A System of Midwifery Part 8

In most instances this symptom will be sufficient to make us suspect that the child is dead, but it now and then occurs where the result of labour proves the child to be alive; this must rather be looked upon as an exception to the rule, for it is not of frequent occurrence. We have observed it in two or three cases: it has been also noticed by Dr. E.

Kennedy, (_op. cit._;) and, therefore, cannot invariably be looked upon as a certain sign of the child's death. We have observed it frequently in cases threatening abortion at an early period: in many it has been followed by premature expulsion, but in others the symptom has gradually disappeared as the health improves, and the patient has eventually been delivered of a living child at the full period.

In these cases, we should rather attribute the source of this symptom to a loss of the firmness and tone peculiar to the uterine parietes during pregnancy, and which depends upon the increased activity of the circulation in them at this period: when this is considerably diminished, the uterine parietes will necessarily become more flaccid, and, therefore, less able to withstand the influence of gravity, or sustain the uterus in its proper situation. The embryo itself during the first two or three months is too small and too light to produce this symptom itself.

The sensation (to the mother) of the child's movements is as fallacious an indication of the child's life as it is of pregnancy; nor can the absence of this sensation be looked upon as a proof of its death. Women are very liable to be misled in this respect; so much so, that it will be much safer for the pract.i.tioner 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 primiparae. 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 a.s.serts that she has distinctly felt the motion of the child, and yet she brings forth a child in such a state of decomposition as proves beyond all doubt that it must have been dead some eight, ten, or more days.

As the sound of the foetal heart is the surest sign of pregnancy, so it is an equally certain proof of the child's life: but is the absence of this sound, a certain symptom of its death? at the best it is a negative evidence, and the value of it must entirely depend upon the skill of the ausculator and the care with which he makes his examination. If, after repeated and careful auscultation of the abdomen, the well-practised ear can no where detect a trace of the foetal pulsations, it may be a.s.serted on very safe grounds that the foetus has ceased to live. This is more particularly the case during the last weeks of pregnancy, when the pulsations are stronger, and the bulk of the child, in proportion to that of the liquor amnii being absolutely, as well as relatively, greater. The distance between the heart and surface of the abdomen is less during the last weeks of pregnancy also; the child's movements are not so free as at an earlier period; and hence, if the foetal heart is beating, it will be more easily discovered.

The uterine souffle affords us little aid in the diagnosis of the child's death: it is frequently very distinct when the child is evidently alive; and where it has been heard previous to its death, it will continue for some hours afterwards, although with diminished strength and over a smaller s.p.a.ce.

During labour there are a variety of symptoms, by the aid of which we can p.r.o.nounce, with a very tolerable degree of certainty, whether the child is alive or not; if alive, the foetal heart can invariably be detected; and, for the reasons above stated, will be heard more distinctly than in the earlier months of pregnancy. If, from the violence or duration of the labour, or any other cause, the child is becoming exhausted, the pulsations become weaker and slower until they stop; so that by the aid of auscultation we possess distinct evidence of the child's life being endangered, and of its complete extinction.

If the _head_ presents during labour, a firm elastic swelling (caput succedaneum) will rise on that portion of it which first enters the v.a.g.i.n.a: this is produced by the circulation in the presenting part of the scalp being obstructed by the pressure which the os uteri and v.a.g.i.n.a 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 primiparae, where the head is advancing slowly, and where it is tightly encircled by the distended v.a.g.i.n.a. But in multiparae, where the soft pa.s.sages have been dilated by repeated labours, the pressure upon the head is so slight, and its pa.s.sage 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 circ.u.mstance which probably arises from the circulation in the brain having ceased; and in those cases where the child has already been dead some time, a crackling or crepitous sensation is communicated to the finger from emphysema, the result of decomposition.

The only case in which the swelling of the head is capable of misleading us, is in lingering difficult labours, where the child has been alive at the beginning, the swelling has formed, but from the duration and severity of the labour the child has died: wider such circ.u.mstances, 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.

CHAPTER IV.

MOLE PREGNANCY.

