A System of Midwifery Part 7

_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 pract.i.tioner if he place much reliance upon it; for the pa.s.sage 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 pract.i.tioner, this may also be looked upon as a certain indication that pregnancy exists. The foetal 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 foetus, 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 b.r.e.a.s.t.s 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 circ.u.mscribed 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 foetus. The case proved to be one of acc.u.mulation of menstrual fluid in the uterus." (Dewees's _Essays 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 foetus and by the pulsations of its 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 foetus per v.a.g.i.n.am, 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 b.r.e.a.s.t.s, 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 v.a.g.i.n.a and os externum, as described by Professor Kluge of the Charite 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 v.a.g.i.n.al 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 circ.u.mstances 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 be _quick with child_ has 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, when a pregnant woman was on the point of being executed through the ignorance of a female jury. (E. Kennedy's _Observations 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 pract.i.tioner p.r.o.nounces; 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 pract.i.tioner 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 circ.u.mstance alone, or even when combined with several others; for I have had the pleasure in several instances of doing away an injurious and cruel suspicion, to which this enlargement 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 circ.u.mstances which rendered it one of great doubt, and, without having had recourse to the most careful and minute examination, might readily have embarra.s.sed a young pract.i.tioner. This lady's case was submitted to a medical gentleman, who, from its history and the feel of the abdomen, p.r.o.nounced 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 b.r.e.a.s.t.s 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 pract.i.tioner, 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 b.r.e.a.s.t.s become painful, swell, and secrete a lymphatic fluid, frequently resembling milk; the digestive organs become disordered; there is irregular appet.i.te, nausea, and inclination to vomit; constipation, muscular debility, change in the colour of the skin, and frequently of the whole condition of the body; the nervous system suffers, and even the mind itself frequently sympathizes; the patient is sensible of movements in the abdomen like those of a living foetus, then bearing down pains running from the loins to the p.u.b.es; 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 Schw.a.n.gerschafts-falle_.) A most extraordinary case of the self-deception with regard to pregnancy, has been published by the celebrated Klein of Stuttgardt: it has been quoted in the work of W. J.

Schmitt above alluded to, and a brief sketch of it has been given by Dr.

Montgomery in his _Expositions of the Signs and Symptoms of Pregnancy_, p.

172, to which we must refer the reader for much valuable information on this and all other subjects connected with the diagnosis of pregnancy.

_Diagnosis of twin pregnancy._ Before concluding this chapter, we shall offer a few observations on the diagnosis of twins. A variety of symptoms have been enumerated as indicating the presence of two foetuses 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 quant.i.ty 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 foetus 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 circ.u.mstance which is very easy of explanation.

The stethoscope affords us the only certain diagnosis of twin pregnancy; and even here it is limited to the sounds of the foetal hearts; the increased extent and power of the uterine souffle, as remarked by Hohl, arising, as he supposed, from the large ma.s.s of the double placenta, is not a proof which can be depended upon. In cases of suspected twin pregnancy the auscultation must be conducted with the greatest possible care, and, generally speaking, a certain diagnosis can only be obtained by two observers ausculting the two hearts at one and the same moment; for, otherwise, the difference between their rhythm is frequently so small as to be inappreciable. The sounds are seldom or never heard at the same level, one being generally heard high up on one side, the other in a contrary direction.

CHAPTER II.

TREATMENT OF PREGNANCY.

_Sympathetic affections of the stomach during pregnancy.--Morning sickness.--Constipation.--Flatulence.--Colicky pains.--Headach.-- Spasmodic cough.--Palpitation.--Toothach.--Diarrhoea.--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 quant.i.ty which now exists in the circulation; the nervous and also the vascular system of the uterus are now in a state of high excitement and activity--a condition which must necessarily communicate itself to those organs which are supplied by the same nerves; viz. the sympathetic, and by the same portion of the circulation, viz. the branches of the abdominal aorta.

No organ, except the stomach, possesses sympathetic connexions so widely extended over the rest of the system as the uterus; and, we may add, that no two organs are so intimately and reciprocally united as the uterus and the stomach. In the unimpregnated state, we see this manifested in a remarkable degree; if the stomach becomes deranged the uterus sympathizes; thus the states of gastric disturbance, known under the general term of dyspepsia, are frequently followed by leucorrhoea, or some derangement of the menstrual function: on the other hand, uterine disease is invariably accompanied by symptoms of gastric disturbance, and, in many cases, to such an extent as to conceal the real seat of the evil, and mislead the attention of the patient and her medical attendant. In like manner we find that during pregnancy, especially in the early stages of it, the patient is annoyed with a great variety of symptoms more or less indicative of derangement in the functions of the primae viae.

