towards the seventh month of her pregnancy, and the labour was very far advanced when I was called to her assistance, since the os uteri was then larger than half a crown; two little bleedings restored a calm, so much that the next day the orifice in question was closed again, and the woman went the usual time. Food of easy digestion prudently administered quieted a labour not less advanced in another woman, where it was suspected to be the consequence of a total privation of every species of nourishment for several successive days. Delivery did not take place till two months and a half afterwards, and at the full time. Emollient glysters and a very gentle cathartic procured the same advantage to a third woman, in whom labour pains came on between the sixth and seventh months of pregnancy, after a colic of several days' continuance, accompanied with diarrhoea and tenesmus." (Baudelocque,) § 2232. Nor is it always easy to decide whether it be the ovum or not which we feel protruding through the os uteri. "When the abortion is in the second or third month, the practitioner must bear in mind that it may have been retention of the menses, and, therefore, what he feels in the os uteri may either be an ovum or a coagulum of blood. To decide this point he must keep his finger in contact with the substance lying in the os uteri, and wait for the accession of a pain (for where clots come away, pains like those of labour are present,) and ascertain whether the presenting mass becomes tense, advances lower, and increases somewhat in size; this will be the case where it is the ovum pressing through the os uteri. On the other hand, if it be a coagulum, which it is well known assumes a fibrous structure, it will neither become tense nor descend lower, but be rather compressed. Generally speaking, the ovum feels like a soft bladder, and at its lower end is rather round than pointed, whereas, a plug of coagulum feels harder, more solid, and less compressible, and is more or less pointed at its lower end, becoming broader higher up, so that we generally find that the coagulum has taken a complete cast of the uterine cavity. If we try to move the uterus by pressing against this part, it will instantly yield to the pressure of the finger, if it be the ovum; whereas, the extremity of a coagulum under these circumstances is so firmly fixed, that when pressed against by the finger the uterus will move also. When abortion happens at a later period of pregnancy, we shall be able to feel the different parts of the child as the os uteri generally dilates, viz. the feet, or perhaps the sharp edges of bones, although we cannot distinguish the form of the head from the cranial bones being so compressed and strongly overlapping each other." (Hohl, on Obstetric Exploration.)
Although expulsion must be looked upon as the only means of placing the patient in a state of safety, where the symptoms have advanced so far as to preclude all hopes of preserving the life of the foetus, there are so many steps of this process to be gone through before it can be entirely completed, that more or less time must necessarily be required for that purpose. The ovum must be completely separated from its attachments to the uterus, and the contractions of that organ must have been of sufficient strength and duration to produce such a degree of dilatation of its mouth and neck as to allow the ovum to pass; but before this can be effected, such a quantity of blood may have been lost as greatly to endanger the life of the patient. Hence we must use such means as shall enable us to control the hæmorrhage, whilst we give the os uteri time to dilate sufficiently: this object will be gained most effectually by plugging the vagina. The best mode of performing this operation is that recommended by Dr. Dewees of Philadelphia: a piece of soft sponge, of sufficient size to fill the vagina without producing uneasiness, must be wrung out of pretty sharp vinegar, and introduced into the passage up to the os uteri; the blood, in filling the cells of the sponge, coagulates rapidly, and forms a firm clot, which completely seals up the vagina without producing any of those unpleasant effects which are produced by the insertion of a napkin rolled up for the purpose. A hard unyielding mass of this nature frequently produces so much tension, pain of back, and irresistible efforts to bear down, as to render it incapable of being borne for any length of time. The sponge plug may be borne for hours without inconvenience; we may either leave it to be expelled with the ovum, or after awhile remove it for the purpose of ascertaining what progress has been made. If the os uteri be still undilated, and the hæmorrhage going on, the plug must be returned. It is however by no means a remedy to be used in every case of hæmorrhage, for in most instances the treatment already mentioned will be sufficient to keep it within safe bounds. Where, however, the flooding has become very alarming, and the os uteri still remains firm and but little dilated, the plug will prove an invaluable remedy; and so long as the os uteri remains in this condition, and the uterus itself shows no disposition to contract, we may safely trust to perfect rest, cold applications, and the plug. Opium, which in the early stages of the attack is so useful in keeping off contractions of the uterus, will now for this very reason be contra-indicated; it will diminish the power of the uterus, and interfere with the process of expulsion.
The acetate of lead has been extolled as a powerful remedy for stopping hæmorrhage, more especially by Dr. Dewees, who states that "in many cases it seems to exert a control over the bleeding vessels as prompt as the ergot of rye does upon the uterine fibre." (System of Midwifery, § 1045.) We have never tried this remedy in premature expulsion, having found the means of treatment above mentioned sufficient; the authority however of such an author demands respect, the more so as it is known to be a valuable remedy in certain forms of menorrhagia.
