CYCLOP/EDIA 
OF 
OBSTETRICS AND GYNECOLOGY 
THE 
Pathology of Pregnancy 
BEING VOLUME TWO OF 
A PRACTICAL TREATISE ON 
OBSTETRICS 
BY 
DR. A. CHARPENTIER, 
ADJUNCT PROFESSOR AT THE FACULTY OF MEDICINE, PARIS. 
TRANSLA TED UNDER THE SUPERVISION OF, AND WITH NOTES AND ADDITIONS 
BY 
EGBERT H. GRANDIN, M.D., 
OBSTETRIC SURGEON TO THE NEW YORK MATERNITY HOSPITAL ; INSTRUCTOR IN GYNECOLOGY AT THE 
NEW YORK POLYCLINIC ; FELLOW OF THE OBSTETRICAL SOCIETY, ETC. 
Sn jfour Volumes 
FORTY-FIVE FINE WOOD ENGRAVINGS AND TWO COLORED PLATES. 
NEW YORK 
WILLIAM WOOD & COMPANY 
1887 Copyright, 1887, 
WILLIAM WOOD & COMPANY. 
The Publishers' 
Book Composition and Electrotyping Co. 
157 and 159 William Street 
New York CONTENTS OF VOLUME IL 
CHAPTER I. ' 
Epidemic diseases ; colic; cholera; intermittent fever ; eruptive fevers ; typhoid 
fever ; sporadic diseases ; pneumonia ; pleurisy ; tuberculosis ; icterus ; 
syphillis ; lead poisoning ; tobacco poison; hysteria; epilepsy ; trauma- 
tism ; goitre ; erosions of the cervix, pages 3-35 
CHAPTER II. 
Lesions of the digestion, the respiration, the circulation ; varices, ascites, edema, 
pernicious anemia : lesions of the secretions ami of the excretions ; ptyalism, 
retention of urine, cystitis; albuminuria; eclampsia; puerperal convulsions; 
neuralgias; paralyses; intellectual disorders ; diseases of the skin ; lesions of 
the pelvic joints; puerperal rheumatism, muscular and articular; chorea ; 
diseases of the vulva and vagina ; abdominal and uterine pains ; displacements 
and distortions of the uterus, pages 37-215 
CHAPTER III. 
Diseases of the ovum, the decidua, placenta, amnion, . . pages 216-283 
CHAPTER IV. 
Diseases of the foetus ; fevers ; inflammatory affections of the various organs ; dis- 
turbances in the circulatory system ; diseases of the bones; congenital 
syphilis ; death of the foetus and consecutive changes, . pages 284-310 
CHAPTER V. 
Miscarriage ; its causes, phenomena, prevention and treatment, . pages 311-349 
CHAPTER VI. 
Extra-uterine pregnancy, pages 350-381 PART V. 
The Pathology of Pregnancy. CHAPTER I. 
DISEASES AFFECTING THE PREGNANT WOMAN, INDE- 
PENDENTLY OF THE GRAVID STATE. 
rpHE gravida may be affected by any disease whatsoever, as well medi- 
cal as surgical. We will briefly pass these diseases in review, and 
note the reciprocal action which they and pregnancy have on one another. 
Pregnancy, indeed, does not protect women from any disease, absolutely, 
and epidemic diseases, whether essentially so, or sporadic, attack, without 
distinction, the gravid and the non-gravid. 
Epidemic Diseases. 
Epidemic Colic {Grippe'). 
Jacquemier, in 1837, found that this affection attacked nearly all the 
women in the Maternite. He did not, however, find, as Cazeaux did, 
that it was more fatal in them than in non-gravid women. Cazeaux, 
however, noted a large number of miscarriages, either the direct conse- 
quences of the disease, or of the violent cramps from which the women 
suffered. 
Cholera. 
The Influence of Pregnancy on Cholera.-Bouchut was the first to show 
that pregnancy has no influence on the appearance of cholera, in that it 
neither protects from, nor does it predispose to it, and that cholera follows 
its usual course without any modification, with its usual variations in 
character and severity. This does not apply to the influence of cholera 
upon pregnancy, the duration of which is usually shortened. 
Frequency.-Among upwards of 3000 cases of cholera, reported by dif- 
ferent observers, 139 occurred in pregnant females, of whom 55 died. 
Age.-According to Henning, the greatest number of eases have occurred 
between the ages of twenty-one and thirty-five; this is also the period 
during which the mortality has been the most considerable. It also in- 
creases with the number of pregnancies. 
Time of Appearance.-According to Dietl and Hennig, women are 
most liable to contract cholera during the latter half of pregnancy. 
Among 63 cases observed by Hennig, there were 33 deaths. The aver- 
age duration of the disease was eight days, the majority of the deaths oc- 
curring on the third day. He states that the malady presents the usual 
four stages, viz., the period of incubation, of diarrhoea and convulsions, 4 
A TREATISE ON OBSTETRICS. 
that of collapse, and that of reaction. The hemorrhages from the genital 
canal, noted in cases of pregnant females, have been attributed by Slav- 
jansky to a special form of endometritis. 
The Influence of Cholera on Pregnancy.-Bouchut noted the occurrence 
of abortion in one-half of the cases in which the patients survived the dis- 
ease. 
The following table gives statistics from various sources in regard to 
the progress of labor: 
Recoveries. 
Deaths. 
Bouchut, 
. 52 cases, 
i Miscarriage 
( None 
25 
27 
16 
6 
19 
21 
Saint Romes, 
. 10 11 
j Miscarriage 
{ None 
4 
6 
1 
3 
6 
Bourgeois, 
. 4 " 
J Miscarriage 
( None 
3 
1 
1 
3 
Gendrin, 
2 " 
j Miscarriage 
i None 
1 
1 
1 
1 
Drasche, 
. 25 " 
J Miscarriage 
| None 
11 
14 
Hennig, . . 
. 30 " 
j Miscarriage 
( None 
27 
12 
18 
2 
9 
10 
Hennig, comparing the results of epidemics in Leipsic, Vienna and 
France, found that about fifty per cent, of the pregnant women miscar- 
ried, the average mortality being forty-eight per cent., while of those who 
were not confined, sixty-six per cent. died. 
The prognosis for both child and mother is very grave; of 85 children 
50 died. Authorities differ as to the cause of death, Bouchut attributing 
it to the mechanical pressure of the uterus, due to the strong contractions 
of the abdominal muscles, others to lack of nourishment on the part of 
the mother, or to asphyxia, while Cazeaux believes that the change in the 
constitution of the blood (through the removal of the serum) leads directly 
to its coagulation in the placental vessels, with a consequent arrest of the 
circulation. The prognosis for the mother is no more favorable, as the 
statistics before quoted prove. Devilliers proposes the induction of pre- 
mature labor instead of waiting until it occurs spontaneously. At first 
sight the figures seem to justify this interference, but Cazeaux calls at- 
tention to the wide variations in the severity of cholera, so that in the 
case of those women who were reported to have died without aborting, it 
terminated fatally before this accident could occur. This author, as well 
as Baginsky, disapproves of inducing premature labor, but Baginsky ad- 
vises that the labor be terminated if it has once begun. Unfortunately, 
the cholera does not allow time for interference before the child perishes. 
Has Cholera any Influence on Delivery?-If Slavjansky has called atten- 
tion to the hemorrhages during pregnancy, they do not appear to be any 
more frequent after delivery, because they have been noted only two or 5 
DISEASES AFFECTING PREGNANT WOMEN. 
three times among the cases observed. Might not their infrequency be ex- 
plained by reference to the changes in the uterine circulation caused by the 
death of the foetus ? Drasche has reported two cases of eclampsia. As 
regards the sequelae of labor, they do not seem to be influenced in any re- 
markable manner; however, Scanzoni appears to admit that women are 
more predisposed to puerperal fever. Hennig has reported two cases of 
peritonitis and parametritis ; both were cured. The treatment is the 
same as that of cholera in the non-puerperal state. 
Intermittent Fever. 
Intermittent fever during pregnancy was described by the ancients, and 
Jacquemier quotes from Schurigius a case in which a woman, pregnant 
for the third time, was, in the second month of pregnancy, seized with a 
very obstinate quartan fever. In the last month, before and after the 
paroxysm, she felt the foetus move, quiver, and clearly turn about from 
one side to the other. Finally, after a violent paroxysm, she was delivered 
of a girl, which was seized at the same hour as the mother with very vio- 
lent attacks of fever, which continued during seven weeks. Hoffmann 
and Russel have reported similar cases. Bourgeois described a case of 
tertian fever, accompanied by convulsive movements of the foetus corre- 
sponding to the maternal attacks, a fact derived from Stokes. Pitre 
Aubinais observed two cases of intermittent fever, which was transmitted 
to the children, so that they were born with enlarged spleens, and showed 
attacks of tertian ague, corresponding to the same days and even the 
same hours as in. the mother. Frank and Joubert have seen similar 
cases. 
Grenser believes that there are forms of intermittent fever that bear a 
certain causal relation to pregnancy. If that were true, they would per- 
sist after delivery, whether this occurs at term or prematurely, and would 
then disappear spontaneously, or would be very easily cured, while inter- 
mittents which occur in women advanced in their pregnancy rarely disap- 
pear before delivery under the administration of quinine or other reme- 
dies, and in all cases they show relapses. But, if the intermittent fever 
does stand in a causal relation to the pregnancy, the attacks recur regularly 
after delivery, just as before, without, on the whole, impeding the nor- 
mal progress of the labor. He recommends the use of large doses of sul- 
phate of quinine. Mendel affirms that it is impossible at the present day 
to admit this causal relation between intermittent fever and pregnancy, 
and considers it as rare. Griesinger insists that pregnant women, and 
especially those who are parturient, are perhaps less predisposed to inter- 
mittent fever than others, and cites the observations of Quadrat, who 
noticed at Prague only two cases among 8,639 pregnant or puerperal 
women, in spite of the prevalence of a severe epidemic. Among 37,183 
women observed by various writers, only twenty cases were reported: 6 
A TREATISE ON OBSTETRICS. 
Frequency of Intermittent. 
Quadrat, . . 8,639 cases. 2 cases. 
Grenser, . . 7,389 " 1 case. 
Mendel, . . 9,142 " 4 after labor. 
Crede, . . 594 " 5 " " 
Strong, . . 2,936 « 2 J J 
x Brummerstadt, . 816 " 1 after labor. 
Busch, . . 6,077 " A number during pregnancy. 
Mendel, . . 1,115 " 2 during pregnancy. 
Busch, . . 1,114 " 2 " " 
Ritter, . . 1,000 " Malaria, 14 cases in puerperium. 
Sachs, ) * 1 - 
Hirsch C * number of cases. 
Hubbard, . 1 case. 
Ange, . . 1 " 
Ritter admits that pregnancy does not insure immunity, that the 
malarial cachexia does not predispose to abortion, and that the intermit- 
tent fever generally assumes an acute form. This acute type always dis- 
appears for a short time during the act of delivery, to reappear during 
the first three weeks of convalescence. It would seem as if the tendency 
of the latter condition was to arouse the acute form in women who were 
the subjects of the chronic. Finally, according to him, the course of 
the acute affection is not regular, and the remission is always incomplete. 
Mendel follows Ritter in believing that intermittent fever is rare, even in 
localities in which it is indigenous. Pregnancy and the puerperal condi- 
tion seem to predispose to it. Although typical intermittent is rare, lar- 
val forms, especially neuralgic, are often noted. All these authorities 
agree on the subject of treatment; all recommend the use of sulphate of 
quinine in larger or smaller doses. Many writers have inveighed against 
the administration of quinine during pregnancy, because of the supposed 
danger of producing abortion, but Cazeaux and others deny that the drug 
is harmful, believing that the general disturbances caused by the attacks 
of intermittent are far more likely to cause the premature expulsion of 
the foetus than the quinine. Many physicians, who have had a large 
practice in malarial districts, have never had cause to fear the action of 
quinine upon pregnant women. It is not only an innocuous remedy, but 
it is the surest preventive when abortion is rendered imminent by the 
occurrence of the fever. (Cazeaux.) 
Spiegelberg affirms that intermittent fever is rare during the last months 
of pregnancy, and that it does not disturb its course. Intermittent, he 
thinks, when it is present in a chronic form, assumes its acute form, or 
a transient acuteness, during pregnancy. He believes strongly in full 
doses of sulphate of quinine, although this drug does not prevent the re- 
currences which appear during the first three months after delivery. The 
disease is temporarily arrested during delivery. DISEASES AFFECTING PREGNANT WOMEN. 
7 
The fever which appears during pregnancy is characterized by the ab- 
sence of intermissions, and by the presence, on the contrary, of a con- 
tinued febrile condition, interrupted by irregular chills. The stage of 
apy rexia is never complete, and even in the most typical cases the inter- 
mittence is never regular in its rhythm. The dose of sulphate of quinine 
should be increased still more during convalescence. Playfair calls atten- 
tion to the transmission from the mother to the foetus; and the frequency 
with which hypertrophy of the spleen is found in young infants in mala- 
rial countries, leads him to infer that the intra-uterine affection must be 
common. He has often noted this fact in India, without, however, having 
been able to convince himself that the mothers had suffered from inter- 
mittent fever during their pregnancy. 
Goth's researches differ in certain respects from the results obtained by 
Ritter. In the course of six years he observed 881 deliveries, in which 
46 women were attacked by malaria during pregnancy, and during a 
period more or less extended subsequently; of these 46, only 27 went to 
full term, 19 being delivered prematurely. 
1 at 4 months. 2 at 5 months. 2 at 6 months. 
5 at 7 " 9 at 8 " 
In 41.3 per cent, of the cases, then, there was an interruption of the 
pregnancy. The inference from these statistics, moreover, is that the 
danger increases with the advancement of the pregnancy, premature de- 
livery being more frequent than abortions. He agrees with Kaminski 
and Runge in attributing the death of the foetus to the elevation of tem- 
perature in the mother (106° F. and above) during the prolonged attack, 
and attaches less importance to the maternal anaemia consecutive to the 
disease, and to the direct infection of the foetus by the malarial poison. 
Goth observed that pregnant women, after the second or third attack, 
complained of lumbar pains, and that slight uterine contractions could 
be detected, and the mortality of children who are born under these con- 
ditions is much higher than that of other countries. They weigh at least 
eleven ounces less than others. As regards the labor, he has noted 
irregularity in the contractions, feeble pains, especially during the first 
stage, until the cervix is completely dilated; this stage is generally twice 
as long as in ordinary cases. This feebleness in the contractions, although 
less evident, is also present during the expulsive stage, because it was 
necessary to interfere more frequently in those cases (forceps, extraction of 
the placenta, etc.) 
The Influence of Labor on Malaria.-This is shown in every instance by 
the arrest of the attacks (Ritter). Goth, on the contrary, has seen some 
cases in which the attacks were, it is true, reduced to the number of* one 
or two, but they reappeared subsequently, and in the great majority of 
the cases the attacks recurred after delivery with the same regularity as 8 
A TREATISE ON OBSTETRICS. 
before. During convalescence women are predisposed to it. Ritter, Goth 
and Mendel have seen women affected after confinement who were free 
from malaria during pregnancy. Quinine acts in the same way after con- 
finement. Goth does not favor maternal nursing in these cases; it may 
be allowed in light, but not in severe cases. 
Eruptive Fevers. 
Small-pox. 
The eruptive fevers seem to acquire an unusual severity in preg- 
nant females, and small-pox especially, according to most authors, pro- 
duces abortion and subsequent death of the patients. All writers agree 
regarding the exceptional gravity of the prognosis of small-pox occurring 
in a pregnant woman. Cazeaux, however, has already made an important 
distinction between discrete and confluent small-pox; the first almost al- 
ways terminating in a cure, even when the pregnancy is interrupted; the 
second, which is so serious in the non-pregnant state, assuming, during 
the period of gestation, a peculiarly grave form. Abortion and death 
would then be the rule, almost certainly. With Jobard, we think it neces- 
sary in this connection to distinguish the three forms of small-pox: 1st. 
Varioloid; 2d. Discrete variola; 3d. Confluent variola. 
1st. Varioloid.-Even when confluent it is generally benign, and only 
rarely causes abortion. Mayer has, however, reported four abortions 
among 37 cases of varioloid. We, ourselves, have observed a case of con- 
fluent varioloid in a woman six months pregnant. The mother was cured, 
the pregnancy pursued its course, and the woman was delivered at term 
of a living child (the fifth) who did not present any pock-marks, and 
who was only more emaciated than this patient's other children. 
2d. Discrete Variola.-Abortion is more frequent (Jobard noted four 
abortions in eight cases), but recovery of the mother is the rule. 
3d. Confluent Variola.-Here, on the contrary, abortion is almost in- 
variably the rule, and the death of the mother follows, in the great ma- 
jority of the cases, during the days immediately succeeding abortion; the 
same result is far more likely to occur if the variola assumes the haemor- 
rhagic form. 
This opinion is now held by all authors, but they still differ as to the 
period at which the abortion occurs. It is during the suppurative stage 
that this accident is especially seen to occur. But abortion does not always 
take place under the same conditions. Sometimes, in short, the foetus is 
expelled dead, sometimes living, and the conditions are evidently all differ- 
ent, so that the causes of abortion may thus be multiplied. As soon as 
the condition of the maternal blood, the infectious germ of the disease, 
the exaggerated influence of the maternal temperature, or the infection 
of the foetus by the mother, who transmits small-pox to it, cause the DISEASES AFFECTING PREGNANT WOMEN. 
9 
death of this foetus, abortion will become inevitable; because this foetus 
is no longer anything but a foreign body, of which the womb will inevi- 
tably tend to relieve itself. But these are not the only causes, and we 
must take into account another phenomenon, which alone may explain the 
frequent abortion: it is uterine hemorrhage. Spiegelberg and others 
refer this to a hemorrhagic endometritis. Brouardel believes that the 
premature contractions of the uterus are due to an excess of carbonic acid 
in the blood. 
Does pregnancy predispose women to contract the grave forms of the 
disease? With Jobard, we think not, and claim that it is by reason of 
the pregnancy itself, and of the abortion, that the disease assumes a form 
and a character exceptionally severe. Brouardel and others show that, in 
certain cases after abortion, small-pox may become hemorrhagic. Variola 
does not predispose to puerperal septicaemia; the latter is a serious com- 
plication, which hastens the fatal termination. Death generally occurs 
from the eleventh to the fourteenth day of the disease, often before, in 
hemorrhagic small-pox. 
The prognosis is exceedingly grave, as Meyer shows in a series of tables, 
of which the following is a summary: Of 29 pregnant women, 5 or 17.2 per 
cent, died, 9 or 31 per cent, aborting; of 47, in another series, 18 or 38.2 
per cent, died, 22 aborting. The mortality was greater in an epidemic 
occurring in the spring and summer. 
As regards the foetus, three alternatives may present: 1st. The child 
may die in the mother's womb; 2d. It may be born alive, and then it is 
either in good condition and grows up, or it is born alive, but succumbs 
a few hours or days after birth; 3d. Finally, the child may be born 
with small-pox pustules. 
1st. The Child dies in the Mother's Womb.-We believe with Spiegel- 
berg and others, that in order to explain this death, great importance 
should be assigned to the maternal temperature, and that if hemorrhage 
plays a part, it is a secondary part, so to speak, compared with that of 
temperature. 
2d. The Child is born Alive and Survives.-It is in cases of varioloid, 
and discrete small-pox especially, that the foetus escapes the danger. But, 
if a certain number are born well, the majority, as we have observed, are 
usually born feeble and emaciated, which accounts for their mortality 
during the days immediately following birth. It is a curious fact that 
these infants quite frequently resist vaccine. Burkhardt, of Bale, re-vac- 
cinated 28 pregnant women, with the following result: In 4 women at the 
end of their pregnancy, vaccination was successful; in 4 children it was 
unsuccessful, one child resisting it for six months. Vaccination seems in 
these cases, then, to affect both mother and child. Hence the necessity 
of re-vaccinating all pregnant women. If vaccine can act thus on the 10 
A TREATISE ON OBSTETRICS. 
foetus through the mother, so much the more reason should there be why 
small-pox should be transmitted in the same manner. 
3d. Certain infants are born with evident marks of variola, either in 
the shape of fully-developed pustules, or cicatrices. Many cases are on 
record in which children were born with small-pox, while the mothers 
remained uninfected; in one instance the child was apparently infected 
at the time of fecundation, the mother remaining well. These cases, it 
must be acknowledged, are really exceptions, and small-pox in the foetus 
is rare. It is only when the mother is infected at the end of gestation 
that this has been verified; and then the foetus comes into the world either 
during the period of invasion (Gariel), or more commonly towards the 
end of the eruptive stage, or at the time of the suppurative fever (Chaig- 
neau (Noblet de Rennes, Legrand). Before the ninth month cases be- 
come more and more rare, while towards the sixth and fifth month they 
are almost exceptional. Male infants seem to be more predisposed to it 
than females. 
If the pustules in the foetus present a striking resemblance to those of 
the adult, they have not the same distribution. Aside from the fact that 
the small-pox is usually discrete, the pustules are scattered in an irregu- 
lar manner, and are not most numerous on the face. Nevertheless, in 
some cases the variola has been confluent. The pustules contain, as a 
rule, a yellowish and slightly opaque, but rarely purulent, fluid. How- 
ever, true suppuration has been noted. Mother and child may be at- 
tacked simultaneously; the small-pox then pursues a parallel course in 
the two subjects. More commonly, however, this does not occur, and 
the small-pox is more advanced in the mother than in the foetus. 
Children have been attacked three months after the mother. Some- 
times the period of invasion seems to be indicated by a peculiar malaise, 
an extreme agitation of the foetus, followed by the cessation of active 
movements. 
The treatment consists in re-vaccinating all pregnant women, because 
the cases reported by Burckhardt, although too few to permit the drawing 
of a positive conclusion, prove, at least, the harmlessness of vaccination, 
as regards both mother and child. 
Scarlet Fever. 
Scarlet fever, although not absolutely rare among the complications of 
labor, appears on the contrary to be the exception during pregnancy, to 
judge from the small number of observations reported by authors. Ca- 
zeaux never saw a case; Bourgeois, however, mentions an epidemic ob- 
served in Vienna in 1801. Scarlatina assumes a grave, malignant type, 
and terminates in abortion in the case of every woman, in death in the 
majority. All the descriptions of writers have reference to scarlet fever 
occurring after delivery. A single observation of Bourgeois seems, how- DISEASES AFFECTING PREGNANT WOMEN. 
11 
over, to have related to a case of scarlet fever which occurred during the 
latter days of pregnancy, the woman dying five days after delivery. • 
Measles. 
Measles is of rare occurrence during pregnancy, for only twenty or 
twenty-five cases at the most can be collected among different authorities. 
According to Levret, it equals in gravity the other eruptive fevers, and is 
almost always accompanied by abortions and premature delivery. Grisolle 
and Cazeaux, on the other hand, observed two cases in which the preg- 
nancy pursued its course. Bourgeois agrees with Levret. Among fif- 
teen cases observed by him, he noted eight abortions or premature births; 
of the eight children, five were non-viable (born before seven months), 
three at the seventh or eighth month. In women who were only between 
the second and fifth month of pregnancy, the disease pursued its usual 
course, but it became more severe as the pregnancy was more advanced. 
The premonitory symptoms of abortion appeared towards the end of the 
disease; as a rule, delivery did not occur until from one to three days later, 
and sometimes the disease had terminated. 
When women were attacked with the disease at the end of pregnancy, 
premature delivery took place at the outset, accompanied by fever and 
serious symptoms. The foetus was dead-born, or perished within a few 
hours or days after birth. The disease pursued its course and the women 
slowly recovered. In rare instances the children were born with measles. 
Bourgeois saw one case, the infant being born fifteen days before full 
term and living only three days. Gautier collected eleven cases, in six of 
which the children presented the morbillous eruption. 
Measles occurring during pregnancy, therefore, may predispose to the 
death of the foetus and to abortion; it does not endanger the mother. 
The prognosis during the puerperal state is less grave. 
Erysipelas. 
Erysipelas, like the other eruptive fevers, may attack pregnant females, 
and pregnancy does not seem to offer any protection from it. Facial ery- 
sipelas, especially, has been observed several times, and if pregnancy does 
not seem to influence the course of the affection, the case is not the same 
as regards the influence of erysipelas upon pregnancy. The latter is often 
interrupted, either by abortion or by premature delivery, and the foetus 
may be directly affected by the rise of temperature in the mother. The 
mother, as in cases of small-pox, may die or be cured; everything depends 
on the severity of the disease. However, erysipelas seems to be less seri- 
ous than variola, and may be placed on the same level as measles. ■ We 
have only seen one case: the woman, who was attacked at about the fourth 
month of pregnancy, presented until term (when she was delivered of a 
living child) a series of erysipelatous eruptions of the face, which reap- 12 
A TREATISE OX OBSTETRICS. 
peared month after month, and were remarkable by reason of the insig- 
nificance of the febrile manifestations, although the eruption was well 
marked. 
Typhoid Fever. 
While Rokitansky and Niemeyei' believe that pregnancy insures a sort 
of immunity from typhoid fever, others regard this opinion as being too 
positive, and, while agreeing in the belief that typhoid is more common 
after delivery than it is during pregnancy, they prove, by numerous ob- 
servations (283), that typhoid may not only attack pregnant women, but 
that it does not always present the same form-that the disease may as- 
sume the abdominal, exanthematic or recurrent type. These three vari- 
eties, moreover, do not seem to manifest either the same frequency, or the 
same severity, the exanthematic and recurrent forms having been most often 
observed. Typhoid fever may attack women at any period of pregnancy; 
however, it occurs more frequently during the first than during the last 
months. But the three types of the disease do not seem to possess the 
same gravity, and while the abdominal variety is most severe, the exan- 
thematic and recurrent would seem to be less dangerous to women. This 
danger also, according to Spiegelbcrg, depends, perhaps, less upon the 
form of the disease than it does upon the period of the pregnancy at 
which it occurs, and upon the abortion which it produces, since the latter 
is inevitably followed by more severe hemorrhages during the early than 
during the later months, when the consequences are simply those of a 
premature delivery. In 322 cases the foetus was expelled prematurely in 
182. 
Cases. 
Miscarriages. Prem. Labor. 
Pregnancy 
to term. 
Bourgeois, 
. 37 
12 10 
15 
Forget, 
. 4 
2 
2 
Grisolle, 
1 
1 
Mauriceau, . 
. 3 
3 
Piorry 
. 2 
1 1 
Wallichs, 
2 
1 1 
Bartels, 
. 1 
1 
Kaminsky, . 
. 87 
54 
33 
Murchison, . 
. 14 
8 1 
5 
W eber, 
. 63 
23 
40 
Duguyot, 
. 62 
40 
22 
Zuelzer, 
. 32 
22 
10 
Lehnerdt, 
. 14 
2 
12 
322 
182 
140 
According to Zuelzer and Wardell, exanthematic typhoid is the least 
serious of all, its influence on pregnancy being almost nil. 
Prognosis.-This is extremely grave for the child, since not only does 
abortion cause its death, but in cases of premature delivery the foetus is 13 
DISEASES AFFECTING PREGNANT WOMEN. 
often dead-born, or, if it is born alive, it frequently perishes during the 
days succeeding its birth, either from congenital asthenia, or with symp- 
toms of typhoid fever. 
What is the true cause o^ the death of the foetus ? All authors agree 
in attributing it to the elevation of the mother's temperature. Kaminsky 
has shown that, as soon as the maternal temperature rises to 104°, the 
foetal heart-beat is observed to become accelerated in proportion to the 
height of the mother's temperature, and, in addition, the foetus executes 
irregular movements at 107° to 107.5°. Foetal death is inevitable, but 
the danger begins at 104°. According to Kaminsky, it is the elevation 
of the maternal temperature, not the typhoid infection, which alone 
causes the death of the foetus; its expulsion may be delayed for a longer 
or shorter time afterwards, even as late as the beginning of the mother's 
convalescence. 
