HYDRORRHEA GRAVIDARUM-REPORT OF

SIX CASES.

BY ALEXANDER MACK, M.D., HAWKINSVILLE.

This disease of the ovum which sometimes, though very rarely, seriously complicates pregnancy, has only small space in our text-books and is but little spoken of by the profession.

It is listed under the heading of "Catarrhal Deciduai Endometritis," which form of endometritis has for its special characteristic a watery discharge from the uterus, known as hydrorrhea gravidarum, gradually dribbling along or occurring in periodical gushes.

Writers differ much as to the nature and the source of this fluid, attach no importance whatever to the pathological condition causing it; some holding to the opinion that it is liquor amnii due to premature rupture of the membranes, while others are inclined to the belief that it is a distinct secretion due to a diseased condition of the decidual membranes.

The fluid varies in amount, occurs rather late in pregnancy, and “differs from the liquor amnii in having a lower specific gravity and in not containing albuminous materials or urinary constituents" (Van der Hoeven).

Young physicians or those who have never had any experience with this trouble, by their failure to recognize it and mistaking it for oncoming labor by reason of it so closely resembling the rupture of the membranes, may do some harm and to that end I desire to report the following cases and to make a few comments.

Case 1.-Mrs. C., white, age thirty; III para; last menstruation Nov. 1, 1898. Pregnancy normal until Jan. 26, 1899, when she suddenly experienced a copious. flow of clear fluid from the vagina supposed at the time to be amniotic fluid. No pain or other symptoms followed this discharge, but the abdomen, which was not unusually large for that period of pregnancy, diminished in size and the outlines of the fetus become abnormally apparent.

Pregnancy continued without interruption, and the abdomen regained its former size. No further symptoms appeared until August 13, 1899, when she was delivered after a labor of forty minutes duration of a living male child.

There appeared to be present a normal amount of amniotic fluid and the sac showed no opening other than that through which the child escaped. The puerperium was normal in all respects.

For several years previous to her pregnancy, the patient ad suffered from a chronic endometritis due to an unre paired laceration of the cervix. This was reported to me by the late Dr. Virgil O. Hardon, of Atlanta, Ga., who had taught and practiced midwifery for a period of twenty-five years, with an experience in this line doubtless equal to any physician in the South, and yet he stated that it was the only case of hydrorrhea gravidarum that he could remember having.

Case 2.-Mrs. L., age forty, XII para; date of expectation March 20, 1903. On Jan. 11th, up to which time nothing unusual had occurred, she was supposed to be in labor prematurely because of a large, clear watery discharge from the vagina, but had no pain at the time, though later did have a few light and irregular pains.

There was no dilatation of the os, but she was uneasy and extremely apprehensive and failed to be assured insomuch as to worry and fret, which no doubt increased the

trouble and brought on premature labor. Five days later, she was delivered of a male child, three and a half pounds, after an extremely hard labor of six hours duration, hip presentation, the child living only about forty-eight hours. There was no opening in the sac other than that through which the child escaped and a sufficient quantity of amniotic fluid was present. This patient's recovery was normal.

She had a fearfully lacerated cervix and had had a number of abortions.

Case 5.-Mrs. Z., white, age twenty-seven, III para. On November 21, 1896, at night, was awakened by a sudden discharge of clear fluid from the vagina. There was no pain whatever. This clear fluid from the vagina continued for five days dribbling along, then ceased.

Eight days later she was delivered of a healthy female child about two weeks premature. Before labor the size of the abdomen considerably diminished and could dis tinctly outline the fetus. Her recovery was rapid and uneventful. There was enough amniotic fluid present and no opening in the sac only the one made by the child.

This patient had a severe laceration of the cervix due to an instrumental delivery with her first labor, and an endometritis following. Two years afterwards she aborted anl later was curetted for uterine fungosities. Has since borne two children without any trouble.

Case 4-Mrs. W., white, age twenty-one, II para. When five and a half months advanced in pregnancy, she was out walking and ran from a cow, though not frightened; that night there was a large, sudden discharge of a clear fluid from the vagina analagous in all respects to amniotic fluid, and it was supposed that she was threatened with miscarriage, although there was no pain or other symptoms. This discharge kept on at intervals for six weeks, when she was delivered of a male child, about four pounds in weight,

which was placed in an improvised incubator. On the eighth day this baby ran a temperature of 107 in the axilla. The labor was normal and lasted about one hour. There was the usual amount of amniotic fluid and no opening in the sac other than that through which the child escaped. Puerperium was normal.

There was no perceptible laceration of the cervix, nor any endometritis preceding pregnancy. This child was

born with a caul. Patient has borne two children since both labors normal.

Case 5.-Mrs. R., white, age about thirty-two, VI para. Date of expectation Oct. 22, 1898. Nothing unusual occurred until Oct. 6, when there was a copious discharge of a clear fluid from the vagina. No pain or other symptoms. Patient was up in a few hours and the abdomen was notably diminished in size. On the eighth of Oct., after a slow labor, she was delivered of a well-formed female child. There was the usual amount of amniotic fluid and no opening in the sac except the one made by the child. Immediately after the expulsion of the child there came from the uterus about a pint or more of a dirty, yellow and very offensive fluid, the odor of which was at once notice:l all over the room. This patient ran a temperature for a few days and the puerperium was prolonged, though she eventually recovered. Three years later she was again in labor and I am informed died from puerperal fever. She suffered very much at times before her pregnancy from endometritis and had the worst lacerated cervix I ever saw.

Case 6.-Mrs. T., white, age thirty, II para. Date of expectation, July 5, 1899. On May 1st, up to which time pregnancy was normal, she experienced a large sudden flow of clear fluid from the vagina while attending her household duties, which she thought was the beginning of premature labor. No pain at all. This discharge continned at intervals for several days and was abundant and the

came on.

size of the abdomen diminished. On the fifth day, pains The fluid was tinged with blood and she was soon delivered of a small female child, which died on the second day, though an effort was made to incubate it. The cervix was torn in a former labor which caused an endometritis previous to this pregnancy. This was an exceptionally hard labor. This patient was anxious for a child and became despondent on the appearance of hydrorrhea gravidarum, and could not be reconciled by my positive assurances, hence premature labor. Four years later she was delivered of a child in a normal labor.

To make a brief summary, we notice that each case was supposed to be labor at first, and that this impression precipated labor in five out of six cases; that in two cases the child was lost, in another, the child was saved by a narrow margin; that in one instance the mother's life was seriously jeopardized and that she did die at her next childbirth.

Again, that all were multiparæ and in five out of six cases there was an endometritis, due to a more or less serious tear of the cervix. In the case of Mrs. W., case 4, there was no perceptible laceration or endometritis, yet we have a history of running followed soon by hydrorrhea gravidarum, and in six weeks labor. That in each case though there was an abundant discharge of fluid before labor actually begun, yet there was a normal amount of liquor amnii during labor, and no evidence of any opening in the sac other than that made by the passage of the child, and we also had a diminution of the size of the abdomen in all.

As to how this fluid became infected in Case 5, I am at a loss for information. We then must have in this little trouble a diseased mucous membrane within the uterus prior to pregnancy and also an unhealthy decidua vera, reflexa and serotina. Later on after the third or fourth month the decidua vera and reflexa are in contact, and we