Where a considerable quantity of blood has been lost, and the patient is much reduced, we must endeavour not only to excite the contractile power of the uterus, but also to assist this organ in the expulsion of its contents: syncope in these cases is a dangerous symptom, because, as the patient is in the horizontal posture, it will seldom be induced except by a serious loss of blood; although we must not therefore allow her to flood until she faints, still, however, when the pulse has become considerably affected, the os uteri dilates more readily, and in this way facilitates the expulsion; we must no longer trust to the plug, for the whole system is beginning to sympathize and grow irritable, the pulse grows quicker and smaller, and the stomach rejects its contents. Although vomiting as well as syncope are symptoms which we cannot safely wait for, they are nevertheless means which nature adopts to relieve herself from the impending danger: by syncope she not only produces greater dilatability of the os uteri, but also, by causing a temporary cessation of the heart's action, she favours the coagulation of blood, and thus checks the discharge; whereas, by the involuntary effort of muscles which she excites by the action of vomiting, the ovum is more speedily separated and expelled.
Where it becomes evident that expulsion cannot be prevented, it is our duty to promote this process before nature has had recourse to the means just mentioned. The ergot of rye is here a valuable remedy, for by inducing or increasing the contractions of the uterus we shorten the process and diminish the danger: the powder given in cold water is decidedly the best form in which it can be given; in infusion its powers seem to be injured by the heat of the water, and in tincture by the action of the spirit: the addition of about half its quantity of borax renders its action more powerful and certain. Borax has been long considered in Germany to possess a specific power in exciting uterine contraction, but it was first recommended for that purpose in this country by Dr. Copland. (Dict. Pract. Med. art ABORTION.) A scruple or half a drachm of ergot powder with ten grains of borax may be given in cinnamon water, and this repeated every hour for several times.
In all cases threatening premature expulsion, wherever there has been much pain and discharge, the napkins which come from the patient should be carefully examined by her medical attendant, for otherwise the ovum may escape among the coagula and not be perceived. Where the separation is nearly complete, a portion of it protrudes at the os uteri; and this we can sometimes hook down with one or two fingers, and bring away: a still better mode is recommended by Levret, viz. of throwing up a pretty powerful stream of warm water by means of a syringe. Dr. Dewees has recommended a wire crotchet, which he has used with very good effect. (Op. cit. § 1011.)[64] We ought not, however, to be in a hurry to bring away the ovum, for when the uterine contractions have been of sufficient strength to dilate the os uteri, it will generally come away of itself. One objection to the wire crotchet is, that it tears the membranes, and lets out the liquor amnii, and perhaps the embryo.[65] This is by all means to be avoided; the larger the body which is to be expelled, the more powerfully and effectually does the uterus contract upon it: hence, therefore, if the membranes of a three or four months' ovum be imprudently pierced with a view of hastening the expulsion, the liquor amnii and embryo escape, but the secundines remain and require protracted efforts of the uterus to expel them, during which time the sufferings of the patient are prolonged, and the hæmorrhage kept up; whereas, if the ovum had remained whole, it would have been expelled more easily and quickly. On the other hand, where the foetus has already attained a considerable size (fifth month,) the plan recommended by Puzos of rupturing the membranes is very desirable; by this means the size of the uterus is reduced by the escape of liquor amnii, and thus the hæmorrhage checked; and the foetus remaining in the uterus is of sufficient weight and bulk to excite contractions to expel itself and the membranes.
The treatment after abortion varies considerably: in many cases it will be merely necessary for the patient to remain in bed for a few days afterwards; but where she has been much reduced, a mild course of tonics will be necessary, in order to prevent that disposition to leucorrhoea and menstrual derangement which is so common a result: this, where it is possible, should be combined with removal into the country, or to the sea-side, or, what is still better to a watering place, where there are mineral springs of chalybeate character. For the treatment of anæmia we must refer our readers to the chapter on HÆMORRHAGE.
I. STAGES OF LABOUR
Preparatory stage.--Precursory symptoms.--First contractions.--Action of the pains.--Auscultation during the pains.--Effect of the pains upon the pulse.--Symptoms to be observed during and between the pains.--Character of a true pain.--Formation of the bag of liquor amnii.--Rigour at the end of the first stage.--Show.--Duration of the first stage.--Description of the second stage.--Straining pains.-- Dilatation of the perineum.--Expulsion of the child.--Third stage.-- Expulsion of the placenta.--Twins.
Parturition may be divided into two great orders, Eutocia and Dystocia, the one signifying natural labour which follows a favourable course both for the mother and her child; the other signifying faulty or irregular labour, the course of which is unfavourable.