The prognosis as regards the mother is more favorable, and, like Spie- 
gelberg, Fiedler believes that its gravity depends much more upon the 
abortion and consequent hemorrhage than upon the disease itself. The 
influence of pregnancy on typhoid fever seems to be obscure. 
Sporadic Affections. 
Pneumonia. 
We have seen, in studying the changes induced in the body by preg- 
nancy, that Kuchenmeister and others have proved that the pulmonary 
capacity is not lessened during this condition-that if the thorax is not so 
deep, this diminution in depth is compensated for by the increase in 
breadth of the base of the chest, and that after delivery the chest resumes 
its usual shape. Pulmonary diseases during pregnancy react seriously 
upon the woman's health, and may all be observed; but, aside from pul- 
monary congestions, oedema, and hemorrhage, it is the acute affection, 
pneumonia, which, according to all authorities, deserves special attention, 
both on account of the gravity which it impresses upon the pregnancy, 
and its influence on gestation. 
Etiology and Frequency.-Pneumonia during pregnancy, as well as in 
the non-pregnant stage, is due to a chill, and consequently it may occur 
without distinction at any period of this pregnancy; only pregnant women, 
according to Rican and Devilliers, are predisposed to it by reason of the 
changes which pregnancy causes in the composition of the blood, especi- 
ally the excess of fibrin. Statistics presented by authorities correspond 
in fact to every period of pregnancy, and the important fact deduced 
from these observations is that pneumonia almost certainly causes abor- 
tion, and that a considerable number of women die. Bourgeois observed 
twelve cases, with eight abortions and as many deaths; Grisolle reports 
only one recovery out of fifteen cases, six women being delivered at term, 14 
A TREATISE ON OBSTETRICS. 
while the other nine miscarried. Wernich thinks that cardiac failure is 
the principal danger in cases of pneumonia during pregnancy. The 
weakened action of the right ventricle leads to stasis of the pulmonary 
circulation, and consequent emptying of the left ventricle. If the pneu- 
monia is extensive, as the vis a ter go becomes diminished on one side (the 
left ventricle), while the obstruction increases on the other (the empty- 
ing of the right ventricle becoming less and less complete), the blood 
stasis in the veins of the general system constantly increases-hence the 
danger. Considering next the influence of pneumonia upon pregnancy, 
and of pregnancy upon pneumonia, he presents the following conclusions: 
1st. The more advanced the pregnancy, the more rapidly does pneu- 
monia cause premature delivery. 2d. The more advanced the pregnancy, 
the more unfavorable is the emptying of the uterus. 3d. The more ad- 
vanced the pregnancy, the more likely is the pneumonia to terminate 
fatally. From a comparison of the statistics, it would seem that pneu- 
monia affects pregnancy less than the exanthemata and typhoid fever, and 
on the contrary approaches cholera in its influence: 
Small-pox, . . . .31 cases. 27 miscarriages. 
Typhoid, .... 38 " 22 " 
Cholera, . . . . 52 " 25 " 
Measles, .... 15 u 8 " 
Pneumonia, . . . . 43 " 21 " 
The Influence of Pregnancy on Pneumonia.-Pneumonia during preg- 
nancy seems to attack more often the right than the left side, which is 
also the rule in the non-parous, but pregnancy causes an especial aggra- 
vation of the symptoms; the fever is marked, the temperature high, the 
skin hot and dry, the pulse rapid and vibrating. But the principal phe- 
nomenon is the disturbance of the respiration, which, according to Ricau, 
depends upon two sets of causes, one of which (pathological) is due to 
the pneumonia, the other (physiological) depends upon the pregnancy. 
A. Causes due to Pneumonia.-1st. The pulmonary alveoli being the 
seat of an exudation which prevents the air from entering them, the re- 
spiratory surface is diminished and the circulation in the inflamed portion 
is retarded; 2d. Hyperaemia and collateral oedema are produced in the 
non-inflamed portion-two conditions which directly contract the area of 
haematosis (Jaccoud); 3d. The pain in the side compels the patient to 
make very shallow respirations-hence a permanent diminution of the 
thoracic cavity; 4th. Fever, in consequence of increased combustion, 
leads to a greater consumption of oxygen, and an increased production of 
carbonic acid, at the expense of the system; this is one of the most potent 
causes of dyspnoea (Niemeyer.) 
B. Causes due to Pregnancy.-Pregnancy, in its turn, acts in twro ways: 
on the one hand by increasing the size of the uterus, which, after the 
sixth month, crowds up the intestines, the stomach and the spleen, and 15 
DISEASES AFFECTING PREGNANT WOMEN. 
limits, in consequence, the contractions of the diaphragm; on the other 
hand, by the changes which it induces in the blood, the red discs being 
diminished in size, and, since these are the oxygen-carriers, the supply of 
this gas in the economy will be lessened, while, again, if the pulmonary 
lesion is very extensive, there will be disturbances of the circulation. 
Statistics of 43 Cases of Pneumonia in Pregnancy. 
Before 180th day of preg- 
nancy, 28 cases. 
Recoveries, 23 
With miscarriage, 6 cases. 
Without, 17 cases. 
With miscarriage, 5 cases. 
Without, 0. 
Deaths, 5 
Recoveries, 8. 
With premature labor, 5 cases. 
Without, 3 cases. 
After 180th day of preg- 
nancy, 15 cases. 
Deaths, 7. 
With premature labor, 5 cases. 
Without, 2 cases. 
The pneumonia, however, may be slight or severe. In the former in- 
stance, if uterine contraction is absent or can be arrested, resolution takes 
place rapidly. If, on the contrary, the pneumonia is severe, it always 
causes abortion. But, while in the first case abortion is usually followed 
by relief, in the second the pulmonary lesions are aggravated, extend over 
both lungs, and death ensues in from two to six days. 
What is the actual cause of the expulsion and death of the fcetus ? 
Violent straining, due to coughing, shock, the accumulation of carbonic 
acid in the blood (which, as Brown-Sequard has shown, incites uterine 
contractions), and heart-failure have been suggested by various authorities. 
We believe in the influence of all these factors, but there is one which, in 
our opinio^, is more powerful than all the rest; here, as in variola and 
typhoid fever, it is the elevation of the maternal temperature, an eleva- 
tion which, by causing the death of the foetus, transforms it into a for- 
eign body, of which the uterus seeks to rid itself. 
Prognosis.-We must consider this from both the child's and the 
mother's standpoint. 
1st. The Foetus.-We have seen that pregnancy is often interrupted, 
and that, in consequence, the life of the child is often compromised. The 
prognosis, then, is exceedingly grave, perhaps a little less so during the 
last three months, but always very serious; and in some cases we can 
witness, as it were, the death-struggle of the fcetus. The active move- 
ments become disturbed, irregular or spasmodic, then they are seen to 
grow gradually weaker, and finally to disappear entirely. The same 
phenomena appear in the cardiac beats; they are first accelerated, then 
diminish, become feeble, and finally cease. 16 
A TREATISE ON OBSTETRICS. 
2d. The Mother.-Without being nearly as grave for the mother as it 
is for the foetus, the prognosis in her case is none the less extremely seri- 
ous; it is sufficient to refer to the statistics presented by authorities. 
Grisolle reports a mortality of 92.8 per cent., Ricau, 35.8, Bourgeois, 75, 
Wernicn, 21.1, and Chatelain, 39. As regards the effect of the expul- 
sion of the foetus, it does not seem to be favorable to the mother; thus, 
out of 82 women who miscarried, 58 died, while only 16 deaths occurred 
among 74 women, who did not abort. Several writers, on the contrary, 
affirm that abortion is followed by the resolution of the pneumonia, and 
hence the advice to induce premature labor. Wernich, Hegar, Martin, Gus- 
serow, and other German authorities, are positively opposed to this meas- 
ure, on the ground that the sudden change of pressure within the thoracic 
cavity, resulting from the rapid emptying of the uterus, must inevitably 
produce fatal pulmonary oedema. 
We believe that artificial abortion should not be entirely rejected, but 
that it should be reserved for special cases. In the face of such a grave 
complication of pregnancy as pneumonia, we think that, when all methods 
of treatment have failed, and the life of the mother is seriously threatened, 
we have no right to deny her a possible chance of being saved, as shown 
by the cases cited by Thirion and Aran. Moreover, all writers agree in 
affirming that the emptying of the uterus lessens, at least for the time 
being, the pulmonary congestion and dyspnoea, and consequently affords 
a decided relief to the patient. Although this relief may be only tempo- 
rary, it is, nevertheless, of benefit to the woman, and, as the child is almost 
inevitably doomed through the presence of the disease alone, our course 
should be governed entirely by the mother's interests. Unfortunately, a 
serious and weighty objection has been presented to those who favor an 
operation; it is, that the induction of abortion and premature labor always 
requires a length of time, which may vary from twelve to thirty-six hours, 
and even longer, during which interval the disease may make rapid strides 
and destroy the patients. This objection, we think, loses much of its force 
if we adopt Barnes's method,-dilate the cervix by dilators of gradually in- 
creasing size, and, when the dilatation is complete, terminate the labor as 
rapidly as possible, without injury to the woman. As for abortion, we 
believe that it should be produced still more rarely, and then by ruptur- 
ing the membranes. The induction of abortion and premature labor are, 
in our opinion, most clearly indicated in cases of double pneumonia, and 
when pneumonia occurs in a woman already affected with cardiac disease, 
or in a rachitic subject-in short, in a woman whose respiratory condition 
was already bad before the occurrence of the pneumonia. 
Chatelain, who favors the induction of abortion in bad cases of pneu- 
monia, unites with Grisolle in advising venesection; this is also the Ger- 
man method. As for emetics, he reserves these until the uterus begins 
to contract, when the hope of saving both mother and child is removed. 17 
DISEASES AFFECTING PREGNANT WOMEN. 
He believes, with Grisolle, Young, Parker, and Gantillon, that tartar 
emetic provokes uterine contractions. As long as there is no evidence of 
delivery, he prefers sulphuret of mercury, either alone or in combination 
with digitalis, which, in his opinion, is the remedy par excellence. Rican, 
on the contrary, does not employ venesection, or does not recommend it 
unless pneumonia is complicated by organic disease of the heart in a preg- 
nant female. He employs tartar emetic and digitalis, giving the former 
in emetic doses, and reserves premature delivery as a last resource. 
Pleurisy. 
Pleurisy seems to be situated more frequently on the right than on the 
left side. It is a curious fact that, while pneumonia is one of the most 
serious complications of pregnancy, pleurisy (except in exceptionally severe 
cases) does not appear to affect either the course of pregnancy or the life 
of the mother. It was actually interrupted only twice in eighteen cases col- 
lected by us, the two women who miscarried being in the last month of 
pregnancy. (Leopold, Budin). Besides, pleurisy may assume either of 
the classical types, the course of the disease apparently being influenced 
principally by this variability in its form. The acute, or sero-fibrinous 
variety, is, according to Leopold, the most favorable, although the exuda- 
tive (whether more or less extensive) is the most common. Pneumonia is 
a rare disease during pregnancy, but pleurisy is still more infrequent, since 
we have been able to collect only eighteen cases. 
As in ordinary pleurisy, the symptoms are the pleuritic "stitch," the 
flatness, cough, dyspnoea, accompanied w7ith pain, fever, the compression 
of the lung, which diminishes the area of hematosis, the compensatory 
congestion and oedema of the healthy lung (in the pregnant woman, espe- 
cially during the later months, the disturbance of respiration referable 
to pregnancy itself is added to the pleuritic dyspnoea), and the displace- 
ment of the heart. As a rule, then, pleurisy in the gravid woman is be- 
nign, and it is only in exceptional cases that it tends to become purulent 
(contrary to its course after delivery), because it usually runs its course 
in from thirty-five to forty days. But this is not always the case, as 
proved by the facts recorded by Leopold and Baratgin, for it may some- 
times assume such a grave character that thoracentesis becomes necessary. 
The pregnancy generally pursues its course, but when abortion and pre- 
mature delivery take place, these have not seemed to exert any special 
influence upon the progress of the effusion; there was not only no in- 
creased effusion, but, on the contrary, the dyspnoea and accompanying 
malaise disappeared rapidly, almost immediately, in spite of the presence 
of the exudation. Emptying of the uterus, therefore, seems in itself to 
relieve the oppression by freeing the thorax; this is especially true when 
the pregnancy is quite advanced. Pleurisy, in fact, apparently pursues 
its usual course, and neither influences nor is much affected by pregnancy. 
Vol. II.-2. 18 
A TREATISE ON OBSTETRICS. 
The prognosis is generally, but not always, favorable for both mother and 
child. 
Treatment.-Grisolle advocates a most thorough and vigorous antiphlo- 
gistic treatment. Fischl, Leopold and Baratgin confine themselves to the 
use of wet cups and opiates, combined with digitalis, employing large blis- 
ters, diuretics, mild purgatives, milk, and a more or less restricted diet, as 
soon as the fever diminishes. But, if there is considerable effusion, intense 
dyspnoea, and threatened asphyxia, with marked cardiac displacement, are 
we justified in resorting to thoracentesis? It was employed twice by 
Duguet, and once by Vendrant and Verneuil; no accident resulted in 
these three cases, and the mothers recovered more or less speedily. Others 
have observed satisfactory results from thoracentesis; pregnancy does not 
seem to contra-indicate it. 
Pulmonary Tuberculosis-Phthisis. 
The most recent and exhaustive work on pulmonary tuberculosis is the 
thesis of Gaulard (1880). According to him, anaemia is the rule in preg- 
nancy. He accepts entirely Peter's idea concerning the pulmonary conges- 
tion of pregnancy, and states that four opinions are still held by scientists 
regarding the relations between phthisis and pregnancy, viz.: 1st. Preg- 
nancy checks the development of phthisis, or arrests its course after it 
has already begun, 2d. Pregnancy accelerates the progress of tuberculosis; 
3d. Pregnancy really aggravates the disease, but the latter undergoes 
marked amelioration during the early months; 4th. Sometimes pregnancy 
interrupts, and seems to arrest the course of the disease-sometimes, on 
the contrary, it aggravates and hastens it. Each of these views has its 
eminent supporters and defenders. 
1st. Pregnancy checks the development of phthisis, or arrests its course 
after it has already begun. But after delivery tuberculosis resumes its 
course, and the temporary amelioration established during pregnancy is 
followed by a relapse which often carries off the patient in a short time. 
This opinion, advanced by Cullen, Borden, Sims, and others, is based on 
the theory that the growing uterus diverts a part of the blood from the 
lungs to nourish the foetus, hence the immunity during pregnancy. The 
hemorrhage accompanying delivery insures amelioration afterward; but 
this is only temporary, because, as this diversion ceases after delivery, the 
pulmonary congestion begins anew, and all the phthisical symptoms reap- 
pear, and become rapidly aggravated. Gaulard calls attention, in connec- 
tion with this theory, to the fact that pregnant females enjoy no immu- 
nity from diseases, and that all authorities insist that pregnancy influences, 
more or less injuriously, every acute or chronic affection. There is, then, 
no reason why pregnancy, which exerts such a particular disturbing 
effect upon a lung that is the seat of pneumonia, should, on the other 
hand, affect favorably a lung strewn with gray nodules, or attacked with DISEASES AFFECTING PREGNANT WOMEN. 
19 
tubercular pneumonia. If, as the supporters of this idea believe, preg- 
nancy produces a salutary derivation of blood from the lung of a tubercu- 
lous woman, why should it produce such a result only in tuberculosis ? 
Now, this derivation does not exist, for the researches of Peter have shown 
eoncl usively that pregnancy unquestionably causes pulmonary congestion, 
and the antagonism between rickets and tuberculosis (admitted by Gubler, 
Beylard and Trousseau) is not certain. As regards the influence of deliv- 
ery and the puerperium upon the progress of phthisis, Lebert thinks that 
it is even more fatal than that of pregnancy, while Gaulard, though ad- 
mitting that phthisical females are generally delivered easily and rapidly, 
nevertheless attributes to these conditions considerable influence, be- 
cause of the exertion demanded by the woman, exertion which increases 
her weakness and induces attacks of pulmonary congestion. Now, it is 
evident that these violent and repeated congestions act unfavorably upon 
tuberculosis, at any stage of its advance; they may even lead to the rup- 
ture of vessels and consequent haemoptysis, and, as Fernet says, " even 
granting that haemoptysis can not cause tubercle, can it not lead to the 
development of a chronic inflammation of the lung ? and, supposing this 
inflammatory process to become caseous, may it not involve the destruc- 
tion of the organ and all the phenomena of pulmonary consumption ? " 
The puerperal state also aggravates pulmonary tuberculosis, and Lebert 
attributes this injurious influence to traumatism, to the feebleness and 
exhaustion of the woman, to loss of blood, and to the lochial discharge. 
Every debilitating agent favors the production and development of tuber- 
cles; the puerperium exerts such an influence, and this applies more par- 
ticularly to lactation. On this point all authorities agree. But, in addi- 
tion to this enfeebling influence of the puerperal condition, does it 
not act directly upon the respiratory apparatus ? If during pregnancy 
the lungs are relieved of a considerable amount of blood, which is diverted 
to the uterus, after delivery there is a sudden change in these relations, 
which leads to congestion, hemorrhage, and acute exacerbation of exist- 
ing inflammations. According to Spiegelberg, the sudden lowering of 
the pressure in the aorta after delivery causes a corresponding elevation 
in the venous pressure, which is still further increased by the closure of 
the uterine sinuses. After labor, the diaphragm can sink lower and the 
blood flows into the lungs more freely. 
2d. Pregnancy not only does offer no resistance to the development of 
phthisis, but, on the contrary, it hastens and aggravates the course of 
tuberculosis. This opinion is based on numerous observations, in the 
course of which tuberculosis existing before conception was sometimes 
seen to advance more rapidly solely by reason of the pregnancy, while, 
again, a tuberculosis previously latent may develop during gestation and 
as a result of its influence. Thus Gaulard reported thirty-two cases in 
which the disease existed before conception, in twenty-five of which the 20 
A TREATISE ON OBSTETRICS. 
patient's condition was aggravated, and collected eighty-four in which it 
developed during pregnancy and was evidently aggravated by the same. 
Caresme noted the appearance of tuberculosis in twelve patients after 
confinement, two of whom subsequently gave birth to other children. 
3d. Mixed Opinion.-Pregnancy aggravates the course of the disease, 
but the latter undergoes a marked amelioration during the early months. 
This view is held by Gardien, Capuron, Pidoux and Peter. 
4th. Finally, there exists a fourth view, still more eclectic in its charac- 
ter, according to which pregnancy sometimes interrupts and seems to ar- 
rest the progress of the disease, sometimes hastens it. This is supported 
by Portal, Andral, and others. 
The ages of the patients have ranged from eighteen and a half to 
thirty-nine and a half years, and the interval elapsing between the initial 
symptoms, from the end of gestation, has varied from a few days to twenty- 
one months. 
Pregnancy, accordingly, exercises a marked influence upon phthisis, 
and this influence will be so much the more injurious if this afferent 
cause is combined with other predisposing ones, such as heredity, malnu- 
trition, bad hygiene, exposure to cold, hard labor, scrofula, pre-existing 
pleurisy, repeated pregnancies, etc. Lebert has presented the following 
statistics showing the duration of the disease. Death occurred in 12 per 
cent, within three months, in 20 per cent, within six months, in 44 per 
cent, between six months and a year, and in 24 per cent, between one and 
six years. According to the same writer the influence of pregnancy upon 
tuberculosis is most marked between the ages of twenty and thirty. He 
draws the following conclusions: 
1st. Latent tuberculosis in young girls most often appears after mar- 
riage as a result of pregnancy, either the first or a subsequent one. 
2d. In exceptional cases, the health in tuberculous women is not affected 
even by repeated pregnancies; in some instances the children are feeble, 
a certain proportion dying early. 
3d. Advanced phthisis usually prevents conception; incipient phthisis 
does not prevent it, and the pregnancy goes on to full term. 
4th. Abortion, pregnancy, and the puerperal state, determine the de- 
velopment of phthisis in at least three-fourths of the cases. 
5th. Children born of a phthisical mother are generally feeble; they 
often become first scrofulous, then tuberculous. 
The Influence of Phthisis on the Product of Conception.-This is much 
less pronounced, though in many instances it is undoubted. Bourgeois 
noted 96 living children among 124 tuberculous mothers; 36 infants con- 
tinued in good health, 60 became scrofulous, and 22 died of tuberculosis 
before their seventh year. Ortega observed 95 women, in whom pulmonary 
phthisis developed before, during, or after gestation. The disease ad- 
vanced steadily in every instance. Although there was sometimes an DISEASES AFFECTING PREGNANT WOMEN. 
21 
amelioration during gestation, it nearly always made rapid strides after 
delivery. 
From these 95 women there were 185 pregnancies. 95 went to term; 28 
premature labors; 9 miscarriages; 18 women did not cough before preg- 
nancy. In 20, the disease appeared in the first half of pregnancy; in 11, 
at term; in 6, before the 9th month; in 2, during lactation; in 10, 4 weeks 
after delivery; in 2, 15 weeks after delivery. 
Icterus. 
Icterus may present itself in the pregnant woman under two forms, the 
sporadic and the epidemic, or the benign and the innocent, and it is evi- 
-dent that it may, according to the conditions, exercise a more or less 
marked influence upon the product of conception. Icterus results from 
an exaggeration of the physiological hyperaemia of the liver. But in ad- 
dition to the simple form there is a malignant type peculiar to pregnant 
females, in which death is caused by an accumulation in the blood of the 
components of the bile which the diseased liver can not eliminate. Others 
say that the form of icterus observed in gravid women differs neither in 
its etiology nor in its development from that which attends other patho- 
logical conditions. Authorities differ widely in their explanations. 
Pouchet attributes the icterus to compression of the hepatic vessels by 
the growing uterus, Meunier to a similar pressure by the distended colon. 
Schroeder and others regard the grave form as identical with French's 
acute yellow atrophy. It is generally conceded that the toxic phenomena 
are due to the presence of bile salts in the blood, and especially to the 
noxious influence of the latter upon the nervous system. 
But it is the epidemic form of icterus that exercises the most marked 
influence upon pregnancy. Among G8 women thus affected 42 miscarried, 
30 of whom died. Abortion usually takes place from three to five days 
after the beginning of the disease, and not only does this fail to bring 
relief, but, on the contrary, the most serious accidents generally occur 
subsequently; and the reported epidemics of icterus, which have never 
been confined exclusively to pregnant women, assume with them, as a 
rule, an exceptional severity. 
The grave variety of icterus presents the phenomena so well described 
by Lavoix. The coloration is more or less intense, the urine contains bile 
or the products of albuminoid decomposition, such as leucin and tyrosin, 
and finally albumin and blood. There are multiple hemorrhages (espe- 
cially gastro-intestinal), petechia? and nervous symptoms, characterized 
particularly by coma or stupor. Its onset is nearly always insidious, being 
often preceded, as in the cases observed by David and Frerichs, by an 
acute gastric catarrh; the yellow tinge developes slowly and constantly, 
accompanied with vomiting of mucus, anorexia, constipation, cephalalgia, 
a general feeling of weariness and depression, but without fever; at other 22 
A TREATISE ON OBSTETRICS. 
times the disease begins with a rigor, followed by intense febrile reaction, 
which quickly subsides when the jaundice appears, with or without fever, 
but attended with severe gastric symptoms, constipation, marked sordes, 
nausea and vomiting, which, although occasional at first, may become 
incessant, the vomited matter consisting at first of food, then of glairy 
mucus, liquid faeces, and bile. There is excessive thirst, great pain in the 
epigastrium, the liver and spleen become enlarged and very tender. This 
condition continues for several days, then follows the ataxic stage, during 
which abortion takes place, although this, according to Lavoix, does not 
affect the progress of the disease. He accordingly disagrees with most 
authors, who claim that abortion occurs first, the ataxic symptoms appear- 
ing subsequently. However that may be, this period of ataxia, convul- 
sions, or delirium, is characterized by extreme agitation, associated with 
disorderly, involuntary, and spasmodic movements. There is intense 
cephalalgia, delirium with subsultus tendinum, disturbances of vision, 
dilated pupils, while at the same time there may be high fever or almost 
none. The urine is scanty, reddish or bloody, often containing albumin, 
and depositing from four to nine per cent, of solid residue, consisting 
principally of leucin, tyrosin and gelatinous extractions, with traces of 
uric acid (not urea), and slight traces only of ammonium. Then comes 
the stage of coma, sometimes interrupted by convulsive phenomena, but 
generally very brief, and soon ending in death. Hemorrhages, although 
they occur, are comparatively rare, being generally confined to those which 
accompany abortion and delivery. The pulse in simple or benign icterus 
remains below the normal, while in the grave form it ranges from 80 to 
120 several times during the same day. Grave icterus in the pregnant 
female generally terminates fatally within five or six days, sometimes 
sooner. In some cases the disease progresses so rapidly that there is no 
time for abortion to take place (Woillez); but death is not the inevitable 
consequence of grave icterus, and there are a certain number of cases in 
which a cure took place in spite of the extreme severity of the disease. 
When the patient die, we find, on autopsy, fatty degeneration of the hepa- 
tic cells, the kidneys, heart, muscular system, but the liver is rather in- 
creased in size than diminished (Lavoix), and it is generally softened. 
The mucous membrane of the bile ducts is necrosed. The abdominal 
cavity contains a yellowish or reddish, semi-purulent exudation, some- 
times in large amount; the spleen is normal or softened, the peritoneum 
is covered with ecchymotic spots, the lungs are congested, oedematous, 
and filled with yellowish fluid. The pericardium contains a certain 
amount of yellowish serum, and there are numerous sub-pericardial ecchy- 
moses. The heart is small, flabby, soft, fatty, and pale, containing with- 
in the right ventricle adhesive blood, or a few soft, spongy, blackish 
clots. The meninges present a slight, often insignificant congestion. 
The autopsy in the case of the foetus shows nothing striking. DISEASES AFFECTING PREGNANT WOMEN. 
23 
We should then, it is evident, always be very reserved in our prog- 
nosis, even when the icterus appears in a mild form, and we consider 
Behier altogether too positive in his opinion that icterus, occurring dur- 
ing the last days of pregnancy, is of a benign character, and that, with- 
out being quite neglected, it is to be considered as of merely secondary 
importance. i 
We are not concerned here with icterus which occurs after labor; it 
may be said, however, that it is very grave, because we may, with Her- 
vieux, regard it in a great majority of cases as symptomatic of puerperal 
poisoning, and as one of the consequences of puerperal peritonitis. 
Treatment.-There can be no question, it is evident, as to the induc- 
tion of abortion or even of premature labor, in the presence of the disas- 
trous results that follow abortion incases of icterus. We should limit our- 
selves, then, to exclusively medical treatment. To relieve the hepatic 
pains by leeches and cupping, to oppose the condition of sordes by ipecac, 
the constipation by purgatives, the vomiting by ice and acid drinks, Vichy 
and Seltzer water and alkaline baths-in a word, we adapt our medicine 
to the symptoms, treating them as they appear, by appropriate remedies. 
Lavoix advises, as a prophylactic, tincture of aconite and quinine; Cazeaux 
change of residence. 
Syphilis. 
All authors agree in admitting the influence of syphilis on pregnancy, 
and of pregnancy on syphilis; but there is a particular factor which im- 
parts to this mutual influence special forms-the age of the syphilis. 
1st. Sometimes a woman is pregnant when she contracts syphilis, and 
the infection can then occur either at the beginning, during the tirst 
months after conception, or during the latter months. 
