TREATMENT OF PREGNANCY.

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.