pregnant fell into a fire, burning the whole front of the abdomen, the
front and inside of the thighs to the knees, the external genitals, and
the left arm. Artificial delivery was deemed necessary, and a dead
child, seemingly burned much like its mother, except less intensely,
was delivered. There was also one large blister near the inner canthus
of the eye and some large blisters about the neck and throat which the
mother did not show. There was no history of syphilis nor of any
eruptive fever in the mother, who died on the tenth day with tetanus.
Graham describes a woman of thirty-five, the mother of seven children,
who while pregnant was feeding some rabbits, when one of the animals
jumped at her with its eyes "glaring" upon her, causing a sudden
fright. Her child was born hydrocephalic. Its mouth and face were small
and rabbit-shaped. Instead of a nose, it had a fleshy growth 3/4 inch
long by 1/4 inch broad, directed upward at an angle of 45 degrees. The
space between this and the mouth was occupied by a body resembling an
adult eye. Within this were two small, imperfect eyes which moved
freely while life lasted (ten minutes). The child's integument was
covered with dark, downy, short hair. The woman recovered and afterward
bore two normal children.
Parvin mentions an instance of the influence of maternal impression in
the causation of a large, vivid, red mark or splotch on the face: "When
the mother was in Ireland she was badly frightened by a fire in which
some cattle were burned. Again, during the early months of her
pregnancy she was frightened by seeing another woman suddenly light the
fire with kerosene, and at that time became firmly impressed with the
idea that her child would be marked." Parvin also pictures the
"turtle-man," an individual with deformed extremities, who might be
classed as an ectromelus, perhaps as a phocomelus, or seal-like
monster. According to the story, when the mother was a few weeks
pregnant her husband, a coarse, rough fisherman, fond of rude jokes,
put a large live turtle in the cupboard. In the twilight the wife went
to the cupboard and the huge turtle fell out, greatly startling her by
its hideous appearance as it fell suddenly to the floor and began to
move vigorously.
Copeland mentions a curious case in which a woman was attacked by a
rattlesnake when in her sixth month of pregnancy, and gave birth to a
child whose arm exhibited the shape and action of a snake, and
involuntarily went through snake-like movements. The face and mouth
also markedly resembled the head of a snake.
The teeth were situated like a serpent's fangs. The mere mention of a
snake filled the child (a man of twenty-nine) with great horror and
rage, "particularly in the snake season." Beale gives the history of a
case of a child born with its left eye blackened as by a blow, whose
mother was struck in a corresponding portion of the face eight hours
before confinement. There is on record an account of a young man of
twenty-one suffering from congenital deformities attributed to the fact
that his mother was frightened by a guinea-pig having been thrust into
her face during pregnancy. He also had congenital deformity of the
right auricle. At the autopsy, all the skin, tissues, muscles, and
bones were found involved. Owen speaks of a woman who was greatly
excited ten months previously by a prurient curiosity to see what
appearance the genitals of her brother presented after he had submitted
to amputation of the penis on account of carcinoma. The whole penis had
been removed. The woman stated that from the time she had thus
satisfied herself, her mind was unceasingly engaged in reflecting and
sympathizing on the forlorn condition of her brother. While in this
mental state she gave birth to a son whose penis was entirely absent,
but who was otherwise well and likely to live. The other portions of
the genitals were perfect and well developed. The appearance of the
nephew and the uncle was identical. A most peculiar case is stated by
Clerc as occurring in the experience of Kuss of Strasburg. A woman had
a negro paramour in America with whom she had had sexual intercourse
several times. She was put in a convent on the Continent, where she
stayed two years. On leaving the convent she married a white man, and
nine months after she gave birth to a dark-skinned child. The
supposition was that during her abode in the convent and the nine
months subsequently she had the image of her black paramour constantly
before her. Loin speaks of a woman who was greatly impressed by the
actions of a clown at a circus, and who brought into the world a child
that resembled the fantastic features of the clown in a most striking
manner.
Mackay describes five cases in which fright produced distinct marks on
the fetus. There is a case mentioned in which a pregnant woman was
informed that an intimate friend had been thrown from his horse; the
immediate cause of death was fracture of the skull, produced by the
corner of a dray against which the rider was thrown. The mother was
profoundly impressed by the circumstance, which was minutely described
to her by an eye-witness. Her child at birth presented a red and
sensitive area upon the scalp corresponding in location with the fatal
injury in the rider. The child is now an adult woman, and this area
upon the scalp remains red and sensitive to pressure, and is almost
devoid of hair. Mastin of Mobile, Alabama, reports a curious instance
of maternal impression. During the sixth month of the pregnancy of the
mother her husband was shot, the ball passing out through the left
breast. The woman was naturally much shocked, and remarked to Dr.
Mastin: "Doctor, my baby will be ruined, for when I saw the wound I put
my hands over my face, and got it covered with blood, and I know my
baby will have a bloody face." The child came to term without a bloody
face. It had, however, a well-defined spot on the left breast just
below the site of exit of the ball from its father's chest. The spot
was about the size of a silver half-dollar, and had elevated edges of a
bright red color, and was quite visible at the distance of one hundred
feet. The authors have had personal communication with Dr. Mastin in
regard to this case, which he considers the most positive evidence of a
case of maternal impression that he has ever met.
Paternal Impressions.--Strange as are the foregoing cases, those of
paternal impression eclipse them. Several are on record, but none are
of sufficient authenticity to warrant much discussion on the subject.
Those below are given to illustrate the method of report. Stahl, quoted
by Steinan, 1843, speaks of the case of a child, the father being a
soldier who lost an eye in the war. The child was born with one of its
eyes dried up in the orbit, in this respect presenting an appearance
like that of the father. Schneider says a man whose wife was expecting
confinement dreamt that his oldest son stood beside his bedside with
his genitals much mutilated and bleeding. He awoke in a great state of
agitation, and a few days later the wife was delivered of a child with
exstrophy of the bladder. Hoare recites the curious story of a man who
vowed that if his next child was a daughter he would never speak to it.
The child proved to be a son, and during the whole of the father's life
nothing could induce the son to speak to his father, nor, in fact, to
any other male person, but after the father's death he talked fluently
to both men and women. Clark reports the birth of a child whose father
had a stiff knee-joint, and the child's knee was stiff and bent in
exactly the same position as that of its father.
Telegony.--The influence of the paternal seed on the physical and
mental constitution of the child is well known. To designate this
condition, Telegony is the word that was coined by Weismann in his "Das
Keimplasma," and he defines it as "Infection of the Germ," and, at
another time, as "Those doubtful instances in which the offspring is
said to resemble, not the father, but an early mate of the
mother,"--or, in other words, the alleged influence of a previous sire
on the progeny produced by a subsequent one from the same mother. In a
systematic discussion of telegony before the Royal Medical Society,
Edinburgh, on March 1, 1895, Brunton Blaikie, as a means of making the
definition of telegony plainer by practical example, prefaced his
remarks by citing the classic example which first drew the attention of
the modern scientific world to this phenomenon. The facts of this case
were communicated in a letter from the Earl of Morton to the President
of the Royal Society in 1821, and were as follows: In the year 1816
Lord Morton put a male quagga to a young chestnut mare of 7/8 Arabian
blood, which had never before been bred from. The result was a female
hybrid which resembled both parents. He now sold the mare to Sir Gore
Ousley, who two years after she bore the hybrid put her to a black
Arabian horse. During the two following years she had two foals which
Lord Morton thus describes: "They have the character of the Arabian
breed as decidedly as can be expected when 15/16 of the blood are
Arabian, and they are fine specimens of the breed; but both in their
color and in the hair of their manes they have a striking resemblance
to the quagga. Their color is bay, marked more or less like the quagga
in a darker tint. Both are distinguished by the dark line along the
ridge of the back, the dark stripes across the forehand, and the dark
bars across the back part of the legs." The President of the Royal
Society saw the foals and verified Lord Morton's statement.
"Herbert Spencer, in the Contemporary Review for May, 1893, gives
several cases communicated to him by his friend Mr. Fookes, whom
Spencer says is often appointed judge of animals at agricultural shows.