2d. Sometimes a woman becomes pregnant at the same time that she 
contract syphilis. The infecting coitus has also been fruitful. 
3d. Pregnancy occurs in a woman who is healthy and in good condition, 
and who has never presented, nor does she then present, any evidence, 
old or recent, of syphilis, but whose husband has possessed, or still pos- 
sesses, a syphilitic diathesis. 
4th. Pregnancy occurs in a woman affected by syphilis at a time more 
or less remote; it was not treated, and the woman presents or does not 
present traces of it. 
In the first place, What are the evidences of syphilis most often met 
with in the pregnant female? According to all the authors who have 
studied the disease, these are especially the primary and secondary mani- 
festations. The tertiary, on the contrary, are rare. These manifestations 
are greatly influenced in their course and in their character by gestation. 
This influence of pregnancy is manifested in two ways, either locally or 
generally, and both chancres and syphilides are subject to the disturbing 24 
A TREATISE ON OBSTETRICS. 
circulatory effects which exist in the pregnant woman, and which result 
either in passive or active congestion. According to Fournier, pregnancy 
complicates the pox by adding to it its own anaemia, its depressing influ- 
ence, its neuralgic tendency, disorders of nutrition, etc. As regards the 
local manifestations, syphilis predisposes to the development of mucous 
syphilides, which assume great importance. The induration is slightly 
marked, being a simple hardened scale-parchment chancre; but, while 
in the non-pregnant woman the duration of the chancre does not gener- 
ally exceed from four to five weeks (rarely more, often less), in the preg- 
nant female the mean duration of the chancre is about two months and 
twenty days. 
According to Fournier, mucous papules are not only very common, but 
they develop in pregnant women a remarkable exuberance, assume rap- 
idly the budding, vegetating, or hypertrophic variety, and often form 
actual tumors, which invade and distort the entire vulva. Moreover, they 
are always more rebellious than usual, and disappear more slowly. 
Syphilitic ulcers are quite frequent in pregnant women; they are livid, of 
a violet color, excavated, and are rendered still deeper by the vascular 
turgescence of the parts. They usually persist for a longer or a shorter 
period and often tend to progress. It is sometimes extremely difficult to 
cause them to cicatrize before delivery. While the duration of syphilides, 
in the non-pregnant state, varies from two to two and one-half months, 
it varies from three to three and one-half during pregnancy. Guerin, 
who agrees with Fournier on this point, affirms that during pregnancy 
the mucous patches increase in number, and grow in spite of general and 
local treatment as long as the pregnancy continues; or, that if they dis- 
appear for a short time, they have a great tendency to return, not only 
on the genitals but also on the fauces, tongue, and lips. Their persist- 
ence, according to him, proves that treatment is not as effective as it is 
in the non-pregnant condition. 
The Influence of Syphilis on Pregnancy.-Although the influence of 
syphilis on pregnancy is unquestioned, it is, however, not absolute, and 
varies with the conditions according to which syphilis appears in women. 
The important feature is the frequency of abortion and premature deliv- 
ery. Among 657 syphilitic females, 231 miscarried, while 426 were de- 
livered at term of living and dead children. But, as we have seen, four 
eases may be presented, and we must consider here: 
The father alone is syphilitic. The mother has never presented, nor 
does she now present, any manifestations of syphilis. The idea of direct 
transmission from the father to the foetus, without participation on the 
part of the mother, ■which was opposed for some time, has been defended 
by Trousseau, Diday, Bourgeois and many others. It remains to-day 
incontestible, and we have observed numerous cases. 
As regards maternal syphilis we have seen that: 1st. The woman may DISEASES AFFECTING PREGNANT WOMEN. 
25 
be affected before conception; 2d. Syphilis and pregnancy may begin 
simultaneously; 3d. Syphilis may have been contracted after conception, 
at a period of pregnancy more or less advanced. 
1st. Syphilis existing before Conception.-A syphilitic woman who be- 
comes pregnant is far more predisposed to abortion than a pregnant woman 
who subsequently becomes syphilitic. This is especially observed in cases 
of repeated abortion, and it is now a classical fact that all accoucheurs, 
both in France and abroad, with a few exceptions (happily rare), advise 
that, when successive abortions are observed in the same woman without 
apparent cause, she should be put on antisyphilitic treatment, and that, 
too, not only when no specific manifestation is present, but even when 
she has never shown any. 
When the pregnancy advances to term, the child may; 1st. Be born 
healthy and in good condition, and may remain so (this is exceptional); 
2d. It may be healthy when born, but may, during the first three months 
after birth, rarely later, show symptoms of syphilis (quite frequent); 3d. 
It may show symptoms of syphilis from its birth, and may then either suc- 
cumb quickly (the rule), or may be cured by appropriate treatment (the 
exception); 4th. Although apparently healthy when born, it may die 
within a few days, either by reason of its feeble condition in consequence of 
premature delivery (often), or from convulsions (when delivered at term.) 
2d. Syphilis and Conception are concomitant.-Here, too, abortion is 
the rule, or at least delivery is often premature, and in consequence of 
the rigid treatment to which the mother is subjected the child may, in 
exceptional cases, be born healthy (or without evident traces of syphilis), 
and then, as in the former instance, may either be cured or may succumb. 
3d. Syphilis is contracted after the fourth or fifth Month of Pregnancy. 
-In this case the danger is less. Abortion does not take place, but de- 
livery is often premature, and when the foetus reaches full term it may 
frequently be born healthy; or it may be apparently healthy when born, 
but may present syphilitic manifestations within two or three months 
after birth. 
4th. Finally, the Woman contracts Syphilis only at the Termination of 
Pregnancy.-Then the danger is almost nil; pregnancy is concluded in 
the ordinary manner at term by the birth of a living, healthy child. It 
is during the secondary stage, that is, from the fourth month to the 
second year of this period, that maternal syphilis seems to predispose 
most to abortion. But, as we know, syphilis may be active at the end of 
three, four, five, six years, or even longer. Those women are most prone 
to abort who are affected with severe forms of the disease-those who, 
to use Fournier's expression, are affected il rudement et visceralementbut, 
abortion may occur in all forms of the disease, even the lightest, and is 
often the sole expression of the diathesis. " There are a certain number 
of women," says Fournier, " who abort exclusively because of syphilis, 26 
A TREATISE ON OBSTETRICS. 
without, at the same time, presenting or having presented, for a period 
more or less remote, any appreciable specific symptoms." In his opinion, 
then, even latent syphilis is still capable of causing abortion. We share 
this conviction fully. 
We see, therefore, that syphilis is one of the diseases that deserves the 
greatest attention on the part of the accoucheur, and we realize the full 
importance of treatment in the interest of the mother as well as the child. 
Some writers (happily few) have nevertheless insisted that these ravages 
should be attributed, not to the pox, but to its antidote, mercury. Such 
a view could not be too strongly opposed, and all obstetricians agree with all 
the syphilographers in advising mercurial treatment during pregnancy, 
not only in the case of women who are actually affected by syphilis, or 
who show evidences of it, but in every instance in which the father has 
had syphilis, and where there have been repeated abortions without any 
known cause. 
Lead-Poisoning. 
Constantin Paul was the first to point out the influence of lead-poison- 
ing on gestation. He has shown, in short, that plumbism manifests it- 
self not only by its classical effects, but also by the death of the foetus, 
or the premature death of the child, no matter whether the father or 
mother was exposed to the poison. Three accidents may occur in women 
thus affected: 1st. Metrorrhagia, more or less profuse, is observed in 
women who have had amenorrhoea for several months, with every evi- 
dence of possible pregnancy; 2d. Abortion from the third to the sixth 
month; 3d. Premature delivery, in which the child is born dead or 
moribund. 
Moreover, during the first three years of infant life the mortality is 
above the average. Constantin Paul describes four classes, viz.: 1st. 
Women -who have had more or less severe manifestations of plumbism, 
and whose pregnancies have varied greatly from normal. Out of fifteen 
pregnancies occurring in four women, there were ten abortions, only one 
child being born alive; 2d. Women who have had normal deliveries be- 
fore being exposed to the influence of lead, and who afterwards observed 
its effects upon the product of conception. Thirty-six cases of pregnancy 
were noted under this head; twenty-nine children were dead born, and 
only two were living at the end of a year; 3d. Women who cease to work 
in lead. One case was observed. A lead-work er who had aborted 
five times, gave up her occupation, and at her next confinement was de- 
livered of a healthy child. 4th. Women who work in lead, and who give up 
their occupation, but resume it later. Two women, after working in lead, 
stopped for three or four years, during which time they had three living 
children; on returning to their old work-shop they had repeated miscar- 
riages. 27 
DISEASES AFFECTING PREGNANT WOMEN. 
Influence of the Father.-The fatal influence of lead is felt equally as 
much when the father has handled lead. Of seven women who married 
men working in lead: 1. 7 labors at term, 1 miscarriage; 2. 2 pregnancies, 
1 miscarriage, 1 premature labor; 3. 2 miscarriages, 3 labors at term; 4. 
4 pregnancies-3 miscarriages, 1 at term; 5. 3 pregnancies-1 miscarriage, 
2 at term; 6. 12 pregnancies-1 miscarriage, 10 children died in 3 years; 
7. 5 pregnancies-2 miscarriages, all the children died shortly. 
If, then, lead-poisoning does not prevent fecundation and influence 
menstruation, its action upon the foetus is incontestable, as the following 
observations prove: 
Seventy-three children were born dead in one hundred and twenty-three 
pregnancies. Miscarriages, 4; premature labors-1 at 7, 3*at 8 months- 
4; dead children, 5; children dying in first year, 20; second year, 8; third 
year, 7; later, 1; living children, 14; living children beyond 3 years, 
10; metrorrhagia dependent on miscarriages, 15. 
The Influence of Tobacco on Pregnancy. 
In connection with the fatal influence which lead exerts upon concep- 
tion, that of nicotine must be mentioned. The researches of Decaisne, Sarre, 
and others, show that miscarriages are very frequent among women em- 
ployed in tobacco manufactories, and that such children as are born alive, 
are poor, wasted, and short-lived. Kostial observed among 506 new-born 
infants, 181 deaths during the first year; 104 died from cerebral affections 
attended with convulsions. The majority of the deaths occur during the 
ages of two to four months-that is to say, during the period when the 
mothers resume their labor, and nurse their infants with milk saturated 
with nicotine. . Jacquemart noted forty-five cases of abortion and pre- 
mature delivery among 100 cases of pregnancy in tobacco-workers, fifteen 
children died shortly after birth, and the mortality of such of the survivors 
as were nursed by their mother was ten per cent, higher than among those 
who were brought up on the bottle. 
Hysteria-Epilepsy. 
We consider these two affections together, although they are quite dif- 
ferent, because there is a form that serves, as it were, as a bond of union 
between them-hystero-epilepsy. 
The Influence of Pregnancy on Hysteria and Epilepsy.-Authors differ 
widely regarding the influence of pregnancy on hysteria. While many 
advise marriage and pregnancy, and think that the hysterical attacks are 
relieved by gestation; others, on the contrary, believe that not only does 
pregnancy fail to relieve hysteria, but that the attacks at the beginning 
become more severe and frequent. They nearly always disappear, it is 
true, during the latter months. Briquet again affirms, that pregnancy 
has sometimes a favorable, sometimes an unfavorable actioh. " Hysteri- 28 
A TREATISE ON OBSTETRICS. 
cal manifestations/' according to him, " depend far more upon moral 
causes and upon the condition of the women at the time, than upon any- 
thing else." 
As regards epilepsy, there is pretty much the same divergence of opin- 
ion. Fernel has seen epilepsy develop during pregnancy and disappear 
after delivery; Tissot regards epilepsy as frequent during pregnancy, and 
sometimes the latter condition seems to diminish the frequency of the at- 
tacks, sometimes to increase them. We believe that, on the whole, the 
latter opinion should be accepted. Sometimes pregnancy modifies epi- 
lepsy by postponing the attacks and rendering them much less severe; 
sometimes, on the other hand, pregnancy exerts a disastrous influence. 
The Influence of Hysteria and Epilepsy on Pregnancy.-This seems to 
be almost nil, and we have, ourselves, seen in two cases out of three, preg- 
nancy go on to term, while in the third, abortion did not occur, notwith- 
standing the fact that the attacks were so severe as to cause the death of 
the patient. 
Traumatism during Pregnancy. 
1. The Influence of Traumatism on Pregnancy.-Gueniot shows that in 
187G the total number of observations amounted to 245, since which time 
many others have been added. The following points are to be noted: 
1st. There is no fixed law regarding the innocuous influence of trauma- 
tism on pregnancy. These consequences are entirely different, according 
to the feeble or increased irritability of the uterus, the healthy or diseased 
state of the foetus, or the freedom of the mother from certain morbid con- 
ditions; 2d. These results vary, but to a less extent according as the 
injury does, or does not, affect directly the genital tract, as the hemor- 
rhage at the time is slight or profuse, and as it is, or is not, complicated 
by an inflammatory process of some intensity. Thus, when a perfectly 
healthy pregnant female is injured (whatever may be the character or 
severity of the lesion), the pregnancy is not usually affected. There 
are three exceptions to this rule, viz.: A. If the lesion is situated in the 
genital tract, or ano-perineal region, the course of pregnancy is often in- 
terrupted, and the injurious effect seems to depend rather on the duration 
or repetition of the traumatic action than on its degree of intensity; B. 
Again, whatever may be the scat of the lesion, if it causes in a very short 
time a considerable loss of blood, the pregnancy is seriously threatened, 
and the woman's life is more or less compromised; C. Finally, if the 
wound is subsequently complicated by inflammation (erysipelas, phlegmon, 
lymphangitis, etc.), it can, through this cause, interrupt the pregnancy; 
3d. When pregnancy is complicated by a pathological condition (abnor- 
mal irritability of the uterus, disease or hypertrophy of the ovum, albu- 
minuria, etc.), the wound, however slight it may be, and wherever it may 
be situated, generally leads to the premature expulsion of the product of 29 
DISEASES AFFECTING PREGNANT WOMEN. 
conception. In this instance the true cause of the trouble, which is attri- 
buted to pregnancy, really lies in the organic or functional affection that 
complicates the latter condition, and not in the injury, which simply acts 
as an adjuvant or secondary cause; 4th. Nevertheless, in view of the 
extreme difficulty, and often impossibility, which the surgeon encounters 
in diagnosticating some of these morbid conditions (uterine irritability, 
disease of the ovum, etc.), it is well to be very circumspect in performing 
operations during pregnancy. If the surgical lesion will involve the 
genital tract, the pregnant condition offers, save in cases of necessity, a 
formal contra-indication to the operation. 
2. The Influence of Pregnancy on Traumatism. -If we consider the facts 
thus far published, pregnancy, in the great majority of cases, does not 
exert any injurious influence upon traumatism. Thus, contusions and 
wounds, even dislocations and fractures, are not followed by any higher 
mortality in pregnant women than in other individuals; moreover, the 
cure of such injuries takes place in the usual manner and within the 
period that is common to each variety of lesion. The following excep- 
tions, however, are included under this rule: A. When the injury 
affects the genital tract, it may be rendered milder or complicated in its 
course, or its termination may be delayed, by the existence of pregnancy; 
B. This holds true even after the third month of gestation, provided that 
the injury affects the lower limbs or a region in which vascular changes 
have taken place. The ordinary complications in A and B are hemor- 
rhage, lymphangitis, erysipelas, gangrene and atonic ulceration; C. As 
regards fractures in particular, although cases of non-union during preg- 
nancy are very exceptional, this condition can not always be exonerated 
from exercising a certain influence in retarding the formation or the so- 
lidity of the callus; D. In complicated pregnancy (above all, where the 
complication tends to produce premature expulsion of the ovum), wounds, 
by leading to abortion, sometimes acquire indirectly a gravity quite un- 
usual, because the woman is then exposed to the different accidents that 
regularly accompany delivery-metrorrhagia, metro-peritonitis, etc. 
3. Contrary to the received opinion, the puerperal state opposes, as a 
rule, neither the regular healing of wounds nor the union of fractures, 
provided that these injuries occur simultaneously with pregnancy or 
delivery. The exceptions to this rule must be ascribed either to the 
particular region affected (the genital tract), to the fever that sometimes 
ushers in the flow of milk, or, above all, to a general or local morbid ten- 
dency in the woman. Wounds occurring after parturition seem to present 
a special gravity, which would seem to be related to the disturbance re- 
ferable to the physiological involution of the organs. Hence the indica- 
tion to defer until three or four months after delivery all operations not 
urgent, which may involve the genital tract or the lower limbs. It 
follows that surgical lesions during pregnancy are far from being so serious 30 
A TREATISE ON OBSTETRICS. 
as we suppose, and that in the case of a tumor, which is developing rapidly 
and is threatening life, we should resort to extirpation rather than to 
the induction of premature labor. 
[In connection with this subject, we append the statistics collected by 
Mann, of Buffalo, and which appear in a paper published in Vol. 7, of 
Am. Gyn. Trans. 
Nature of Operation. 
Number. 
Abortions. Deaths. 
Venereal warts of vulva, 
. 19 
3 
" " " vagina, . 
. 3 
Elephantiasis vulvas, 
2 
Sarcoma " 
: i 
Lipoma " 
i 
Cyst " 
i 
Abscess vulvo-vag. glands, . 
5 
1 
1 
Unruptured hymen, .... 
1 
Polypus vaginas, .... 
. 4 
1 
1 
Cyst "..... 
1 
Abscess 11 .... 
. 1 
Stenosis 11 . . 
1 
Ant. Elytrorrhaphy, .... 
1 
Vesico-vag. fist., .... 
. 5 
2 
Ureth. caruncle, . 
1 
Dilat. of ureth. for stone, . 
. 5 
Cystotomy, .... 
. 2 
Recto-vag. fistula, .... 
. 2 
Stricture of rectum, .... 
1 
1 
Fissure in Ano, 
. 3 
2 
Fistula in Ano, 
1 
1 
1 
Ruptured perineum, .... 
. 7 
1 
Polyp of cervix (small), 
. 3 
1 
" " " . (large), . . . 
. 7 
3 
1 
Lacerated cervix, .... 
. 6 
2 
Cancer " .... 
. 6 
2 
90 
20 
4 
The whole paper is of interest, and our readers are referred to it for 
more detailed information in regard to these operations.-Ed.] 
Goitre. 
The Influence of Goitre on Pregnancy.-Of all the writers who have 
called attention to the greater frequency of goitre in woman than in 
man, Jeans-Louis Petit was the first to note its influence on the puerperal 
state. Tarnier says, that hypertrophy of the thyroid gland is generally 
inconsiderable, causes no trouble during pregnancy, and after delivery 
resumes nearly its original size. Goitre does not seem to us to be quite 
as rare as is generally supposed, and although the number of observa- 
tions is limited, it docs not usually lead to any serious accidents. How- 
ever, this is not always true, and it may in some instances assume an 31 
DISEASES AFFECTING PREGNANT WOMEN. 
exceptional gravity. Ollivier, who affirms that goitre usually appears 
from the third to the fourth month of pregnancy, recognizes several dis- 
tinct forms, viz.: 
1st. Subacute and Transient Goitre.-It developes slowly, and only in 
exceptional cases assumes a considerable size, being often unrecognized 
during the first pregnancy. No pulsation is present, the health is not 
affected, and the enlargement often disappears almost entirely after de- 
livery. 
2d. Acute and Grave Goitre.-This form developes rapidly, and gives rise 
to attacks of suffocation. Tarnier reports a case in which death occurred 
from asphyxia; Bailly one that terminated fatally in spite of tracheotomy. 
Suppuration sometimes occurs, the condition being a true thyroiditis. 
3d. Chronic Goitre.-Sometimes the enlargement appears during 
pregnancy, and remains stationary after delivery, or even undergoes a 
slight increase in size at each successive pregnancy; sometimes, the acute 
form becomes chronic, or the goitre is only recognized after delivery. 
Finally, chronic goitre in the gravid woman may pursue its course until 
a more or less advanced stage of pregnancy, when it rapidly enlarges, 
so as to compress the trachea, and cause suffocation. 
Pastriot divides goitres from an anatomical standpoint into three vari- 
eties, the vascular, parenchymatous, and cystic. In the vascular there is 
congestion and apoplexy of the thyroid gland. During the straining 
that attends delivery, the dilated vessels rupture, leading to hemorrhage 
at some point in the goitre, and effusion of blood between the lobules. 
In the second form, there is a true hypertrophy of the fibrous tissue, the 
enlargement being due, not to the thyroid gland itself, but to a gelatinous 
fluid which fills the surrounding cellular tissue (cellular goitre.) Lar- 
rey, again, has described an emphysematous goitre, which he thinks is 
independent of the thyroid gland, being due solely to emphysema. In 
the cystic variety, as described by Pastriot, there is a cavity containing a 
material (generally fluid, sometimes solid), which has formed in the midst 
of the normal gland elements. Porcher admits the existence of two 
forms, simple hypertrophy of the thyroid, and glandular or vesicular 
goitre, also the fibro-cellular, colloid, and vascular varieties. He believes 
that menstruation, as well as pregnancy, affects the development of the 
swelling. 
Diagnosis and Prognosis.-The enlargement usually begins gradually, 
or else it appears suddenly during the efforts of parturition. Although 
at first of small size, it increases in size with each pregnancy, and then 
either disappears after delivery, remains stationary, or continues to de- 
velop, and is attended with evidences of compression, either of the recur- 
rent laryngeal nerves, or of the trachea itself, change in the voice, dys- 
pnoea, dysphagia, suffocation, etc. 
Treatment.-As goitre is generally benign during pregnancy, we should 32 
A TREATISE ON OBSTETRICS. 
resort to general measures and internal treatment. Forbid the patient to 
nurse, and give iodine. Pastriot advises parenchymatous injections of 
the pure tincture of iodine, the iodized tincture of Richter (iodide of 
potassium, 15 grains, tincture of iodine, 300 grains, distilled water, 600 
grains), or a saturated solution of iodide of potassium. But one question 
remains for consideration. If an acute or chronic goitre threatens the 
life of the patient, shall we perform tracheotomy, or induce labor ? The 
facts, as thus far collected, do not favor either proceeding, but we be- 
lieve that we have no right to reject them. In the presence of a patient 
with threatening asphyxia, the first indication is to remove the cause, the 
compression of the trachea, and the disturbance of respiration due to 
pregnancy. If there is suppuration, make a free incision into the thyroid 
abscess. Some months ago, Tillaux reported to the Academy a case of 
extirpation of the thyroid body, because of an enlargement which threat- 
ened the life of the patient. Are we justified in performing this opera- 
tion during pregnancy ? In spite of the success which attended the opera- 
tion in the hand of that skillful surgeon, we should not venture to resort 
to it. 
Ulcerations of the Cervix during Pregnancy. 
Ulcerations of the cervix have been noted by all physicians who have 
examined the patients with the speculum. These may assume the four 
forms described by Robert, viz.: superficial erosions or excoriations, granu- 
lar or nodular, fungoid, and callous (cicatricial ?) erosions. These different 
forms may be presented by simple or specific erosions, although the cica- 
tricial variety has only been observed in pregnant women. 
[Throughout this section we substitute the word erosion for ulceration, 
as being more scientific and in accord with recent pathological terminology. 
Aside from lupus and chancre, it is questionable if a true ulcer is ever 
found on the cervix. Further, many of the instances which the author 
calls ulceration are in reality simply the eroded everted mucous mem- 
brane of the lacerated cervix. A glance at Figs. 1 to 7 prove this. 
-Ed.] 
If, says Cazeaux, we examine the cervix at the end of pregnancy, we 
find it, as a rule, of a deep reddish or violet color (like wine-lees), but with 
this difference in the primipara and multipara: In the former there are 
rarely any traces of erosion, but we commonly see around the os externum 
fleshy nodules, varying in size from a pin's head to a pea, which bleed at 
the slightest touch, while in the latter, the cervix is fissured, the canal 
presenting a series of fungoid projections, separated by clefts; on the 
surface of some of these projections are hypertrophied follicles, while 
others resemble flabby granulations, being deprived of epithelium and 
bleeding easily. 
According to Gosselin, Cazeaux, and others, these erosions are rarely 
due to a pathological condition, but to the passive congestion induced by DISEASES AFFECTING PREGNANT WOMEN. 
33 
pregnancy. Other writers regard them as of great significance, and even 
as the principal cause of difficult labor and abortion. The latter influence is 
ascribed especially to that variety of cervical erosion which is characterized 
by a fungoid appearance, fissuring of the cervix and tendency to bleeding. 
Coffin and Bichet believe that the majority of fungoid erosions exist be- 
Fig. 1.-Cervix of a Primipara, 155 days 
before Delivery. (Nieberding.) 
Fig. 2.-Cervix of a Primipara, 41 days 
before Delivery. (Nieberding.) 
Fig. 3.-Cervix of a Primipara, 
36 DAYS BEFORE DELIVERY. 
(Nieberding.) 
Fig. 4.- -Cervix of a I-para, 
31 days before Delivery. 
(Nieberding.) 
Fig. 5.-Cervix of a II-para. 
27 DAYS BEFORE DELIVERY. 
(Nieberding.) 
Fig. 6.-Cervix of a I-para, 15 days before 
Delivery. (Nieberding.) 
Fig. 7.-Cervix of a Primipara, 4 days be- 
fore Delivery. (Nieberding.) 
fore pregnancy, or date from a former delivery, and that they exercise 
an actual influence on the course of pregnancy, abortion being the usual 
consequence of their presence, especially when the cervical canal is exten- 
sively involved. Among 110 women in the latter half of pregnancy Lieven 
found more or less severe erosions in 32, 10 of whom were pri mi parse; 
slight erosion 13; follicular 7; mucous polypi 1; papillary erosions 16; 
vegetations 1. 
Vol. II.-3. 34 
A TREATISE ON OBSTETRICS. 
In most cases he found the mucous membrane at the edge of the os of 
a reddish hue, contrasted with the rest of the portio vaginalis, which is 
bluish, livid, deprived of epithelium in spots, and bleeds at the slightest 
touch (simple erosion). lie often encountered cervices, on the red, eroded 
surfaces of which were innumerable small, florid projections, the size of 
a pin-head, distinguished by their bright color from the surrounding tis- 
sue (papillary erosions). He claims that there is no true ulceration, but 
a simple ectropion of the mucous membrane, due to the dilatation of the 
os during pregnancy with accompanying eversion of the mucous surface, 
the latter being sometimes so great that the natural folds are obliterated, 
and the mucosa assumes a uniform, smooth, glistening aspect. He en- 
deavors to support his views regarding the non-identity of erosions and 
ulcerations by reference to the work of Huge and Veit, who have shown 
that the latter condition is characterized by loss of epithelium, while in 
simple erosion the lesion is always covered by a new layer of pavement 
epithelium. These authors affirm that erosions are produced by exten- 
sive proliferation of the epithelium, accompanied by dilatation and hy- 
perplasia of the glands, and the formation of papillae covered with cylin- 
drical epithelium, ectropion and erosion being in their opinion two dis- 
tinct affections, which may, however, be associated, even while they re- 
main distinct. 
Among 28 primiparae, Nieberding found ectropion in 21, the posterior 
lip being alone involved in 7. The os externum, instead of presenting its 
usual rounded form, appeared as an irregular cleft, from which radiated 
fissures in the form of a star, some of which were recent and bled readily. 
These, according to Birnbaum and himself, are due to the distension 
which affects the cervix, in common with the lower uterine segment, from 
the pressure of the foetal head. These were observed in 19 out of the 
28 cases. 
Lieven and Nieberding give the following figures: 
In 60 -|- parae, Lieven found the normal cervix 11 times. 
" 42 " Nieberding " " " " 15 " 
" Ilparae, Lieven " " " " in 26 per cent. 
