AN EXPOSITION

OF THE

SIGNS AND SYMPTOMS OF PREGNANCY.

CHAPTER I.

GENERAL OBSERVATIONS ON THE STATE OF THE FEMALE SYSTEM DURING PREGNANCY.

AFTER a careful consideration of the matter, I came to the conclusion that it would conduce to a clearer and more satisfactory appreciation of the value of certain details on which we must hereafter enlarge, if, before entering on the consideration of individual signs of pregnancy, I were to premise some general observations on the effects produced in the female system by that condition, whether resulting from the necessary alterations in the component structures and size of the uterus, and the consequent change of relations between it and other organs, or from certain physiological phenomena connected with the train of actions originating in conception, and thence necessarily continued for the evolution and development of the new organization; and then to glance briefly at some of the practical considerations more obviously connected with these phenomena in their relation to external objects, and to notice the precautionary measures by which we should seek to protect the pregnant female from any injury she might sustain from their influence.

It is well known that immediately on conception, the uterine system becomes endowed with a remarkable increase of vital action affecting its various constituents, so that it is thrown into a condition which, although not properly inflammatory, we may

certainly consider with Baillie1 "a state analogous to inflammation:" thus, there takes place, at once, a great increase in the vascular supply directed towards the organ and its appendages, the vessels are gorged and distended with blood, and many of them, previously impervious to its passage, now begin to circulate that fluid freely: the tissue of the organ becomes infiltrated with serum, so that its bulk is increased, its texture softened, and its fibres separated, while, upon its internal surface, lymph is poured out, and the mucous membrane lining the cavity undergoes a transformation by which the decidua is elaborated; which, however, is really not a new product, but the inner portion of the uterine structure in what W. Hunter calls a state of efflorescence, being hypertrophied and endowed with a higher degree of vital activity; in which state, it is cast off, and when examined, presents to the eye many of the characters of the false membranes the results of inflammatory action in other situations; subsequently, large quantities of serum are rapidly secreted to form the liquor amnii; and lastly, the nerves of the uterus increasing both in number and size, as W. Hunter3 suspected and Tiedemann and Dr. R. Lee have proved, impart to it a more exalted degree of sensibility, which, from their close connection with the great abdominal plexuses and mediately with the brain and spinal marrow, is quickly diffused throughout the system at large, which is soon found to participate in the excitement emanating from the uterus. "The virtue," says Harvey, "which proceeds from the male in coitu has such prodigious power of fecundation, that the whole woman, both in mind and body, undergoes a change:" there is felt a sensation of feverish uneasiness, chills alternating with flushes of heat, sick stomach, disturbed sleep, languor, and sometimes, drowsiness; menstruation is suppressed, and the breasts soon begin to evince an active sympathy, becoming swollen and sensitive; the pulse is generally quickened, especially at first, the blood exhibits modified charac

Hunter on the Gravid Uterus, p. 82. "Lobstein compare l'uterus d'une femme grosse à un organe attaqué d'une inflammation lente et chronique.' Desormeaux.

2 Vide Baillie ut jam cit. "La membrane caduque est l'analogue des fausses membranes et la preuve de l'excitation de la matrice."-Burdach.

3 Anat. Grav. Uterus, p. 21. 4 Tabulæ et Nervorum Uteri Descriptio, p. 10.

ters of inflammation, and venesection is found the most effectual means of relief in many of the most urgent affections of preg nancy, "even in constitutions," says Denman,' "which at other times do not well bear that evacuation"-all of which, it may be observed, appear the natural, and no doubt salutary, consequences of the plastic activity prevailing in the great organ of reproduction at the time.

In consequence of this increase of vital action imparted to it, the uterus acquires a principle of growth which steadily proceeds, until, instead of being an insignificant organ buried deep amongst the contents of the pelvis, it attains to dimensions of such magnitude, and undergoes changes in its component structures so remarkable, that, whether considered absolutely or relatively, they present to our observation a series of phenomena at once the most extraordinary and beautiful of any that claim our admiration in the arrangements of the animal economy: surely the enthusiasm of Swammerdam is not to be censured as exces-sive, when he described it as the miraculum naturæ. The virgin. uterus is about 21 to 2 inches long, 1 broad, and about an inch from back to front, with a cavity which would not more than receive into it the kernel of an almond. According to the calculations of Levret, its superficies may be taken at 16 inches, but at the end of the ninth month of gestation, its length is from 12 to 14 inches, its breadth from 9 to 10, and from back to front from 8 to 9 inches: its superficies is now estimated at about 339 inches, and its cavity, which before impregnation was equivalent to about 11, or quam proxime ths, of a cubic inch, will now contain 408, so that its capacity is increased a little more than 519 times, and its solid substance from 4 to 51 cubic inches, or nearly in the ratio of 12 to 1; and at the same time, a similar increase of size is observed in its several constituents; for instance, blood vessels which before conception would not have admitted the point of a probe will now readily receive the end of our little finger, and yet, let but a few weeks elapse after parturition, and the organ has again resumed its original contracted and diminutive state. But, as we might anticipate, such expansion of an organ so situated must involve many changes affecting.

