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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