We may define eutocia to be the safe expulsion of the mature foetus and its secundines by the natural powers destined for that purpose. No function exhibits such infinite varieties, within the limits of health and safety to the mother and her offspring, as that of parturition; no two labours, even in the same individual are exactly alike; still, however, the great objects of the process will be the same, viz. 1st. the preparation of the passages and the foetus for its expulsion; 2dly, the expulsion of the foetus; and 3dly, the expulsion of the placenta and membranes.
That we may form a clearer and more comprehensive view of this process, labour has usually been divided into stages or periods, marked by the changes just now alluded to: hence it is generally said to consist of three stages; the first, or preparatory stage, commencing with the first perceptible contractions of the uterus, and terminating in the full dilatation of the os uteri; the second, or stage of expulsion, terminating with the birth of the child; and the third, consisting of the expulsion of the placenta.
Preparatory stage.--Precursory symptoms. For some time before the commencement of actual labour, a variety of changes are taking place which must be looked upon as the precursors of this process: during the last weeks of pregnancy, nature appears, as it were, to be preparing for the great change which is at hand, and to be making such arrangements as shall enable it to be completed with the least possible danger both for the mother and her child.
One of the earliest warnings which we have of approaching labour is an alteration in the form of the abdominal tumour; the cervix uteri has by this time (especially in primiparæ) entirely disappeared; the presenting part of the child has therefore descended to the lowest part of the uterus; the fundus has sunk lower and more forwards; and from the diaphragm being enabled to act with greater freedom, the respiration is performed with more ease and comfort to the patient; she therefore feels more capable of moving about, and is in better health and spirits than for some time previously. Upon examination per vaginam, the head will be found deep in the cavity of the pelvis, covered by the lower and anterior segment of the uterus; the os uteri is still closed, and situated in the upper part of the hollow of the sacrum, forming merely a small circular depression. In women who have already had children, a portion of the cervix uteri is still remaining; it is thick and bulky; and in some cases, where the uterus has been greatly distended in several successive pregnancies, it is nearly as long as in the unimpregnated state; the os tincæ or os uteri externum is open, its edge irregular from former labours; the upper extremity of the canal of the cervix is contracted, and forms the os uteri internum; it has been closed during the greater part of pregnancy, but usually is now sufficiently open to admit the finger; the os uteri is neither so high up nor so far backwards in the pelvis as in primiparæ, and is reached with greater ease; whereas, the head of the child, instead of being felt in the cavity of the pelvis, generally remains at the brim until labour is more advanced.
First contractions. The first contractions of the uterus (in a state of health) are so slight as scarcely to be noticed by the patient: they create a sensation of equable pressure and general tightness round the abdomen, and during the contraction the uterus feels somewhat firmer, but they are neither attended with pain, nor do they appear at first to have any effect upon the os uteri; these precursory contractions generally come on a day or two before actual labour commences, and sometimes are felt at intervals for one or two weeks. Where the uterus has been exposed to any source of irritation, and especially where there is a disposition to rheumatic affection of this organ, they may produce much suffering and give rise to one form of what are called false pains, hereafter to be described. "The first contractions, says M. Leroux (Sur les Pertes de Sang, § 41.,) are feeble, and communicate no sensation to the patient; in order to discover them we must hold our hand upon the abdomen, and if we feel the globe of the uterus raise itself and become hard, this is a true contraction. These contractions gradually increase until they excite pain: but pain is not essential to a contraction; it depends on the distension and compression of the nerves produced by the resistance of the body upon which the uterus acts, and increases in severity in proportion to the degree of resistance and contraction."
In proportion as the lower part of the uterus descends into the cavity of the pelvis, so does it exert a degree of pressure on the neighbouring parts; the capacity of the bladder and rectum is diminished; and being therefore unable to contain the usual quantity of urine and fæces, and being probably rendered more irritable by the pressure above-mentioned, the patient experiences frequent calls to pass water and evacuate the bowels, which is sometimes effected with considerable difficulty: in some instances she is obliged to lean forward, or support the abdomen, in order to take the weight of the child off the neck of the bladder before she can empty it: the same cause occasionally requires the use of the catheter, and sometimes renders the introduction of it a matter of considerable difficulty.
As these various changes make their appearance, the patient becomes restless and anxious; she cannot remain long in the same posture; the slight precursory contractions which have been just described, are becoming stronger, and begin to produce a sensation of pain; the os uteri (in primiparæ) opens somewhat, its edge at first is exceedingly thin, and feels almost membranous; by degrees however it swells, grows thick and cushiony, and is now more dilatable.