_Nature and origin.--Varieties.--Diagnostic Symptoms.--Treatment._

When any cause has occurred to destroy the life of the embryo during the early weeks of pregnancy, one of two results follows, either that expulsion takes place sooner or later, or the membranes of the ovum become remarkably changed, and continue to grow for some time longer, until at length they form a fleshy fibrous ma.s.s, called _mole_, or _false conception_.[47]

It is well known that the venous absorbing radicles of the chorion, which give it that s.h.a.ggy appearance during the first months of pregnancy are the means by which the embryo is furnished with a due supply of nourishment at this period: if the embryo should die from any cause, and the uterus show no disposition to expel the ovum, the nourishment which has been collected by the absorbing power of the chorion appears now to be directed to the chorion itself, which therefore puts on a fleshy growth and increases very rapidly in size. (Roederer, _Elementa Artis Obstetricae_, 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 haemorrhage 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 haemorrhage which solidifies by coagulation; and not only render the chorion or incipient placenta much thicker and more solid, but give it also a lobulated tuberculated appearance: from the same reason, the little funis, which is probably not an inch long, is greatly distended, being in some cases as thick as the body of the embryo itself, the blood having penetrated from the placental cells into the cellular tissue of the chord. This is by no means an uncommon form of mole; externally it is covered by the decidua, which appears to be in a natural condition, and the inner surface of the cavity is lined by a fine membrane, having all the usual characters of the amnion. The lobulated appearance is chiefly seen from within, the amnion being raised by a number of irregular convexities.

"When the blood is poured out from its containing vessels into the substance or cells of the placenta, or between the membranes, gradually coagulates, and a.s.sumes 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 a.s.sumes a chocolate brown, a reddish or brownish yellow hue; and latterly, if time sufficient be allowed, it presents a pale yellowish white or straw-coloured substance, the fibrinous portion of the coagulum being then left alone."[48] This form of mole, as far as our own observation goes, seldom attains any considerable size, rarely exceeding four inches in length, and is usually expelled between the eighth and twelfth week. The size and condition of the foetus varies a good deal; in some cases it appears nearly healthy, although the cord is much thickened and distended; this is probably owing to its having been expelled shortly after its death, or to its having gone on to live a short time after the injury which had caused haemorrhage: 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 ma.s.s of vesicles of irregular size and shape like hydatids, which appear to be the absorbing extremities of the veins of the chorion distended with a serous fluid; it is difficult to distinguish these from real hydatids; the more so, as Bremser a.s.serts that he has occasionally met with real hydatids among them. Perhaps the mode of their attachment will in some degree a.s.sist the diagnosis: these vessicles, or _hydatids of the placenta_, as they have been called, are attached over a large portion of the uterus,--an arrangement we believe, not generally seen in real hydatids, which are mostly attached to a single stalk or pedicle. Indeed, it may be doubted if the ma.s.ses of vesicles which are occasionally expelled from the uterus are ever true acephalocysts, as they are invariably connected with a blighted ovum, and are, therefore, formed as before observed, by a dropsical state of the venous radicles of the chorion.

A variety of other molar growths have also been enumerated by authors; in fact, "the term _mole_ has been rather vaguely applied to almost every shapeless ma.s.s which issued from the uterus, whether this proved to be coagulated blood, detached tumours, or a blighted conception." (Churchill, _on the Princ.i.p.al 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 circ.u.mstance, 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 b.r.e.a.s.t.s flaccid, with unusual la.s.situde, 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 haemorrhage comes on, and may be repeated several times, causing much loss of strength and exhaustion, and attended with a good deal of pain, more especially if the uterus be about to throw off its contents. In that form of mole where the parietes of the ovum have been thickened and lobulated by ma.s.ses 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, haemorrhage sooner or later makes its appearance, the patient's health still farther declines, leucorrhoea comes on, followed by oedema of the feet, general breaking up of the health, and even incipient cachexia. Occasionally the discharge is excessively putrid and offensive. Where it is of the hydatic species, we can frequently ascertain its character by the expulsion of two or three hydatids which have separated from the main ma.s.s, 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 haemorrhage 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 ma.s.s to be expelled: indeed, under these circ.u.mstances, it is frequently more profuse than haemorrhage 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 ma.s.s 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 haemorrhage 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 v.a.g.i.n.a, its body felt considerably enlarged, and there was a round circ.u.mscribed 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 haemorrhage 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 haemorrhage; towards evening there came on strong expelling pains, during which she discharged a vast quant.i.ty of something which puzzled her attendants. The next morning I found her quite well--her pain, haemorrhage, and vomiting, having ceased. I was then taken into her dressing-room, and shown a large wash-hand basin full of what looked like myriads of little white currants floating in red-currant juice. They were hydatids floating in b.l.o.o.d.y water."

