TWO CASES OF HYDRORRHEA GRAVIDORUM. Br Brojendro Nath
Banerjee,
L. M. S.
I shall first narrate two cases from my own practice, and then briefly discuss the etiology and treatment of this rare and misleading disease. Case No. 1.?/Et. 35 ; 13th pregnancy ; of robust constitution but a confirmed asthmatic. Had prolapse of the uterus death of a foetus (7 months old) in seven years ago after the She passed fsetal bones for a couple of months the womb. continually after this. This time from the 4th month of gestation she began to of an pass white and sometimes sanguinolent discharge quantity. Every time with the appearance of this discharge, she thought she would miscarry, but to her suran prise she passed on to full term, and was delivered of emaciated child which died in a week. I first saw her in the 6th month of her pregnancy when I found the discharge resembled Liq. umnii both in color and be no discharge for a week or so. consistency. There would It used to come on in a gush as also guttatim. Sometimes in it which were either of a pure mucous flakes were noticed white color. It also used to be attended with white or
alarming
dirty
down pain. Sometimes the patient would describe it as false other times as true pain. The patient having carried 12 children already, was greatly alarmed by this unusual
bearing
discharge mostly attended with labor pain. She was almost sure that the child had died, and that she would again pass bony pieces as she did once. She would not perceive the foetal movement for days together, and
this alarmed her the more. This case was examined by four well known Assistant-SurAtmaram Pandurang of Bombay, geons as well as by Dr. while on a visit to this place. Astringents were prescribed fruitlessly to check the discharge. t did not prescribe any medicine, but insisted on absolute rest from which she latterly derived much benefit. I attended her during child-birth. The baby was a thin emaciated one weighing about 3 lbs. There was the usual flow of Liq. amnii. The amnotic membrane was in fact places (four I remember) greatly thickened, and in several calcified. It also contained a circular hole about the size of This hole was evidently the result of a four anna piece. giving way of portion of calcified part. Half of the placenta was carnified and a calcified spot about the size of a rupee was noticed in it. Case No. II.?JEt. 2G; 7th pregnancy; very thin, scrofuand occasionally suffered from lous, asthmatic, hysteric, hemoptysis. In the beginning of the first week of the 8th month of her gestation, one morning she noticed some bloody discharge. That very evening without any premonitory severe symptom a gush of fluid escaped followed by very bearing down pain.
16
THE INDIAN MEDICAL GAZETTE.
When I saw her at 10 p. M., she was in a hysteric fit, lying motionless but groaning. In my presence another gash occurred and about a couple of pints of thin fluid escaped on the floor. There was no tinge of blood. She came to her senses about an hour afterwards. She complained of very severe pain?the nature of which she could not describe. I gave her (at 12 p. m.) 20 drops of laudanum and she fell into a deep sleep. At 3 A. M. in the morning she rose from her sleep with unbearable bearing down pain and another gush of about half a pint. Internal examination revealed that the os was contracted and firm, and there was no probability of early miscarriage. The discharge troubled her in an abated degree for a fort-
night only.