After giving various examples he goes on to say: 'A friend of mine near
this had a valuable Dachshund bitch, which most unfortunately had a
litter by a stray sheep-dog. The next year the owner sent her on a
visit to a pure Dachshund dog, but the produce took quite as much of
the first father as the second, and the next year he sent her to
another Dachshund, with the same result. Another case: A friend of mine
in Devizes had a litter of puppies unsought for, by a setter from a
favorite pointer bitch, and after this she never bred any true
pointers, no matter what the paternity was.'
"Lord Polwarth, whose very fine breed of Border Leicesters is famed
throughout Britain, and whose knowledge on the subject of breeding is
great, says that 'In sheep we always consider that if a ewe breeds to a
Shrop ram, she is never safe to breed pure Leicesters from, as dun or
colored legs are apt to come even when the sire is a pure Leicester.
This has been proved in various instances, but is not invariable.'"
Hon. Henry Scott says: "Dog-breeders know this theory well; and if a
pure-bred bitch happens to breed to a dog of another breed, she is of
little use for breeding pure-bred puppies afterward. Animals which
produce large litters and go a short time pregnant show this throwing
back to previous sires far more distinctly than others--I fancy dogs
and pigs most of all, and probably horses least. The influence of
previous sires may be carried into the second generation or further, as
I have a cat now which appears to be half Persian (long hair). His dam
has very long hair and every appearance of being a half Persian,
whereas neither have really any Persian blood, as far as I know, but
the grand-dam (a very smooth-haired cat) had several litters by a
half-Persian tom-cat, and all her produce since have showed the
influence retained. The Persian tom-cat died many years ago, and was
the only one in the district, so, although I cannot be absolutely
positive, still I think this case is really as stated."
Breeders of Bedlington terriers wish to breed dogs with as powerful
jaws as possible. In order to accomplish this they put the Bedlington
terrier bitch first to a bull-terrier dog, and get a mongrel litter
which they destroy. They now put the bitch to a Bedlington terrier dog
and get a litter of puppies which are practically pure, but have much
stronger jaws than they would otherwise have had, and also show much of
the gameness of the bull-terrier, thus proving that physiologic as well
as anatomic characters may be transmitted in this way.
After citing the foregoing examples, Blaikie directs his attention to
man, and makes the following interesting remarks:--
"We might expect from the foregoing account of telegony amongst animals
that whenever a black woman had a child to a white man, and then
married a black man, her subsequent children would not be entirely
black. Dr. Robert Balfour of Surinam in 1851 wrote to Harvey that he
was continually noticing amongst the colored population of Surinam
'that if a negress had a child or children by a white, and afterward
fruitful intercourse with a negro, the latter offspring had generally a
lighter color than the parents.' But, as far as I know, this is the
only instance of this observation on record. Herbert Spencer has shown
that when a pure-bred animal breeds with an animal of a mixed breed,
the offspring resembles much more closely the parent of pure blood, and
this may explain why the circumstance recorded by Balfour has been so
seldom noted. For a negro, who is of very pure blood, will naturally
have a stronger influence on the subsequent progeny than an
Anglo-Saxon, who comes of a mixed stock. If this be the correct
explanation, we should expect that when a white woman married first a
black man, and then a white, the children by the white husband would be
dark colored. Unfortunately for the proof of telegony, it is very rare
that a white woman does marry a black man, and then have a white as
second husband; nevertheless, we have a fair number of recorded
instances of dark-colored children being born in the above way of white
parents.
"Dr. Harvey mentions a case in which 'a young woman, residing in
Edinburgh, and born of white (Scottish) parents, but whose mother, some
time previous to her marriage, had a natural (mulatto) child by a negro
man-servant in Edinburgh, exhibits distinct traces of the negro. Dr.
Simpson--afterward Sir James Simpson--whose patient the young woman at
one time was, has had no recent opportunities of satisfying himself as
to the precise extent to which the negro character prevails in her
features; but he recollects being struck with the resemblance, and
noticed particularly that the hair had the qualities characteristic of
the negro.' Herbert Spencer got a letter from a 'distinguished
correspondent' in the United States, who said that children by white
parents had been 'repeatedly' observed to show traces of black blood
when the women had had previous connection with (i.e., a child by) a
negro. Dr. Youmans of New York interviewed several medical professors,
who said the above was 'generally accepted as a fact.' Prof. Austin
Flint, in 'A Text-book of Human Physiology,' mentioned this fact, and
when asked about it said: 'He had never heard the statement questioned.'
"But it is not only in relation to color that we find telegony to have
been noticed in the human subject. Dr. Middleton Michel gives a most
interesting case in the American Journal of the Medical Sciences for
1868: 'A black woman, mother of several negro children, none of whom
were deformed in any particular, had illicit intercourse with a white
man, by whom she became pregnant. During gestation she manifested great
uneasiness of mind, lest the birth of a mulatto offspring should
disclose her conduct.... It so happened that her negro husband
possessed a sixth digit on each hand, but there was no peculiarity of
any kind in the white man, yet when the mulatto child was born it
actually presented the deformity of a supernumerary finger.' Taruffi,
the celebrated Italian teratologist, in speaking of the subject, says:
'Our knowledge of this strange fact is by no means recent for Fienus,
in 1608, said that most of the children born in adultery have a greater
resemblance to the legal than to the real father'--an observation that
was confirmed by the philosopher Vanini and by the naturalist
Ambrosini. From these observations comes the proverb: 'Filium ex
adultera excusare matrem a culpa.' Osiander has noted telegony in
relation to moral qualities of children by a second marriage. Harvey
said that it has long been known that the children by a second husband
resemble the first husband in features mind, and disposition. He then
gave a case in which this resemblance was very well marked. Orton,
Burdach (Traite de Physiologie), and Dr. William Sedgwick have all
remarked on this physical resemblance; and Dr. Metcalfe, in a
dissertation delivered before this society in 1855, observed that in
the cases of widows remarrying the children of the second marriage
frequently resemble the first husband.
"An observation probably having some bearing on this subject was made
by Count de Stuzeleci (Harvey, loc. cit.). He noticed that when an
aboriginal female had had a child by a European, she lost the power of
conception by a male of her own race, but could produce children by a
white man. He believed this to be the case with many aboriginal races;
but it has been disproved, or at all events proved to be by no means a
universal law, in every case except that of the aborigines of Australia
and New Zealand. Dr. William Sedgwick thought it probable that the
unfruitfulness of prostitutes might in some degree be due to the same
cause as that of the Australian aborigines who have had children by
white men.
"It would seem as though the Israelites had had some knowledge of
telegony, for in Deuteronomy we find that when a man died leaving no
issue, his wife was commanded to marry her husband's brother, in order
that he might 'raise up seed to his brother.'"
We must omit the thorough inquiry into this subject that is offered by
Mr. Blaikie. The explanations put forward have always been on one of
three main lines:--
(1) The imagination-theory, or, to quote Harvey: "Due to mental causes
so operating either on the mind of the female and so acting on her
reproductive powers, or on the mind of the male parent, and so
influencing the qualities of his semen, as to modify the nutrition and
development of the offspring."
(2) Due to a local influence on the reproductive organs of the mother.
(3) Due to a general influence through the fetus on the mother.
Antenatal Pathology.--We have next to deal with the diseases,
accidents, and operations that affect the pregnant uterus and its
contents; these are rich in anomalies and facts of curious interest,
and have been recognized from the earliest times. In the various works
usually grouped together under the general designation of "Hippocratic"
are to be found the earliest opinions upon the subject of antenatal
pathology which the medical literature of Greece has handed down to
modern times. That there were medical writers before the time of
Hippocrates cannot be doubted, and that the works ascribed to the
"Father of Medicine" were immediately followed by those of other
physicians, is likewise not to be questioned; but whilst nearly all the
writings prior to and after Hippocrates have been long lost to the
world, most of those that were written by the Coan physician and his
followers have been almost miraculously preserved. As Littre puts it,
"Les ecrits hippocratiques demeurent isoles au milieu des debris de
l'antique litterature medicale."--(Ballantyne.)
