PRENATAL ANOMALIES. 6 page

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

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