The labor was a precipitate one in full term. She felt mild pain at 4 in the evening. At 4-30 P. M. she was delivered of a healthy child on her couch. The membranes were entire and the placenta healthy. There was the usual discharge of the liq. amnii. Remarks.?Both these cases simulated labor. In the first one the discharge continued for five months without causing any injury to the mother. In the 2nd case the discharge continued for a fortnight only and ceased suddenly. In the first case the discharge occurred both in gushes and guttatim, but in the 2nd one never guttatim, but always in gashes. Professor Leishman says, that in this singular affection, which has also been called " false water," a discharge of fluid takes place from the uterus, the amnionic sac remaining entire. He also says that this occurs pretty frequently towards the end of pregnancy, as in my 2nd case, though in my first one it appeared as early as in the 4th month. The chief point of interest in these cases is the determination of cause and source of this colorless fluid. Leishman says that the affection arises from a secretion which has its source in the inner surface of the uterus, and which, in proportion to its quantity, separates the coverings of the ovum from their uterine attachment. A cavity is thus formed between the dicidua and the womb which gradually increases aa more fluid becomes effused, until making its way downwards towards the cervix it finds a mode of exit. Dr. Playfair says, that the liydrorrhoea gravidorum most probably depends on some obscure morbid state of the uterine mucous membrane, but I believe it has not been proved whether the mucous membrane of a gravid uterus retains its epithelial lining. It is certain that the epithelial lining is destroyed on account of the adhesion of the amniotic sac with the mucous membrane of the uterus. Mucous membranes can not secrete when devoid of their epithelial lining. There are other theories :?by some it is attributed to the rupture of a cyst placed between the ovum and uterine walls. Baudilocque thinks it to be a transudation of the liq. amnii through the membrane. Burgess and Dubois believed it to depend on a laceration of the membranes at a distance from the os uteri. Mattei attributes it to the existence of a sac between the chorion and the amnion. Dr. Playfair remarks that it may be that in some instances a single discharge of fluid may come from one of the two last mentioned But if it be continuous and repeated, another sourcc causes. must be sought for. Hegar maintains that it is the result of abundant secretion from the glands of the mucous which membrane accumulates between the decidua and chorion, and escapes through the os uteri. Leaving aside theories, the chief point of interest to us as physicians is correct diagnosis. In our country it is very difficult to arrive at a correct diagnosis, because we are generally not allowed to hold any internal examination without which nothing can be ascertained in such cases. What shall we do in such cases ? Should we decline to treat or resort to quackery by giving medicine and advice without arriving at a correct diagnosis ? These cases simulate miscarriage. To prevent miscarriage objects are used if the os be not dilated. We can not prescribe unless we are satisfied as to the proper condition of the os uteri. In my opinion, concientious medical men should decline to interfere if internal examination be not allowed If all native medical men decline to treat such cases, our countrymen will be obliged to allow us to hold internal examination for the purpose of making a correct diag-
[January 2,
1882.
Banerjee,
L. M. S.
I shall first narrate two cases from my own practice, and then briefly discuss the etiology and treatment of this rare and misleading disease. Case No. 1.?/Et. 35 ; 13th pregnancy ; of robust constitution but a confirmed asthmatic. Had prolapse of the uterus death of a foetus (7 months old) in seven years ago after the She passed fsetal bones for a couple of months the womb. continually after this. This time from the 4th month of gestation she began to of an pass white and sometimes sanguinolent discharge quantity. Every time with the appearance of this discharge, she thought she would miscarry, but to her suran prise she passed on to full term, and was delivered of emaciated child which died in a week. I first saw her in the 6th month of her pregnancy when I found the discharge resembled Liq. umnii both in color and be no discharge for a week or so. consistency. There would It used to come on in a gush as also guttatim. Sometimes in it which were either of a pure mucous flakes were noticed white color. It also used to be attended with white or
alarming
dirty
down pain. Sometimes the patient would describe it as false other times as true pain. The patient having carried 12 children already, was greatly alarmed by this unusual
bearing
discharge mostly attended with labor pain. She was almost sure that the child had died, and that she would again pass bony pieces as she did once. She would not perceive the foetal movement for days together, and
this alarmed her the more. This case was examined by four well known Assistant-SurAtmaram Pandurang of Bombay, geons as well as by Dr. while on a visit to this place. Astringents were prescribed fruitlessly to check the discharge. t did not prescribe any medicine, but insisted on absolute rest from which she latterly derived much benefit. I attended her during child-birth. The baby was a thin emaciated one weighing about 3 lbs. There was the usual flow of Liq. amnii. The amnotic membrane was in fact places (four I remember) greatly thickened, and in several calcified. It also contained a circular hole about the size of This hole was evidently the result of a four anna piece. giving way of portion of calcified part. Half of the placenta was carnified and a calcified spot about the size of a rupee was noticed in it. Case No. II.?JEt. 2G; 7th pregnancy; very thin, scrofuand occasionally suffered from lous, asthmatic, hysteric, hemoptysis. In the beginning of the first week of the 8th month of her gestation, one morning she noticed some bloody discharge. That very evening without any premonitory severe symptom a gush of fluid escaped followed by very bearing down pain.