The first to be considered is the transmission of contagious disease to
the fetus in utero. The first disease to attract attention was
small-pox. Devilliers, Blot, and Depaul all speak of congenital
small-pox, the child born dead and showing evidences of the typical
small-pox pustulation, with a history of the mother having been
infected during pregnancy. Watson reports two cases in which a child in
utero had small-pox. In the first case the mother was infected in
pregnancy; the other was nursing a patient when seven months pregnant;
she did not take the disease, although she had been infected many
months before. Mauriceau delivered a woman of a healthy child at full
term after she had recovered from a severe attack of this disease
during the fifth month of gestation. Mauriceau supposed the child to be
immune after the delivery. Vidal reported to the French Academy of
Medicine, May, 1871, the case of a woman who gave birth to a living
child of about six and one-half months' maturation, which died some
hours after birth covered with the pustules of seven or eight days'
eruption. The pustules on the fetus were well umbilicated and typical,
and could have been nothing but those of small-pox; besides, this
disease was raging in the neighborhood at the time. The mother had
never been infected before, and never was subsequently. Both parents
were robust and neither of them had ever had syphilis. About the time
of conception, the early part of December, 1870, the father had
suffered from the semiconfluent type, but the mother, who had been
vaccinated when a girl, had never been stricken either during or after
her husband's sickness. Quirke relates a peculiar instance of a child
born at midnight, whose mother was covered with the eruption eight
hours after delivery. The child was healthy and showed no signs of the
contagion, and was vaccinated at once. Although it remained with its
mother all through the sickness, it continued well, with the exception
of the ninth day, when a slight fever due to its vaccination appeared.
The mother made a good recovery, and the author remarks that had the
child been born a short time later, it would most likely have been
infected.
Ayer reports an instance of congenital variola in twins. Chantreuil
speaks of a woman pregnant with twins who aborted at five and a half
months. One of the fetuses showed distinct signs of congenital variola,
although the mother and other fetus were free from any symptoms of the
disease. In 1853 Charcot reported the birth of a premature fetus
presenting numerous variolous pustules together with ulcerations of the
derm and mucous membranes and stomach, although the mother had
convalesced of the disease some time before. Mitchell describes a case
of small-pox occurring three days after birth, the mother not having
had the disease since childhood. Shertzer relates an instance of
confluent small-pox in the eighth month of pregnancy. The child was
born with the disease, and both mother and babe recovered. Among many
others offering evidence of variola in utero are Degner, Derham, John
Hunter, Blot, Bulkley, Welch, Wright, Digk, Forbes, Marinus, and
Bouteiller.
Varicella, Measles, Pneumonia, and even Malaria are reported as having
been transmitted to the child in utero. Hubbard attended a woman on
March 17, 1878, in her seventh accouchement. The child showed the rash
of varicella twenty-four hours after birth, and passed through the
regular coarse of chicken-pox of ten days' duration. The mother had no
signs of the disease, but the children all about her were infected.
Ordinarily the period of incubation is from three to four days, with a
premonitory fever of from twenty-four to seventy-two hours' duration,
when the rash appears; this case must therefore have been infected in
utero. Lomer of Hamburg tells of the case of a woman, twenty-two
years, unmarried, pregnant, who had measles in the eighth month, and
who gave birth to an infant with measles. The mother was attacked with
pneumonia on the fifth day of her puerperium, but recovered; the child
died in four weeks of intestinal catarrh. Gautier found measles
transmitted from the mother to the fetus in 6 out of 11 cases, there
being 2 maternal deaths in the 11 cases.
Netter has observed the case of transmission of pneumonia from a mother
to a fetus, and has seen two cases in which the blood from the uterine
vessels of patients with pneumonia contained the pneumococcus. Wallick
collected a number of cases of pneumonia occurring during pregnancy,
showing a fetal mortality of 80 per cent.
Felkin relates two instances of fetal malaria in which the infection
was probably transmitted by the male parent. In one case the father
near term suffered severely from malaria; the mother had never had a
chill. The violent fetal movements induced labor, and the spleen was so
large as to retard it. After birth the child had seven malarial
paroxysms but recovered, the splenic tumor disappearing.
The modes of infection of the fetus by syphilis, and the infection of
the mother, have been well discussed, and need no mention here.
There has been much discussion on the effects on the fetus in utero of
medicine administered to the pregnant mother, and the opinions as to
the reliability of this medication are so varied that we are in doubt
as to a satisfactory conclusion. The effects of drugs administered and
eliminated by the mammary glands and transmitted to the child at the
breast are well known, and have been witnessed by nearly every
physician, and, as in cases of strong metallic purges, etc., need no
other than the actual test. However, scientific experiments as to the
efficacy of fetal therapeutics have been made from time to time with
varying results.
Gusserow of Strasbourg tested for iodin, chloroform, and salicylic acid
in the blood and secretions of the fetus after maternal administration
just before death. In 14 cases in which iodin had been administered, he
examined the fetal urine of 11 cases; in 5, iodin was present, and in
the others, absent. He made some similar experiments on the lower
animals. Benicke reports having given salicylic acid just before birth
in 25 cases, and in each case finding it in the urine of the child
shortly after birth.
At a discussion held in New York some years ago as to the real effect
on the fetus of giving narcotics to the mother, Dr. Gaillard Thomas was
almost alone in advocating that the effect was quite visible. Fordyce
Barker was strongly on the negative side. Henning and Ahlfeld, two
German observers, vouch for the opinion of Thomas, and Thornburn states
that he has witnessed the effect of nux vomica and strychnin on the
fetus shortly after birth. Over fifty years ago, in a memoir on
"Placental Phthisis," Sir James Y. Simpson advanced a new idea in the
recommendation of potassium chlorate during the latter stages of
pregnancy. The efficacy of this suggestion is known, and whether, as
Simpson said, it acts by supplying extra oxygen to the blood, or
whether the salt itself is conveyed to the fetus, has never been
definitely settled.
McClintock, who has been a close observer on this subject, reports some
interesting cases. In his first case he tried a mixture of iron
perchlorid and potassium chlorate three times a day on a woman who had
borne three dead children, with a most successful result. His second
case failed, but in a third he was successful by the same medication
with a woman who had before borne a dead child. In a fourth case of
unsuccessful pregnancy for three consecutive births he was successful.
His fifth case was extraordinary: It was that of a woman in her tenth
pregnancy, who, with one exception, had always borne a dead child at
the seventh or eighth month. The one exception lived a few hours only.
Under this treatment he was successful in carrying the woman safely
past her time for miscarriage, and had every indication for a normal
birth at the time of report. Thornburn believes that the administration
of a tonic like strychnin is of benefit to a fetus which, by its feeble
heart-beats and movements, is thought to be unhealthy. Porak has
recently investigated the passage of substances foreign to the organism
through the placenta, and offers an excellent paper on this subject,
which is quoted in brief in a contemporary number of Teratologia.
In this important paper, Porak, after giving some historical notes,
describes a long series of experiments performed on the guinea-pig in
order to investigate the passage of arsenic, copper, lead, mercury,
phosphorus, alizarin, atropin, and eserin through the placenta. The
placenta shows a real affinity for some toxic substances; in it
accumulate copper and mercury, but not lead, and it is therefore
through it that the poison reaches the fetus; in addition to its
pulmonary, intestinal, and renal functions, it fixes glycogen and acts
as an accumulator of poisons, and so resembles in its action the liver;
therefore the organs of the fetus possess only a potential activity.
The storing up of poisons in the placenta is not so general as the
accumulation of them in the liver of the mother. It may be asked if the
placenta does not form a barrier to the passage of poisons into the
circulation of the fetus; this would seem to be demonstrated by
mercury, which was always found in the placenta and never in the fetal
organs. In poisoning by lead and copper the accumulation of the poison
in the fetal tissues is greater than in the maternal, perhaps from
differences in assimilation and disassimilation or from greater
diffusion. Whilst it is not an impermeable barrier to the passage of
poisons, the placenta offers a varying degree of obstruction: it allows
copper and lead to pass easily, arsenic with greater difficulty. The
accumulation of toxic substances in the fetus does not follow the same
law as in the adult. They diffuse more widely in the fetus. In the
adult the liver is the chief accumulatory organ. Arsenic, which in the
mother elects to accumulate in the liver, is in the fetus stored up in
the skin; copper accumulates in the fetal liver, central nervous
system, and sometimes in the skin; lead which is found specially in the
maternal liver, but also in the skin, has been observed in the skin,
liver, nervous centers, and elsewhere in the fetus. The frequent
presence of poisons in the fetal skin demonstrates its physiologic
importance. It has probably not a very marked influence on its health.
