PRENATAL ANOMALIES. 5 page

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

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