" " " Nieberding " " " " "23 " " 
" Illparae, Lieven " " " " " 50 " " 
" c< u Nieberding " " " " " 50 " " 
The latter refers to the view of Aran, Bennet, and others, that erosions 
and ulcerations are due to chronic inflammation of the cervix, and that 
they exercise an important influence upon pregnancy, .delivery, and the 
puerperal state, and admits that they most frequently give rise to uncon- 
trollable vomiting (Spiegelberg), hemorrhage, abortion, degeneration of 
the placenta, etc, etc. Scanzoni and Lieven have never observed such 
effects. 
Treatment.-Whatever view we may accept, the practitioner is con DISEASES AFFECTING PREGNANT WOMEN. 
35 
fronted with the important questions-Shall we treat these lesions during • 
pregnancy ? and if we do, What form of caustic shall we use ? The result 
is doubtful whether we employ nitrate of silver, caustic fluids, or iron. 
Miscarriage results too often from the treatment, and not from the dis- 
ease itself. We adopt Cazeaux's conclusion: abstain from all treatment 
as long as the ulceration does not show a marked tendency to involve a 
great part of the cervix; then, if you do interfere, bear in mind that you 
run the risk of seriously disturbing the pregnancy. 
[Cazeaux's opinion, while true of lacerations, will not hold for erosions. 
In case of hemorrhage or profuse leucorrhoea from erosion, applications, 
far from being harmful, are positively beneficial. We have yet to see 
miscarriage induced by applications to an erosion, and we believe this to 
be the experience of other gynecologists and obstetricians.-Ed.] EXPLANATION OF PLATES V and VI. 
(From Mun de.) 
1. Catarrhal Erosion of Nulliparous Cervix. 
2. Follicular Erosion of Parous Cervix, with Fissure. 
3. Stellate Laceration, without Eversion. * 
4. Stellate Laceration with Eversion and Cystic Hyperplasia. 
5. Eversion of Anterior Lip with Cystic Hyperplasia. 
G. Patulous Os, without distinct External Fissure. 
7. Right Laceration with Eversion. 
8. Bilateral Laceration, first degree, with Eversion. 
9. Bilateral Laceration, second degree, with Eversion. 
10. Bilateral Laceration, third degree, with Eversion, Lips held apart 
by Tenacula. 
11. Bilateral Laceration, third degree, with Eversion, mostly cicatrized, 
and not ulcerated. Both upper corners show fresh breaking down of 
cicatrix. 
12. Large Cystic Hyperplasia of Anterior Lip, Simulating Epithelioma. pentier 
PLATE V. 
EROSIONS AND LACERATIONS OF CERVIX. 
H. BENCKE, LITH. N. Y. rentier 
PLATE VI. 
EROSIONS AND LACERATIONS OF CERVIX. 
H. BENCKE, LITH. N.Y. CHAPTER II. 
DISEASES OF PREGNANCY. 
TDREGNANCY, as we have seen, produces in the entire economy im- 
portant and profound modifications, which in their turn cause 
functional disturbances that find expression in a series of morbid condi- 
tions, constituting, properly speaking, the diseases of the pregnant woman. 
But these troubles do not appear simultaneously and invariably, and, 
while in some cases they constitute a true morbid condition, in others they 
pass, so to speak, unrecognized. From this point of view we can say, 
there are as many variations as there are women, or even pregnancies, 
because it is not rare to see certain females pass through one or two preg- 
nancies in a condition of almost perfect health, while the succeeding one 
or more pregnancies are accompanied by profound malaise. Moreover, 
it is not uncommon to observe certain phenomena appear at the begin- 
ning of pregnancy, to disappear for a time, and then to reappear with 
renewed intensity. We shall, then, adopting the classification of Desor- 
meaux and Cazeaux, review in turn the disturbances of digestion, of cir- 
culation, respiration, secretion, excretion, locomotion, and, finally, of 
the sensory and intellectual functions. 
Disturbances of Digestion. 
As Pajot says, the functions of the digestive apparatus may be. exag- 
gerated, diminished or perverted. 
Exaggeration.-There are many women whose digestive functions are 
not only not disturbed by pregnancy, but, on the contrary, seem to be aug- 
mented. Their appetites increase, digestion is more active, the nutrition is 
improved, and, as the women themselves affirm,pregnancy seems to produce 
in them an unusual condition of health; but, it must be acknowledged 
that this is the exception, and that most often the digestive functions are 
either diminished or perverted. 
Anorexia.-This degree is marked by loss of appetite and aversion for 
food, which may occur at the beginning of pregnancy, as well as during its 
progress or at its termination; it is usually most marked at the beginning. 
This aversion may amount to positive disgust, in which case the physician 
is often extremely embarrassed in the presence of the, so to speak, passive 
resistance of the patient to every sort of food. Food hot or cold, vegeta- 
bles, fruits, nothing is acceptable, even fluids being rejected, so that it is 
very difficult to nourish the patients. We are only too fortunate if we 38 
A TREATISE ON OBSTETRICS. 
have to deal only with anorexia pure and simple, and if it ooes not reach 
the third stage. 
Aversion for Food. - In this case we meet with numberless difficulties, 
which vary with each individual. A woman thus affected, who could,before, 
tolerate only red wine, now rejects it entirely; another, who only cared for 
meat of a white color, can not endure even the sight of it. A patient who 
could only eat meat that was well done, does not fancy it unless it is rare; 
another, who liked vegetables, regards them with horror, etc. Thus nume- 
rous are the difficulties which are sometimes encountered by the physician 
in the presence of a positive aversion- for every sort of food. All treatment 
fails, as a rule, when directed towards this condition, which may persist for 
some time, but ordinarily yields spontaneously, as the pregnancy advances. 
This phenomenon, in fact, is usually produced during the first two or 
three months, and belongs among what are known as the sympathetic 
troubles of pregnancy. Sometimes, however, this condition evidently 
depends upon a dyspeptic state in the woman, and then it yields to slight 
purgatives, as rhubarb, magnesia, and some bitters, as quassia; but that 
which usually succeeds the best is alcohol in small doses. In other in- 
stances, digestion is painful or retarded, gas is formed in the stomach, 
there is distension of the abdomen, and drowsiness. We have found of 
value in these cases black coffee after meals, and especially small doses of 
alcoholics (brandy, Kirsch, champagne) mixed with Seltzer or other alka- 
line mineral waters, also pepsin. 
Disturbance and Perversion of the Digestive Functions. 
The perversion consists in the existence of what is called pica, malacia, 
or the " longings " of pregnant women. These, again, present themselves 
under every form, being represented by the capricious appetite of women 
for the most absurd and disgusting things. We must, up to a certain 
limit, pay respect to these caprices of the stomach, so far, at least, as they 
are not directed towards injurious articles. Chalk, charcoal, ashes, de- 
cayed and acid fruit, " high " meat, are the usual objects desired. This 
longing is not seldom unaccompanied by other phenomena, such as gas- 
tralgia, cramps in the stomach, and acidity. Among the troubles to be 
mentioned is one that is frequent and is borne very ill by women-a sen- 
sation of heat, or burning, extending from the pharynx to the stomach, 
and constituting the pyrosis of pregnant women. Alone or accompanied 
by another phenomenon, which we shall study later (ptyalism), it gener- 
ally persists for a long time and resists all treatment. However, good re- 
sults have been obtained with alkaline mineral waters, bismuth, charcoal, 
ice, antispasmodics, etc. 
Vomiting. 
The most common digestive trouble is nausea and vomiting. Although 39 
DISEASES OF PREGNANCY. 
the latter is generally borne comparatively well by the patient, in some 
cases it becomes so severe as to be uncontrollable, and thus to seriously 
endanger life. Sometimes nausea alone is present, but this is rare. 
Vomiting is so common in pregnant women that, in the majority of cases, 
it is an almost certain sign of pregnancy. 
a. Simple Vomiting.-Vomiting usually appears at the beginning of 
pregnancy, sometimes in the first days; at other times it does not occur 
until later, at the second, third, or fourth month. As a rule, it begins 
at the first month, continues until the fourth, and then disappears, until 
the end of pregnancy, when it sometimes reappears. Although regarded 
by most writers as due to the impression made upon the entire economy 
by the enlargement of the uterus, it has been regarded by others as char- 
acteristic of certain uterine lesions, especially erosions of the cervix 
(Bennett); but these erosions, although frequent, are not present in all 
women who vomit, and moreover, how do we explain its disappearance, 
at the end of a few months of pregnancy, and that too, spontaneously, 
often even suddenly ? When it reappears at the end of pregnancy, it is 
usually attributed to a disturbance of the stomach, resulting from en- 
largement of the uterus. Vomiting usually occurs in the morning on 
changing the position from the horizontal to the vertical. The vomited 
matter consists of glairy mucus, fluids more or less watery, which, after 
a certain time, are accompanied by bile. Sometimes it is very easy, at 
others it is accompanied by severe straining, and continues thus every 
day, sometimes once, and again at frequent intervals. At other times 
the women do not vomit upon rising, but after teach meal, the vomited 
matter consisting of food; or vomiting occurs during the meal, or three 
or four hours after, either from some unknown cause, or from fatigue, 
emotion, etc. In some cases it takes place easily and suddenly, in others, 
on the contrary, it is preceded for some time by a condition of nausea, 
more fatiguing perhaps than the vomiting itself. Sometimes it is pain- 
less, sometimes, on the other hand, it is accompanied by severe pains in 
the epigastrium and the entire abdomen. As a rule, women bear it very 
well, but sometimes, when it is repeated too often, it causes disturbance 
of nutrition, leading to marked emaciation, and a condition of weakness 
and general fatigue which is extremely annoying. Although it some- 
times resists every method of treatment, it occasionally disappears sud- 
denly, either in consequence of a lively emotion, as in a case cited by 
Cazeaux, or because the morbid reflex impulse is transferred to another 
organ. I once saw vomiting cease on the appearance of a slight diar- 
rhoea, which lasted two days. It usually has no influence upon the course 
of the pregnancy, remains bearable, and causes the patients annoyance 
and malaise, rather than actual suffering. It is not the same in other 
cases (unhappily too frequent), in which it assumes the character of 
b. Uncontrollable Vomiting.-We may, with Dubois and the majority 40 
A TREATISE OX OBSTETRICS. 
of writers, regard vomiting as uncontrollable " whenever it affects seri- 
ously the health of the woman, and resists the judicious use of a certain 
number of remedies." Uncontrollable vomiting is not extremely rare, 
because Dubois himself saw 20 fatal cases; Delbet had. collected 62 cases 
in 1854, Gueniot 118 in 1863, and since then the number has greatly 
increased. We may, with Dubois and Gueniot, consider three stages. 
First Stage.-The onset is rarely abrupt; more usually, the vomiting 
gradually becomes uncontrollable, succeeding insensibly to the ordinary 
vomiting at the outset of pregnancy; but this gradual transition is not 
always present, and we often see within a short time the vomiting assume 
an exceptionally grave character, and rapidly become uncontrollable. It 
usually begins during the early months of pregnancy, rarely in the latter 
half, judging at least by Gueniot's statistics, in which he notes the fact 
that, among 43 cases, 38 occurred before the third month. Uncontrollable 
vomiting does not present any well-marked characteristic at the outset; 
it usually announces itself by a condition of almost constant nausea, and 
by its violence, which becomes more and more alarming. It takes place 
not only in the morning and after meUs, but in the interval, and without 
provocation, that is to say, it is almost incessant. It is caused by the 
smallest amount of food or drink; the vomited matter consists of glairy 
mucus, bile, or food, according as the stomach is full or empty; some- 
times pure bile is vomited, or there may be streaks of blood. It is in some 
instances very painful, and is accompanied by violent straining, fatigue, 
and gastric pains, while in others there is not much disturbance; in other 
cases, there are slight'remissions, of which we may take advantage to 
give the patient a little nourishment, or, on the other hand, in spite of 
its continuance, it is accompanied by caprices or vagaries on the part of 
the stomach, which make it possible for the patients to tolerate the most 
indigestible things. (Sandras.) The patients are then condemned to 
almost complete abstinence, which is shown by their anxious look, weari- 
ness, pain, and marked emaciation, accompanied by a complete change 
in their features and loss of strength-in short, a very pronounced moral 
and physical depression. It is sometimes complicated by ptyalism and 
diarrhoea, which may either coincide or alternate. (Haigton.) This 
stage is characterized by the entire absence of fever, or if this is present, 
it is of short duration and slight intensity. A slight evening rise indicates 
the transition to the 
Second Stage.-This stage succeeds the first insensibly, and almost with- 
out transition. It is marked especially by the aggravation of all the phe- 
nomena described in the first stage, but above all, by the fever, which be- 
comes continuous, and more and more marked. The skin becomes hot 
and dry, except the extremities, which are cold, and are covered with 
clammy perspiration; vomiting is incessant, nothing, not even pure water DISEASES OF PREGNANCY, 
41 
being retained. The throat and mouth become dry, sordes appear on 
the teeth, the tongue is dry and red, the breath fetid, there is excessive 
thirst, the urine becomes scanty, high colored, and offensive, and diarrhoea 
is regularly present. Gueniot describes, moreover, violent pains in the 
head, the pit of the stomach, and the hypochondriac regions; there is 
frightful emaciation, and such feebleness that attacks of fainting or syncope 
occur incessantly. In some cases (unhappily too rare), there still occur 
remissions, during which the patients can retain a little nourishment. 
Third Stage.-It is a curious fact that the vomiting diminishes and 
even ceases entirely, while the fever increases still more, and characteris- 
tic cerebral and sensory disturbances appear, delirium, coma, and hallu- 
cinations. The attacks of fainting and syncope return on making the 
slightest movement, the fever continues, the pulse becomes feeble and 
almost insensible, varying from 120 to 140, and coma appears, to con- 
clude the scene. 
Course and Duration.-It is a remarkable fact that there are frequent, 
more or less complete, remissions, especially during the first and second 
stages. Among the complications Gueniot mentions ptyalism, diarrhoea, 
syncope, thrush, gangrene of the mouth, and pulmonary tuberculosis; 
as secondary complications, hysteria, epileptiform convulsions, albu- 
minuria and eclampsia, atresia uteri, and cancer of the stomach are 
noted. The same writer reports 46 deaths among 118 cases, while 
Delbet mentions 30 fatal cases out of a total of 62. 
Pathological Anatomy.-This affords only imperfect indications, 
because the autopsies are often completely negative, or reveal lesions of 
very diverse character. There has been found atrophy of the muscular 
system and of the adipose tissue, decrease in the size of the intestine, with 
occasionally slight softening and injection of the mucous membrane of 
the stomach. Various other non-characteristic lesions have been noted. 
Causes.-Pregnancy must be mentioned as the essential predisposing 
cause, which acts through the organic and functional modifications that 
it impresses upon the uterus, as though by the more or less marked 
general stimulation of the nervous system; but, to this general predis- 
posing cause we must add a nervous disposition, multiparity, inflamma- 
tion of the uterine tissue or ovum, erosions, atresia, or hypertesthesia of 
the os externum, and displacements of the uterus. Finally, in addition 
to these causes, which bear an intimate relation to pregnancy, vomiting 
occurs, due to some functional or organic gastric trouble. 
Diagnosis.-It would seem at first sight as if the diagnosis ought to be 
extremely easy. However, Gueniot has rightly shown that it includes 
three very distinct factors, viz. : 1st. The diagnosis of pregnancy; 2d. 
The diagnosis of the adjuvant or determining cause of the vomiting; 3d. 
The differential diagnosis between obstinate vomiting due to pregnancy, 42 
A TREATISE ON OBSTETRICS. 
and that due to some other cause independent of gestation. Errors are 
most likely to be made in the last instance. 
Prognosis.-This is exceedingly grave, above all after the beginning 
of the second stage, while in the third, death is almost inevitable. The 
death of the foetus, or spontaneous abortion, is generally favorable, but it 
would be a mistake to infer that all danger has disappeared in conse- 
quence of such an event. 
Treatment.-This consists in attention to diet and hygiene, in strictly 
medical as well as surgical and obstetrical treatment. 
1. Diet and Hygiene.-Since uncontrollable vomiting rarely begins 
abruptly, and more usually succeeds the light form, we shall do well at 
the outset to establish a rigid diet, excluding heavy and indigestible food, 
all forms of stimulants, especially alcoholic, and recommending the use 
of white meats, jellies, milk-diet, in short, easily-digested articles. The 
physician can not, however, lay down absolute rules, but must consider 
the caprices of the stomach. We must vary the diet as much as possible, 
and, if the stomach succeeds in tolerating any fluid or solid article of 
nourishment, we must not spoil our chances of success by insisting on a 
prolonged use of it, but should combine it with others. Increase the 
nourishment, very gradually, since relapses are frequent. If they occur, 
try something else, varying the food constantly, as the main object is 
to gain time; vomiting often ceases spontaneously after an interval, as the 
pregnancy advances. 
Medical Treatment.-The very multiplicity of the remedies suggested 
by different writers, proves their small value and uncertain action. The 
idea is to resort to rectal alimentation, but this is uncertain, because the 
enemata soon cause diarrhoea, a condition often associated, as we have 
seen, with uncontrollable vomiting. Raw meat is often repugnant, and 
prolonged rest on the back, sea voyages and walking, are not easily 
recommended to women in this condition. The oldest form of treat- 
ment is the antiphlogistic (venesection, leeches, etc.), but the results 
have been contradictory. Some physicians have applied leeches directly 
to the cervix uteri with success. Local revulsives, sinapisms, blisters, etc., 
as well as purgatives and emetics, have sometimes succeeded, sometimes 
failed; the same may be said of acids, alkalies, aromqtics, and antispas- 
modics. Opium, especially, seems to have a decided action, whether 
given by the mouth or hypodermatically (the latter method being prefer- 
able), while applications of belladonna to the cervix have been successful. 
Hydrocyanic acid, tincture of iodine, iodide and bromide of potassium, 
oxalate of cerium (used by Simpson in 45-grain doses), tincture of nux 
vomica, calomel in small doses, pepsin, cold, alcohol (especially Kirsch, 
brandy, and iced champagne), and ice internally and externally, may be 
mentioned as empirical remedies. Ether-spray, applied to the epigastriufn DISEASES OF PREGNANCY. 
43 
and along the spinal column, has recently been recommended, also 
electricity and subcutaneous injections of ether. All of the foregoing 
remedies have succeeded in some cases, but as a rule they have failed. 
[Other remedies which we have found in certain cases of value, are: 
The hydrate of chloral,'in grain doses repeated every few minutes, till 15 
to 20 grains have been taken, and associated for a tim^ with the re- 
cumbent position. The hydrochlorate of cocaine, in grain doses, has 
twice given us good results, but in other instances failed. Very hot 
water sipped slowly will often answer.-Ed.] 
There remains then, 
3d. Surgical Treatment.-This consists in cauterization of the cervix 
uteri, a procedure originally suggested by Bennet, and used successfully 
by various authorities. Bennet confines the cauterization with nitrate of 
silver or iron to the region of the os externum, with the view of checking 
the vomiting without interrupting the pregnancy, while Giordano, on 
the contrary, aims at terminating it, and hence applies the' caustic as 
high up as the os internum. Copeman has been successful in the em- 
ployment of digital dilatation of the cervix. We have never obtained 
any results with this treatment unless it caused abortion. Moreau has 
cured patients by replacing the uterus when it was malposed. [Cope- 
man's method is of greater utility than the reader would judge from the 
author's statement. Obstetricians in this country, who have resorted to it, 
report numerous successes, even in desperate cases. Either the finger or 
the steel-branched dilator may be used, a necessary precaution 
being to pass neither beyond the internal os. Where miscarriage results, 
the chances are it is because this precaution has been neglected. Of the 
advocates of this method in this country, we may mention Goodell, 
Munde, Wylie. The latter claims for it precedence over all other 
methods.-Ed.] 
4th. Obstetrical Treatment.-This consists in the induction of 
abortion, in preference to premature labor. If the child is viable (after 
the seventh month), we must act at once in the interests of both the 
mother and the child. Simmond (1813), was the first to practice this 
measure. Since then a large number of successful cases have been 
recorded, in*fact two-thirds of the cures are obtained in this way. The 
determination of the proper time at which to interfere is one of the 
most delicate questions in our profession. Dubois affirms that inter- 
ference is most proper during the second stage, when the following 
conditions are present: Incessant vomiting of all ingesta, even a small 
quantity of water, marked feebleness and emaciation, preventing the 
patient from making the slightest exertion, attacks of syncope, following 
the least movement or excitement, profound alteration of the features, 
marked continued fever] extreme acidity of the breath, and, finally, the 
failure of every applied remedy. 44 
A TREATISE ON OBSTETRICS. 
[In our opinion it is not good practice to wait for the appearance of 
the symptoms of the second stage before resorting to the induction of 
abortion, for then we simply add the additional shock of labor to a 
constitution already strained to the utmost by the vomiting. In case 
the usual remedies by the mouth, associated with rectal enemata of 
peptonized milk (and these will not induce diarrhoea if cold water 
enemata precede each nutrient enema), and also with dilatation, do not 
succeed in releasing the woman from the vomiting, which if it continues 
will kill her, then, before exhaustion sets in, miscarriage or premature 
labor should be induced. A consultation should always precede any 
operation of the kind.-Ed.] 
Leven believes that we can prevent the development of uncontrollable 
vomiting, and that we can stop it after it has begun. The following 
are his views, which we are far from adopting in every respect: Dys- 
pepsia, loss of appetite and vomiting begin with pregnancy. The 
woman craves the most indigestible articles, such as can only aggravate 
the existing dyspepsia, while she feels an aversion for solid nourishment 
(meat, fish, etc.), which the stomach requires in order to remain in 
health. The same may be said of her desire for stimulants. Physicians 
have habitually humored, rather than checked, these tendencies, think- 
ing that the vomiting would cease spontaneously as the pregnancy 
advanced. On the contrary, the stomach, after having been injured by 
improper diet, becomes so irritable that it will not tolerate nourishing 
food, and the woman really dies of hunger. If the physician recognizes 
the condition as dyspepsia, and begins his treatment at the outset of 
pregnancy, the result will be different. For several days nothing should 
be given but liquid nourishment (not soups, which are irritating, but 
milk), while hot applications and sinapisms are used over the region of 
the stomach, phosphate of lime, or bismuth, being administered inter- 
nally. Milk will be tolerated for a few weeks, when the stomach will 
gradually be able to retain solid food. 
We can not accept these conclusions, because they do not explain why 
vomiting should suddenly cease after simple dilatation of the cervix. 
• 
Constipation. 
Constipation is the rule in pregnant women, and sometimes resists 
every remedy employed to relieve it. It has been mentioned by all 
writers from the earliest times. While in the majority of cases it may 
give rise simply to anorexia, disturbances of digestion, and pains in the 
back and abdomen, in some instances it occasions more serious manifes- 
tations. Aside from the increased straining of the woman in her efforts 
to expel the hardened fieces, it may cause pelvic congestion, as shown 45 
DISEASES of pregnancy. 
by a feeling of tension, weight, fullness, by the presence of hemorrhoids, 
etc.; it may even produce uterine contractions and abortion, as was 
noted by Hippocrates and other ancient writers. We must accordingly 
oppose it most carefully, by the use of proper diet, enemata, and mild 
purgatives. 
DlAREH(EA. 
This is not so rare as we may think. It sometimes alternates with 
constipation, or it may be the patient's habitual condition, and, though 
usually harmless, it may, in some instances, assume a grave character, 
resembling to some extent uncontrollable vomiting, which it may 
furthermore often complicate. Abortion and premature labor may occur 
in consequence. We have obtained excellent results in a case of obstinate 
diarrhoea, by giving night and morning a pill containing gr. | of 
nitrate of silver. An enema night and morning, containing fifteen or 
twenty drops of laudanum, is usually sufficient. 
Disturbances of Respiration. 
We can not insist too strongly on the fact that during pregnancy 
there is a larger quantity of blood in circulation, and that as a result the 
pulmonary circulation is increased. It is not even necessary that a 
cardiac lesion should be present in order to cause capillary bronchitis 
and pulmonary hemorrhage which rapidly becomes dangerous. We 
have observed two cases in which unknown females were brought to the 
clinic in a condition of asphyxia or coma, similar to the coma which 
succeeds an attack of eclampsia. They perished, in spite of venesection, 
and an autopsy in both cases revealed the presence of pulmonary conges- 
tion and hemorrhage, without heart-disease. Peter's observations 
have shown that, aside from disease, the lungs in pregnancy are warmer 
than in the non-pregnant state, the increased heat being due directly 
to the greatdr supply of blood. It is not rare to witness a proof of the 
pulmonary congestion in the haemoptysis which appears after delivery. 
Disturbances of the Circulation. 
Influence of Pregnancy on Diseases of the Heart.-By reference to 
the previous remarks concerning the modifications in the circulatory 
system produced by pregnancy, the reader will see that, aside from the 
hypertrophy of the uterine vessels, the changes in the circulation may 
consist in: 1st. Increase of the total quantity of the blood. 2d. Alter- 
ation of the constituent parts of the blood, as shown by the increase of 
water, white corpuscles, and by the diminution in the number of red 
discs, albumin, and iron, as well as the fibrin (at least early in preg- 
nancy). There exists in the pregnant woman, therefore, a peculiar 46 
A TREATISE ON OBSTETRICS. 
condition, neither plethora nor anaemia, characterized by cardiac hyper- 
trophy and murmurs, dyspnoea, oppression, and a tendency to congestion 
of the viscera, especially the lungs. Peter believes that the amount of 
blood increases during pregnancy, simply because of the existence of 
this condition, and the needs of the foetus, so that the hemorrhage after 
delivery is physiologically necessary, in order to relieve the woman of 
the extra quantity of blood. Hypertrophy of the left side of the heart 
is a purely mechanical result of the increased work, caused by the high 
aortic tension, from the direct pressure of the uterus (Raynaud), or the 
additional foetal circulation. This hypertrophy is only temporary, 
disappearing rapidly and completely after delivery. But it may persist 
in some instances, and become permanent, increasing with each subse- 
quent pregnancy, and culminate in a true cardiac affection, which, in 
its turn, under the influence of pregnancy, becomes the starting-point 
for a group of symptoms, now known as the cardiac symptoms of 
pregnancy (accidents gravido-cardiaques). 
Pregnancy is only one of the causes which hasten the progress of 
heart-disease, the phenomena of which develop more or less rapidly 
during pregnancy and under its influence. This influence may be 
transient, when the valvular lesion or myocarditis is not aggravated, but 
repeated pregnancies do cause aggravation of them. Porak shows that 
on the whole, cardiac lesions, although not infrequent after delivery 
and during the puerperium, are rare during pregnancy. Opinions 
differ regarding the presence of cardiac hypertrophy in pregnancy, some 
authorities believing in the existence of hypertrophy, others in dilatation, 
while others affirm the co-existence of both conditions. Letulle arrives 
at the following conclusions: Physiological hypertrophy of the heart 
during pregnancy is not constant, the apparent enlargement of the organ 
being sometimes due to its elevation by the diaphragm. The presence 
of temporary dilatation is proved by the jugular reflux, cardiac and 
venous murmurs, and anaemia; some of these symptoms disappear after 
delivery. The dilatation is to be referred to the increased tension in 
the right ventricle, as well as to obstruction from pulmonary trouble; 
in this case, hypertrophy and dilatation may co-exist, when errors of 
diagnosis are easy, especially if the heart is elevated by the diaphragm. 
Porak found that the weight of the heart in women dying soon after 
delivery varied from 8 to 10.9 ounces, while Letulle states that the 
weight varies from 8 to 10 ounces, the normal'organ varying from 6.9 
to 7.2 ounces. Cohnstein found hypertrophy of the left ventricle in 
ten cases out of twenty, dilatation in eight, myocarditis in eight and 
aortic stenosis in five. We do not see how Porak can arrive at this con- 
clusion. Idiopathic hypertrophy of the heart must be rare, but it is 
not so in regard to actual cardiac lesions, and the persistence of the 
hypertrophy after repeated pregnancies is intimately related to such DISEASES OF PREGNANCY. 
