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 has 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 fœtus, 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 Schwangerscafts-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 fœtuses 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 fœtus 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.

CHAPTER II.

TREATMENT OF PREGNANCY.

SYMPATHETIC AFFECTIONS OF THE STOMACH DURING PREGNANCY.-MORNING SICKNESS. -CONSTIPATION.-FLATULENCE. COLICKY PAINS.-HEADACH.-SPASMODIC COUGH. -PALPITATION.-TOOTHACH.-DIARRHEA.-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 portion 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 four 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 tablespoonful 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 gentle 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