On the contrary, accumulation in the placenta and nerve centers
explains the pathogenesis of abortion and the birth of dead fetuses
("mortinatatite") Copper and lead did not cause abortion, but mercury
did so in two out of six cases. Arsenic is a powerful abortive agent in
the guinea-pig, probably on account of placental hemorrhages. An
important deduction is that whilst the placenta is frequently and
seriously affected in syphilis, it is also the special seat for the
accumulation of mercury. May this not explain its therapeutic action in
this disease? The marked accumulation of lead in the central nervous
system of the fetus explains the frequency and serious character of
saturnine encephalopathic lesions. The presence of arsenic in the fetal
skin alone gives an explanation of the therapeutic results of the
administration of this substance in skin diseases.
Intrauterine amputations are of interest to the medical man,
particularly those cases in which the accident has happened in early
pregnancy and the child is born with a very satisfactory and clean
stump. Montgomery, in an excellent paper, advances the theory, which is
very plausible, that intrauterine amputations are caused by contraction
of bands or membranes of organized lymph encircling the limb and
producing amputation by the same process of disjunctive atrophy that
the surgeons induce by ligature. Weinlechner speaks of a case in which
a man devoid of all four extremities was exhibited before the Vienna
Medical Society. The amputations were congenital, and on the right side
there was a very small stump of the upper arm remaining, admitting the
attachment of an artificial apparatus. He was twenty-seven years old,
and able to write, to thread a needle, pour water out of a bottle, etc.
Cook speaks of a female child born of Indian parents, the fourth birth
of a mother twenty-six years old. The child weighed 5 1/2 pounds; the
circumference of the head was 14 inches and that of the trunk 13
inches. The upper extremities consisted of perfect shoulder joints, but
only 1/4 of each humerus was present. Both sides showed evidences of
amputation, the cicatrix on the right side being 1 inch long and on the
left 1/4 inch long. The right lower limb was merely a fleshy corpuscle
3/4 inch wide and 1/4 inch long; to the posterior edge was attached a
body resembling the little toe of a newly-born infant. On the left side
the limb was represented by a fleshy corpuscle 1 inch long and 1/4 inch
in circumference, resembling the great toe of an infant. There was no
history of shock or injury to the mother. The child presented by the
breech, and by the absence of limbs caused much difficulty in
diagnosis. The three stages of labor were one and one-half hours,
forty-five minutes, and five minutes, respectively. The accompanying
illustration shows the appearance of the limbs at the time of report.
Figure 10 represents a negro boy, the victim of intrauterine
amputation, who learned to utilize his toes for many purposes. The
illustration shows his mode of holding his pen.
There is an instance reported in which a child at full term was born
with an amputated arm, and at the age of seventeen the stump was
scarcely if at all smaller than the other. Blake speaks of a case of
congenital amputation of both the upper extremities. Gillilam a
mentions a case that shows the deleterious influence of even the weight
of a fetal limb resting on a cord or band. His case was that of a
fetus, the product of a miscarriage of traumatic origin; the soft
tissues were almost cut through and the bone denuded by the limb
resting on one of the two umbilical cords, not encircling it, but in a
sling. The cord was deeply imbedded in the tissues.
The coilings of the cord are not limited to compression about the
extremities alone, but may even decapitate the head by being firmly
wrapped several times about the neck. According to Ballantyne, there is
in the treatise De Octimestri Partu, by Hippocrates, a reference to
coiling of the umbilical cord round the neck of the fetus. This coiling
was, indeed, regarded as one of the dangers of the eighth month, and
even the mode of its production is described. It is said that if the
cord he extended along one side of the uterus, and the fetus lie more
to the other side, then when the culbute is performed the funis must
necessarily form a loop round the neck or chest of the infant. If it
remain in this position, it is further stated, the mother will suffer
later and the fetus will either perish or be born with difficulty. If
the Hippocratic writers knew that this coiling is sometimes quite
innocuous, they did not in any place state the fact.
The accompanying illustrations show the different ways in which the
funis may be coiled, the coils sometimes being as many as 8.
Bizzen mentions an instance in which from strangulation the head of a
fetus was in a state of putrefaction, the funis being twice tightly
bound around the neck. Cleveland, Cuthbert, and Germain report
analogous instances. Matthyssens observed the twisting of the funis
about the arm and neck of a fetus the body of which was markedly
wasted. There was complete absence of amniotic fluid during labor.
Blumenthal presented to the New York Pathological Society an ovum
within which the fetus was under going intrauterine decapitation.
Buchanan describes a case illustrative of the etiology of spontaneous
amputation of limbs in utero Nebinger reports a case of abortion,
showing commencing amputation of the left thigh from being encircled by
the funis. The death of the fetus was probably due to compression of
the cord. Owen mentions an instance in which the left arm and hand of a
fetus were found in a state of putrescence from strangulation, the
funis being tightly bound around at the upper part. Simpson published
an article on spontaneous amputation of the forearm and rudimentary
regeneration of the hand in the fetus. Among other contributors to this
subject are Avery, Boncour, Brown, Ware, Wrangell, Young, Nettekoven,
Martin, Macan, Leopold, Hecker, Gunther, and Friedinger.
Wygodzky finds that the greatest number of coils of the umbilical cord
ever found to encircle a fetus are 7 (Baudelocque), 8 (Crede), and 9
(Muller and Gray). His own case was observed this year in Wilna. The
patient was a primipara aged twenty. The last period was seen on May
10, 1894. On February 19th the fetal movements suddenly ceased. On the
20th pains set in about two weeks before term. At noon turbid liquor
amnii escaped. At 2 P.M., on examination, Wygodzky defined a dead fetus
in left occipito-anterior presentation, very high in the inlet. The os
was nearly completely dilated, the pains strong. By 4 P.M. the head was
hardly engaged in the pelvic cavity. At 7 P.M. it neared the outlet at
the height of each pain, but retracted immediately afterward. After 10
P.M. the pains grew weak. At midnight Wygodzky delivered the dead child
by expression. Not till then was the cause of delay clear. The funis
was very tense and coiled 7 times round the neck and once round the
left shoulder; there was also a distinct knot. It measured over 65
inches in length. The fetus was a male, slightly macerated. It weighed
over 5 pounds, and was easily delivered entire after division and
unwinding of the funis. No marks remained on the neck. The placenta
followed ten minutes later and, so far as naked-eye experience
indicated, seemed healthy.
Intrauterine fractures are occasionally seen, but are generally the
results of traumatism or of some extraordinary muscular efforts on the
part of the mother. A blow on the abdomen or a fall may cause them. The
most interesting cases are those in which the fractures are multiple
and the causes unknown. Spontaneous fetal fractures have been
discussed thoroughly, and the reader is referred to any responsible
text-book for the theories of causation. Atkinson, De Luna, and Keller
report intrauterine fractures of the clavicle. Filippi contributes an
extensive paper on the medicolegal aspect of a case of intrauterine
fracture of the os cranium. Braun of Vienna reports a case of
intrauterine fracture of the humerus and femur. Rodrigue describes a
case of fracture and dislocation of the humerus of a fetus in utero.
Gaultier reports an instance of fracture of both femora intrauterine.
Stanley, Vanderveer, and Young cite instances of intrauterine fracture
of the thigh; in the case of Stanley the fracture occurred during the
last week of gestation, and there was rapid union of the fragments
during lactation. Danyau, Proudfoot, and Smith mention intrauterine
fracture of the tibia; in Proudfoot's case there was congenital talipes
talus.
Dolbeau describes an instance in which multiple fractures were found in
a fetus, some of which were evidently postpartum, while others were
assuredly antepartum. Hirschfeld describes a fetus showing congenital
multiple fractures. Gross speaks of a wonderful case of Chaupier in
which no less than 113 fractures were discovered in a child at birth.
It survived twenty-four hours, and at the postmortem examination it was
found that some were already solid, some uniting, whilst others were
recent. It often happens that the intrauterine fracture is well united
at birth. There seems to be a peculiar predisposition of the bones to
fracture in the cases in which the fractures are multiple and the cause
is not apparent.