Action of the pains. The os uteri does not dilate merely by the mechanical stretching which the pressure of the membranes and presenting part exert upon it; it dilates in consequence of its circular fibres being no longer able to maintain that state of contraction which they had preserved during pregnancy; they are overpowered by the longitudinal fibres of the uterus, which, by their contractions, pull open the os uteri equally in every direction.
The vagina also swells and grows more cushiony, and this is followed by a copious secretion of colourless and nearly inodorous mucus. "The more albuminous it is the better, and it is always a good sign when lumps of albuminous matter come away from time to time; the thicker, softer, and more cushiony the os uteri is, the more mucus does it secrete." (Wigand, Geburt des Menschen, vol. ii. p. 292.) The thin hard os uteri does not dilate, its fibres are all in close contact, and like a well-twisted cord will not yield; whereas, when they are separated from each other by the swelling of the os uteri, they easily yield to the dilating force which is applied to them. Besides serving the purpose of lubricating the passage, the secretion of mucus is of great importance as a topical depletion, for, by thus unloading the congested vessels, they diminish the vascularity and heat of the part, and render it more capable of dilatation. "If, on the other hand, the entrance of the vagina is small, the neighbouring parts cool, dry, inelastic, and as if tightly stretched over the bones; if the finger, in spite of being well oiled and carefully introduced, produces pain upon the gentlest attempt to examine, we may expect a tedious and difficult labour." (Op. cit. p. 190.)
The patient is now no longer able to conceal her pains when they come on. If she be in the act of conversing she stops short, and remains silent until the severity of the pain is over; if she be walking about her room she is obliged to stand still for the time, and rest against or hold by something until the pain has gone off. The true labour pains are situated in the back and loins; they come on at regular intervals, rise gradually up to a certain pitch of intensity, and abate as gradually; it is a dull, heavy, deep sort of pain, producing occasionally a low moan from the patient: not sharp or twinging, which would elicit a very different expression of suffering from her.
Auscultation during the pains. "If we direct our attention to the changes of tone which the uterine pulsations present during auscultation, we shall find them generally stronger, more distinct and varied in tone during labour; and this is especially the case just before a pain comes on. Even if the patient wished to conceal her pains, this phenomenon, and more especially the rapidity of the beats, would enable us to ascertain the truth. The moment a pain begins, and even before the patient herself is aware of it, we hear a sudden short rushing sound, which appears to proceed from the liquor amnii, and to be partly produced by the movement of the child, which seems to anticipate the coming on of the contraction: nearly at the same moment all the tones of the uterine pulsations become stronger; other tones, which have not been heard before, and which are of a piping resonant character, now become audible, and seem to vibrate through the stethoscope, like the sound of a string which has been struck and drawn tighter while in the act of vibrating. The whole tone of the uterine circulation rises in point of pitch. Shortly after this, viz. as the pain becomes stronger and more general, the uterine sound seems as it were to become more and more distant, until at length it becomes very dull, or altogether inaudible. But as soon as the pain has reached its height and gradually declines, the sound is again heard as full as at the beginning of the pain, and resumes its former tone, which in the intervals between the pains is as it was during pregnancy, except somewhat louder. This is the course of things if the pain be a true one, and attain its full intensity: where the pains are false or irregular it is very different; the uterine sound either remains unaltered, or increases only for an instant, or its seeming increase of distance, as above mentioned, is not observed." (Die Geburtshülfliche Exploration, von Dr. A. T. Hohl, erster theil, s. 105.)
Effect of the pains upon the pulse. It is curious to observe the effect which a regular pain has upon the rapidity of the mother's pulse; as the former comes on and goes off, so does the other increase or diminish. "The increasing rapidity of the pulse announces the commencement of the pain; it rises and attains its summum with it; and as the pain subsides so does the pulse gradually resume the rate which it had during the intervals; a similar ebb and flow may be heard in the uterine souffle. The more regular the pain is, and the more distinctly it rises to its full extent, the more marked, regular, and distinct, is this change in it. We may also invert the order of things, and say, the more distinctly the rapidity of the pulse comes on and announces the pain, the more regularly it rises and attains a certain height, which it maintains, and then gradually subsides; in like proportion will the pain be more perfect, attain its full extent more completely, and act more efficaciously upon the regular progress of the labour. Where however the rapidity of the beats subsides before it had scarcely begun to increase, the pain is too weak; or where the rapidity rises by sudden starts, the pain is a hurried one; and in either case its effect will be imperfect." (Hohl, op. cit. vol. i. p. 108.) In order that we may ascertain these changes correctly, we ought to note the rapidity of the pulse during each successive quarter of a minute as directed by M. Hohl; thus, in a pain which lasts two minutes, the increase and diminution in the rapidity of the pulse may be as follows, 18. 18. 20. 22.; 24. 24. 22. 18. As labour advances it increases, so that shortly before the birth of the child we shall find that what was the rate of the pulse during the height of the pains at the beginning is now the rate of it during the intervals.