1 Introduction, p. 220. 5th edit.

other parts also; and as it acquires this increase of volume, it gradually deserts the pelvis and rises out of its cavity into that of the abdomen, disturbing the relations hitherto existing not alone between it and other abdominal viscera, but also the ordinary relations of these with each other. The first organ generally affected in this way is the bladder, which, in the early periods of pregnancy, is liable to increased irritability, owing to its receiving its supply of nerves from a common trunk with those of the uterus, so that frequent micturition is often a very early consequence of a gravid uterus, and one which occasionally continues very troublesome throughout the greater part of gestation. Sometimes, retention of urine is caused by the mechanical pressure of the uterus, before it has quitted the cavity of the pelvis, though the same symptom may occur without our being able to detect this, or any other obvious cause for its production. Towards the close of pregnancy, the female is often unable to retain her water except for a short time, and suffers much inconvenience by its coming away involuntarily while she walks, or if she coughs, laughs, or sneezes; this is caused by the weight of the uterus resting on the fundus of the bladder, which it presses heavily against the inner and upper edge of the symphysis pubis, over which it is now, in some degree, turned, in consequence of the uterus in its ascent drawing it up as well as the vagina, with the anterior wall of which the bladder is so intimately connected; and from the stretching of the round ligaments of the uterus, as well as from the increased sensibility of the nerves which they contain, considerable uneasiness is felt in the direction of these cords, and about their termination at the sides of the pubes. This uneasiness extends also along the nerves of the thigh, producing numbness, cramps, and even considerable pain along the limb, which latter symptoms are often observed amongst the earliest indications of uterine irritation, whether arising from functional derangement, organic disease, or the healthy excitement of pregnancy. It is not unusual, under such circumstances, to find the power of one or both of the lower limbs more or less impaired; and, in some few rare instances, they have become partially or completely paralytic, and even hemiplegia has been observed; but to what degree the mere enlargement of the uterus is the agent in the production of such a state seems very doubt

ful, especially as we sometimes find the paralysis affecting the upper extremities; the blood drawn under such circumstances has been observed to present highly inflammatory characters; but whatever measures may be adopted, the affection is never perfectly removed until after delivery, from which it would appear to depend on cerebral disturbance, originating probably in uterine irritation, and referable to the state of pregnancy as its specific cause.

When the uterus has acquired considerable size, it begins to interfere with the circulation, especially that through the veins, and, by its pressure upon the trunks which return the blood from the lower extremities and parts within the pelvis, gives rise to anasarcous swellings of the feet and legs, and sometimes to more formidable effusions within the cavity of the peritoneum. Varicose veins and hemorrhoidal tumors are probably to be ascribed to the same cause, though perhaps the latter would be with more propriety referred to congestion of the hemorrhoidal veins from the torpid and constipated state of the bowels. Having so far assigned a mechanical agency in the production of these anasarcous swellings which so frequently occur in pregnancy, it must be observed that, although they may thus be, to a certain extent, satisfactorily accounted for in the lower extremities, there is frequently evidence of some more general cause operating in the system, probably the increased activity of the exhalants, which is indeed a condition of these vessels necessary for the perform. ance of a very important process essential to the well-being of the foetus, namely, the secretion of the liquor amnii. Without reference to some such general action, we could not satisfactorily explain the production of oedema of the upper extremities and face which sometimes accompanies pregnancy, as in a lady seen by the writer some years since, in the ninth month of her first pregnancy, whose case was, for many reasons, one of great interest and anxiety about the middle of the eighth, swelling of her feet and legs began, and continued until it reached half-way up the thighs; then, her hands became similarly affected-she could hardly close them, and was obliged to put off her rings; her face at length became affected, and to such a degree that when she got

Edinburgh Monthly Journal, vo'. xii. p. 492.