The results to the fetus of injuries to the pregnant mother are most
diversified. In some instances the marvelous escape of any serious
consequences of one or both is almost incredible, while in others the
slightest injury is fatal. Guillemont cites the instance of a woman who
was killed by a stroke of lightning, but whose fetus was saved; while
Fabricius Hildanus describes a case in which there was perforation of
the head, fracture of the skull, and a wound of the groin, due to
sudden starting and agony of terror of the mother. Here there was not
the slightest history of any external violence.
It is a well-known fact that injuries to the pregnant mother show
visible effects on the person of the fetus. The older writers kept a
careful record of the anomalous and extraordinary injuries of this
character and of their effects. Brendelius tells us of hemorrhage from
the mouth and nose of the fetus occasioned by the fall of the mother;
Buchner mentions a case of fracture of the cranium from fright of the
mother; Reuther describes a contusion of the os sacrum and abdomen in
the mother from a fall, with fracture of the arm and leg of the fetus
from the same cause; Sachse speaks of a fractured tibia in a fetus,
caused by a fall of the mother; Slevogt relates an instance of rupture
of the abdomen of a fetus by a fall of the mother; the Ephemerides
contains accounts of injuries to the fetus of this nature, and among
others mentions a stake as having been thrust into a fetus in utero;
Verduc offers several examples, one a dislocation of the fetal foot
from a maternal fall; Plocquet gives an instance of fractured femur;
Walther describes a case of dislocation of the vertebrae from a fall;
and there is also a case of a fractured fetal vertebra from a maternal
fall. There is recorded a fetal scalp injury, together with clotted
blood in the hair, after a fall of the mother: Autenrieth describes a
wound of the pregnant uterus, which had no fatal issue, and there is
also another similar case on record.
The modern records are much more interesting and wonderful on this
subject than the older ones. Richardson speaks of a woman falling down
a few weeks before her delivery. Her pelvis was roomy and the birth was
easy; but the infant was found to have extensive wounds on the back,
reaching from the 3d dorsal vertebra across the scapula, along the back
of the humerus, to within a short distance of the elbow. Part of these
wounds were cicatrized and part still granulating, which shows that the
process of reparation is as active in utero as elsewhere.
Injuries about the genitalia would naturally be expected to exercise
some active influence on the uterine contents; but there are many
instances reported in which the escape of injury is marvelous. Gibb
speaks of a woman, about eight months pregnant, who fell across a
chair, lacerating her genitals and causing an escape of liquor amnii.
There was regeneration of this fluid and delivery beyond term. The
labor was tedious and took place two and a half months after the
accident. The mother and the female child did well. Purcell reports
death in a pregnant woman from contused wound of the vulva. Morland
relates an instance of a woman in the fifth month of her second
pregnancy, who fell on the roof of a woodshed by slipping from one of
the steps by which she ascended to the roof, in the act of hanging out
some clothes to dry. She suffered a wound on the internal surface of
the left nympha 1 1/2 inch long and 1/2 inch deep. She had lost about
three quarts of blood, and had applied ashes to the vagina to stop the
bleeding. She made a recovery by the twelfth day, and the fetal sounds
were plainly audible. Cullingworth speaks of a woman who, during a
quarrel with her husband, was pushed away and fell between two chairs,
knocking one of them over, and causing a trivial wound one inch long in
the vagina, close to the entrance. She screamed, there was a gush of
blood, and she soon died. The uterus contained a fetus three or four
months old, with the membranes intact, the maternal death being due to
the varicosity of the pregnant pudenda, the slight injury being
sufficient to produce fatal hemorrhage. Carhart describes the case of a
pregnant woman, who, while in the stooping position, milking a cow, was
impaled through the vagina by another cow. The child was born seven
days later, with its skull crushed by the cow's horn. The horn had
entered the vagina, carrying the clothing with it.
There are some marvelous cases of recovery and noninterference with
pregnancy after injuries from horns of cattle. Corey speaks of a woman
of thirty-five, three months pregnant, weighing 135 pounds, who was
horned by a cow through the abdominal parietes near the hypogastric
region; she was lifted into the air, carried, and tossed on the ground
by the infuriated animal. There was a wound consisting of a ragged rent
from above the os pubis, extending obliquely to the left and upward,
through which protruded the great omentum, the descending and
transverse colon, most of the small intestines, as well as the pyloric
extremity of the stomach. The great omentum was mangled and comminuted,
and bore two lacerations of two inches each. The intestines and stomach
were not injured, but there was considerable extravasation of blood
into the abdominal cavity. The intestines were cleansed and an
unsuccessful attempt was made to replace them. The intestines remained
outside of the body for two hours, and the great omentum was carefully
spread out over the chest to prevent interference with the efforts to
return the intestines. The patient remained conscious and calm
throughout; finally deep anesthesia was produced by ether and
chloroform, three and a half hours after the accident, and in twenty
minutes the intestines were all replaced in the abdominal cavity. The
edges were pared, sutured, and the wound dressed. The woman was placed
in bed, on the right side, and morphin was administered. The sutures
were removed on the ninth day, and the wound had healed except at the
point of penetration. The woman was discharged twenty days after, and,
incredible to relate, was delivered of a well-developed, full-term
child just two hundred and two days from the time of the accident. Both
the mother and child did well.
Luce speaks of a pregnant woman who was horned in the lower part of the
abdomen by a cow, and had a subsequent protrusion of the intestines
through the wound. After some minor complications, the wound healed
fourteen weeks after the accident, and the woman was confined in
natural labor of a healthy, vigorous child. In this case no blood was
found on the cow's horn, and the clothing was not torn, so that the
wound must have been made by the side of the horn striking the greatly
distended abdomen.
Richard, quoted also by Tiffany, speaks of a woman, twenty-two, who
fell in a dark cellar with some empty bottles in her hand, suffering a
wound in the abdomen 2 inches above the navel on the left side 8 cm.
long. Through this wound a mass of intestines, the size of a man's
head, protruded. Both the mother and the child made a good
convalescence. Harris cites the instance of a woman of thirty, a
multipara, six months pregnant, who was gored by a cow; her intestines
and omentum protruded through the rip and the uterus was bruised. There
was rapid recovery and delivery at term. Wetmore of Illinois saw a
woman who in the summer of 1860, when about six months pregnant, was
gored by a cow, and the large intestine and the omentum protruded
through the wound. Three hours after the injury she was found swathed
in rags wet with a compound solution of whiskey and camphor, with a
decoction of tobacco. The intestines were cold to the touch and dirty,
but were washed and replaced. The abdomen was sewed up with a darning
needle and black linen thread; the woman recovered and bore a healthy
child at the full maturity of her gestation. Crowdace speaks of a
female pauper, six months pregnant, who was attacked by a buffalo, and
suffered a wound about 1 1/2 inch long and 1/2 inch wide just above the
umbilicus. Through this small opening 19 inches of intestine protruded.
The woman recovered, and the fetal heart-beats could be readily
auscultated.
Major accidents in pregnant women are often followed by the happiest
results. There seems to be no limit to what the pregnant uterus can
successfully endure. Tiffany, who has collected some statistics on this
subject, as well as on operations successfully performed during
pregnancy, which will be considered later, quotes the account of a
woman of twenty-seven, eight months pregnant, who was almost buried
under a clay wall. She received terrible wounds about the head, 32
sutures being used in this location alone. Subsequently she was
confined, easily bore a perfectly normal female child, and both did
well. Sibois describes the case of a woman weighing 190 pounds, who
fell on her head from the top of a wall from 10 to 12 feet high. For
several hours she exhibited symptoms of fracture of the base of the
skull, and the case was so diagnosed; fourteen hours after the accident
she was perfectly conscious and suffered terrible pain about the head,
neck, and shoulders. Two days later an ovum of about twenty days was
expelled, and seven months after she was delivered of a healthy boy
weighing 10 1/2 pounds. She had therefore lost after the accident
one-half of a double conception.