47 
lesions. Degeneration of the myocardium, leading to rupture of the 
heart, has been observed, especially during the puerperal state. 
Endocardial Lesions.-Endocarditis often occurs during pregnancy, 
and may be acute, sub-acute, or chronic. The acute form may be of 
the typhoid or pyaemic variety, and is marked by the presence of 
exuberant vegetations on the endocardium, resulting in emboli (due to 
coagulation or the detachment of bits of vegetations), the plugging of 
vessels and hemiplegia. However, acute endocarditis during pregnancy 
is rare. 
Sub-acute and Chronic Endocarditis. This is comparatively frequent, 
and may succeed the acute form. Valvular lesions are many, and 
their location different, but the mitral valves are most commonly 
affected, either alone or in common with the others. Porak found 
mitral insufficiency in twenty-two cases, stenosis in thirteen, both condi- 
tions being present in twenty-two, making fifty-seven in all; the aortic 
valves were affected in thirteen cases, insufficiency being noted nine 
times and stenosis twice, both being present in two cases. In twenty- 
two other cases, the two valves were simultaneously involved. These 
lesions may be well borne by the women, but cardiac troubles may arise, 
presenting, according to Porak, four variations, viz.: 1st. There may 
be disturbance of the heart's innervation, leading to palpitation of a 
more or less irregular character, which increases with the progress of 
the pregnancy and is accompanied by dyspnoea, attacks of oppression, 
generally transient, but sometimes very violent and attended with ver- 
tigo, head-ache, precordial pains, but no physical signs pointing to 
the lungs. More usually the woman is disturbed and oppressed, but has 
no attacks except on making strong efforts or movements. She com- 
plains of short breath rather than palpitation and of syncope; in time 
the dyspnoea increases, so that the patient is obliged to remain in bed 
in a semi-recumbent attitude, every movement being followed by palpi- 
tation and syncope, and increasing the dyspnoea. Most often the 
condition is complicated by pulmonary congestion and oedema, which 
increases as the pregnancy advances, and may be accompanied by 
haemoptysis, apoplexy, epistaxis, hematemesis, etc., troubles which assume 
an exceptional gravity. A third variety is asystole, which may be 
more or less marked, and may cause greater or less disturbances of 
the general circulation leading to ascites hydro-thorax secondary 
affections of the liver and kidneys, etc. Emboli may occur in a fourth 
variety, which, when carried to the liver, kidneys, lungs, or brain, will 
cause various symptoms. All the foregoing phenomena may be con- 
founded, united, or may appear more or less simultaneously and 
perfectly, according to the accessory circumstances and causes. All 
heart-lesions do not present the same frequency and gravity. The 
mitral lesion is the most common; next to this, pulmonary congestion 48 
A TREATISE ON OBSTETRICS. 
and oedema. Affections of the aortic valves are much more rare, are 
generally better tolerated, and give rise to few symptoms; finally, 
lesions involving the right side of the heart are still more grave, since 
they lead very rapidly to asystole and its consequences. 
As a rule, the cardiac troubles of pregnancy do not acquire the 
maximum intensity until after the first congestion. Though borne 
pretty well at first, they reappear with more intensity at each new preg- 
nancy, until the storm breaks forth with its full fury and attains its 
height at the moment of delivery. After delivery a marked amelioration 
usually occurs; there is, at the same time, to use Peter's words, "a 
maternal and cardiac delivery." But at each new pregnancy there is an 
exacerbation, and the patients succumb to the cardiac cachexia. Death 
usually occurs during the puerperal state. Porak noted the following 
conditions in eighty-four cases of pregnant women suffering from cardiac 
troubles: The condition remained stationary in twenty-one, was aggravated 
during pregnancy in fifty-five, and during labor in eleven. Ameliora- 
tion after delivery was noted in twenty-two cases, thirty-one women 
died, five before delivery, two during delivery, and twenty-five during 
the puerperium. We may say, then, without hesitation, that pregnancy 
hastens the course of cardiac diseases, and predisposes particularly to 
pulmonary congestion and embolism. 
The Influence of Cardiac Diseases on Pregnancy.-Diseases of the 
heart show their influence on pregnancy, by causing metrorrhagia, 
premature delivery, and abortion, and by causing the death of the 
foetus, either directly on account of the mother's affection, or in con- 
sequence of changes in the placenta. 
I. Metrorrhagia.-.Attacks of metrorrhagia may be produced at the 
usual time of the menstrual flow, and may thus give rise to the belief 
that menstruation persists during pregnancy, but they differ from it 
as regards both the amount and the quality of the blood, and the 
duration of the flow. Duroziez has reported several cases. Metrorrhagia 
may occur before the expulsion of the foetus, but it is especially observed 
at the time of delivery; it accompanies premature delivery and abortion, 
and is usually referable to uterine inertia. The hemorrhage may be so 
excessive as to threaten the life of the woman. 
II. Abortion and Premature Labor.-These are very frequent, and 
the children who are born at full term do not live long. According to 
Casanova, they do not occur except in the case of women in whom the 
valvular lesion has already been manifested by symptoms more or less 
marked, as dyspnoea and palpitations. They reappear with so much the 
more readiness, according as there have been previous pregnancies. He 
believes that, in more than half of the cases, the pregnancy is not com- 49 
DISEASES OF PREGNANCY. 
pleted, and that the child may be born in three conditions-dead, living, 
or expelled prematurely. According to See, the foetus perishes from 
asphyxia and inanition, because it no longer finds in the vitiated blood 
of the mother either the oxygen or the other materials necessary for its 
nutrition. It then becomes a foreign body, which is soon expelled from 
the uterine cavity. 
The Foetus is born Dead.-The most rational explanation of this is 
that of Brown-Sequard and Marty, which is as follows. Venous blood 
stimulates the nerve-centres and contractile tissues; oxygen furnishes the 
contractile force, carbonic acid sets it in motion. In this way is produced 
the contraction of the uterus, which is so useful throughout the entire 
course of pregnancy, in preventing stagnation of the blood in the uterine 
sinuses and plexuses. But, as soon as some cause disturbs the general cir- 
culation, and increases the embarrassment of the uterine circulation (car- 
diac or pulmonary disease), the uterine contractions become so strong as 
to exceed the physiological limit, producing either abortion, or premature 
delivery. Abortion results from congestion and hemorrhage into the 
placental tissue, separating the placenta, and extending within the uterus 
as in other organs. Duroziez noted 21 miscarriages among 41 women 
with heart disease, 5 were delivered at six months, and 37 of the children 
who were born alive, died before reaching five years. Among 220 cases 
collected by Courrejol and Porak, 128 were delivered at terms. 
Prognosis.-Although the prognosis is evidently grave, both for the 
mother and for the child, generally speaking it varies according to the 
different lesions. All writers agree in regarding mitral lesions as far 
more serious than aortic; the latter, says Casanova, and especially steno- 
sis, are not dangerous affections, but, on the contrary, they are well 
borne, and are compatible with long life, and if it were not for the con- 
tinual fear of fatal syncope, or of premature weakening of the heart's 
contractions, the prognosis would be quite favorable. Others believe 
that the lesions become aggravated during the latter months of preg- 
nancy, and undergo amelioration afterward. It is believed that aortic 
stenosis in particular, may exert a very injurious influence on pregnancy. 
Aortic insufficiency is characterized by its long period of immunity, 
which depends upon the compensatory hypertrophy of the left ventricle. 
See thinks that the lesion is perfectly compatible with gestation, at least 
that there are no functional symptoms. This is not always the case, and 
sudden death may occur. Mitral lesions are unquestionably the most 
serious of all, although opinions differ with regard to stenosis. When 
the latter is combined with insufficiency the prognosis is much worse. 
Mitral lesions lead to dyspnoea, congestions, and pulmonary troubles. 
Lesions involving simultaneously different valves are the most grave; 
those of the right heart are secondary according to Berthiot, but Lee 
Vol. ii.-4. 50 
A TREATISE ON OBSTETRICS. 
cites a case in which a pregnant female with a pre-existing tri-cuspid 
lesion died during an attack of pulmonary congestion. 
Porak has constructed a table, based on 92 cases of heart-disease, 35 
of which terminated fatally. The mitral valve was affected in 54, the 
aortic in 13, and both valves in 22; the foetus was expelled prematurely 
in all but 3 cases, lie regards mitral stenosis as a very serious affection, 
often terminating fatally. 
Treatment.-In view of the fatal influence mutually exerted by preg- 
nancy and diseases of the heart, the first question which presents itself 
is, "Ought we to allow a young woman with heart-disease to marry?" 
In general we reply in the negative, especially if a mitral lesion is pres- 
ent; strictly speaking, perhaps, we may be less positive if the lesion is 
aortic, but, even then it is well to warn the family of the danger to which 
they would expose the girl, and Peter's opinion ought to be regarded as 
a rule which is almost absolute, viz.: Oppose marriage in a patient with 
heart-disease; if she is married, do not let her become a mother; if she 
is a mother, prevent her from nursing her child; and if such a patient 
become pregnant, let her avoid most carefully fatigue, emotion, and 
every cause which, by disturbing the pulmonary circulation, may render 
still graver the prognosis of the cardiac affection. 
Medical Treatment.-This can not be laid down arbitrarily. Peter 
recommends venesection highly; this is undoubtedly useful in reliev- 
ing congestion of cardiac origin. Digitalis certainly acts favorably in 
many cardiac affections, but it is not adapted to all. It is certain that it 
relieves palpitations and produces diuresis, but it does not affect palpita- 
tion of purely nervous origin, iq which bromide of potassium combined 
with ether is of utility, and, where pain is present, local bleeding is 
attended with good results. Peter uses digitaline, but we prefer the 
tincture of digitalis, or the infusion of the leaves, in doses of three grains. 
The troubles arising from haematosis should be treated with venesection, 
sulphuret of mercury in doses of two and a half grains, ipecac, inhalations 
of volatile salts, compressed air, preparations of iron, calomel with 
squills and digitalis, turpentine, purgatives, diuretics, etc. Can we use 
chloroform during labor in the case of a pregnant woman with heart 
disease? This question has never been definitely settled. We know 
that nearly all surgeons regard affections of the heart as contra-indicat- 
ing the use of this anaesthetic. Championniere administers chloroform 
to all of his operative cases without distinction. 
Obstetrical Treatment.-If the woman does not present any serious 
troubles, the only thing to do is evidently to wait; but, if they become 
more serious, and the life of the woman seems to be in jeopardy, should 
we confine ourselves to purely expectant treatment, and merely combat 
the cardiac symptoms? Two cases may present themselves. DISEASES OF PREGNANCY. 
51 
I. Labor has Commenced.-In this case, all accoucheurs agree with 
Pajot and Dubois whose ideas are quoted in Dubois's article. The or- 
dinary and evident indication is to terminate the labor as rapidly as pos- 
sible without injury to the mother, without injury, because we absolutely 
disapprove of forced delivery. The five cases mentioned by Porak in his 
article, do not appear to us to warrant a like management, and the bad 
results given by the general adoption of forced delivery do not appear 
much improved, according to the observations to which we refer-i.e., 
one child really survived; for in the four other cases, twice the infant 
died, and twice its fate was not known. As for the mothers, the results 
seem a little more favorable, but still the observations are too incomplete 
to allow us to judge of the question. 
II. Labor has not Commenced.-Ought labor to be induced, when we 
know the danger which threatens the life of the mother, and consequently 
that of the child ? All authors agree on this subject, and all answer in the 
affirmative. We are in accord with this opinion. But ought abortion to 
be produced ? In this case the child's life is sacrificed to prolong the life 
of the mother, a life very much endangered not only at present by actual 
dangers, but in the more or less remote future by some cardiac disease 
even. Besides, authorities are not agreed; some disapprove entirely of 
the production of abortion, others believe in producing an abortion, but 
under certain conditions. 
We place ourselves among the latter. We do not forget, however, that 
producing abortion is a serious operation when viewed from a moral 
standpoint, and we only believe ourselves authorized to do so when all 
other therapeutic measures have been exhausted, and when the life of 
the mother is in serious and imminent peril by intense and persistent 
gravido-cardiac complications. 
Finally, if the mother dies, and the -child is viable, it is the duty of 
the accoucheur to perform the Csesarean section without hesitation. 
Whatever be the chance for the child, no one has the right to deprive 
it of that one chance. We will return again to this subject in the 
chapter devoted to delivery post mortem. 
Varices. 
Three situations are particularly the seat of varices in pregnant women. 
These places of election, so to speak, are the lower extremities, the 
genital organs, external and internal, the anus and the rectum. But 
these places are not the only ones invaded, they have been met with on 
the trunk, and finally they may extend into the bladder and urethra, 
thus: 1. Varices of the lower extremities; 2. Varices of the internal and 52 
A TREATISE ON OBSTETRICS. 
external genital organs; 3. Varices of the aims and rectum. 4. Varices 
of the trunk; 5. Varices of the urethra and bladder. 
I. Varices of the lower extremities may be superficial or deep. 
(a.) Superficial Varices.-Briquet distinguishes four varieties: 
1st. Simple Enlargement.-The vessels have a greater calibre than 
usual, but they remain contractile and are not tortuous, their walls do 
not become thin, but always have a thickness proportionate to the calibre 
of the vessel. 
2d. Uniform Dilatation with Thickening.-According to Verneuil, the 
calibre of the vessel is increased, its form remains cylindrical, but the 
underlying connective tissue alone being hypertrophied, there is not 
only thickening and lengthening, but tortuosity, and, on section, the 
vessels remain gaping, and their internal surface show some longitudinal 
folds and ridges. 
3d. Unequal Dilatation with Thickening and Thinning.-The changes 
here are greater and involve all the coats. There is at the same time a 
multiplication and elongation of the flexures, but the middle coat is no 
longer regularly hypertrophied, but it is thick in certain places and 
thin in others; hence the swellings, the unequal dilatation forming true 
varicose swellings of various shapes and appearances. The valves in 
the veins being very much altered, the venous circulation is seriously modi- 
fied. 
4th. Venosity.-This is, according to Briquet, simply development 
of small veins which are very numerous, enlarged and branching indefi- 
nitely. They are very superficial, even sub-epidermic, and they may 
color the skin violet or bright red. 
According to Cornil, "the varicose dilatations of less degree, and 
these are the most common, are produced by a new formation of connec- 
tive tissues (bundles of fibres and cells), by the extension of the vasa- 
vasorum, which penetrate as far as the internal part of the middle layer, 
by the distension or sinuous state, the winding condition and the thick- 
ening, more or less considerable, of the walls of those vessels, and by 
extravasation of the coloring matter of the blood in the connective 
tissue of the walls of the veins. 
The thickness of the middle layer, thus modified, is from two to ten 
times greater than in the normal state. In these sack-like or fusiform 
dilatations of the varicose veins, the wall is very thin, the internal 
surface is smooth, the dilatation is very irregular, and the periphery of 
the tumor is easily separated from the surrounding tissue. The dilata- 
tion on section shows that the middle fold has almost or entirely 
disappeared. The membrane which constitutes the dilated pouch is 
composed almost wholly of the connective tissue, modified by external 
tissues and by the internal tunic of the vein. DISEASES OF PREGNANCY. 
53 
Varices, in a word, are the result of a chronic inflammation of the 
veins, characterized essentially by the multiplication of the elements of 
the connective tissues (bundles and cells), above all of the internal layer 
of the middle membrane, by the distension and extension of the net-work 
of the vasa-vasorum, and, secondarily, by the dilatation and by the 
calcareous degeneration of the walls of the changed vessels. The blood 
remains in the normal condition, and the veins seem covered in the 
midst of indurated tissue. Budin believes that this is due, not to a true 
induration, but to a simple infiltration of the surrounding tissues, lie has 
said, with reason, that this induration, this thick lining, disappears 
almost immediately after confinement. 
(b.) Deep Varices.-Verneuil acknowledges that the primary situation 
of varices lies in the deep veins, and above all, in the muscular and 
intramuscular veins of the calf. These deep vessels are at first the seat 
of dilatation, and of valvular insufficiency, and thus two modifications 
are transmitted to the other branches of the sub-aponeurotic tissue. 
Superficial varices would be then only the consequence, only the 
manifestation of the deep varices. 
Symptoms.-They differ according as we have to do with superficial 
or deep varices. They have a different appearance according to their 
situation and the degree of dilatation. Sometimes they are capillary 
varices, located on the feet, ankles or calves of the legs; sometimes they 
form blue or red spots analogous to naevi, scattered over different areas, 
running up on the thigh and connecting among themselves by long 
vesicles. In a condition more advanced, the dilated veins are longer; 
they form sometimes lozenge-shaped meshes, at other times isolated 
tortuosities, or finally there may be true bundles of dilated veins. 
Ordinarily, che neighboring tissue is thickened, infiltrated, as in 
oedema; at other times, on the contrary, these veins seem separated 
from the finger by an extremely thin septum. When, on the other 
hand, there is a coagulum formed, the veins then take the form of a 
hard cord, knotty, and roll more or less under the finger. 
Varices are most common in the external saphenous; they may extend 
down the leg on the posterior and inner surface of the calf. On the 
inner surface these varicose tumors may be of variable size, sometimes 
enormous, accompanied with oedema, weight, itching, dullness and even 
a sort of paralysis of the extremities. The first appearance may t>e in 
the first pregnancy, may be after several pregnancies. They may man- 
ifest themselves, during the first months or more slowly, and go on 
increasing with the pregnancy. 
At other times they show themselves in one pregnancy and not in 
another. Finally, they may disappear, if not completely, at least in 
great part,, after confinement. Labor, according to Budin, does not 54 
A TREATISE ON OBSTETRICS. 
modify them, it would have indeed the contrary effect. According to 
Cazin, the varices would be swollen and tumefied. 
Verneuil has given a masterly description of the symptoms in cases of 
deep varices. ''There is at first a feeling of fatigue in walking, an 
extreme heaviness of the affected extremity, accompanied by an appreci- 
able numbness; next, frequent cramps of the calves, accompanied by 
prickling or itching. When the numbness and pain acquire a certain 
intensity, the limbs become weak and trembling and can scarcely 
support the weight of the body. The pain is limited, in general, to the 
back part of the leg, reaching its maximum in the calf. It is deeply 
seated, poorly circumscribed, and manifests itself often in the sole of 
the foot, and ceases at night, and, in the recumbent position, may 
come on gradually, or is of sudden onset. 
"It appears again in resuming the vertical position or in walking. 
The involvement of the superficial varices does not, necessarily, increase 
the difficulty, and the extremities which offer only venosities are often 
the most painful. This pain may be referred, according to Verneuil, to 
the nearness of the dilated veins to the accompanying nerves. The 
limb, to the touch, appears doughy; when it is quiet and reduced in 
size it gives a spongy sensation, analogous, in some cases, to that of 
varicocele. 
"In places one can make out indurations, nodosities, situated in the 
midst of soft tissue. These are due to phleboliths, to clots of blood, 
signs of circumscribed phlebitis, or of spontaneous coagulation. Often 
the varicose extremities are studded with brown patches, as pigment, 
various eruptions scattered over the surface of the skin (small boils, 
erythema, eczema, prurigo), and accompanied by itching, which often 
precedes the appearance of subcutaneous varices. The perspiration 
is increased in the affected limb; perhaps there is an increase even in 
the local temperature." 
Authors arc not agreed as to the frequency of varices, because, while 
Cazin has only met 78 cases in 1659 confinements, Lesguillon has 
reported 1 case in 20, and Budin has met them 100 times in 300 cases. 
Etiology.-The following have been successively assigned as a cause: 
Weight, the number of pregnancies, occupation, the position of the 
uterus, temperature, pendulous abdomen, deformities of the pelvis, 
cardiac disease, pulmonary disease, and age of the woman. All these 
causes may operate in certain cases, but they are found as well in women 
who have no varicose veins. 
Pressure of the uterus on the vascular trunks has also been assigned 
as a cause, but the development of varices is far from being in harmony 
with the development ard inclination of the uterus. 
Richard has proposed the following theory: " In consequence of the 55 
DISEASES OF PREGNANCY. 
development of the organs of gestation, the arteries increase in size, the 
veins develop equally, and seem to communicate more easily with the 
arteries. As a result, the veins of the pampiliform plexus dilate under 
the influence of intravenous pressure; consequently, the blood passes 
more rapidly and easily toward the dilated capillaries, and the longer 
the dilating force lasts, the longer will it tend to dilate the vessels. 
" The increase of venous pressure in the veins forming the plexus 
which runs along the side of the uterus, will have for its effect increased 
tension in all the great vessels, which serve as an outlet to the veins of 
the uterine system, that is to say: 1st. Into the left renal vein; 2d. 
Into the inferior vena cava; 3d. Into the hypogastric vein, and, by the 
intermediate veins, into the common iliac vein. The blood of the venous 
system, situated below the vena cava inferior, finding before it a tension 
superior to its own, slackens its flow; thence, stasis in the hypogastric, 
femoral, popliteal, posterior tibial, the saphenous and their tributaries, 
and consequently the formation of varices." 
Budin rightly observes that with this theory it is difficult to explain 
the cases in which varices appear in the first months of pregnancy. 
The increase in the mass of the blood, modifications in its composition, 
increase of vascular tension (Lesguillon), changes in the nervous system 
(Dubois, Barnes), weakening of the venous walls by the simple fact of 
pregnancy, are assigned as causes. All these causes may act, but it is 
difficult to say, as Budin avers, to which, in each particular case, any 
belong. 
Varices in pregnant women may be complicated with oedema, but not 
so frequently as one might suppose. Lesguillon has only quoted one case 
in 47" women, and moreover oedema can exist without varices, varicose 
ulcers rarely (because Lesguillon gives 2 cases in 47 women); erysipelas 
and phlebetis, these are common. Everything then goes on as in 
limited phlegmon; but in some exceptional cases, this phlebitis may be- 
come the cause of purulent infection of emboli (Budin, Blot). Lastly, 
varices may break, and these ruptures may be followed by serious and 
even fatal hemorrhages. 
It is, in general, above the malleoli that they take place, and they 
may be spontaneous or they may be produced under the influence of a 
blow or shock. When they are arrested, they do not generally endanger 
the pregnancy. 
Complications alone make the prognosis serious. In the treatment of 
simple varices one is limited to rest, and the employment of an elastic 
stocking, which has some advantages; if complications arise, these ought 
to be the guide for treatment. Ruge, Martin, Otto Albert, Spiegelberg, 
have advised a radical cure of varices during pregnancy, i.e., in making 
subcutaneous injections repeated in different places, of fid. ex. ergot in 56 
A TREATISE ON OBSTETRICS. 
doses of two grains. Since, Budin justly observes, the varices should 
disappear ordinarily or be improved considerably at the end of the con- 
finement, it is best then to try palliative methods, and contend against 
the complications with suitable treatment. 
II. Varices of the genital Organs.-They may be formed on the vulva 
or even as far as the cervix; lastly, they may extend into the broad and 
round ligaments. Situated ordinarily between the labia majora and 
minora, often on the labia majora alone, they may be unilateral, extend 
as far as the clitoris to the mons veneris, invading more or less the vagina; 
form varicose tumors more or less long on the labia majora, the walls of the 
vagina (occasionally only on these walls), and extend, as Budin has shown, 
as far as the cervix, broad ligament, and even to the round ligament. 
Distorting more or less these parts, giving them a bluish, livid or tume- 
fied aspect, they may break and produce hemorrhages more or less severe. 
The ruptures may be produced either during pregnancy or during 
confinement. During pregnancy, the rupture may be spontaneous or 
be the result of scratches, falls, shocks and blows on the vulva. During 
confinement, it is at the time of the birth of the child or soon after that 
the rupture takes place, and, if these varices are within the vagina, they 
may become the origin of thrombi, which we will study further on more 
in detail. 
III. Varices of the Anus and lower part of the Rectum.-They give 
rise to hemorrhages, which are found so often during pregnancy, and, 
oddly enough, often after confinement. 
It is the constipation so habitual in pregnant women, and the strain- 
ing which they make in the act of defecation, which is in reality the 
true cause of these hemorrhoids. Not serious, in general, during 
pregnancy, they may be after confinement, filling up the anus, where 
they form, sometimes, an enormous pad, extremely painful. They may 
become the seat and focus of anal fistulas (we have seen two cases), and 
during pregnancy of serious hemorrhage (we have seen an example of 
this). 
IV. Varices on the Trunk.-In this case it is chiefly on the abdomen 
where tliey are found in greatest number. To the case reported by Petit 
and Budin, we can add one which occurred in our practice. The varices 
reached as high as the chest and even on one breast. Richard has 
reported one similar case (varices of the mammae). Cazin finally has 
seen a case of varices on the buttocks. 
V. Varices of the Urethra and Bladder.-Budin has reported some 
cases from Skene, Richet, Winckel and Bar. 
Serous Diathesis-Ascites-Dropsies. 
Among the morbid phenomena which arc the result of disturbances of 
the circulating system, must be mentioned first the dropsies of pregnant DISEASES OF PREGNANCY. 
57 
women, which have their seat in th6 cellular tissue, and may extend 
«ven to the great serous cavities. Stolz and his pupils Thierry, Lauth, 
Schindler, wished to make one morbid entity, and have classed all these 
phenomena under the name of serous diathesis, serious cachexia of preg- 
nant women, and of the recently confined woman. 
We believe, for our part, that they have gone too far in this matter, 
and that the dropsies which occur in pregnant women, and those lately 
confined, are only the manifestation of a general state, in which, it is 
true, the altered state of the blood is the chief cause, but which, apart 
from this altered blood state, may be produced by a group of causes in- 
dependent of each other. In our opinion there is a great difference 
between dropsies which may occur during pregnancy, and those which 
manifest themselves after confinement, and we admit, completely, the 
division which Raymond has given of the puerperal state; minor and 
major puerperal state. For us, it is impossible to compare precisely the 
condition of a woman during pregnancy and that of a woman after 
confinement. During pregnancy, as Pajot has said, all tends to hyper- 
trophy, afterward all to atrophy. And although the puerperal period, 
in our opinion, commences with conception, only to finish after confine- 
ment, according to all authorities the true puerperal state commences 
only after the confinement, or better still after the labor, and it impresses 
with a peculiar gravity all the affections, which, happily, rarely affect 
women during pregnancy. Besides, this is what is shown by the study 
of the works of Lauth, Thierry, and Thirion de Namur; because their 
observations referred almost always fo those women recently confined. 
There may be a relation between dropsies which occur during pregnancy 
and those which occur after labor; this fact is unquestionable, but in 
this last case the puerperal period plays the chief part. 
Assuredly we do not question the considerable influence in the 
production of these dropsies played by the altered state of the blood in 
pregnant women, so well studied to-day, both in quality and quantity; 
but the diminution of the albumin does not suffice to explain all the 
dropsies of pregnant women, and of those recently confined, and we do 
not believe that the cachexia, the serous diathesis of pregnant women or 
of those recently confined, can be considered as a true morbid entity. 
If it were so, all pregnant women would, in different degrees, present 
these dropsies, and they constitute, on the contrary, the exception, 
chiefly in their serious forms. 
We cannot accept then, as absolutely true, the definition of Schindler: 
"The serous cachexia of pregnant and recently confined women, is pro- 
duced by a general or partial dropsy of the cellular subcutaneous tissue, 
by extravasation into the serous cavities, or by the infiltration of the 
interstitial tissue of vital organs, all united to diminish the albumin of 
the blood during pregnancy." 58 
A TREATISE ON OBSTETRICS. 
The pupils of Stoltz themselves are not all agreed, because, while 
Thierry admits a serous diathesis, Lauth and Schindler admit serous 
cachexia. We refer to the thesis of Lauth for the history of the subject. 