_The treatment_ previous to the expulsion of the mole should be gently alterative and tonic; the chylopoietic functions should be kept in regular action, and the strength sustained. When haemorrhage comes on, we must be guided a good deal by the quant.i.ty 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 ma.s.s protruding into the v.a.g.i.n.a, which may be hooked down by the fingers, and thus the expulsion of the whole ma.s.s 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 a.n.a.logy. The after treatment will always be a matter of considerable importance, and will, in a great measure resemble that in abortion or mis-carriage.

Patients who have suffered from a mole pregnancy generally have their strength seriously reduced and their health much broken: hence, they are liable to leucorrhoea, menorrhagia, or dysmenorrhoea, which entail a long series of troublesome and even dangerous affections, the recovery from which will be slow and difficult, requiring a long course of tonic medicines, and removal to the sea-coast or some watering-place where there are chalybeate springs.

CHAPTER V.

EXTRA-UTERINE PREGNANCY.

_Tubarian, ovarian, and ventral pregnancy.--Pregnancy in the substance of the uterus._

The ovum when impregnated does not always quit the ovary and pa.s.s along the Fallopian tube into the uterus. It may remain in the ovary and become here developed; it may pa.s.s into the Fallopian tube and remain there; or from some defect in the action of the fimbriated extremity of this ca.n.a.l, it may escape into the cavity of the abdomen, and become attached to some of the viscera. Hence, extra-uterine pregnancy has been divided into three species, viz. _graviditas tuberia_, _ovaria_, and _ventralis_, according to the situation which the ovum takes. A fourth has been also described by M. Breschet, which he has called _graviditas in substantia uteri_, a modification probably of tubarian pregnancy.

[Ill.u.s.tration: _a_ The uterus, its cavity laid open. _b_ Its parietes thickened, as in natural pregnancy. _c_ A portion of decidua separated from its inner surface. _d_ Bristles to show the direction of the Fallopian tubes. _e_ Right Fallopian tube distended into a sac which has burst, containing the extra-uterine ovum. _f_ The foetus. _g_ The chorion.

_h_ The ovaries; in the right one is a well marked corpus luteum. _i_ The round ligament.]

This singular deviation from the usual course of conception is fortunately of rare occurrence, for few cases terminate favourably. If it be in the Fallopian tube or ovary, these become immensely distended into a species of sac or cyst, to the sides of which the placenta adheres: as the ovum increases, this at length gives way from excessive distension, and the patient usually dies from internal haemorrhage. In ventral pregnancy, the sac is attached to the abdominal viscera, and is usually imbedded among the convolutions of the intestines: hence the duration of extra-uterine pregnancy will depend upon its situation; thus, if it be in the Fallopian tube, it rarely lasts beyond two months; whereas, ovarian pregnancy will continue for five or six months; on the other hand, in ventral pregnancy the foetus will not only be carried to the full term, but far beyond that period, amounting to several years.[50]

Although the uterus does not receive the ovum into its cavity as it does in natural conception, it nevertheless undergoes many of those changes which are known to take place in regular pregnancy. The layer of coagulable lymph, which is effused upon its internal surface, and which forms the membrana decidua of Hunter, is present, and the uterus undergoes a slight increase of volume. As the ovum increases, excruciating pains are felt in the lower part of the abdomen, coming on at irregular intervals, and of irregular duration; in some cases lasting for a short time, in others continuing for twenty-four hours. These attacks of pain are generally accompanied with very painful forcing and tenesmus, and not unfrequently with a discharge of b.l.o.o.d.y mucus from the v.a.g.i.n.a. In tubarian pregnancy, however, the case generally follows a much shorter course: the patient is suddenly seized with an acute pain in the lower part of the abdomen, followed by nausea and vomiting; she becomes faint and weak; the abdomen evidently increases in size (from effusion of blood into the cavity;) the debility becomes more alarming, and death quickly follows.