Verrier has collected the results of traumatism during pregnancy, and
summarizes 61 cases. Prowzowsky cites the instance of a patient in the
eighth month of her first pregnancy who was wounded by many pieces of
lead pipe fired from a gun but a few feet distant. Neither the patient
nor the child suffered materially from the accident, and gestation
proceeded; the child died on the fourth day after birth without
apparent cause. Milner records an instance of remarkable tolerance of
injury in a pregnant woman. During her six months of pregnancy the
patient was accidentally shot through the abdominal cavity and lower
part of the thorax. The missile penetrated the central tendon of the
diaphragm and lodged in the lung. The injury was limited by localized
pneumonia and peritonitis, and the wound was drained through the lung
by free expectoration. Recovery ensued, the patient giving birth to a
healthy child sixteen weeks later. Belin mentions a stab-wound in a
pregnant woman from which a considerable portion of the epiploon
protruded. Sloughing ensued, but the patient made a good recovery,
gestation not being interrupted. Fancon describes the case of a woman
who had an injury to the knee requiring drainage. She was attacked by
erysipelas, which spread over the whole body with the exception of the
head and neck; yet her pregnancy was uninterrupted and recovery ensued.
Fancon also speaks of a girl of nineteen, frightened by her lover, who
threatened to stab her, who jumped from a second-story window. For
three days after the fall she had a slight bloody flow from the vulva.
Although she was six months pregnant there was no interruption of the
normal course of gestation.
Bancroft speaks of a woman who, being mistaken for a burglar, was shot
by her husband with a 44-caliber bullet. The missile entered the second
and third ribs an inch from the sternum, passed through the right lung,
and escaped at the inferior angle of the scapula, about three inches
below the spine; after leaving her body it went through a pine door.
She suffered much hemorrhage and shock, but made a fair recovery at the
end of four weeks, though pregnant with her first child at the seventh
month. At full term she was delivered by foot-presentation of a healthy
boy. The mother at the time of report was healthy and free from cough,
and was nursing her babe, which was strong and bright.
All the cases do not have as happy an issue as most of the foregoing
ones, though in some the results are not so bad as might be expected. A
German female, thirty-six, while in the sixth month of pregnancy, fell
and struck her abdomen on a tub. She was delivered of a normal living
child, with the exception that the helix of the left ear was pushed
anteriorly, and had, in its middle, a deep incision, which also
traversed the antihelix and the tragus, and continued over the cheek
toward the nose, where it terminated. The external auditory meatus was
obliterated. Gurlt speaks of a woman, seven months pregnant, who fell
from the top of a ladder, subsequently losing some blood and water from
the vagina. She had also persistent pains in the belly, but there was
no deterioration of general health. At her confinement, which was
normal, a strong boy was born, wanting the arm below the middle, at
which point a white bone protruded. The wound healed and the separated
arm came away after birth. Wainwright relates the instance of a woman
of forty, who when six months pregnant was run over by railway cars.
After a double amputation of the legs she miscarried and made a good
recovery. Neugebauer reported the history of a case of a woman who,
while near her term of pregnancy, committed suicide by jumping from a
window. She ruptured her uterus, and a dead child with a fracture of
the parietal bone was found in the abdominal cavity. Staples speaks of
a Swede of twenty-eight, of Minnesota, who was accidentally shot by a
young man riding by her side in a wagon. The ball entered the abdomen
two inches above the crest of the right ilium, a little to the rear of
the anterior superior spinous process, and took a downward and forward
course. A little shock was felt but no serious symptoms followed. In
forty hours there was delivery of a dead child with a bullet in its
abdomen. Labor was normal and the internal recovery complete. Von
Chelius, quoting the younger Naegele, gives a remarkable instance of a
young peasant of thirty-five, the mother of four children, pregnant
with the fifth child, who was struck on the belly violently by a blow
from a wagon pole. She was thrown down, and felt a tearing pain which
caused her to faint. It was found that the womb had been ruptured and
the child killed, for in several days it was delivered in a putrid
mass, partly through the natural passage and partly through an abscess
opening in the abdominal wall. The woman made a good recovery. A
curious accident of pregnancy is that of a woman of thirty-eight,
advanced eight months in her ninth pregnancy, who after eating a hearty
meal was seized by a violent pain in the region of the stomach and soon
afterward with convulsions, supposed to have been puerperal. She died
in a few hours, and at the autopsy it was found that labor had not
begun, but that the pregnancy had caused a laceration of the spleen,
from which had escaped four or five pints of blood. Edge speaks of a
case of chorea in pregnancy in a woman of twenty-seven, not
interrupting pregnancy or retarding safe delivery. This had continued
for four pregnancies, but in the fourth abortion took place.
Buzzard had a case of nervous tremor in a woman, following a fall at
her fourth month of pregnancy, who at term gave birth to a male child
that was idiotic. Beatty relates a curious accident to a fetus in
utero. The woman was in her first confinement and was delivered of a
small but healthy and strong boy. There was a small puncture in the
abdominal parietes, through which the whole of the intestines protruded
and were constricted. The opening was so small that he had to enlarge
it with a bistoury to replace the bowel, which was dark and congested;
he sutured the wound with silver wire, but the child subsequently died.
Tiffany of Baltimore has collected excellent statistics of operations
during pregnancy; and Mann of Buffalo has done the same work, limiting
himself to operations on the pelvic organs, where interference is
supposed to have been particularly contraindicated in pregnancy. Mann,
after giving his individual cases, makes the following summary and
conclusions:--
(1) Pregnancy is not a general bar to operations, as has been supposed.
(2) Union of the denuded surfaces is the rule, and the cicatricial
tissue, formed during the earlier months of pregnancy, is strong enough
to resist the shock of labor at term.
(3) Operations on the vulva are of little danger to mother or child.
(4) Operations on the vagina are liable to cause severe hemorrhage, but
otherwise are not dangerous.
(5) Venereal vegetations or warts are best treated by removal.
(6) Applications of silver nitrate or astringents may be safely made to
the vagina. For such application, phenol or iodin should not be used,
pure or in strong solution.
(7) Operations on the bladder or urethra are not dangerous or liable to
be followed by abortion.
(8) Operations for vesicovaginal fistulae should not be done, as they
are dangerous, and are liable to be followed by much hemorrhage and
abortion.
(9) Plastic operations may be done in the earlier months of pregnancy
with fair prospects of a safe and successful issue.
(10) Small polypi may be treated by torsion or astringents. If cut,
there is likely to be a subsequent abortion.
(11) Large polypi removed toward the close of pregnancy will cause
hemorrhage.
(12) Carcinoma of the cervix should be removed at once.
A few of the examples on record of operations during pregnancy of
special interest, will be given below. Polaillon speaks of a double
ovariotomy on a woman pregnant at three months, with the subsequent
birth of a living child at term. Gordon reports five successful
ovariotomies during pregnancy, in Lebedeff's clinic. Of these cases, 1
aborted on the fifth day, 2 on the fifteenth, and the other 2 continued
uninterrupted. He collected 204 cases with a mortality of only 3 per
cent; 22 per cent aborted, and 69.4 per cent were delivered at full
term. Kreutzman reports two cases in which ovarian tumors were
successfully removed from pregnant subjects without the interruption of
gestation. One of these women, a secundipara, had gone two weeks over
time, and had a large ovarian cyst, the pedicle of which had become
twisted, the fluid in the cyst being sanguineous. May describes an
ovariotomy performed during pregnancy at Tottenham Hospital. The woman,
aged twenty-two, was pale, diminutive in size, and showed an enormous
abdomen, which measured 50 inches in circumference at the umbilicus and
27 inches from the ensiform cartilage to the pubes. At the operation,
36 pints of brown fluid were drawn off. Delivery took place twelve
hours after the operation, the mother recovering, but the child was
lost. Galabin had a case of ovariotomy performed on a woman in the
sixth month of pregnancy without interruption of pregnancy; Potter had
a case of double ovariotomy with safe delivery at term; and Storry had
a similar case. Jacobson cites a case of vaginal lithotomy in a patient
six and a half months pregnant, with normal delivery at full term.
Tiffany quotes Keelan's description of a woman of thirty-five, in the
eighth month of pregnancy, from whom he removed a stone weighing 12 1/2
ounces and measuring 2 by 2 1/2 inches, with subsequent recovery and
continuation of pregnancy. Rydygier mentions a case of obstruction of
the intestine during the sixth month of gestation, showing symptoms of
strangulation for seven days, in which he performed abdominal section.
Recovery of the woman without abortion ensued. The Revue de Chirurgien
1887, contains an account of a woman who suffered internal
strangulation, on whom celiotomy was performed; she recovered in
twenty-five days, and did not miscarry, which shows that severe injury
to the intestine with operative interference does not necessarily
interrupt pregnancy. Gilmore, without inducing abortion, extirpated the
kidney of a negress, aged thirty-three, for severe and constant pain.