_Morning sickness._ One of the most troublesome, and by no means the least frequent, is vomiting, which, from coming on usually in the morning, is commonly called morning sickness; in some cases the female merely rejects what food or mucus may be present in the stomach, after which she feels relieved; in others she continues to strain violently and ineffectually for some time. In the former case it resembles the common vomiting from a deranged stomach, and cannot be considered as the direct result of sympathy with the uterus: the tone of the stomach has become impaired, and vomiting has followed as a consequence of its being loaded with undigested food and depraved secretions. Hence, in these cases, it is generally preceded by nausea and the other common precursory symptoms of this act: in the latter, however, it appears to be the immediate result of irritation transmitted from the uterus, and a.s.sumes 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 quant.i.ty 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 a.s.sist its operation with a little warm water, or chamomile tea: after which the bowels should be briskly opened by a saline laxative, as for instance, a seidlitz powder, sulphate and carbonate of magnesia, &c.: small doses do more harm than good, as, from their slow and ineffective action, they rather tend to increase the irritation and aggravate the symptoms. In severe cases, especially where the pulse is excited, a small bleeding may be used with much advantage, but in most instances the usual treatment of gastric derangement, as it occurs in the unimpregnated state, produces most relief. The bowels should be first opened in the way already mentioned, after which a combination of Pil. Hydrarg. and Extr. Hyosc. or Extr. Humuli, is to be given at night, and a vegetable tonic during the day.

Acids, more especially the mineral, have been very judiciously recommended by Dr. Dewees, and, when combined with any bitter infusion, will be found of great service. Where the constant secretion of acid is very distressing, the nitric acid will be found particularly useful; it allays the irritability of the stomach, and produces a healthy state of its secretion. Opiates are by no means desirable remedies, and rather tend to aggravate the disease by still farther injuring the tone of the stomach and producing constipation. We have known them given in considerable doses and in very powerful forms, but without relief. Hydrocyanic acid, creosote, &c., have also been tried, but with no permanent success; in such cases Dr. Burns has found the application of leeches useful, "especially if accompanied with pain or tension in the epigastric region."

On the same principle, we presume, have we found a sinapism of great service. Where the vomiting, in spite of all the above modes of treatment, still goes on unabated, there is nothing which, in our experience, is so useful as covering the epigastrium with a hot flannel, upon which a mixture of camphorated spirits of wine and laudanum has been sprinkled.

"We have," says Dr. Dewees, "in several instances, confined patients for days together, upon lemon juice and water with the most decided advantage.

We have repeatedly found much benefit from the use of the spirit of turpentine three or four times a day, in doses of twenty drops: this medicine is very easily taken, if it be mixed in cold sweetened water.

When the system is not excited to febrile action, and where the stomach rejects every thing almost as soon as swallowed, we have often known a table-spoonful of clove-tea act most promptly and successfully."

(_Compendious System of Midwifery._)

_Heartburn_ is another form of gastric derangement which frequently occurs to a very distressing degree, and must be looked upon as a modification of morning sickness; in many cases it arises from the presence of acid in the stomach, but in others it is merely a sympathetic result of gastric irritation, without any proof of acidity being present. The treatment of heartburn is much the same as that just described for morning sickness, the main object being to restore the stomach and bowels to a healthy condition. Besides the mineral acids, small quant.i.ties of iced water will be found very grateful, relieving the sense of burning in the back of the pharynx, and diminishing, in great measure, that gastric irritability of which it is a symptom.

The frequent, and sometimes almost unlimited, use of antacid absorbents, viz. magnesia or chalk, in this disease, is a practice much to be deprecated: compounds are thus formed in the stomach which are positively injurious, and, beyond the temporary relief procured by removing the acid, they tend to aggravate these symptoms, by increasing the state of gastric derangement. The only chemical antacid which should be given in these cases is the carbonate of soda; by this means a compound is formed (the common muriate of soda,) which of all others is most grateful to the stomach, and which, from its gently laxative effects, is well adapted to keep up a healthy action of the bowels. It is scarcely credible to what extent the use of antacids may be carried to relieve the cardialgia of pregnancy. Dr. Dewees mentions having attended a lady with several children, "who was in the constant habit of eating chalk during the whole term of pregnancy; she used it in such excessive quant.i.ties as almost rendered the bowels useless. We have known her many times not to have an evacuation for ten or twelve days together, and then only procured by enemata, and the stools were literally nothing but chalk. Her calculation, we well remember, was three half pecks for each pregnancy. She became as white nearly as the substance itself, and it eventually destroyed her, by deranging her stomach so much that it would retain nothing whatever upon it." (_System of Midwifery_, -- 275.)