Symptoms to be observed during and between the pains. When a pain comes on, the uterus grows hard and tense; if the fundus be somewhat to one side, as is not unfrequently the case, it now gradually moves, so that the median line of the uterus corresponds with that of the patient's body; the various prominences of the child are no longer to be felt, the whole is now firm and unyielding; the os uteri is put tightly upon the stretch, the membranes which were loose become tense and are firmly pressed against it, and the presenting part is rendered indistinct: as the pain gradually subsides, the uterus becomes softer, and yields to the pressure of the hand; the different parts of the child which project, as also its movements, can now be felt more distinctly; the patient is free from pain, and feels herself in an agreeable state of tranquillity, which is frequently attended by a short refreshing doze; the os uteri, which has become somewhat more dilated during the last pain, is now soft and loose, so that we can hook the finger into it and move it about; the tight bladder of membranes becomes relaxed and flaccid, and retracts more or less into the uterus, so that we shall now be able to introduce the finger into the os uteri and feel the presenting part through the membranes; while the presenting part of the child, which during the pain was fixed, can be moved somewhat by the finger.
Characters of a true pain. In examining the course of a true pain we shall find that the contractions of the uterus do not begin in the fundus, but in the os uteri, and pass from the one to the other. (Wigand, op. cit. vol. ii. p. 197.) Every pain which commences in the fundus is abnormal, and either arises from some derangement in the uterine action, or is sympathetic with some irritation not immediately connected with the uterus, as from colic, constipation, &c. We very seldom find that a contraction of the uterus, which has commenced in the fundus, passes into the cervix and os uteri, and becomes a genuine effective pain; usually speaking, the contraction is confined to the circumference of the fundus, without detruding the foetus at all. When a genuine pain comes on, so far from the head being pressed against the os uteri, it at first rises upwards, and sometimes gets even out of reach of the finger, whilst the os uteri itself is filled with the bladder of membranes: if it had commenced in the fundus instead of the inferior segment of the uterus, so far from the head being drawn up at the first coming on of the pain, it would have been forcibly pushed down against the os uteri. In the course of a few seconds the contraction gradually spreads over the whole uterus, and is felt especially in the fundus; the head which had been raised somewhat from the os uteri is now again pushed downwards to it, and seems to act as a wedge for the purpose of dilating it; it is not until the whole uterus is beginning to contract that the patient has a sensation of pain. We may, therefore, consider that a genuine uterine contraction consists of certain phenomena which occur in the following order: first, the os uteri grows tight, and the presenting part rises somewhat from it; then the rest of the uterus, especially the fundus, becoming hard, the patient has a sensation of pain, and the presenting part of the child advances. The period of time necessary for all these changes varies not only in different individuals, but in the same individual in different labours, and in different stages of the same labour.
"The more completely the os uteri is opposite the fundus, and the more the axis of the uterus corresponds with that of the pelvis, the sooner are the pains, cæteris paribus, capable of dilating the os uteri." (Wigand, vol. ii. p. 273.) The cushiony state of the vagina and os uteri, and the free secretion of thick albuminous mucus from these parts, as already mentioned, will be of great importance in ensuring their easy dilatation. Where this secretion is either absent, or very scanty, the passages become dry, hot, and tender, from no relief being afforded to the congested vessels by its effusion; and vice versâ, where there is a febrile state of the circulation and considerable topical excitement, the secretion is sparing, or, perhaps, stops entirely. This state may arise from a variety of causes, such as from general plethora, too warm clothing, bad ventilation, derangement and irritation of the primæ viæ, and abuse of spirituous and other stimulating liquors: it may arise from constipation, or may be induced by rough and too frequent examination. The patient becomes flushed, excited, and feverish, with a hot skin, dry tongue, thirst, and headach; the uterine contractions become irregular, they produce much suffering, and but very little advance in the progress of the labour; the passages are in a state of inflammation, and more especially the os uteri, which is much swollen and excessively tender. The process of labour is completely interrupted, and can only be restored to a healthy condition by bleeding, warm bath, laxatives, and enemata.