Scanzoni, who designated this condition under the name of serous 
cachexia, affirmed that "this state of the blood, common in pregnant 
women, gave rise to a serous exudation, often abundant in the serous 
cavities (pericardium, pleura, peritoneum), in the cellular tissue under 
the skin and sub-serous tissue (lower extremities, vulva and vagina), 
in the parenchyma of some organs (lung and brain, even to a transuda- 
tion into the cavity of the amnion (hydramnion), and into the internal 
walls of the uterus (hydrorrhoea). This condition endangers the life 
of the mother and child. Its influence during pregnancy deserves the 
more attention, because to it is added the pressure exercised by the 
distended uterus on the neighboring organs. 
"Thus, pulmonary oedema, effusion into the pleura and into the 
pericardium, become more serious, because of the obstacle which the 
uterus presents to the dilatation of the thorax. Thus the oedema of the 
lower extremities and the genitals is increased by the pressure on the 
pelvic vessels, often to such an extent that motion becomes impossible, 
and the distension of the skin is extremely painful." 
Devilliers and Rcgnauld, who have especially studied dropsies of the 
cellular tissue, have divided them into two great classes. 1st. (Edema 
or anasarca, which may be simple or involve the organs of respiration and 
circulation. 2d. (Edema or anasarca with albuminuria. 
Simple (Edema. 
Causes.-The first chief cause consists in the changes of the blood, 
particularly if there is a local or general congestion, a febrile state, severe 
or slight. Age and child-bearing have no influence, but it is not the 
same with privation, fatigue, moral influences, living in unhealthy 
dwellings, dampness-in a word, all the causes which exert a depressing 
influence on the pregnant woman. Sometimes, however, one sees 
oedema in a woman in a robust condition. 
But to these general causes are added influences which we call local 
and mechanical. Among them, the activity of a new life which 
stimulates the uterus, the determination of a considerable amount of 
blood which this new state exacts, are the powerful causes of the dis- 
turbance of the circulation. They may wonderfully modify the lower 
portions of the body and induce congestion or stasis, of which they may 
become the seat. 
It is through the development of the uterus, whose influence is felt DISEASES OF PREGNANCY. 
59 
in the last month of pregnancy; the inclination of the uterus, which 
explains sufficiently the preference of the infiltration to the limb on 
the corresponding side; the form, the direction of the foetal part, the 
form of the pelvic cavity and its unusual size, which allows communica- 
tion more or less direct between the uterus and the blood vessels; the 
resistance of the abdominal wall; the development and height of the 
uterus, which impedes the expansion of the thorax; the large size of 
the foetus; the increased distension of the uterus by twin pregnancy, 
hydramnion, tumors of the foetus, tumors of the uterus or pelvis, 
abdominal tumors, prolonged standing in certain occupations; finally, 
predisposition in certain individuals to varices. Such are the main 
causes of simple oedema. 
Prodhomme, together with Andral and Gavarret, Becquerel and 
Rodier, Regnauld and Devilliers, considered the alteration of the blood 
as the predisposing cause (diminution of albumin); but it must play, 
like these last, a great role in the influence of the mechanical obstacles to 
the circulation; the serous infiltration which complicates these condi- 
tions is only, according to him, the result of a local plethora. He tells 
us that the influence of the uterus on the neighboring organs is shown 
again by this fact, established by Depaul, that when the Caesarean 
operation is performed, one almost always finds a varying quantity of 
serum in the peritoneal cavity. It is the same in supra-pubic oedema, 
which he has shown is present in case of twin pregnancy. 
(Edema combined with Diseases of central Organs.-Aside from 
simple oedemas, we find oedemas or anasarcas with affections of the 
central organs of the circulation and of respiration. In this condition, 
the organic causes of the disturbance of the circulation, and the con- 
sequent infiltration of serum, increases again all those conditions which 
the puerperal state in women developes. If dropsy does not exist before 
the pregnancy; it will develop almost certainly in its course, and if it 
had already shown itself beforehand, it will increase considerably more 
in simple oedema. This is the case, particularly where the serous 
cavities are invaded, and then we have ascites, pleurisy with effusion, 
percarditis; at times even the dropsy will commence in these cavities. 
It is understood, moreover, that these are dropsies which induce serious 
complications for mother and child (symptoms of asphyxia, premature 
expulsion of the foetus, etc.). 
(Edema complicated by Albuminuria.-In this case, oedema is only an 
accompanying symptom, and it is the albuminuria which constitutes the 
disease. 
Symptoms and Course. -It is in general during the last three months 
of pregnancy that oedema commences to show itself; however, when it 
is dependent on a general cause, it may commence with pregnancy, or 60 
A TREATISE ON OBSTETRICS. 
during the third or fourth month (Cazeaux); and while it shows itself 
most often during pregnancy, it may only appear after confinement. 
Its course may be acute or chronic, slow, and acccording to Lauth, 
Thierry, Schindler, there are three degrees. 
1st. Slow Chronic Form, First Degree.-Nearly always, the swelling 
begins in the lower extremities. It is noticed, toward evening, that 
there is oedema about the malleoli, which disappears after rest and the 
horizontal position, to reappear when the woman remains up for a certain 
length of time. As the pregnancy advances, the infiltration extends, 
reaches the feet, legs, knees and thighs, and no longer disappears com- 
pletely during the night. The skin becomes dull, pale, is now insen- 
sible to, and pits on, pressure. This increase in size of the lower 
extremities is accompanied by loss of motion more or less marked. 
Sometimes it is utterly impossible to stand, on account of the vague 
pains and weight, and finally, the oedema rising still higher, ends by 
involving the genital organs, and becomes a considerable inconvenience. 
In the second degree, the oedema continues its ascent, involves in its 
turn the abdominal wall, forms above the pubes a tumor, quite a large 
cushion, then reaches the upper extremities, the face, eye-lids, involving 
thus all the cellular tissue under the skin, and giving to the woman a 
peculiar appearance. But while, according to Lauth, it remains still 
limited or nearly so in the cellular tissue under the skin, according to 
Schindler, the peritoneum is involved generally in its turn by an effusion 
more or less abundant. The oedema, carried to this extent, threatens 
the woman with serious complications. As evinced by the feeling of 
extreme tension, of general heaviness, they experience vague pains in 
all the limbs; the respiration becomes difficult, anxious, oppressed, and 
symptoms of asphyxia and syncope manifest themselves, and next appear 
disturbances of digestion and diarrhoea. The urine is diminished, of 
a deep red color, sometimes albuminous; the pulse is small, feeble, and 
soft. There is a cardiac bruit transmitted into the carotids; but won- 
derful as it may seem, fever is the'exception. It is not rare in this case, 
in view of the condition of the woman, to see the pregnancy interrupted, 
and the patient confined prematurely and spontaneously, usually at the 
end of the eighth month. Carried to this extent, the oedema may dis- 
appear after confinement (Lasserre, Lauth), but, in certain cases, it is 
not so. and the dropsy continues to increase, and the disease passes into 
the third stage, that is to say, the effusion spreads into the great serous 
cavities of the abdomen, thorax, and skull, and death results quickly. 
We may add that these oedemas, so extensive, are most commonly compli- 
cated by albuminuria, and that eclampsia comes in its turn to add its deadly 
influence to the troubles experienced by the woman, already so severe. 
The third degree is accompanied always, contrary to the first two. by DISEASES OF PREGNANCY. 
61 
a true rise of temperature, is characterized by effusion in the serous cavi- 
ties; it may originate only after confinements, or show itself already dur- 
ing pregnancy, and one may understand without difficulty the danger 
which it brings with it, both for the mother and child. Such is the 
common course of oedema, in pregnant women, but it is not always so. 
Second Form, Acute.-In some cases it takes a course truly acute, 
and is then generally accompanied by some fever. 
It is, moreover, in these grave cases that one meets with infiltration in 
the upper extremities and in the serous cavities. But as Prodhomme 
remarks, "while the effusion in the serous cavities generally only advances 
according as the infiltration rises from the lower to the upper parts, 
the visceral oedema, so to speak, more independent of the state of general 
infiltration, sometimes waits to form until the latter has attained a con- 
siderable degree, sometimes declares itself when the infiltration of the 
lower extremities is scarcely marked. Then they may appear rapidly, 
presenting in their progress the characters of the metastatic serous con- 
gestion which Lasserre has noted in the recently confined woman. It is 
then that we see arise pulmonary oedema, pleuritic pericardial effusions, se- 
rous effusion into the cranial cavity, cerebral oedema, and finally 
death." 
Of all the serous cavities, that which is most often and first involved 
is the abdominal cavity, and ascites is one of the varieties comparatively 
frequent in the dropsies of pregnant women. Cazeaux claims that hydram- 
nios, hydrorrhoea and ascites are only varieties of the intra-abdominal 
serous effusion. We cannot accept this opinion. Hydrorrhoea and 
hydramnios are special diseases, as we hope to show, and although it is 
true that hydramnios coincides often with ascites, there are a number of 
cases in which ascites exists alone, without the complication of hydramnios, 
showing thus the possible independence of these two dropsies. (Edema 
only arises secondarily, that is to say, when the disease has reached a 
certain stage; while ascites, except in case it depends upon some disease 
of the liver, never shows itself unless the oedema becomes general, or at 
least has taken a serious form or in some manner an acute. We will 
return to it in the study of hydrorrhoea and hydramnion in the chapter 
on the diseases of the ovum. We confine ourselves here to the study of 
ascites during pregnancy. 
Ascites. 
The first symptoms of ascites manifest themselves sometimes during 
the first months of pregnancy, more often toward the fifth or sixth month, 
rarely later. It may be produced slowly, gradually, or, as we have seen 
in one case, rapidly. In this last case, moreover, the quantity of effusion 62 
A TREATISE ON OBSTETRICS. 
into the abdominal cavity may be considerable, and if the effusion ap- 
pears early M there may be a marked disproportion between the size of the 
abdomen and what it should beat that period of gestation; and as, on the 
other hand, ascites is generally complicated by general oedema, there 
results a period of pain and suffering, which only goes on increasing as 
the disease advances. 
The effusion goes on increasing more and more until the infiltration 
becomes general; the patient presents a puffy appearance which gives 
the face a pale, livid look. The abdominal walls are greatly stretched 
and oedematous, extremely painful, and preserve the impress of the finger. 
Cazeaux compares this appearance to that of elephantiasis. The um- 
bilicus, enlarged at its base, forms a more or less prominent tumor, which 
can, according to Cazeaux, acquire the size of a hen's egg; but this 
tumor does not exist constantly, and, in one case, the umbilicus did not 
form such a tumor. All was limited to an enormous distension of the 
umbilical ring, and to a thinning of considerable of the skin in the 
neighborhood. 
The lower extremities and the greatly swollen genital organs increase still 
more the woman's suffering, who can neither stand, sit nor keep the dorsal 
decubitus, on account of the dyspnoea and pain accompanying respiration. 
If we try to palpate the abdomen, the extreme sensibility and the 
enormous distension of the abdominal walls render this almost useless. 
We make out easily dullness, but this dullness, contrary to that which 
occurs in ordinary ascites, is not displaced by the change of position of 
the patient. 
The presence of the uterus changes, indeed, the ordinary conditions, 
and as Scarpa has pointed out, the dullness, slight or null (in the hypo- 
gastric and iliac region) is very pronounced and very superficial in the 
left hypochondriac region. 
Fluctuation, very evident in certain cases, is difficult or even impossible 
to perceive in others, in consequence of the sensitiveness and distension of 
the abdominal wall. This is also the case even when ascites is com- 
plicated with hydramnion. The uterus is with difficulty made out 
through the walls of the abdomen. Its size can only be made out with 
much difficulty, the foetal parts are hard, if not impossible to feel. and. 
if the woman at this time perceives foetal movements, these are dull and 
.obscure; often auscultation gives no results. 
Depaul has nevertheless given two signs which enable us to recognize 
the uterus: first its abnormal mobility; this seems to us difficult to prove, 
but there is another sign, which is of great importance. It is this fact, 
mentioned by Depaul, which has been to us in one case a great* help in 
making our diagnosis, that when the abdomen is palpated for a certain 
time its form is seen to change, become more globular, more prominent, DISEASES OF PREGNANCY. 
63 
and at the same time forms under the hand a hard, globular mass, and 
one can with difficulty, it is true, but more or less clearly, appreciate its 
size and form. This mass is no other than the uterus, which hardens by 
the fact of its contraction. [The intermittent uterine contractions of 
Braxton-Hicks. -Ed. ] 
When the effusion is moderate, the woman only experiences a feeling 
of constraint, of general fatigue and of slight oppression, but when the 
effusion becomes great enough to greatly distend the abdomen, the pains 
become severe, depriving the woman of rest and sleep. And, moreover, 
as the effusion progresses rapidly, fever arises, but what is more promi- 
nent is dyspnoea, which may go on to complete orthopnoea, threatening 
the woman with asphyxia, syncope and serious complication from the side 
of the pulmonary cavity. 
In this case premature labor often comes on, especially if the woman 
has passed the seventh month, but unfortunately it is not always so; and 
particularly in the case where ascites is large in amount after the fifth 
month, one is often obliged to interfere. At other times, at last, the 
spontaneous death of the child interrupts the course of the disease; the 
child becomes thus a foreign body, remaining more or less long in the 
uterine cavity before it is expelled. It is understood that the prognosis 
of ascites complicating pregnancy will be more serious as it makes its ap- 
pearance at a period remote from full term, because its course is likely 
to be more rapid, and it will also be complicated with hydramnion. We 
will return again to this subject. 
Aside from ascites, serous effusions have a variable influence on preg- 
nancy; most often pregnancy follows its regular course; the effusions 
may disappear some days before confinement, or they may persist to that 
time. Pregnancy may be interrupted prematurely, or more rarely the 
patient may die before labor comes on. As for the child, it may be born 
strong and well developed, but it may also be born prematurely, or, 
finally, it may die during pregnancy. In general, delivery leads to a de- 
cided improvement almost immediately, and, at the end of some days, 
everything returns to its normal condition, but this is not always the case. 
Treatment.-When the dropsy is slight, rest and simple purgatives will 
suffice in general, associated perhaps with tonics and iron in small doses. 
But when the dropsy is more pronounced, we advise, as in case of 
dropsy with albuminuria, a milk diet. In one case we obtained excellent 
results. The oedema was general, but without effusion into the serous 
cavities. Cazeaux rejects absolutely the use of venesection and advises 
laxatives, vapor baths, friction and diuretics. Not only do we not believe 
venesection injurious, but, in the presence of congestion in such cases, we 
believe that it is, on the contrary, perfectly justifiable to a moderate 
degree, i.e., to relieve the vascular system of 3000 to 4000 grains of blood. 
We are more conservative in regard to punctures, which a great many 64 
A TREATISE ON OBSTETRICS. 
authors advise us to make on the labia majora and the lower extremities, 
in cases in which the oedema is very marked. The vitality of the tissue 
is somewhat modified, and the punctures may become the point of origin 
of gangrene. We are inclined, in such cases, to make three or four on 
each extremity and far apart. With Cazeaux, we do not advise blistering 
and irritating the skin. It is especially in cases of pulmonary congestion 
and encephalitis that we would advise blood-letting. 
Whenever the effusion has reached the visceral cavities, we advise, first 
and foremost, venesection, together with a milk diet, and, if these means 
fail, we advise paracentesis. The operation of thoracentesis, followed 
by success, without the interruption of pregnancy, as shown by Duguet 
in cases of acute pleurisy, ought to encourage us to perform the opera- 
tion in cases of non-inflammatory effusion as in the passive effusion, so 
to speak, of serous cachexia, and we would not, for our part, hesitate to 
have recourse to it. But, as we have said, the serous effusion is most 
commonly in the peritoneal cavity, and, in view of imminent asphyxia, 
paracentesis should be resorted to. 
As Cazeaux has remarked, the enlarged uterus makes it impossible to 
insert the trocar in the place usually selected in ascites. Scarpa also, in 
his paper on pregnancy complicated with ascites, advises that the punc- 
ture be made in the left hypochrondriac region, between the upper border 
of the external oblique musclesand the borders of the false ribs, in order to 
avoid the uterus, the puncturing of which he does not consider as serious as 
Chambon seems to think, and he quotes, in regard to this point, the cases 
of Camper, Langius, Reiscard and de Nissi, in which abortion was simply 
produced. 
In a case of ascites, Langstaff, as cited by Cazeaux, made an incision two 
inches below the umbilicus,to expose the peritoneum,which he pierced with 
a medium-sized trocar, but forcing it very slightly so as not to wound the 
uterus. After drawing off about ten pints of fluid,the uterus came in contact 
with the trocar, which gave such pain that it had to be withdrawn. A flex- 
ible sound or catheter, introduced between the uterus and the anterior sur- 
face of the peritoneum, withdrew the rest of the fluid. Eight hours after 
the operation, peritonitis, three days later abortion, recovery. Ollivier 
d'Angers, in a case in which the umbilicus projected considerably, opened 
this with a scalpel, a watery fluid poured out, and he withdrew at once 
twenty pounds of fluid. The discharge continued for twelve days; on 
the thirteenth the wound closed; twenty-eight days after the first punc- 
ture it had to be repeated, with the same result, and twelve days later 
natural labor set in, with the birth of a living, though feeble child; re- 
covery. 
When pregnancy is not far advanced paracentesis is the only resort, but 
when it is advanced to the eighth month, or further, should not the in- 
duction of premature labor be preferred? Cazeaux does not believe in DISEASES OF PREGNANCY 
65 
this, because he thought that paracentesis would offer sufficient relief, so 
that pregnancy would go to full term without difficulty. 
We think Cazeaux too hopeful on this point. Paracentesis, itself, is 
not always harmless. It may (as the case of Langstaff proves) give rise 
to peritonitis, which, on the one hand, may induce premature labor, and, 
on the other, may seriously compromise the life of the mother and child. 
Why then should we not have recourse to the induction of premature labor ? 
Still more should we do so if ascites is complicated by dropsy of the uterus 
i.e., by hydramnion. 
Pernicious Anemia of Pregnancy. 
It was not until 1871, when Gusserow published his first observations, 
that the pernicious anemia, of pregnant and puerperal women was really 
demonstrated. It has been studied by different authors, but in reality 
it is a rare disease, as the small number of observations collected up to 
date proves. Batut has only been able to collect a dozen well-authenti- 
cated cases. 
Etiology.-The abode of the woman, the manner of living and even 
the climate are said to be causes; but the real causes are pregnancy, and 
the functional disturbances which accompany the condition of child-bear- 
ing; also hemorrhages-in a word, all the causes which tend to depress 
the pregnant woman, which are summed up in the expression physiologi- 
cal distress. 
Symptoms.-At the outset it is generally insidious; and it is only in 
consequence of excessive fatigue, of a departure from the usual manner 
of living, that the patient experiences a general weakness, which, increas- 
ing rapidly, confines her in bed. At other, times, it is on account of 
some debilitating cause, abortion, uncontrollable vomiting, diarrhoea, that 
anemia declares itself, and this especially from the sixth or seventh month 
of pregnancy. Sometimes, as in the cases of pernicious anemia of 
Thierry, of Lauth, of Stoltz, it is only after labor that the disease appears, 
which is characterized by two great symptoms or phenomena, i.e., the 
absence of albumin in the urine, and a considerable diminution of the 
solid constituents of the blood, and particularly of the haemoglobin, which 
falls as low as 10 in 1000. 
Then the face becomes colorless, slightly puffy, the tongue is dry 
but not coated, and fever soon appears, which is accompanied with a cer- 
tain amount of emaciation, but always leaves the patient in a fair con- 
dition, which persists in spite of a certain amount of digestive trouble not 
slow in showing itself. 
We are always impressed with the general feebleness of the patient, 
which renders all movement difficult and painful, and this is accompa- 
nied by headache, dizziness, vertigo and sleeplessness, more or less com- 
plete, and above all by violent palpitations and dyspnoea, with a tendency 
Vol. IL-5. 66 
A TREATISE ON OBSTETRICS. 
to syncope on the least effort or exertion. The syncope increases in 
severity and duration according as the disease increases. It may even 
become fatal. 
On auscultation, the heart presents a systolic souffle more or less strong, 
which is transmitted into the vessels of the neck. The seat of the souffle 
is not fixed; sometimes at the apex of the heart, sometimes it is percep- 
tible over the whole cardiac area; as a rule it is heard at the base of the 
heart. As the disease advances, the souffle becomes dull, and, at the 
same time, the dyspnoea becomes worse, and there are disturbances of 
vision, the conjunctiva loses its color, and becomes extremely pale. 
This condition is accompanied by dropsy, at first localized in the cellu- 
lar tissue and lower extremities. It soon becomes general, and invades 
the serous cavities, pleura, pericardium, peritoneum, and always without 
albumin in the urine. Quinquaud has noticed some retinal hemorrhages, 
but they are rare. 
'rhe hemorrhages which frequently appear are epistaxis and bleeding 
from the gums; and, at the same time, patients are tormented by neural- 
gic pains, usually facial neuralgias. 
As to the digestive tract we observe all sorts of possible troubles, pyro- 
sis, nausea, vomiting, cramps, and complete anorexia. Then the patient 
becomes prostrated, more or less completely, the pulse is feeble, the heart 
slow and feeble, and she dies exhausted. In certain cases, in place of 
this rapid and progressive course, the anaemia becomes chronic, so to 
speak, with intermissions and remissions, more or less marked. These 
are deceitful because they inspire the hope of recovery which rarely comes. 
Pathological Anatomy. - On autopsy nothing characteristic is found, 
for the lesions described by some authors are met with in other morbid 
conditions. 
Treatment.-It consists, above all, in regulating the diet, but this is 
not easy to do, considering the difficulty of nourishing and sustaining 
the patient. Tonics, iron, etc., have been used. Oxygen has been re- 
commended, and, finally, Gusserow has used transfusion, as also has Fer- 
rand. It has failed in four cases. [In this pernicious anemia, arsenic 
frequently serves a better purpose than iron. Further, the bin-oxide of 
manganese, an excellent blood regenerator, might be tried. -Ed.] 
Considering the severity of the disease, is one authorized to induce 
premature labor or abortion ? 
This question we answer in the affirmative; the interest of the mother 
precedes all other considerations. We should not interfere too soon or 
too late, and it is the condition of the mother alone which can indicate 
the proper time to interfere. This will not always save the patient, for, 
in a number of cases, the pernicious anemia began after confinement. 
We must look to the future to settle this grave question. DISEASES OF PREGNANCY. 
67 
Ptyalism. 
Excessive salivation, or ptyalism, is not, in pregnant women, as rare 
or insignificant a symptom as Cazeaux seems to think. Besides the 
inconvenience and discomfort which it brings upon the pregnant woman, 
it weakens her considerably, interrupts assimilation, induces a certain 
amount of depression, which leads to emaciation and a tired feeling, 
sometimes very marked. It is true, the health of the woman is not, in 
general, seriously undermined; but ptyalism none the less merits the at- 
tention of the physician. Sometimes it may be accompanied by vomiting, 
sometimes, on the contrary, it may exist alone. Slight in some women, in 
others it becomes very abundant, even in the night, and deprives the patient 
of a certain amount of sleep. According to Cazeaux, it may be a temporary 
affair, in general of slight duration. The cases of serious and abundant 
salivation we have had do not allow us to share this opinion. In 7 cases 
the ptyalism began, so to speak, with pregnancy (3 times in the same 
woman), and persisted after the pregnancy, once 15 days, once 18 days, twice 
for 2 to 3 weeks, and 3 times in the same woman for 3 to 4 months after 
labor. Cazeaux himself has had similar cases. 
Unfortunately, the means of treating the disease are of little avail. 
Astringent gargles, sugar, ice, have usually failed. That which has 
the most power, and still its power is limited, is the use of bitter sub- 
stances, quassia, dry bitter orange peel, (of which the patient can keep a 
small piece always in the mouth,) brandy, used as a gargle several times 
a day. We have never, as Cazeaux, seen ptyalism cease toward the end 
of pregnancy, but have seen it, on the contrary, persist even to the 
end of that pregnancy, and appear again in the same woman in three suc- 
cessive pregnancies. 
Gingivitis of Pregnancy. 
This disease is characterized by a redness, a congestion of the gums on 
both maxillae, a puffiness which covers a part of each tooth, and forms 
thus a pad, more often on the anterior of both maxillae as far as the molar 
teeth. This pad of gums bleeds easily, the teeth become loose, shaky, 
and may, later on, fall out of their sockets. Then results a difficulty 
in mastication which becomes the more painful as the lesion is more 
pronounced. 
Pinard in 73 women, of whom 43 were multiparae and 32 primiparae, 
found it 31 times in primiparae and 14 times in multiparae. Multiparae 
are, then, more liable to this disease than primiparae. Former pregnancies 
and bad general condition appear to play an important part in the course. 
Gingivitis, as a ride, continues through pregnancy and only disappears a 
month or two after confinement. It persists, sometimes, longer in women 
Lesions of the Secretions and the Excretions. 68 
A TREATISE ON OBSTETRICS. 
who nurse. We have at present under observation a young woman in 
the seventh month of her pregnancy, who presents not only this gingivitis, 
but a true gingival tumor of the size of an almond, situated near the left 
canine tooth. The tumor is a bloody, fungoid tumor, which resists all 
treatment. Tincture of iodine, glycerol of tannin, chlorate of potash, rec- 
ommended by Pinard, have failed; chromic acid alone relieved the patient, 
but did not produce a cure, which will probably occur after confinement. 
The following solution, chloral and alcohol equal parts, advised by 
Pinard, has failed completely. 
Excretion of Urine. 
The secretion of urine during pregnancy is the same as in the non- 
pregnant state. It is neither increased nor diminished. But it is not 
the same with the excretion, which suffers marked modifications. At 
times there is retention, sometimes incontinence, and finally an incessant 
desire to urinate, occurring at different periods of pregnancy. These 
troubles may be referred to various causes, and in regard to incontinence, 
in particular, it may be observed in two distinct conditions. Sometimes 
it may succeed, or, better, accompany retention-that is to say, an incon- 
tinence by distension; on the other hand, there may be no retention; 
but, in multipart in particular, the vesical sphincter has lost some of its 
tonicity, and in walking, coughing, laughing, lifting, such women eject 
a small amount of water, which the bladder, having lost its retentive 
power, is unable to hold. There may be a true inflammation of the blad- 
der, cystitis, pains, malaise, frequent micturition. 
It is the grouping of all these urinary troubles, (not included in albu- 
minuria), which Monod and Terrillon have studied lately with great care, 
and both have shown that they are much more frequent than one would 
suppose. Thus Monod, on questioning 124 primiparse or multipart, not 
only as regards the existence of the urinary trouble, but also as to the 
pain, the frequency, and the time of the appearance of the trouble, has 
found that in 4 cases the vesical symptoms have shown themselves at the 
beginning of pregnancy in 33 women out of 131 cases. Here are the 
observations taken of 124 women: 
Women who did not suffer from urinary troubles in any period of 
pregnancy, 61. 
Women having urinary symptoms, 63. 
Women who had frequent micturition in the last two or three months, 
or rather in the last four months of pregnancy, 37. 
Women having vesical symptoms during the first weeks, 26. 
Of these 26 women, frequent desire to urinate only, 11; frequent and 
painful micturition and complicated by haematuria, 15. Among the 26 cases 
of urinary troubles at the beginning of pregnancy, 16 were primiparae, 
10 multiparae. To these figures must be added seven cases of Monod, DISEASES OF PREGNANCY. 
69 
and wo have the following total of cases in which the urinary troubles 
began at the commencement of pregnancy: Number of women, 131; 
with urinary trouble, 33. 
The causes of these troubles are, 1st. Mechanical. 2d. Inflammatory. 
