With regard to the fœtal pulsations, we find them generally beating at the rate of from 130 to 150 double strokes in a minute, and the age of the fœtus 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 fœtal 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 fœtal 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 fœtus 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 fœtal 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 fœtal 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 fœtal heart; even in acute inflammatory affections, in pneumonia, pleurisy, where there was severe dyspnœa, 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 fœtus. (Naegelé,op. cit.p. 39.) Dr. Kennedy has observed some remarkable cases where the fœtal 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 fœtalheart 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 fœtus 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 fœtal 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 fœtal 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 fœtal 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 fœtal 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 thefunic souffle.
The sound of the fœtal 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 fœtal 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 fœtus 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 fœtal 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 fœtus 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 fœtus 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 fœtus 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 fœtus 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 ofballottementby 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; forthe 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 fœtal 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 fœtus, 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 fœtus. The case proved to be one of accumulation of menstrual fluid in the uterus.” (Dewees’sEssays 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 fœtus and by the pulsations ofits 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 fœtus 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 bequick with childhas 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, whena pregnant woman was on the point of being executed through the ignorance of a female jury. (E. Kennedy’sObservations 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 andcruel 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 minditself 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 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 hisExpositions 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 fœtal 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.
TREATMENT OF PREGNANCY.
Sympathetic affections of the stomach during pregnancy.—Morning sickness.—Constipation.—Flatulence.—Colicky pains.—Headach.—Spasmodic cough.—Palpitation.—Toothach.—Diarrhœa.—Pruritus pudendi.—Salivation.
Sympathetic affections of the stomach during pregnancy.—Morning sickness.—Constipation.—Flatulence.—Colicky pains.—Headach.—Spasmodic cough.—Palpitation.—Toothach.—Diarrhœa.—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 leucorrhœa, 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 onusually 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 acombination 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.)
Heartburnis 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 aggravatethese 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.)
Theconstipation, 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 lifeof the fœtus, 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.
Diarrhœais 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 fœtus, but it acts also in a more direct manner by exciting uterine contractions, particularly when accompanied, as is frequently the case, with tenesmus. The diarrhœa 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 pudendito 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.
Salivationis 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.
SIGNS OF THE DEATH OF THE FŒTUS.
Difficulty of the subject.—Signs before labour.—Motion of the Fœtus.—Sound of the fœtal 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.
Difficulty of the subject.—Signs before labour.—Motion of the Fœtus.—Sound of the fœtal 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 fœtus 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 onlyto those cases where the child cannot be deliveredpar 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, orvice versâ. The most practical arrangement of these symptoms will, we think, be under the two following heads: those which occurbeforelabour, and those which occurduringlabour.
The symptoms of the child’s death, which are usually enumerated as occurringbeforelabour, 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 fœtus than she does of her own liver or spleen. The living fœtus obeys the laws of organic life; the dead fœtus 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 ratherbe 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 fœtal 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 fœtal pulsations, it may be asserted on very safe grounds that the fœtus 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 asrelatively, 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 fœtal 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 fœtal 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 theheadpresents 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 childhas 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.
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, calledmole, orfalse 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. (Rœderer,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 theusual 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 fœtus 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, whichappear 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, orhydatids 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 termmolehas 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 thickenedand 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, leucorrhœa comes on, followed by œdema 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, andshown 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 treatmentprevious 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 leucorrhœa, menorrhagia, or dysmenorrhœa, 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.