Formation of the bag of the liquor amnii. When the os uteri has dilated more or less, a quantity of liquor amnii begins to collect between the head and the membranes, so that when a pain comes on they form a tense, elastic, and conical bag, which presses firmly against the os uteri, and protrudes through it into the vagina, and from its form and elastic nature greatly facilitates the speedy dilatation of it. If the edge of the os uteri be still thin, it will become so tense during the pain, and the bag of membranes will press so firmly against it, that we shall have some difficulty for the moment in distinguishing the one from the other. As the labour advances, the intervals between the pains become shorter, whereas the pains themselves are of longer duration and more effective. In this way pain succeeds pain until the os uteri, at length, attains its full degree of dilatation; if the membranes have not yet ruptured, we may now expect them to burst with every succeeding pain.
Rigour at the end of the first stage. At this moment the patient is occasionally seized with a sudden and violent fit of shivering, so much so as to make the teeth chatter, and even communicate a tremulous motion to the bed itself; this is not the result of cold, nor is it relieved by the application of external warmth; and, in many cases, the patient will express her surprise that she should shiver thus violently, and yet not feel cold. It appears to be a modification of convulsive action, excited by sympathy between the os uteri on its becoming fully dilated, and certain muscles in other parts of the body.
Show. On examination at this stage of the process, streaks of blood will be found in the mucus which soils the finger, and sometimes it amounts to a slight discharge of blood: this appearance is called by midwives "a show," as it usually indicates that the os uteri is nearly or fully dilated. It is produced by a separation of the membranes from the vicinity of the os uteri, and consequent rupture of any little vascular twigs which may have passed from the uterus to them.
The full dilatation of the os uteri terminates the first stage of labour. During this stage, the action of the pains does not appear to have been so much for the expulsion of the child, as for preparing it as well as the passages for this purpose, viz. by so arranging and regulating the different forces of the uterus, and at the same time by giving the child such a position (i. e. with its long axis parallel to that of the uterus,) and the os uteri such a degree of dilatation, as shall ensure its expulsion with the greatest possible ease and safety.
Duration of the first stage. The duration of the first stage of labour varies exceedingly, both in primiparæ and those who have had several children; nor is it at all easy to determine with precision the exact moment when labour commences. The sensation of pain to the patient is no guide whatever, for what is attended with much suffering in one patient is scarcely sufficient to excite the notice of another. The dilatation of the os uteri as marking its commencement, must also be taken with some caution: in primiparæ, where it generally remains closed until the contractions are becoming painful, it would obviously be wrong to date the commencement of labour from the moment that the os uteri opens, as regular uterine contractions have been evidently present for some hours previously, although not of sufficient force to produce actual pain. On the other hand, in women who have already had several children, the os uteri is found open some days and even weeks before labour comes on. As a general rule, we may state that regular and genuine contractions of the uterus, sufficiently powerful to produce pain, seldom require more than six hours to effect the full dilatation of the os uteri; in many cases a much shorter time will be sufficient; whereas, in others, the first stage of labour may last for more than quadruple this period before it is completed: in neither can it be considered as abnormal; and we usually find that where the pains of the first stage have been slow and lingering, they become remarkably quick and active during the second stage. This agrees with the experience of Dr. Churchill, in his report of the Western Lying-in Hospital at Dublin, viz. that, "no evil consequences resulted, and they (the labours where the first stage was so protracted) were amongst those in whom the remaining stages of labour were shortest."
The first stage terminates with the full dilatation of the os uteri; the rupture of the membranes is a change which is necessarily more or less uncertain, as to the precise period of labour at which it takes place. Thus, in primiparæ, it frequently occurs before the first stage is completed; whereas in other cases the membranes sometimes do not give way until the head approaches or has even passed through the os externum; generally speaking, however, they burst at this period of the labour, and usually effect a remarkable change in the whole process. The pains are now of longer duration and more powerful, the intervals between them are shorter, and yet, although the suffering is actually more severe, it is more tolerable to the patient than that of the first stage. During the first stage they are chiefly confined to one spot in the loins; and as they must necessarily continue for some hours without any distinct evidence of the labour being advanced by them, the patient feels discouraged and gets a little impatient at the endurance of so much apparently useless suffering: but as soon as the gush of liquor amnii takes place, she feels that a great alteration has been produced; the abdomen becomes smaller: the pains assume a very different character, and every thing combines to assure her that she has made progress, and encourages her to patience and resolution.
Description of second stage. The os uteri has now disappeared entirely, so that the vagina and uterus form one continuous canal, and is thus admirably adapted for the easy passage of the head: the anterior lip, however, dilates much more slowly than the other parts of it, and this is especially the case in primiparæ, for, being pressed between the head and pelvis it becomes oedematous, and swells to a considerable size: if the pains be strong, it is pushed down more or less before the head, and may be frequently felt beneath the symphysis pubis, and occasionally it is detruded so far as to be visible between the labia. According to Wigand, the swelling of the anterior lip sometimes attains such a size as makes it liable to be mistaken for the bladder of the membranes (op. cit. vol. ii. p. 308;) it seldom produces much obstacle to the advance of the head, and with a little patience gradually disappears of itself. All attempts to push it up above the head are objectionable, because, in the first place, the finger cannot reach sufficiently high to effect this object, and therefore the swelling descends again to its former situation; and, secondly, the efforts to push it up only tend to inflame it and increase the swelling. Those who imagine that they can push up the anterior lip of the os uteri above the head deceive themselves; and even if they do succeed, it merely shows that had they let it alone, it would have gone up very shortly of itself.