The _constipation, flatulence, colicky pains, and headach, the spasmodic cough, palpitation, toothach_, &c. are symptoms arising from the same cause, a knowledge of which circ.u.mstance 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 circ.u.mstances, 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 quant.i.ty suddenly from the system, as it may greatly endanger the life of the foetus, and from the state of the nervous irritability, may even run the risk of bringing on convulsions; syncope is always more or less hazardous to a pregnant woman, and should if possible be avoided. Some caution will be also necessary in our choice of aperient medicines; drastic purgatives, as aloes, colocynth, scammony, &c. are not suited to the state of pregnancy, as they irritate the lower bowels, and thus excite a disposition to uterine contraction; mild, but effectual laxatives, such as castor oil, confectio sennae, a seidlitz powder, are better adapted; the latter, especially will be found useful, as, from its being taken during effervescence, it is better calculated to quiet the stomach.

_Diarrhoea_ is sometimes an exceedingly troublesome symptom during pregnancy. It not only weakens the patient and thus tends indirectly to induce abortion by destroying the life of the foetus, but it acts also in a more direct manner by exciting uterine contractions, particularly when accompanied, as is frequently the case, with tenesmus. The diarrhoea which is met with in pregnant women is not so frequently, as has been supposed, the result of irritation from the uterus, producing simply an increased peristaltic action of the bowels without any considerable derangement of their functions; by far the most usual form is connected with a very deranged state of the alimentary ca.n.a.l; 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. Creta, and Dover's powder, will excite the liver to a healthier action, and still farther control their inordinate activity. If the disposition to tenesmus be troublesome, a small injection of starch and opium will afford relief. If the stomach will bear it, a rice-milk diet for a day or two is desirable; it is a gentle demulcent to the irritable intestines, and has a slightly constipating effect.

_Pruritus pudendi_ to a very distressing degree occasionally comes on during pregnancy, and though in most instances a very manageable form of disease, yet if its nature be not properly understood it proves exceedingly obstinate, and much suffering is the result. It appears to be essentially different from the common prurigo, being an aphthous state of the lining membrane of the v.a.g.i.n.a 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 v.a.g.i.n.a, which is usually incrusted with one confluent ma.s.s of aphthae; whereas, on the perineum and margins of the l.a.b.i.a 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]

Aphthae of the v.a.g.i.n.a 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 v.a.g.i.n.a of pregnancy is not a common affection.

_Salivation_ is another affection which is occasionally, though rarely, met with in pregnancy. It is usually attended with morning sickness, constant nausea, and deranged bowels, and may reduce the patient excessively: attention to the state of the bowels, followed by gentle alteratives and tonics, generally gives relief.

CHAPTER III.

SIGNS OF THE DEATH OF THE FOETUS.

_Difficulty of the subject.--Signs before labour.--Motion of the Foetus.--Sound of the foetal 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 ou le chirurgien doive faire plus grande reflexion, et apporter plus de precaution aux choses qui concernent son art, c'est en celle ou il s'agit de juger si l'enfant qui est dans la matrice est vivant, ou bien s'il est mort." There are few circ.u.mstances 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 pa.s.sage 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 a.s.sure 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 Caesarean 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 circ.u.mstances, it becomes a most serious question whether we are always justified in destroying the life of the foetus 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 Caesarian operation, as are used upon the Continent, and apply it not only to those cases where the child cannot be delivered _par 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 circ.u.mstances 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, or _vice versa_. The most practical arrangement of these symptoms will, we think, be under the two following heads: those which occur _before_ labour, and those which occur _during_ labour.

The symptoms of the child's death, which are usually enumerated as occurring _before_ labour, 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 b.r.e.a.s.t.s are flabby, and sometimes there is a fetid slimy discharge from the v.a.g.i.n.a. 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 appet.i.te 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 foetus than she does of her own liver or spleen. The living foetus obeys the laws of organic life; the dead foetus those of gravity. When once the child has ceased to exist, it acts like any other ma.s.s of inanimate matter, and pushes the uterus down to that side which is lowest.