They occur not only during pregnancy but more frequently after con- 
finement. They are due to pressure exerted by the foetal head on the 
base of the bladder, and to obstetrical operations, and are the product of 
true inflammatory lesions, which may produce sloughs or fistulas. But 
during pregnancy there is one cause more important than all others, the 
pressure exerted by the gravid uterus, which causes retention, and all the 
sequelae more or less severe which accompany it. 
Monod rightly distinguishes four cases; 1st. Retention during preg- 
nancy; 2d. Cystitis beginning at the commencement of pregnancy; 3d. 
Cystitis after the puerperal period; 4th. Cystitis independent of the 
puerperal state, but dependent upon uterine influences. 
1. Retention during Pregnancy.-The chief cause is retroversion of the 
gravid uterus. We only mention it here, and treat of it at length in a 
special chapter. We will say here, that it may become the cause of 
cystitis more or less severe, and can go on to the exfoliation of the vesical 
mucous membrane, (Wardell, Spencer Wells, Wittich, Philips, White- 
head-Haussman, Moldenhauer, Schatz, etc.). Finally, Playfair has re- 
ported a case in which retention was due to a mal-position of the foetus- 
transverse position. 
2. Cystitis.-But there is another cause of urinary troubles which declares 
itself in the first weeks of conception, and which is independent of all the 
ordinary causes of vesical inflammation. This cause of urinary troubles, 
mentioned by Terrillon, Ollivier, Hervieux, Madame Puejac of Montpel- 
lier, is simple cystitis, which may be accompanied by slight frequent 
micturition or dysuria, or acute pain, or hiematuria, or even by abor- 
tion, as in Ollivier's case. 
Cystitis, according to Monod, may be the result of passive hyperemia 
of the vessels which supply the bladder and uterus, accompanying those 
uterine congestions which occur at the beginning of pregnancy. It is 
not of special importance, except in regard to the conditions causing it. 
Mons has already mentioned cystitis of the first month of pregnancy, 
which he, with Churchill, attributes to a vesical catarrh, produced by 
reflex irritation: after the second month it is to be attributed to irritation, 
to pressure of faecal matter, the result of constipation, and also to retrover- 
sion. 
He acknowledges several varieties of cystitis, and mentions the fact that 
Tillaux, Parent, Richet have reported cases of varicose cystitis or hemor- 
rhoids of the bladder. Aside from this kind of cystitis, he mentions two 
varieties which he calls post-puerperal cystitis. One is produced only 
by traumatism during confinement, the other is idiopathic, and may be 70 
A TREATISE ON OBSTETRICS. 
produced after abortion, after a normal labor, and may disappear almost 
immediately after confinement, or more slowly (six weeks according to 
Monod, Gueneau de Mussy, Hervieux, Olshausen, Kaltenbach, Voille- 
mier, etc.). Finally, he mentions cystitis in women independent of the 
puerperal state, but not treated of here, and he arrives at the following 
conclusions: 
1st. Urinary symptoms, in pregnant women, arise from two different 
causes, and to each are attached a distinct group of clinical symptoms. One, 
the pressure of the gravid uterus which produces retention, the other 
vesical congestion, which is explained by the vascular connection between 
the uterus and bladder, and which produces, in the latter organ, a predis- 
position to inflammation. 2d. An acute cystitis, which is manifested 
during the first weeks of gestation. 3d. Cystitis observed immediately 
after or in the first weeks following a normal labor, which is called post- 
puerperal cystitis on account of the time of its appearance. 4th. The 
anatomical relation and vascular connection between the uterus and the 
bladder accounts for the frequency with -which urinary troubles accom- 
pany a great many diseases of the uterus, even under certain physiological 
modifications of this organ during menstruation or at the menopause, for 
example. 
There are, then, certain inflammations of the bladder peculiar to women, 
and, contrary to the common opinion, cystitis is far from being rare. 
Terrillon has reported a number of analogous cases, and the discussion 
of the subject (1880) in the Surgical Society, allowed several surgeons to 
increase the number of observations. 
Albuminuria. 
Albuminuria, albuminuria of Piorry, Bright's disease, consists, Jaccoud 
says, in a disturbance of the renal secretion, characterized by the presence 
of albumin in the urine. Considered from the standpoint of pregnancy, it 
may, according to Dumas, be presented under two very different forms: 
" One, which is entirely and intimately dependent upon pregnancy itself, 
the other independent of it, for its primary cause; but which, by the 
fact of its being coincident with pregnancy, follows a definite course, and 
apart from its origin, develops under its influence as the preceding. 
"Physiological pregnancy, by modifying the quality and quantity of the 
blood, is a predisposing general cause of albuminuria. But to produce 
the last, a cause must be added, and this may be due to a true patho- 
logical state of the blood, a morbid condition of the kidney, an acci- 
dental cause, or mechanical pressure exerted by the uterus, when it has 
acquired a sufficient size. The influence of labor may be similar to the 
mechanical pressure at the end of pregnancy; but it can only produce 
this effect when the predisposing cause has exercised its previous influ- 
ence. Finally, a woman may become pregnant when she already has. DISEASES OF PREGNANCY. 
71 
albuminuria. In this case there is a double influence to consider, one ex- 
erted by the albuminuria on the pregnant woman, and the other the 
influence of pregnancy on albuminuria." 
The conclusions of Dumas only confirm the opinion of Tarnier, who 
rightly admits that the albuminuria of pregnancy alone can no longer 
be regarded as a symptom of a single lesion, but that the passage 
of albumin in the urine depends, on the contrary, upon very different 
causes. We shall see in the section on pathogeny how many theories 
this question of albuminuria has raised. However it is, we can, with 
Dumas, state it as settled, that three conditions are necessary for the 
normal secretion of urine. 1st. A normal distribution of the generated 
fluid, or the mechanical integrity of the circulatory system; 2d. A normal 
condition of the blood; 3d. A normal filtration or anatomical and func- 
tional integrity of the kidney. 
But these three conditions not being met with in pregnant women, 
hence the possibility of albuminuria. Moreover, albuminuria may have 
existed before pregnancy. Finally, albuminuria may show itself only 
during labor. 
Hence the division admitted to-day by almost all authors: 1st. Albumi- 
nuria in pregnant women, with pre-existing renal lesions; 2d. Idiopathic 
albuminuria; 3d. Albuminuria complicating labor. 
Albuminuria of Pregnancy with Pre-existing renal Lesions. 
Pregnancy may occur in women having renal lesions before they be- 
come pregnant, and these lesions may or may not have been suspected. 
Bright's disease in these cases develops more rapidly and yields more 
quickly to pathological manifestations. Under the influence of pregnancy 
renal lesions may increase more and more, and produce, Bamberger says, 
in a short time, marked and incurable disorders. Pregnancy becomes a 
powerful auxilliary cause, and Dickinson has given an exact picture of 
the progress of the disease. 
" When the renal disease advances with pregnancy, it rarely attains a 
serious stage during the first gestation. Women may die, it is true, in 
eclampsia, but if they live, little by little the cedema will disappear, the 
urine will cease to be albuminous, and they will enjoy perfect health until 
the next pregnancy, which will lead to some accident. The oedema will then 
increase considerably; the patient will be more exposed to eclampsia, the 
complication will be slower in disappearing after confinement, and thus, 
at each new pregnancy, the renal symptom will become more chronic, 
until the albuminuria continues between the pregnancies, and the patient 
will then be exposed to all the complications which accompany granular 
kidneys." 
Hypolitte, who has reported a case, proves that in these cases albumi- 
nuria does not disappear from the urine, but persists until Bright's disease 72 
A TREATISE ON OBSTETRICS. 
has run its course in one way or another. But in these instances, as he 
has observed, the convulsions are not those of albuminuria gravidarum; 
they are uraemic convulsions and not eclamptic, and it is easy to make a 
diagnosis by taking the temperature, the appearance of uraemia and 
eclampsia differing essentially as we shall see. 
True Albuminuria Gravidarum. 
Albuminuria is far from being a rare disease, at least so the following 
statistics show: 
Blot among 205 women nine months pregnant, 41 times. 
Hypolitte " 165 " " " " 32 " 
Independent of labor, 32 cases, . 10 " 
Meyer 106 " " " .6 " 
36 in labor and puerperal state . 31 " 
Litzmann, . 37 " " " " " . 16 " 
Abeille, 10 per cent., 
Moricke, . 20 1 case. 
Petit, . . 143 29 cases. 
Dumas, who has collected all these statistics, gives 1 in 5 or 6. 
As to age, Devilliers and Regnault have fixed upon from 17 to 38 years, 
or from 17 to 30 years, as the period when the disease is most often seen. 
Bailly, on the contrary, attaches only a secondary importance to age. It 
is necessary, however, to take into account these statistics and those 
furnished by Peter, which seem to indicate that albuminuria is more 
common in young women than in older ones. 
Among 113 women, of which 27 were suffering from albuminuria, Peter 
found: 
Age. 
No. 
Albuminuria. 
15 to 20 years, 
19 
. . 6 
21 " 26 " . 
46 
11 
26 " 30 " , 
28 
6 
31 " 35 " . 
13 
1 
36 " 37 " . 
6 
3 
42 " 
1 
0 
Ought we not here to refer it to primiparity rather than to age, since 
it is more common as the women are younger? 
The influence of primiparity is, indeed, indisputable, and it is acknowl- 
edged by all authorities, thus: 
Blot, 
i Primipara, 
[ Multipara, 
99 
106 
Albuminuria, 30 
" 11 
Moricke, 13 cases, - 
( Primipara, 
( Multi para, 
" 10 
" 3 
Petit, 212 women, - 
i Primipara, 
1 Multipara, 
52 
60 
" 13 
" 13 
Bare during the first months, albuminuria is noticed above all after DISEASES OF PREGNANCY. 
73 
the sixth month and during labor. There have been reported, however, 
a number of cases of early albuminuria. These have been observed by: 
Bach, . . . at 6 weeks. 
Cazeaux, . . "4 months. 
Cohen, . . " 5 " 
Tn Therapeutic Bulletin/4 54 " 
Devanet, . . "6 " 
Ollivier, . . at 3 months. 
Depaul, . . "6 " 
Bernheim, . "7 " 
Petit, 
( " 5 
( " 6 
We have seen a case at six months and a half in a multipara who had 
shown it in two previous pregnancies, one of which was complicated 
with eclampsia. 
What are thecauses of albuminuria in pregnancy? The causes which, 
theoretically, produce albuminuria may be reduced to three: 1. Alteration 
in the blood, super-albuminous. 2. Excess of intra-vascular tension, 
(the hydremic state of pregnant women.) 3. Temporary or permanent 
disorder of the kidneys. 
1st. Super-Albuminous Blood.-This theory is based on the experiments 
of Cl. Bernard, who produced albuminuria by injecting into the veins 
a certain quantity of albuminous liquid; on the experiments of Schiif, of 
Stokvis, who showed that the development of artificial albuminuria is de- 
pendent upon the molecular state of the albumin injected; on the influ- 
ence of exclusive albuminous diet. (Cl. Bernard, Bareswell, Brown- 
Sequard, Tessier, Hammond). Gubler has proposed the following theory: 
" During pregnancy the mother's blood should furnish the foetus with 
material for nutrition, but only in a soluble and diffusible form, since 
there is no communication between the foetal and maternal surfaces of the 
cotyledons of the placenta. 
"There are, in consequence, various forms of albumin which are called 
upon to nourish the new being, and during this time, the maternal organ- 
ism must provide for a double waste by absorbing more, by a more strict 
economy of the proteid elements, or indeed by these two causes together. 
A greater quantity of these materials must be found ready at hand. It 
is enough that by virtue of a simple change in the mode of respiratory 
combustion the ternary substances should be consumed, and that the albu- 
minoid materials escaping the catalytic action of the liver, the direct 
changes in the capillaries should be entirely reserved for the role of plas- 
tic alimentation. 
"Now, by this new way of working, a system badly regulated or new 
may go beyond the mark, and the albumin becomes relatively excessive 
for the wants of the two organisms grafted one on the other. 
"This is the easier, since the albumin which has passed through the foetus 
without being employedin its development comes back loaded with waste 
material, since respiration is not yet established in the latter, whose urine 
normally contains albumin, as in batrachians, and never contains urea. 
Besides, this albumin, as a whole, has returned into the circulation of the 74 
A TREATISE ON OBSTETRICS. 
mother, seeing that the renal secretion, not appearing outside, is nearly 
suppressed during intra-uterine life. Albuminuria in pregnant women 
thus implies an over-production of albuminoid substances, considering 
the wants of the two organisms. 
" At times the mother produces too much, sometimes the foetus does 
not consume enough; at other times the two causes join in producing 
the result. 
"If these products increase with weight and dimensions, one may con- 
clude that the albuminuria is produced by organic disorders in the mother. 
If an albuminuric mother gives birth to a weak, sickly child, there is 
ground for assuming the want of development of the latter as having 
occasioned an excess of albumin in the blood and in the urine." 
As Hypolitte remarks, if this theory is admitted, albuminuria should 
be met almost constantly in pregnancy, but it is not, and, what is more, 
this theory does not explain the albuminuria of the first months when the 
nutrition of the foetus is very slight. Finally, the sudden disappearance 
of albuminuria after confinement in some cases could not be thus ex- 
plained; and again, children who are born of women suffering from albu- 
minuria do not appear much more sickly than others. Thus: 
W eight. Cases. 
Blot, in 32 cases of albuminuria, Twins, together, 12 pounds. 1 
Children more than 7| " 5 
" from 7|to6| " 20 
" less than C | " 6 
Depaul, in 13 cases at term : 
Weight. Cases. 
Albuminuric and eclampsic, from 9 to 8f pounds. 2 
" " 6f " 4 
" 6| " 5| " 5 
' 5f " 4f " 2 
Showing, in a total of 56 children, 39 were of an average weight or above, 
and 17 only below. 
Petit in 93 cases, 49 being boys and 44 girls, found 22 cases of albumi- 
nuria, 11 boys, 11 girls. Eleven times the weights were taken carefully 
and there were found, 
Weight. Cases. 
Between 8f-74 pounds, 3 
" 4 
6|-5^ " 2 
5f-4f " 2 
The average weight of each infant at term was from 7-f to 6| pounds. 
Cassin does not admit this, since he has found that children born of 
albuminuric mothers, weigh less than others, where the condition docs 
not exist. He believes in the depressing influence of albuminuria. DISEASES OF PREGNANCY. 
75 
Robin admits that, in pregnant women, haematosis is incomplete. This 
predisposes to an hydra?mic state of the blood, and the relaxation of the 
tissues; and facilitates and explains the passage of albumin into the urine, 
which impoverishes the blood and tends to increase its fluidity. 
2d. Excess of Intra-Vascular Tension.-Beau and Cazeaux, relying on 
the analyses of Andral and Gavarret and Becquerel and Rodier, first pro- 
pounded the theory of the existence of a serous-plethora in chlorosis and 
pregnancy. This plethora necessitates an increased arterial tension, 
which causes the passage of albumin into the urine. 
Upheld by Mangenest, Devilliers and Regnault, Robin and Verdeil, 
Bouillaud, Potain, Gregory, Johnson, Simon, Braun, Anderson, Finger, 
Gallo, Calderini and by Mosier, Kierulf, Herman, Stokvis, who have shown 
that an excess of water alone in the blood can produce albuminuria, by 
interrupting the equilibrium existing between the plasma and the globules, 
and adding the albumin of the latter to the serum, this theory has 
been taken up lately in a masterly way by Peter, who has given it the 
name of serumuria. 
"Even as," Peter says, "the pregnant woman, for the haematosis and the 
haematopoesis of the foetus, makes the materials for both, even so she per- 
forms the urinary functions for both. 
' ' The pregnant woman excretes daily a greater quantity of urine. While 
the woman in a normal state eliminates from 330 to 360 grains, Quinquaud 
has shown that of urea, the pregnant woman eliminates from 450 to 600 
grains, i.e., nearly one and a half to twice more than in the unimpreg- 
nated state. If she thus makes more urine in twenty-four hours, she 
ought to do more excretory work, i.e., more blood should be filtered by 
the kidneys, the greater the functional hyperaemia. But the more the 
blood in the organ the greater the vascular pressure, and the greater the 
vascular pressure the more the filtration, not only of the serum of the 
blood, but even of the blood itself, a phenomenon which is improperly 
called albuminuria, but which is serumuria." 
Moreover the kidney has a functional relation with the uterus, which 
has been established by Buquet. This author has noticed the enlarge- 
ment of the kidneys at the catamenia, in a case of ectropion of the organs. 
Finally, the renal arteries give passage to a large amount of blood, 
which congests the utero-ovarian arteries very much during pregnancy; 
hence the dilatation of the renal vessels and the increase in the hyperaemia 
of those organs. 
Blot had already pointed out, as a cause of albuminuria, the active and 
passive congestion of the kidneys, and a sympathetic nervous irritation of 
the organs, on account of the relation which exists between them and the 
uterus, and which produces albuminuria, just as irritation of the pneumo- 
gastric produced it in the experiments of Claude Bernard. 
Martin admits a direct relation between the kidneysand uterus. Every 76 
A TREATISE ON OBSTETRICS. 
increased stimulation of the uterine sympathetic system will react on the 
renal, and produce albuminuria. 
Blot, and some other authors, have added, as a cause of blood pressure, 
the mechanical action of the uterus, which presses on the great vessels of 
the abdomen, and impedes thus the return circulation. 
Frerichs, Braun, Rosenstein, Wieger, Beckmann, Krassing, Brown- 
Sequard, Jaccoud, Rose Cormak, Barker, Correnti, Molas, Mohammed, 
Moricke, Hubert de Louvain, have accepted this last theory. 
It is impossible, indeed, to deny this action of the uterus in the last 
months of pregnancy, but if it is true that albuminuria is most often met 
with in this period it is none the less true that it is sometimes very often 
met with, so to speak, at a period when it is impossible to refer it to the 
pressure of the uterus. We are forced, therefore, to look for another 
cause, and that of Peter seems the most rational. 
This theory of Peter has lately been urged by Moricke: " The stasis of 
the blood is the cause and origin, for the most part, of nephritis in preg- 
nant women. This stasis acts in two ways: first, causing, as Peter says, 
a renal hypercemia; second, alterations in the blood. We know, from 
modern research, that want or lack of oxygen is the cause which produces 
fatty degeneration of the kidneys. The intra-abdominal pressure being 
increased during pregnancy (aside from the direct pressure exercised by 
the gravid uterus on the renal vessels), produces an obstacle to the return 
of venous blood to the kidneys. The circulation is not increased in the 
kidneys, but diminished notably; a less number of red globules pass in a 
given time than in the normal state. (These red corpuscles are, on ac- 
count of the pregnant state, less numerous). Consequently, the quantity 
of oxygen which is taken from these globules by the tissues is diminished 
in amount. There results, then, disturbances of nutrition and fatty de- 
generation. Would this condition of the blood predispose also to inflam- 
matory changes? This seems probable, according to Nasse, who says: 
"up to the present, the uterine lymphatics have not been studied in 
pregnant animals, but it is very possible that they may play some part 
in renal inflammation, and even the change in the blood in pregnancy is 
analogous, in a general way, to that which exists in cases of renal inflam- 
mation." 
Bailly rejects this explanation, for he thinks that serous-polyaemia is a 
theoretical rather than a real state of the blood, and, although certain 
eclampsic women are pale and anemic, others, apparently strong and vig- 
orous, are none the less victims of the disease. 
3rd. Temporary or Permanent Kidney Disease.-In other words, Can 
pregnancy become the cause of renal lesions ? 
AVe have seen that Nasse and Moricke incline to the affirmative, although 
they admit this only hypothetically. Rumberg goes farther and says that 
albuminuria cannot exist without a kidney lesion. The filtration of al- 77 
DISEASES OF PREGNANCY. 
bumin is only explainable by some modification in the permeability of the 
membranes, and, even as Robert has shown by his statistics that Bright's 
disease is much more common in pregnant women during the period of 
sexual activity, Ollivier arrives at the same results, and concludes that 
in a good many cases pregnancy may cause or hasten Bright's disease. 
We find, then, that the theory of renal lesions as a cause of albuminu- 
ria gravidarum, a theory first stated by Rayer and sustained by Gregory 
Christison, Addison, Johnson in England, by Imbert Gourbeyre, Cohen, 
Blot, Cazeaux, Devilliers, Regnault, Bach,Gubler, Becquerel and Vernois, 
Lorrain, Jaccoud, Wieger, and modified by Peter and Petit in France, 
defended also by Litzmann, Frerichs, Braun, Schottin and Rosenstein, is 
generally accepted. 
But opinions differ as to the frequency of these alterations. While Bailly 
admits that albuminuria is very common, particularly in the acute form, 
in pregnant women, Blot, Abeille, Barker, Braun, Bamberger, Iloff- 
meier, Mbricke, Hypolitte, recognize the renal lesions, but consider them 
much less common, and add that the renal lesions may, sometimes, ante- 
date the pregnancy, and at other times depend upon other causes than 
those of pregnancy. Bartels, Spiegelberg and Schroeder claim that the 
changes in the kidney during pregnancy are analogous, not to say identi- 
cal, to those in the liver, and admit, with Dickinson, that the kidney 
during pregnancy may undergo a fatty degeneration. There exists a 
puerperal kidney as well as a cardiac kidney, the first being more dan- 
gerous than the second. 
Olshausen acknowledges the kidney lesion, but the primary lesion he 
considers a catarrh of the bladder, the other only being a secondary lesion. 
The inflammation is transmitted to the uterus, thence to the kidneys 
secondarily. 
Cassin has revived the opinion of Bouchard, and refers to this interest- 
ing fact: il When albuminous urine is boiled, add Tanret's reagent, or 
picric acid, albumin coagulates, and this coagulation may take place in 
two ways: 
"Either the urine remains opalescent or milky, or it may separate out, 
and the albumin presents a solid mass in the liquid (this mass may be 
solid or lumpy or as fine as sand). Each of these conditions has a distinct 
significance. The finely coagulated albumin represents a transient albu- 
minuria, such as one observes in severe fevers, alcoholism. The retrac- 
tile coagulum, on the other hand, indicates a renal lesion, provided we are 
certain that the urine contains neither blood nor pus." 
Cassin, in 47 albuminuric women in labor, has found in 31 cases the 
urine opalescent in appearance, and 16 times the albumin was precipi- 
tated in lumps. In the 31 cases, the albumin disappeared in forty-eight 
hours; of the 16 cases, in six the albuminuria was slight, in ten the albu- 
minuria persisted, in seven the urine contained cells and a great number 78 
A TREATISE ON OBSTETRICS. 
of granular casts, identical to those which line the tubules. In the ten 
in which the albuminuria was retractile, 4 had puerperal complications. 
The observations were taken on 124 women: 
5 observations during the 7th month 0 albuminuric 
45 " " 8th " 5 
124 " " 9th " 8 " 1 in 15.5. 
The figures of the ninth month represent the total, because the exami- 
nations of the previous months were continued. 
Cassin, taking the different opinions of authorities, shows that they 
may be reduced to three: 1st. A chemical condition of the blood. 2d. 
Change in pressure. 3d. Conditions of the histological elements of the 
kidneys. But he denies, or at least accepts only partially, the first two 
theories, and accepts the idea of fatty degeneration of the kidney. " It is 
sufficient to realize that the liver and kidney are organs which cooperate 
with each other, in order to infer that changes which pregnancy produces 
in the latter organ would take an important part in the pathology of 
albuminuria." 
Hoffmeier, who believes in the theory of the kidney lesions, has made a 
careful study of them, and found in 5000 confinements in Schroeder's 
clinic, from September 1st, 1867, to April 1st, 1878, 137 cases of nephritis, 
of which 104 were complicated by eclampsia-2 per cent. He has col- 
lected them in the following table: 
Nephritis with Eclampsia, 
Nephritis alone, .... 
Total, .... 
O co 
4- W 
Total. 
O' 
to 
11 
41 
Deaths. 
* 
co 
O' 
c> to 
co to 
Living. 
co 
tO 
Cl to 
to o 
Children 
born dead. 
Cl 
4- I-* 
Cl O' 
Children 
born living. 
to to 
? 
CD 
co 
CO to 
Acute. 
Ci 
31 
15 
Chronic. 
From this table we see that nephritis does not compromise the life of 
mother and child solely on account of the possible complication of 
eclampsia, but that the form in which it presents itself ought to be given 
serious consideration. 
This is, besides, the opinion of Bartels, who says, " In cases in which 
pregnancy, confinement, and the puerperal state pass without ursemic 
symptoms being developed, rapid recovery generally follows, with a com- 
plete disappearance of the renal symptoms; but, as Litzmann adds, the 
passage into a chronic state is more frequent than in other forms of acute 
nephritis. " 
Hoffmeier has often noted a corresponding alteration of the liver, and 
sees in this proof that nephritis depends upon an over-activity of the renal DISEASES OF PREGNANCY. 
79 
function, and in the fact that albuminuria is met often in twin pregnan- 
cies. In 137 cases of nephritis, there were 9 cases of multiple pregnancy. 
Nephritis during pregnancy may occur in two forms; acute parenchy- 
matous-m this form chiefly do we have eclampsia (in 104 cases given 
above, in 89 renal symptoms declared themselves suddenly)-at other times 
a chronic form, characterized generally by a diminution of urine which 
may go on to complete suppression. The urine contains a considerable 
amount of albumin, and more or less casts. In 137 cases cited by Hoff- 
meier, 46 presented this form, of which 31 had simple nephritis and 15 
nephritis with eclampsia. It is in this form, as Litzmann and Georgi have 
shown, that one sees the disease develop a chronic inflammation of the 
kidneys. 
lloffmeier has found in 28 women, discharged living, 8 only could be 
considered cured, 5 were unknown and 15 were discharged still having 
symptoms of the disease. 
What is the conclusion to be drawn from all these theories ? On which 
can we rely ? We believe it is impossible to adopt one exclusively, and it 
is also true that each of the authorities who have proposed these different 
theories would be obliged to confess that they could not explain all cases 
of albuminuria during pregnancy by it alone. The theory which attri- 
butes albuminuria to a temporary or permanent renal lesion seems to us 
most rational, and yet it has happened to us, as to all authors, to make 
autopsies on eclampsic and albuminuric women, and never to have found 
either superficially or with the microscope any renal lesion. We think 
that Cassin is absolutely correct when he concludes in regard to these dif- 
ferent theories in the following way: " Pregnancy produces a condition 
favorable to the passage of albumin into the urine, but the change of 
the blood, by pressure, or by its constitution, the influence of renal stea- 
tosis, do not explain it, because leucomuria should be as frequent as the 
gravid state. They explain only the tendency to albuminuria. The fire 
is ready, a spark is wanted to light it up-then, under the least pathologi- 
cal influence, the renal trouble shows itself without always being the ex- 
pression of the same lesion." 
Mohammed and Barnes have further demonstrated that the use of the 
sphygmograph in the puerperal state would give us warning of impending 
albuminuria, and its frequent consequence, eclampsia. " The strong 
arterial tension which exists generally in the latter part of pregnancy is 
most marked in primipara* and constitutes a predisposition to albumin- 
uria and eclampsia. One should fear, then, these two accidents. Where 
the lying-in period is normal, this high tension soon disappears, as we 
can prove at the second to the third day, in the tracing which corresponds 
to the milk fever. This tracing is very characteristic. It indicates a full 
pulse, soft, slightly dicrotic, beating 120, and is simply the vascular excita- 
bility following the secretion of milk. It is analogous, according to Mo- 80 
A TREATISE ON OBSTETRICS. 
hammed, to the condition which exists in man during a state of alcoholism. 