Straining pains. As the head enters the vagina, not only do the contractions of the uterus become much more powerful, but now another set of forces are called into action, and the half involuntary efforts of the abdominal and other muscles come to aid the uterus in expelling its contents. The sole object of this stage is the expulsion of the child, and even the vagina by its contractions contributes to effect it. The head is therefore subjected to considerable pressure; hence we may now feel the cranial bones overlapping each other at the sutures, and the fontanelles diminished in size; and, from the tightness with which the head is embraced by the vagina, the circulation in the scalp is more or less impeded, and a large oedematous swelling, called caput succedaneum, forms on that part of the head which presents.
Each pain is attended with a violent and irresistible impulse to bear down, and every muscle which can assist in effecting this object is now brought into play. The tone of the patient's voice, the expression of her face, the hurried breathing and sudden inspiration, stopping short the moment a pain comes on, in order that she may add still greater power to the efforts which she is about to make, all betoken a very different process to that of the first stage, and one which requires a powerful struggle of muscular strength and energy for its completion. Hence it is that the sound of the patient's voice during the pain is frequently of itself sufficient to inform us how far labour is advanced, for "we never see the really powerful straining pains come on (the head may be never so low in the pelvis,) so long as the os uteri is not fully dilated." (Wigand, op. cit. vol. ii. p. 310.) This is a wise provision of Nature, for by this means it prevents the danger of laceration to which the os uteri would be otherwise exposed, and shows the importance of not permitting a patient to strain and bear down until the os uteri be fully dilated. In those cases where a patient has been induced to exert herself prematurely, the efforts being voluntary are never so powerful, and soon produce much fatigue.
Several reasons have been assigned why the straining pains should come on at this stage. It cannot be owing to the pressure of the head upon the parts of the pelvis, as has been supposed and especially the rectum, thus producing the sensation of a violent desire to evacuate the bowels, because, in almost every case of first labour, the head for several days before the actual commencement of labour is sufficiently deep in the pelvis to produce these effects. It evidently arises from a sympathetic connexion "between the os uteri and vagina on the one hand, and the abdominal and other muscles on the other. We see this connexion most distinctly in those difficult labours where the head is pushed down deeply in the pelvis even to the very outlet, and where the os uteri which is but little dilated is protruded before it. In such cases we never see the really powerful and continued action of the abdominal muscles excited, let the head press never so forcibly upon the rectum; but as soon as the os uteri (perhaps after much suffering) has retracted over the head, the whole auxiliary action of the abdominal muscles commences." (Ibid. vol. ii. p. 467.)
There is the same relation between these muscles and the vagina, as there is between them and the rectum: the moment the vagina becomes distended, it begins to contract upon the distending body, and like the rectum excites them to strong and involuntary action. The tenesmus of dysentery is a sympathetic action of the same nature; the rectum is highly irritated by the acrid nature of its contents, and excites an irresistible disposition to bear down. The patient wishes for the next pain and yet she dreads it, from the suffering it creates, and the tremendous effort which it compels her to make; the pulse is quicker, and is not only so during the intervals, but undergoes a greater increase of rapidity during the pains themselves than in the first stage; the face becomes red, swollen, and bathed in perspiration; the breath is hurried; the lips are apart; the eyes are wild; every thing betokens a state of the highest excitement. When a pain comes on, she catches hold of whatever she can reach, plants her feet upon any thing which is firm, and, by thus fixing her extremities, she is enabled to bear down with greater power and effect. During the struggle the face often changes its expression surprisingly, so much so, that even her own attendants would scarcely recognise her.
Dilatation of the perineum. As pain succeeds pain, gradually increasing both in force as well as duration, the head descends along the vagina, and begins to press against the perineum; the rectum becomes flattened; the sphincter ani dilated, and therefore any fæcal matter which may have been lodging there is unavoidably expelled; the anterior wall of the rectum is pressed close against the anus, and where the pressure is very great, even protrudes somewhat through it; the hæmorrhoidal veins are frequently much distended, and form a roll of cushiony swelling around the anus. A small quantity of liquor amnii dribbles away from time to time, but is neither during a pain, nor during the absence of a pain, for in the former case the pressure of the head acts as a plug and prevents its escape, and in the latter there is no uterine contraction present to expel it: the liquor amnii dribbles away only at the moment when a pain is coming on or going off.
