the prognosis ip evidently grave. both for the mother and for the child. generally speaking it varies according to the different lesions. All writers agree in regarding mitral lesions as far more serious than aortic; the latter, says Casanova, and especially steno sis, are not dangerous affections, but, on the contrary, they are well borne, and are compatible with long life, and if it were not for the con tinual fear of fatal syncope, or of premature weakening of the heart's contractions, the prognosis would be quite favorable. Others believe that the lesions become aggravated during the latter months of preg nancy, and undergo amelioration afterward. It is believed that aortic stenosis in particular, may exert a very injurious influence on pregnancy.
Aortic insufficiency is characterized by its long period of immunity, which depends upon the compensatory hypertrophy of the left ventricle. See thinks that the lesion is perfectly compatible with gestation, at least that there are no functional symptoms. This is not always the case, and sudden death may occur. Mitral lesions are unquestionably the most serious of all, althongh opinions differ with regard to stenosis. When the latter is combined with insufficiency the prognosis is much worse. Mitral lesions lead to dyspncea, congestions, and pulmonary troubles. Lesions involving simultaneously different valves are the most grave; those of the right heart are secondary according to Berthiot, but Idath.„ cites a case in which a pregnant female with a pre-existing tri-cuspid lesion died during an attack of pulmonary congestion.
Porak has constructed a table, based on 92 cases of heart-disease, 35 of which terminated fatally. The mitral valve was affected in 54, the aortic in 13, and both valves in 22; the fcetus was expelled prematurely in all but 3 cases. He regards mitral stenosis as a very serious affection, often terminating fatally.
Treatment.—In view of the fatal influence mutually exerted by preg nancy and diseases of the heart, the first question which presents itself is, "Ought we to allow a young woman with heart-disease to marry?" In general we reply in the negative, especially if a mitral lesion is pres• ent; strictly speaking, perhaps, we may be less positive if the lesion is aortic, but, even then it is well to warn the family of the danger to which they would expose the girl, and Peter's opinion ought to be regarded as a rule which is almost absolute, viz.: Oppose marriage in a patient with heart-disease; if she is married, do not let her become a mother; if she is a mother, prevent her from nursing her child; and if such a patient become pregnant, let her avoid most carefully fatigue, emotion, and every c,ause which, by disturbing the pulmonary circulation, may render still graver the prognosis of the cardiac affection.
Medical Treatment.—This can not be laid down arbitrarily. Peter recommends venesection highly; this is undoubtedly useful in reliev ing congestion of cardiac origin. Digitalis certainly acts favorably in many cardiac affections, but it is not adapted to all. It is certain that it relieves palpitations and produces diuresis, but it does not affect palpit9, tion of purely nervous origin, in which bromide of potassium combined with ether is of utility, and, where pain is present, local bleeding is attended with good results. Peter uses digitaline, but we prefer the
tincture of digitalis, or the infusion of the leaves, in doses of three grains. The troubles arising from liwmatosis should be treated with venesection, sulphuret of mercury in doses of two and a half grains, ipecac, inhalations of volatile salts, compressed air, preparations of iron, calomel with squills and digitalis, turpentine, purgatives, diuretics, etc. Can we use chloroform during labor in the case of a pregnant woman with heart ‹lisease? This question has never been definitely settled. We know that nearly all surgeons regard affections of the heart as contra-indicat ing the use of this ana>sthetic. Championniere administers chloroform to all of his operative cases without distinction.
Obstetrical Treatment.—If the woman does not present any serious troubles, the only thing to do is evidently to wait; but, if they beconie more serious, and the life of the woman seems to be in jeopardy, should we confine ourselves to purely expectant treatment, and merely combat the eardiac symptoms? Two cases may present themselves.
I. Labor has Commenced.—Ia this case, all accoucheurs agree with Pajot and Dubois whose ide,as are quoted in Dubois's article. The or dinary and evident indication is to terminate the labor as rapidly as pos sible without injury to the mother, without injury, because we absolutely disapprove of forced delivery. The five cases mentioned by Porak in his article, do not appear to us to warrant a like management, and the bad results given by the general adoption of forced delivery do not appear much improved, according to the observations to which we refer—i.e., one child really survived; for in the four other cases, twice the infant . died, and twice its fate W ail not known. As for the mothers, the results seem a little more favorable, but still the observations are too incomplete to allow us to judge of the question.
II. Labor has not Comnienced.—Ought labor to be induced, when we know the danger which threatens the life of the mother, and consequently that of the child ? All authors agree on this subject, and all answer in the affirmative. We are in a,ccord with this opinion. But ought abortion to be produced ? In this case the child's life is sacrificed to prolong the life of the mother, a life very much endangered not only at present by actual dangers, but in the more or less remote future by some cardiac disease even. Besides, authorities are not agreed; some disapprove entirely of the production of abortion, others believe in producing an abortion, but under certain conditions.
We place ourselves among the latter. We do not forget, however, that producing abortion is a serious operation when viewed from a moral standpoint, and we only believe ourselves authorized to do BO when all other therapeutic measures have been exhausted, and when the life of the mother is in serious and imminent peril by intense and persistent gravido-cardiac complications.
Finally, if the mother dies, and the child is viable, it is the duty ol the accoucheut to perform the Ctesarean section without hesitation. 'Whatever be the chance for the child, no one has the right to deprive it of that one chance. We will return again to this subject in the chapter devoted to delivery post mortem.