16
THE INDIAN MEDICAL GAZETTE.
When I saw her at 10 p. M., she was in a hysteric fit, lying motionless but groaning. In my presence another gash occurred and about a couple of pints of thin fluid escaped on the floor. There was no tinge of blood. She came to her senses about an hour afterwards. She complained of very severe pain?the nature of which she could not describe. I gave her (at 12 p. m.) 20 drops of laudanum and she fell into a deep sleep. At 3 A. M. in the morning she rose from her sleep with unbearable bearing down pain and another gush of about half a pint. Internal examination revealed that the os was contracted and firm, and there was no probability of early miscarriage. The discharge troubled her in an abated degree for a fort-
night only.
The labor was a precipitate one in full term. She felt mild pain at 4 in the evening. At 4-30 P. M. she was delivered of a healthy child on her couch. The membranes were entire and the placenta healthy. There was the usual discharge of the liq. amnii. Remarks.?Both these cases simulated labor. In the first one the discharge continued for five months without causing any injury to the mother. In the 2nd case the discharge continued for a fortnight only and ceased suddenly. In the first case the discharge occurred both in gushes and guttatim, but in the 2nd one never guttatim, but always in gashes. Professor Leishman says, that in this singular affection, which has also been called " false water," a discharge of fluid takes place from the uterus, the amnionic sac remaining entire. He also says that this occurs pretty frequently towards the end of pregnancy, as in my 2nd case, though in my first one it appeared as early as in the 4th month. The chief point of interest in these cases is the determination of cause and source of this colorless fluid. Leishman says that the affection arises from a secretion which has its source in the inner surface of the uterus, and which, in proportion to its quantity, separates the coverings of the ovum from their uterine attachment. A cavity is thus formed between the dicidua and the womb which gradually increases aa more fluid becomes effused, until making its way downwards towards the cervix it finds a mode of exit. Dr. Playfair says, that the liydrorrhoea gravidorum most probably depends on some obscure morbid state of the uterine mucous membrane, but I believe it has not been proved whether the mucous membrane of a gravid uterus retains its epithelial lining. It is certain that the epithelial lining is destroyed on account of the adhesion of the amniotic sac with the mucous membrane of the uterus. Mucous membranes can not secrete when devoid of their epithelial lining. There are other theories :?by some it is attributed to the rupture of a cyst placed between the ovum and uterine walls. Baudilocque thinks it to be a transudation of the liq. amnii through the membrane. Burgess and Dubois believed it to depend on a laceration of the membranes at a distance from the os uteri. Mattei attributes it to the existence of a sac between the chorion and the amnion. Dr. Playfair remarks that it may be that in some instances a single discharge of fluid may come from one of the two last mentioned But if it be continuous and repeated, another sourcc causes. must be sought for. Hegar maintains that it is the result of abundant secretion from the glands of the mucous which membrane accumulates between the decidua and chorion, and escapes through the os uteri. Leaving aside theories, the chief point of interest to us as physicians is correct diagnosis. In our country it is very difficult to arrive at a correct diagnosis, because we are generally not allowed to hold any internal examination without which nothing can be ascertained in such cases. What shall we do in such cases ? Should we decline to treat or resort to quackery by giving medicine and advice without arriving at a correct diagnosis ? These cases simulate miscarriage. To prevent miscarriage objects are used if the os be not dilated. We can not prescribe unless we are satisfied as to the proper condition of the os uteri. In my opinion, concientious medical men should decline to interfere if internal examination be not allowed If all native medical men decline to treat such cases, our countrymen will be obliged to allow us to hold internal examination for the purpose of making a correct diag-
[January 2,
1882.