Expulsion of the child. As the head descends farther it begins to press more powerfully on the perineum, and during each pain pushes it out like a large ball; and then, as a contraction goes off, and the resiliency of the soft parts regain their superiority, it retires again. The breadth of the perineum (viz. from the anus to the vulva) increases, whilst it diminishes considerably in thickness, especially towards its anterior margin. Whilst passing through the inferior aperture or outlet of the pelvis, the head advances more or less forwards under the pubic arch, and begins to distend the os externum; during a pain it separates the labia, and protrudes between them, and again retires as the pain goes off; a larger and larger portion of the head gradually forces itself through the os externum as this dilates; the perineum becomes still thinner, so that at length it is scarcely thicker than parchment. When more of the head has passed through, it does not now recede when the pain goes off; the os externum and perineum are at their greatest distension, for the largest diameter of the head, which is presented to the os externum is now encircled by it; the next pain brings the head into the world.
This is the moment of greatest pain, and the patient is frequently quite wild and frantic with suffering; it approaches to a species of insanity, and shows itself in the most quiet and gentle dispositions. The laws in Germany have made great allowances for any act of violence committed during these moments of phrenzy, and wisely and mercifully consider that the patient at the time was labouring under a species of temporary insanity. Even the act of child-murder, when satisfactorily proved to have taken place at this moment, is treated with considerable leniency. This state of mind is sometimes manifested in a slighter degree by actions and words so contrary to the general habit and nature of the patient, as to prove that she could not have been under the proper control of her reason at the moment. It is a question how far this state of mind may arise from intense suffering, or how far the circulation of the brain may be affected by the pressure which is exerted upon the abdominal viscera.
A short cessation of pain succeeds the birth of the head. The violent distension of the os externum has ceased for a time, and the patient feels comparatively easy; but in the course of a few minutes the pains return as before, although not quite so severe: first, the shoulder, which is turned forwards, passes under the pubic arch, followed by the other which sweeps over the perineum. The rest of the child is expelled with comparative ease, and as soon as its pelvis has passed through the os externum, a gush of the remaining liquor amnii, which had been retained in the upper portions of the uterus, follows; the whole abdomen instantly sinks and becomes flaccid, while the uterus contracts into a firm globe upon the placenta, which is shortly to be expelled. A most delightful and perfect calm succeeds, and the sense of freedom from suffering, and joy for the termination of her trial, are expressed in the liveliest terms of gratitude.
Third stage.--Expulsion of the placenta. The period between the birth of the child and expulsion of the placenta varies considerably. Sometimes it follows the child very rapidly, so that, apparently, they are both expelled by the same effort of uterine action; at others, the interval is more considerable. There is generally an interval of ten or fifteen minutes, and then pains of a totally different character make their appearance: these are supposed to denote the separation of the placenta from the uterus, and, from their being usually attended with discharge of more or less blood, have been termed dolores cruenti by many of the foreign writers. The expulsion of the placenta is attended with little or no suffering; it descends into the vagina inverted, i. e. with its foetal or amniotic surface turned outwards: whether or not this is produced by pulling at the cord is perhaps a question.
Twins. If there be twins, the placenta of the first child is seldom expelled until after the birth of the second child. The membranes of the second ovum become distended with liquor amnii, project into the vagina and burst as in a common single labour; the passages have been sufficiently dilated and prepared by the birth of the first child, so that, when the uterus begins to contract, the expulsion of the second will be readily and easily effected. The uterus may resume its efforts for this purpose in twenty minutes after the birth of the first child, or it may remain quiescent for several hours without at all disturbing the regular and natural course of the process which will be precisely the same as in the previous case.
The placentæ of twins are usually expelled together, forming one large placentary mass; their vessels, however, are distinct from each other, so that with care one placenta can be peeled away from the other. In other cases, they are separated from each other by an intervening space of membranes; and in one rare instance of triplet placentæ the umbilical arteries of two placentæ anastomosed with each other, before dividing into smaller branches.
Upon the expulsion of the placenta, the uterus, being now emptied of its contents, contracts into a firm hard ball, which may be felt behind the symphysis pubes, or sometimes a little to one side, of about the size of a full grown foetal head. This state of hard contraction gradually disappears, and a discharge of blood called lochia follows, which having continued for a few days becomes colourless, and at length ceases altogether. For a description of the changes which the uterus and passages undergo in returning to their former condition as in the unimpregnated state, we refer to the chapter on the FEMALE ORGANS OF GENERATION.