Tiffany removed the kidney of a woman of twenty-seven, five months
pregnant, without interruption of this or subsequent pregnancies. The
child was living. He says that Fancon cites instances of operation
without abortion.
Lovort describes an enucleation of the eye in the second month of
pregnancy. Pilcher cites the instance of a woman of fifty-eight, eight
months in her fourth pregnancy, whose breast and axilla he removed
without interruption of pregnancy. Robson, Polaillon, and Coen report
similar instances.
Rein speaks of the removal of an enormous echinococcus cyst of the
omentum without interruption of pregnancy. Robson reports a
multi-locular cyst of the ovary with extensive adhesions of the uterus,
removed at the tenth week of pregnancy and ovariotomy performed without
any interruption of the ordinary course of labor. Russell cites the
instance of a woman who was successfully tapped at the sixth month of
pregnancy.
McLean speaks of a successful amputation during pregnancy; Napper, one
of the arm; Nicod, one of the arm; Russell, an amputation through the
shoulder joint for an injury during pregnancy, with delivery and
recovery; and Vesey speaks of amputation for compound fracture of the
arm, labor following ten hours afterward with recovery. Keen reports
the successful performance of a hip-joint amputation for malignant
disease of the femur during pregnancy. The patient, who was five months
advanced in gestation, recovered without aborting.
Robson reports a case of strangulated hernia in the third month of
pregnancy with stercoraceous vomiting. He performed herniotomy in the
femoral region, and there was a safe delivery at full term. In the
second month of pregnancy he also rotated an ovarian tumor causing
acute symptoms and afterward performed ovariotomy without interfering
with pregnancy. Mann quotes Munde in speaking of an instance of removal
of elephantiasis of the vulva without interrupting pregnancy, and says
that there are many cases of the removal of venereal warts without any
interference with gestation. Campbell of Georgia operated inadvertently
at the second and third month in two cases of vesicovaginal fistula in
pregnant women. The first case showed no interruption of pregnancy, but
in the second case the woman nearly died and the fistula remained
unhealed. Engelmann operated on a large rectovaginal fistula in the
sixth month of pregnancy without any interruption of pregnancy, which
is far from the general result. Cazin and Rey both produced abortion
by forcible dilatation of the anus for fissure, but Gayet used both the
fingers and a speculum in a case at five months and the woman went to
term. By cystotomy Reamy removed a double hair-pin from a woman
pregnant six and a half months, without interruption, and according to
Mann again, McClintock extracted stones from the bladder by the urethra
in the fourth month of pregnancy, and Phillips did the same in the
seventh month. Hendenberg and Packard report the removal of a tumor
weighing 8 3/4 pounds from a pregnant uterus without interrupting
gestation.
The following extract from the University Medical Magazine of
Philadelphia illustrates the after-effects of abdominal hysteropasy on
subsequent pregnancies:--
"Fraipont (Annales de la Societe Medico-Chirurgicale de Liege, 1894)
reports four cases where pregnancy and labor were practically normal,
though the uterus of each patient had been fixed to the abdominal
walls. In two of the cases the hysteropexy had been performed over five
years before the pregnancy occurred, and, although the bands of
adhesion between the fundus and the parietes must have become very
tough after so long a period, no special difficulty was encountered. In
two of the cases the forceps was used, but not on account of uterine
inertia; the fetal head was voluminous, and in one of the two cases
internal rotation was delayed. The placenta was always expelled easily,
and no serious postpartum hemorrhage occurred. Fraipont observed the
progress of pregnancy in several of these cases. The uterus does not
increase specially in its posterior part, but quite uniformly, so that,
as might be expected, the fundus gradually detaches itself from the
abdominal wall. Even if the adhesions were not broken down they would
of necessity be so stretched as to be useless for their original
purpose after delivery. Bands of adhesion could not share in the
process of involution. As, however, the uterus undergoes perfect
involution, it is restored to its original condition before the onset
of the disease which rendered hysteropexy necessary."
The coexistence of an extensive tumor of the uterus with pregnancy does
not necessarily mean that the product of conception will be blighted.
Brochin speaks of a case in which pregnancy was complicated with
fibroma of the uterus, the accouchement being natural at term. Byrne
mentions a case of pregnancy complicated with a large uterine fibroid.
Delivery was effected at full term, and although there was considerable
hemorrhage the mother recovered. Ingleby describes a case of fibrous
tumor of the uterus terminating fatally, but not until three weeks
after delivery. Lusk mentions a case of pregnancy with fibrocystic
tumor of the uterus occluding the cervix. At the appearance of symptoms
of eclampsia version was performed and delivery effected, followed by
postpartum hemorrhage. The mother died from peritonitis and collapse,
but the stillborn child was resuscitated. Roberts reports a case of
pregnancy associated with a large fibrocellular polypus of the uterus.
A living child was delivered at the seventh month, ecrasement was
performed, and the mother recovered.
Von Quast speaks of a fibromyoma removed five days after labor. Gervis
reports the removal of a large polypus of the uterus on the fifth day
after confinement. Davis describes the spontaneous expulsion of a large
polypus two days after the delivery of a fine, healthy, male child.
Deason mentions a case of anomalous tumor of the uterus during
pregnancy which was expelled after the birth of the child; and Daly
also speaks of a tumor expelled from the uterus after delivery. Cathell
speaks of a case of pregnancy complicated with both uterine fibroids
and measles. Other cases of a similar nature to the foregoing are too
numerous to mention. Figure 13, taken from Spiegelberg, shows a large
fibroid blocking the pelvis of a pregnant woman.
There are several peculiar accidents and anomalies not previously
mentioned which deserve a place here, viz., those of the membranes
surrounding the fetus. Brown speaks of protrusion of the membranes from
the vulva several weeks before confinement. Davies relates an instance
in which there was a copious watery discharge during pregnancy not
followed by labor. There is a case mentioned in which an accident and
an inopportune dose of ergot at the fifth month of pregnancy were
followed by rupture of the amniotic sac, and subsequently a constant
flow of watery fluid continued for the remaining three months of
pregnancy. The fetus died at the time, and was born in an advanced
state of putrefaction, by version, three months after the accident. The
mother died five months after of carcinoma of the uterus. Montgomery
reports the instance of a woman who menstruated last on May 22, 1850,
and quickened on September 26th, and continued well until the 11th of
November. At this time, as she was retiring, she became conscious that
there was a watery discharge from the vagina, which proved to be liquor
amnii. Her health was good. The discharge continued, her size
increased, and the motions of the child continued active. On the 18th
of January a full-sized eight months' child was born. It had an
incessant, wailing, low cry, always of evil augury in new-born infants.
The child died shortly after. The daily discharge was about 5 ounces,
and had lasted sixty-eight days, making 21 pints in all. The same
accident of rupture of the membranes long before labor happened to the
patient's mother.
Bardt speaks of labor twenty-three days after the flow of the waters;
and Cobleigh one of seventeen days; Bradley relates the history of a
case of rupture of the membranes six weeks before delivery. Rains cites
an instance in which gestation continued three months after rupture of
the membranes, the labor-pains lasting thirty-six hours. Griffiths
speaks of rupture of the amniotic sac at about the sixth month of
pregnancy with no untoward interruption of the completion of gestation
and with delivery of a living child. There is another observation of an
accouchement terminating successfully twenty-three days after the loss
of the amniotic fluid. Campbell mentions delivery of a living child
twelve days after rupture of the membranes. Chesney relates the history
of a double collection of waters. Wood reports a case in which there
was expulsion of a bag of waters before the rupture of the membranes.
Bailly, Chestnut, Bjering, Cowger, Duncan, and others also record
premature rupture of the membranes without interruption of pregnancy.
Harris gives an instance of the membranes being expelled from the
uterus a few days before delivery at the full term. Chatard, Jr.,
mentions extrusion of the fetal membranes at the seventh month of
pregnancy while the patient was taking a long afternoon walk, their
subsequent retraction, and normal labor at term. Thurston tells of a
case in which Nature had apparently effected the separation of the
placenta without alarming hemorrhage, the ease being one of placenta
praevia, terminating favorably by natural processes. Playfair speaks of
the detachment of the uterine decidua without the interruption of
pregnancy.