In ovarian pregnancy the fatal termination is merely postponed till a later period, during which the patient has to undergo attacks of most terrible suffering: at length, after a paroxysm more than usually severe, and frequently attended with the sensation of something giving way in the abdomen, faintings come on, speedily followed by death. During the attacks there is obstinate constipation, which is attended with painful and fruitless efforts to evacuate the bladder and r.e.c.t.u.m; the face is pale, and expressive not only of the most acute suffering, but of great anxiety and mental depression; nevertheless, in the intervals of the attacks she feels easy, and appears well and cheerful.

The termination of a ventral pregnancy is very different; after a time the foetus dies, and may either remain enclosed in the cyst for life, or it may be discharged in portions by means of an abscess, either through the intestines, uterus, v.a.g.i.n.a, or abdominal parietes. Cases have occurred where it has come away by the bladder; in the former case, where it is retained, it diminishes more or less in size, becomes hard and closely packed together, and, in some instances, encrusted with a layer of calcareous matter.

It is to our venerable friend, the late Dr. Heim, of Berlin, that we are indebted for much curious and interesting knowledge respecting extra-uterine pregnancy. Although the symptoms in the very early stages are so obscure as to render it nearly impossible to detect its presence, he has nevertheless observed some facts connected with it, which are peculiar, and deserve to be noticed. No morning sickness has been observed in cases of extra-uterine pregnancy, a circ.u.mstance which can easily be accounted for, if we bear in mind the causes of morning sickness in natural pregnancy: the patient could only lie on the affected side, and the abdomen was observed to swell irregularly, not in the same manner as in regular pregnancy.

In tubarian and ovarian pregnancy, the pain was in the pelvis, but in ventral pregnancy it occupied more or less the whole abdomen, the parietes of which were very tender upon pressure. In cases where the foetus died at an early period, the symptoms gradually disappeared after a time, especially when followed by the bursting of an abscess through the r.e.c.t.u.m or any other part. One of the most remarkable facts which Dr. Heim observed, was a peculiar whining tone of voice, with which the patient expressed her sufferings during a paroxysm of pain; so peculiar, that when once heard, the sound can never be mistaken. On several occasions Dr. Heim was enabled by means of this symptom alone to decide confidently as to the nature of the case the moment he entered the room, a fact which would appear scarcely credible had not the results of the cases proved the correctness of his a.s.sertion. A most interesting case of this sort occurred, which he p.r.o.nounced to be ventral pregnancy, and when it had gone the full term gastrotomy was performed, a living child was extracted but the unfortunate mother perished: she could not be induced to submit to the operation until inflammation had come on, and she died in two days after.

It must always remain a matter of great obscurity as to the immediate _causes_ of extra-uterine pregnancy, more especially of the ovarian and ventral species; and the more so as we are still ignorant of the mechanism by which the fimbriated extremity of the Fallopian tube grasps the ovary immediately over the impregnated vesicle of de Graaf at the moment of conception. In many cases we are inclined to think that this function of the Fallopian tube is destroyed by adhesions between it and the ovary, a circ.u.mstance of not uncommon occurrence; but from the alteration in the shape and size of these parts, as also from the extensive adhesions which are usually found after death, in such cases it will ever be difficult, and perhaps impossible, to prove it.

The _treatment_ of extra-uterine pregnancy must be chiefly guided by the prevailing symptoms: where any portion of the abdomen is very tender to the touch, leeches and warm fomentations will be required; the pain during the attacks can only be alleviated by frequently repeated opiates; and constipation must be carefully guarded against by laxatives and enemata between the paroxysms. Where an effort is made by nature to discharge the foetus by means of an abcess, the case will require all our care to sustain the powers of the system through a long protracted struggle.

Portions of the foetus come away from time to time, and if the exit afforded them be by way of the intestine, the suffering produced is very great, particularly when any of the larger bones are pa.s.sing. The presence of such a ma.s.s of semi-decomposed animal matter in the abdomen is of itself sufficient to injure the general health materially: hence it is that patients, during the process of expulsion, suffer greatly from severe attacks of fever, which recur from time to time. Where the abscess opens through the abdominal parietes, the whole is completed with much greater ease and safety to the patient: in some instances the tumour has been opened, and a foetus with a large quant.i.ty of putrid pus has been removed.