Guerrant gives a unique example of normal birth at full term in which
the placenta was found in the vagina, but not a vestige of the
membranes was noticed. The patient had experienced nothing unusual
until within three months of expected confinement, since which time
there had been a daily loss of water from the uterus. She recovered
and was doing her work. There was no possibility that this was a case
of retained secundines.
Anomalies of the Umbilical Cord.--Absence of the membranes has its
counterpart in the deficiency of the umbilical cord, so frequently
noticed in old reports. The Ephemerides, Osiander, Stark's Archives,
Thiebault, van der Wiel, Chatton, and Schurig all speak of it, and it
has been noticed since. Danthez speaks of the development of a fetus in
spite of the absence of an umbilical cord. Stute reports an observation
of total absence of the umbilical cord, with placental insertion near
the cervix of the uterus.
There is mentioned a bifid funis. The Ephemerides and van der Wiel
speak of a duplex funis. Nolde reports a cord 38 inches long; and
Werner cites the instance of a funis 51 inches long. There are modern
instances in which the funis has been bifid or duplex, and there is
also a case reported in which there were two cords in a twin pregnancy,
each of them measuring five feet in length. The Lancet gives the
account of a most peculiar pregnancy consisting of a placenta alone,
the fetus wanting. What this "placenta" was will always be a matter of
conjecture.
Occasionally death of the fetus is caused by the formation of knots in
the cord, shutting off the fetal circulation; Gery, Grieve, Mastin,
Passot, Piogey, Woets, and others report instances of this nature.
Newman reports a curious case of twins, in which the cord of one child
was encircled by a knot on the cord of the other. Among others, Latimer
and Motte report instances of the accidental tying of the bowel with
the funis, causing an artificial anus.
The diverse causes of abortion are too numerous to attempt giving them
all, but some are so curious and anomalous that they deserve mention.
Epidemics of abortion are spoken of by Fickius, Fischer, and the
Ephemerides. Exposure to cold is spoken of as a cause, and the same is
alluded to by the Ephemerides; while another case is given as due to
exposure white nude. There are several cases among the older writers in
which odors are said to have produced abortion, but as analogues are
not to be found in modern literature, unless the odor is very poisonous
or pungent, we can give them but little credence. The Ephemerides gives
the odor of urine as provocative of abortion; Sulzberger, Meyer, and
Albertus all mention odors; and Vesti gives as a plausible cause the
odor of carbonic vapor. The Ephemerides mentions singultus as a cause
of abortion. Mauriceau, Pelargus, and Valentini mention coughing.
Hippocrates mentions the case of a woman who induced abortion by
calling excessively loud to some one. Fabrieius Hildanus speaks of
abortion following a kick in the region of the coccyx. Gullmannus
speaks of an abortion which he attributes to the woman's constant
neglect to answer the calls of nature, the rectum being at all times in
a state of irritation from her negligence. Hawley mentions abortion at
the fourth or fifth month due to the absorption of spirits of
turpentine. Solingen speaks of abortion produced by sneezing. Osiander
cites an instance in which a woman suddenly arose, and in doing so
jolted herself so severely that she produced abortion. Hippocrates
speaks of extreme hunger as a cause of abortion. Treuner speaks of
great anger and wrath in a woman disturbing her to the extent of
producing abortion.
The causes that are observed every day, such tight lacing, excessive
venery, fright, and emotions, are too well known to be discussed here.
There has been reported a recent case of abortion following a
viper-bite, and analogues may be found in the writings of Severinus and
Oedman, who mention viper-bites as the cause; but there are so many
associate conditions accompanying a snake-bite, such as fright,
treatment, etc., any one of which could be a cause in itself, that this
is by no means a reliable explanation. Information from India an this
subject would be quite valuable.
The Ephemerides speak of bloodless abortion, and there have been modern
instances in which the hemorrhage has been hardly noticeable.
Abortion in a twin pregnancy does not necessarily mean the abortion or
death of both the products of conception. Chapman speaks of the case of
the expulsion of a blighted fetus at the seventh month, the living
child remaining to the full term, and being safely delivered, the
placenta following. Crisp says of a case of labor that the head of the
child was obstructed by a round body, the nature of which he was for
some time unable to determine. He managed to push the obstructing body
up and delivered a living, full-term child; this was soon followed by a
blighted fetus, which was 11 inches long, weighed 12 ounces, with a
placenta attached weighing 6 1/2 ounces. It is quite common for a
blighted fetus to be retained and expelled at term with a living child,
its twin.
Bacon speaks of twin pregnancy, with the death of one fetus at the
fourth month and the other delivered at term. Beall reports the
conception of twins, with one fetus expelled and the other retained;
Beauchamp cites a similar instance. Bothwell describes a twin labor at
term, in which one child was living and the other dead at the fifth
month and macerated. Belt reports an analogous case. Jameson gives the
history of an extraordinary case of twins in which one (dead) child was
retained in the womb for forty-nine weeks, the other having been born
alive at the expiration of nine months. Hamilton describes a case of
twins in which one fetus died from the effects of an injury between the
fourth and fifth months and the second arrived at full period. Moore
cites an instance in which one of the fetuses perished about the third
month, but was not expelled until the seventh, and the other was
carried to full term. Wilson speaks of a secondary or blighted fetus of
the third month with fatty degeneration of the membranes retained and
expelled with its living twin at the eighth month of uterogestation.
There was a case at Riga in 1839 of a robust girl who conceived in
February, and in consequence her menses ceased. In June she aborted,
but, to her dismay, soon afterward the symptoms of advanced pregnancy
appeared, and in November a full-grown child, doubtless the result of
the same impregnation as the fetus, was expelled at the fourth month.
In 1860 Schuh reported an instance before the Vienna Faculty of
Medicine in which a fetus was discharged at the third month of
pregnancy and the other twin retained until full term. The abortion was
attended with much metrorrhagia, and ten weeks afterward the movements
of the other child could be plainly felt and pregnancy continued its
course uninterrupted. Bates mentions a twin pregnancy in which an
abortion took place at the second month and was followed by a natural
birth at full term. Hawkins gives a case of miscarriage, followed by a
natural birth at full term; and Newnham cites a similar instance in
which there was a miscarriage at the seventh month and a birth at full
term.
Worms in the Uterus.--Haines speaks of a most curious case--that of a
woman who had had a miscarriage three days previous; she suffered
intense pain and a fetid discharge. A number of maggots were seen in
the vagina, and the next day a mass about the size of an orange came
away from the uterus, riddled with holes, and which contained a number
of dead maggots, killed by the carbolic acid injection given soon after
the miscarriage. The fact seems inexplicable, but after their expulsion
the symptoms immediately ameliorated. This case recalls a somewhat
similar one given by the older writers, in which a fetus was eaten by a
worm. Analogous are those cases spoken of by Bidel of lumbricoides
found in the uterus; by Hole, in which maggots were found in the vagina
and uterus; and Simpson, in which the abortion was caused by worms in
the womb--if the associate symptoms were trustworthy.
We can find fabulous parallels to all of these in some of the older
writings. Pare mentions Lycosthenes' account of a woman in Cracovia in
1494 who bore a dead child which had attached to its back a live
serpent, which had gnawed it to death. He gives an illustration showing
the serpent in situ. He also quotes the case of a woman who conceived
by a mariner, and who, after nine months, was delivered by a midwife of
a shapeless mass, followed by an animal with a long neck, blazing eyes,
and clawed feet. Ballantyne says that in the writings of Hippocrates
there is in the work on "Diseases", which is not usually regarded as
genuine, a some what curious statement with regard to worms in the
fetus. It is affirmed that flat worms develop in the unborn infant,
and the reason given is that the feces are expelled so soon after birth
that there would not be sufficient time during extrauterine life for
the formation of creatures of such a size. The same remark applies to
round worms. The proof of these statements is to be found in the fact
that many infants expel both these varieties of parasites with the
first stool. It is difficult to know what to make of these opinions;
for, with the exception of certain cases in some of the seventeenth and
eighteenth century writers, there are no records in medicine of the
occurrence of vermes in the infant at birth. It is possible that other
things, such as dried pieces of mucus, may have been erroneously
regarded as worms.