Afterward the pulse becomes gradually normal, also the temperature 
(100° to 101°) which accompanies this strong tension pulse. If it persists, 
it indicates some unfavorable complication which may predispose to al- 
buminuria, i.e., a chill, which increases tension in the kidneys, constipa- 
tion, which poisons the blood, unless indeed this increased arterial tension 
is not due to nervous excitability, which alone may suffice to cause it, as 
the author observed in a case after the use of chloroform and forceps." 
(Ilypolitte.) 
We cannot accept this comparison of Barnes, milk fever being, 
in our opinion, very rare, and its physiological appearance, as is 
seen from study and. observation, and the thesis of Chantreuil, is accom- 
panied by a pulse of about 100 to 104 and a temperature of about 98.2°. 
Should the pulse and temperature pass these limits, the puerperal period 
is no longer physiological but pathological, the woman is sick, and, if the 
high tension pulse exists as a prodroma of albuminuria (as it may, wo 
admit, according to Mohammed and Barnes), it may also be met with in 
other conditions, particularly in any of the accidents which complicate a 
physiological lying-in period, and endanger seriously the woman's life. 
Summing up the causes of albuminuria in pregnant women, we can 
say with Dumas: 
1st. Pregnancy is a predisposing cause of albuminuria: a. By 
the age at which it occurs; b. The disturbances in the stomach, 
lungs and nervous system which accompany it; c. The modifications in 
the quality and quantity of the blood which are the result; cl. The nature 
of the albuminoid material introduced into the circulation; e. The con- 
gestion of certain organs which this state of blood induces. Women are, 
during pregnancy, predisposed to albuminuria. 
2d. Pregnancy is an efficient cause of albuminuria, a. In primiparae; b. 
By the functional relations which exist between the uterus and the kid- 
neys; c. By the increase of urinary secretion; d. By the mechanical 
pressure of the uterus, (in primiparae, twin pregnancies, retroversion, hy- 
dramnios, rachitis; c. By morbid conditions which may accompany it and 
to which it may always give a serious aspect (pernicious anaemia, diseases 
of the heart). 
3d. Pregnancy may act at the same time as a predisposing and exciting 
cause, whenever there exists one of the occasional causes which we have 
enumerated. Hence: 
a. Albuminuria dependent upon changes in the blood, (albuminuria 
in the early part of pregnancy, albuminuria or dyscrasia of pregnancy). 
b. Albuminuria dependent upon anatomical and functional changes 
of the kidneys (organic albuminuria of pregnancy). 
c. Accidental albuminuria of pregnancy. 
d. Mechanical albuminuria of pregnancy (albuminuria in the last 
months of pregnancy). 81 
DISEASES OF PREGNANCY. 
Symptoms.-The first and only valid one is the presence of albumin in 
the urine. There are two methods for analysis, heat and nitric acid; but 
if one wishes to be more exact, he must adopt the method of Petit or 
Ritter. [The descriptions of these methods are omitted, and our 
readers are referred to works on medical chemistry for methods of estima- 
ting the amount of albumin in the urine.-Ed.] 
Other symptoms are the general condition of the patient, who is chlorotic 
or anaemic, with various digestive disturbances, and becomes gradually 
pale and feeble. Next, oedema appears; first in the lower extremities, 
slowly becomes general, and invades the face, so that the patient presents 
a characteristic appearance. 
(Edema remains permanent in these localities, but it may vary in its 
amount, and even collect in the serous cavities, and there may be general 
anasarca. But puffiness about the face is never absent. The pulse, 
small, hard, thready, quick, is, in some cases, particularly when eclamp- 
sia is imminent, almost imperceptible. Finally, there may be hemor- 
rhages, epistaxis, haematuria. Thirst is excessive, digestive disturbances 
are very pronounced, and may be accompanied by pain in the epigastric 
region, and alternately obstinate constipation or a persistent diarrhoea. 
Next the respiratory functions are more or less disturbed, there is dyspnoea, 
cough, and lastly neuralgic pains appear, cephalalgia, indistinct vision even 
to blindness, stupidity and deafness. These last symptoms generally an- 
nounce eclampsia, but they are often slightly pronounced, and albumin- 
uria may pass unperceived if the urine is not carefully examined. 
This is, indeed, a precaution that should be taken in all pregnant 
women, particularly primiparae. The examination should be repeated ht 
intervals, above all at the end of pregnancy, for at this time albuminuria 
is most likely to show itself, although it sometimes appears earlier. 
Prestat reports cases in second month, Bach in sixth week, Cazeaux at 
four months, Cohen and Peter at five months. As a general rule it ap- 
pears sooner in primiparae than in multipart. Another reason for exam- 
ining the urine at frequent intervals, is that the quantity of albumin 
which may be found is variable, not only from one day to another, but from 
morning to evening. Albuminuria may disappear completely for a time 
to reappear again in greater quantity. Its duration may be very tran- 
sient, sometimes only for a few days or hours but more often for five or 
six weeks, increasing up to the time of confinement, to disappear entirely 
in three or four weeks after labor. This is not always the case, and we 
have seen it once persist after confinement. Tarnier has seen it last fif- 
teen months. 
We confined, six months ago, a patient in whom albuminuria still per- 
sists. Finally, albuminuria alone may kill the patient, as observations 
show. 
Vol. II -6. 82 
A TREATISE ox obstetrics. 
The greater the albuminuria, the more quickly will pregnancy be in- 
terrupted. 
In.the twenty-eight cases cited above from Hoffmeier, only ten went 
to full term. In eight of these the pregnancy was interrupted in the ninth 
month (the Germans count pregnancy by the ten lunar months), and in 
nine at a time when the foetus was not viable; and of eighteen women 
who died, five went to the end of their pregnancy; in five pregnancy was 
interrupted in the ninth, or from the ninth to the tenth month; three 
before the beginning of the ninth month. 
Of forty-five cases of pregnancy with nephritis: pregnancies going to 
term, fifteen; premature confinements, thirteen; abortions, seventeen. 
Albuminuria of Labor. 
Under this name, we understand not only albuminuria recognized dur- 
ing labor, but, according to Ilypolitte, Peter, Dumas, Cassin, albuminuria 
of the two or three days which immediately precede labor. It appears 
essentially dependent on this act, begins and ends with it, and its duration 
and intensity are often proportionate to the duration of labor. Petit has 
shown that if Peter's theory can fully explain all the particulars of album- 
inuria of pregnancy, it is not so in albuminuria of labor, and, whilst adopt- 
ing in great part the ideas of his teacher, he thus modifies Peter's theory: 
'\1 priori one would think that expulsive efforts alone are capable of 
eongesting the kidney enough to cause filtration of the urine, but if we 
consider what hikes place in the part of the abdominal circulation during 
dilatation, we will easily realize that this organ must undergo, at the 
salne time with each uterine contraction, a certain degree of hypersemia, 
capable also, although in a less degree, of producing the same result. 
The uterine vessels, arteries and veins, acquire an extreme development 
during pregnancy; the uterine circulation is interrupted more or less com- 
pletely in the uterine walls during a uterine contraction. The enormous 
quantity of blood brought continuously by the utero-ovarian arteries ceases 
at each uterine pain, to find a free flowthrough the uterus. There results 
then, by a mechanism somewhat analogous to that of the hydraulic ram, 
an increased pressure in the portion of these arteries which remain perme- 
able and also in the trunks from which they spring. 
"The utero-ovarian arteries arise from the antero-lateral part of the ab- 
dominal aorta, a short distance from the origin of the renal arteries, and 
at times they arise from the renal arteries themselves. It is then in the lat- 
ter, as well as in the kidney, that this increased pressure is felt soonest and 
strongest. But while it shuts off the passage of arterial blood toward the 
uterus, each uterine contraction presses out in some way the engorged 
uterine blood, and accelerates the return utero-ovarian circulation: again, 
the abnormal distension of the trunks to which these veins lead, i.e., the 
part of the inferior vena cava, near the opening of the emulgent veins, DISEASES OF PREGNANCY. 
83 
or some of the emulgent veins themselves, hinders the course of the blood 
which returns to the kidneys; and venous stasis in the organs results, i.e., 
a condition favorable to the production of albuminuria. If these views 
are correct, uterine contraction exerts a pressure toward the kidney from 
two sides at once: through the arteries by increasing arterial tension, 
through the veins, by increasing venous pressure; and we perceive how 
this arterial tension, persisting for a long time, determines the passage of 
albumin into the urine; above all if we admit with Peter that there exists 
physiologically, by the fact of pregnancy alone, a functional hyperamiia of 
the kidney. 
Finally, Peter believes that the abdominal muscles have a part in this 
pressure. As to the notable increase in the albumin which he has de- 
monstrated in the first urine passed after the birth of the foetus, Petit 
explains this by the fact that, " accustomed to work during pregnancy, 
under a gradually increasing pressure, of which they are suddenly de- 
prived, the kidneys find themselves exposed to an intense congestion." 
Frequency.-Albuminuria of labor is much more frequent than that of 
pregnancy, and it has been met with by Blot 1 in 5; Petit 1 in 4.8; 
Hypolitte 1 in 4.23; Litzmann 40.78 per cent. Mdricke 37. per cent. 
Age and primiparity play an important part: thus Cassin has found, in 
427 cases, 197 primiparae, 67 or 34 per cent; 250 multiparae, 42 or 16 
per cent. 
Number of Pregnancies. 
143 II. parse, . . . . . . 25 = 1 in 5.68 
66 III. " 9 = 1 " 7.3 
12 IV. " 3 = 1 " 4 
13 V. " 1 = 1 " 13 
4 VI. " 0 
7 VII. " 2 = 1 " 3.5 
5 having had more than 7 children, . . 2 = 1 " 2.5 
9 less than 18 years, . . . . 5 = 1 in 1.8 
142 from 18 to 24 years, . . . . 43 = 1 3.3 
37 " 24 " 30 " . . . . 15 = 1 " 2.4 
7 more than 30 " . . . . 4 = 1 " 1.6 
The difference of the length of labor is very marked; less, however, 
than would be supposed. Thus, according to Cassin: 
Av. length of labor. 
Primiparae, albuminuric, 31; vertex presentation L.O.A. 17| hours, 
non-albuminuric, ... " 12 " 
albuminuric, .... R.O.P. 12 " 
non-albuminuric, . . . " 16 to 17 " 
Multiparae, albuminuric, 31 . . . . L.O.A. 9| " 
non-albuminuric,» . . " ' 7 " 
albuminuric, . . . . R.O.P. 18| " 
non-albuminuric, ... " 9 " 84 
A TREATISE ON OBSTETRICS. 
In our opinion this table is not of great value, because it is in positive 
contradiction to facts daily observed. 
Presentations in R.O.P. would give, if one refers to the tables of Cassin, 
a duration of labor much greater in multiparas than in primiparae, but 
the contrary is true. Indeed, intervention is more frequent in primiparae 
than in multiparae; but even taking into account this intervention, the 
duration of labor is not comparable in the two cases. It is the same of 
dystocia, of which Cassin does not describe the nature. 
In 338 women not albuminuric, there were 12 cases of dystocia, or 3.5 
per cent. 
In 109 women albuminuric, there were 18 cases of dystocia or 16.5 per 
cent. Albuminuria, in turn,predisposes to hemorrhage. Thus, from Cazin: 
In 338 women not albuminuric, there were 26 cases of hemorrhage. 
In 109 women albuminuric, there were 23 cases of hemorrhage. 
We note finally, according to Payer, Blot, Imbert Goubeyre, Molas, 
etc., that these hemorrhages, generally uterine, manifest themselves par- 
ticularly at the time of delivery, and may be met with in other organs, 
the liver, brain, lungs and bladder. 
Although we have insisted at length on the frequency of oedema and 
dropsy, it is not to be believed that there is a constant and absolute rela- 
tion between oedema and albuminuria; because, on the one hand, it may 
be absolutely absent, when women are albuminuric, according to the re- 
searches of Blot, and the cases we have cited in our thesis of 1872, and, 
on the other hand, oedema exists often in pregnant women, without a 
trace of albumin in the urine, and this fact has been demonstrated with- 
out a doubt by Devilliers and Regnault. 
The last point to be noted is the relation which exists between albu- 
minuria and eclampsia, and, without encroaching on the following chapters, 
which are devoted to eclampsia, there is a statement one can make almost 
absolutely,-we say almost, because there are some exceptions. This is 
the statement: " If all albuminuric cases are not eclampsic, all eclampsia 
patients are albuminuric." 
Peter does not admit this. It follows, however, from these statistics: 
Albu. 
Non-albm 
Lever, 
in 
14 cases of eclampsia, 
13 
1 
Brummerstadt, 
a 
135 " " " 
. 106 
29 
Miezkowski, 
ii 
50 " " " 
. ' . 46 
4 
Staude, 
Ci 
40 " « " 
. ' . 32 
8 
Macdonald, 
cc 
9 « « 
8 
1 
Depaul has met in his private practice and in that of his colleagues, by 
whom he was called in consultation, twenty cases where he did not find 
albumin, and we can add cases of Trousseau, Leuret, P. Dubois, Imbert 
Goubeyre, Mascarel, L'huillier, Schroeder, Trelat, Spiegelberg, Davis, 
Hartmann, Hicks, Osborn, Van du Meersch, Dohrn, Fabre, etc. DISEASES OF PREGNANCY. 
85 
These cases, although exceptional, tend to increase, and they justify our 
assertion. The frequency of the occurrence of eclampsia and albuminuria 
has been noted by all authors: Blot in 41, albuminuric 7 times; Stoltz in 
7, 1; Devilliers in 20, 11; Mayer in 63, 7; Litzmann in 13, 5; Braun in 35, 
6; Imbert Goubeyre in 159, 94; Hubert du Louvain in 135, 36; Rosen- 
stein in 40, 10; Hoffmeier in 30, 10; Macdonald in 5, 5. 
The two tables reported in our thesis were furnished us by : 
Labors. 
Eclampsia. 
No albuminuria. 
Clinic, . 
. 30,283 
133 
4 only. 
Maternity, . 
54 
2 " 
As albuminuria, so eclampsia is more frequent during labor than 
during pregnancy, and there is here also a direct relation between eclamp- 
sia and albuminuria. Eclampsia in some cases may appear early, most fre- 
quently, however, during the seventh or ninth month, above all during 
the few days or hours which precede labor, but it may come also after 
labor-thus: 
Cases. 
During 
During 
After 
Pregnancy. 
Labor. 
Labor. 
Jacquemier, 
. 197 
53 
59 
85 
Jaccoud, 
. 47 
18 
20 
8 
Braun, 
. 44 
12 
21 
11 
Wieger, 
. 455 
109 
235 
111 
Scanzoni, . 
. 28 
2 
23 
3 
Pajot, 
. 200 
60 
100 
40 
Diagnosis.-This depends on two conditions: 1st. To establish the fact 
of albuminuria. The examination of the urine leaves no doubt; 2d. To 
find out whether the albuminuria is dependent upon pregnancy, or upon 
other causes. Here the sign given by Bouchard and Cassin may be of 
great importance, coagulation of albumin indicating, according to them, 
a renal lesion; the non-retractile coagulum indicates a transient albumi- 
nuria, such as we observe in severe forms of alcoholism, etc. The im- 
portance of this sign is understood (if further observations confirm it) not 
only from a diagnostic, but also from a prognostic standpoint. 
Prognosis.-The disease may be always considered grave, because, if a 
number of women are cured, there are a great many who die, either from 
the disease itself or from the complications, and we have seen how the 
albuminuria of pregnancy can become the starting point of a chronic 
nephritis. 
The prognosis will vary according to the nature, the duration, more or 
less long, of urinary troubles, their intensity, the existence or not of kid- 
ney lesions and the morbid cause, the severity of the complications. 
The prognosis is particularly grave when the albuminuria exists pre- 
vious to pregnancy, although we make an exception in case of albumin- 86 
A TREATISE ON OBSTETRICS. 
uria of labor and of eclampsia. Hoffmeier, in 48 cases of chronic 
nephritis, has noted death 18 times. In 104 cases of eclampsia death has 
resulted in 39 per cent.; Rosenstein 32.9 per cent.; Devilliers in 11 out 
of 20 cases. 
Albuminuria is no less fatal to the foetus than to the mother, and even 
excluding eclampsia, which has an extremely bad prognosis for the child, 
albuminuria is none the less one of the causes which threatens seriously 
the life of the child. On the one hand, indeed, it may die from the dis- 
ease itself, and again, albuminuria being a frequent cause of abortion and 
premature labor, it compromises certainly the life of the child, or subjects 
it to all those untoward circumstances in which the child finds itself when 
born before term. 
Blot reports 6 cases of premature labor. Bayer, Barker, Hubert de 
Louvain admit the frequency of abortion and premature labor. The 
same is true of Braun, 80 per cent. Hoffmeier in 45 cases of nephritis 
has only seen 15 cases go to term, 13 premature labors, 17 abortions; and 
in 33 cases of simple nephritis, 20 children died, 13 lived; in 104 cases 
of nephritis with eclampsia 62 children died, 46 lived, i.e., in a total of 
137 cases, 82 children died, 61 lived. 
• Finally, albuminuria, aside from post-partum hemorrhage, predisposes 
the patient to puerperal complications, (peritonitis, septicaemia, puerperal 
mania, etc.,) and we readily see the importance of treatment. 
Treatment.-Considering the number of causes of albuminuria and the 
different theories which have been given to it, one can understand, as 
Guinean de Mussy has said, how absurd it would be to seek for a uni- 
form treatment for albuminuria; but it is not at all the same of the al- 
buminuria of pregnancy. This, indeed, presents peculiar characteristics, 
by the fact that it is intimately dependent upon pregnancy, by its fre- 
quent relation to eclampsia, by the influence which it exercises on the 
child; by those circumstances, in a word, under which it is produced. 
The increase in the quantity of blood, the alterations in the pregnant 
woman, the changes which take place in the circulation, the particular 
tendency to congestion which the woman presents during gestation, seem, 
a priori, to indicate the direction this treatment should take. 
Diminish, combat, suppress, if you can, this tendency to renal conges- 
tion, bring the blood into its normal condition; these are the two great 
indications which should govern our treatment of albuminuria gravidarum. 
Venesection fills better than any other treatment the first indication, 
and here we agree with Peter, our teacher and friend. We cannot go as 
far as he does, in admitting that the greater frequency of complications, 
and of eclampsia, in the last thirty years, depends on the fact that vene- 
section in pregnant women has been lost sight of. But it cannot be de- 
nied that venesection, in a great many cases, renders wonderful service, say 
4500 grains, and, as we have already said, we have seen Beau derive excel- DISEASES OF PREGNANCY. 
87 
lent results from it. We prefer general blood-letting to local (leeches, 
cupping,) which do not appear to us without inconveniences, in oedemat- 
ous and greatly swollen women. Should we make use of it in every case ? 
No, for if bleeding has its advantages, it also has its disadvantages, and 
it may, in certain women, even when it is moderate, cause a feeble state 
which cannot be without danger to mother and child. Venesection, in- 
deed, withdraws blood-globules from the pregnant woman who has less 
than the normal amount. Finally, there are cases where it is impossible 
to use it. We have at this moment a case in mind. The woman in ques- 
tion is pregnant for the fourth time, and, beside a slight amount of albu- 
men, has hemorrhages, dependent, probably, on a faulty insertion of the 
placenta. 
The patient has been pregnant for eight and one-half months, and has 
already had, at intervals of forty-eight hours, two hemorrhages, slight it 
is true, but dependent upon placenta praevia. In presence of the possibil- 
ity of a future severe hemorrhage, we do not dare to weaken the patient 
by blood-letting, inasmuch as these two spontaneous hemorrhages have 
not led to any amelioration of the condition of the patient. 
Further, before bleeding, we should always make use of purgatives, in 
a repeated and constant manner. We try to obtain, by means of purga- 
tives, a serous intestinal discharge, which withdraws from the woman a 
larger quantity of serum, leaving behind the blood-globules, and therefore 
we prefer the saline purgatives, sulphate of soda, sulpho-vinate of soda, 
Seidlitz powders, Carlsbad salts, mineral purgatives, Seidlitz, Birminstoff, 
Pullna, Hunyadi Janos, and they are employed by us every day in doses of 
a glass, or at least every other day; in a word, we try to produce a revul- 
sive effect on the intestine. But, in turn, we discard all revulsives ap- 
plied to the skin, in particular sinapisms and blisters; for several times 
we have seen gangrenous patches produced where they had been applied, 
and this should not surprise us when we consider the changes of nutri- 
tion in the oedematous, infiltrated, and distended tissue. 
We try, further, in all our pregnant women, to build up the constitution, 
by tonics, iron, quinine, wine, etc. But we have little faith in the action 
of these agents in albuminuria, and they are excluded by the treatment 
which we will recommend shortly. 
It is the same with diuretics, which to us, as to Jaccoud, appear per- 
haps more hurtful than useful; with diaphoretics which are inefficient. 
As for tannin and iodide of potash, they are simply adjuvants, and it is 
the following treatment, in our opinion, that it is best to use, for it is by 
far superior to all others. This is the milk diet recommended by Tar- 
nier: 
"1st day, a quart of milk with two portions of food. 
" 2d day, two quarts il " one portion " " 
" 3d day, three " " " f " 88 
A TREATISE ON OBSTETRICS. 
" 4th day, and following days, four quarts of milk, or milk ad libitum 
without other food, without other drink. 
" In the severe cases, if prodromata of eclampsia appear, put the patient 
at once on three or four quarts of milk per day. 
" The influence of the milk diet is never slow in manifesting itself, and 
in eight or fifteen days after the commencement of the treatment, the al- 
buminuria is diminished very considerably or even cured." 
More radical than Tarnier, we put the patient at once, and in all cases, 
on a milk diet, without limiting the dose which she ought to take, and 
prohibit immediately all other kinds of food or drink. 
To accustom the patient gradually to a milk diet, (which ought to be 
taken pure, not boiled, no sugar, but warm or cold as desired-we pre- 
fer it cold), the first day they may take a coffee-cupful every half hour or 
three quarters of an hour or more. The coffee-cup is replaced the next 
day or the day after by a tea-cup, and when the patient becomes accustom- 
ed to milk, she may take it in bowls-full, day or night, when she feels in- 
clined. 
Since we have employed this treatment, we have seen eleven cases of 
albuminuria more or less grave; in ten cases we have seen it entirely suc- 
cessful. Albuminuria, if it has not entirely disappeared, at least dimin- 
ishes in enormous proportions, and in ten cases the women have gone to 
term and been confined, without eclampsia, of living children. Twice only 
have we failed; in one case the woman was syphilitic, and the albumin- 
uria had persisted six months after the confinement. There was no 
eclampsia. The woman was delivered at seven months of a dead child, hav- 
ing in it and on its placenta syphilitic lesions. 
In the other case the milk diet completely failed. It is true that the 
patient bore it badly, it was not taken continuously, and consequently 
the method was imperfectly used. But for successful treatment, it is 
necessary that it should be administered for a certain time, that it should 
be done in a rigorous and exclusive manner, and that it should be com- 
menced as early as possible. 
But this is not always possible, and one meets, unfortunately, in 
certain cases an irresistible repugnance. We have seen such a case in 
consultation, and were obliged to resort to venesection, and to purgatives. 
The woman was seized, nevertheless, with eclampsia, which was cured by 
chloroform and chloral. One need not fear to continue the milk diet for' 
a long time, even after the disappearance of the albuminuria, for this 
disappearance may be momentary. Besides, the patient once accustomed 
to the diet, it is well borne, and we have continued it for three months in 
the case of one of our patients, who was delivered at term, without 
eclampsia, of a well nourished child. The albuminuria only disappeared 
eight days after confinement. 
There remains the question of the artificial interruption of pregnancy. 89 
DISEASES OF PREGNANCY. 
This question was raised for the first time by Tarnier, in case of al- 
buminuria gravidarum, in the notes which he added to the treatise of 
Cazeaux. 
" All accoucheurs/' says Tarnier, " are agreed that labor is a favorable 
circumstance in eclampsia. We might ask them if, to arrest albuminuria 
of pregnancy, and to prevent possible convulsions, one ought not to con 
sider the induction of premature labor. This question has generally been 
answered in the negative. Indeed, observations are not wanting to de- 
monstrate that after suitable treatment, above all after the use of vene- 
section, the albuminuria may diminish, that eclampsia, even after having 
appeared, may disappear, and it is not rare to see under these circum- 
stances, the pregnancy continue its course, and terminate in a normal 
confinement. These observations, together with the fact that the women 
with marked albuminuria do not necessarily have eclampsia, indicate, 
that one ought only to consider the question of premature labor as pre- 
ventive treatment in eclampsia with great caution. We believe, how- 
ever, that the induction of premature labor may, in exceptional cases, 
render some service. Suppose, at the outset, a woman eight months 
pregnant, albuminuric, threatened with eclampsia, in whom labor com- 
mences prematurely and spontaneously; certainly this last circumstance 
would appear to the majority of accoucheurs favorable, and nothing 
would be tried to stop the labor. Admit this, and one will be very near 
accepting the induction of premature labor. One must not believe, on 
the other hand, that eclampsia awaits the appearance of labor to declare 
itself, and that complications will arise at the same time with labor. 
Often, on the contrary, eclampsia appears before the end of pregnancy, 
labor only coming on afterward; here the prognosis is still less grave, as 
the labor is more advanced. For all these reasons, we believe that we 
should not discard absolutely the induction of premature labor, but in or- 
der that we may feel authorized to propose this operation, We should re- 
quire that the following conditions should coexist: 
" 1. That pregnancy has reached the end of the eighth month, in order 
that the new-born child can be raised without too great risk or difficulty. 
(i 2. That the albuminuria should have reached a certain degree, or that 
the patient should suffer from some prodromata of eclampsia. 
"3. That the woman should be a primipara, or that she should have 
suffered from eclampsia in a previous pregnancy. 
" 4. That the medical treatment has proved inefficient,particularly vene- 
section. 
• " Under these conditions, the induction of premature labor seems to me 
rational, and I am disposed to adopt it, unless further facts give a decided 
contradiction to my present way of thinking." 
We do not know whether Tarnier would still persist in these views 
since he has adopted a milk diet and such wonderful results have been 90 
A TREATISE ON OBSTETRICS. 
obtained from it; but they have been accepted by Moricke, who goes fur- 
ther than Tarnier, and, considering all treatment as useless, strongly ad- 
vises the induction of premature labor; also Schroeder, who admits the 
induction of labor; and Richardson, who wishes that all treatment should 
be first tried, and when nothing diminishes the quantity of albumin, and 
when the quantity of urine becomes less and less marked, that the induc- 
tion of premature labor should be practised; Lohlein, Odebrecht, Martin, 
who wait for some evidence of eclampsia. 
We are opposed to Tarnier, and these other authorities, and we discard 
the question of premature labor for the following reasons: 
1. The success which we have had with the milk diet is such that we 
believe all other treatment useless, particularly when the milk diet is care- 
fully and sufficiently observed during pregnancy, and soon enough to 
produce its effects. 
2. When the albuminuria is slight, the interruption of pregnancy ap- 
pears useless, the gravity of the accidents which occur in pregnant women, 
who are at the same time albuminuric, being, in general, in direct rela- 
tion with the amount of albumin. 
3. When albuminuria produces serious symptoms, it depends upon, not 
only pregnancy, but also a serious renal affection, which may progress 
after confinement, and cause, as the observations of Hoffmeier prove, the 
death of the patient. 
4. Labor, as we have seen, has a marked influence in the production 
of albuminuria and of eclampsia; and as the induction of premature 
labor, and with still more reason abortion, always requires a certain 
length of time, the result may be that during this time the patient 
may be placed in a condition still more unfavorable than that in which 
she already is, by the mere fact of the albuminuria from which she is 
suffering. 
Finally, although it is true that, in a number of cases, albuminuria has 
disappeared after the death of the fcetus, and the real cessation of preg- 
nancy, there are many other instances where it has reappeared at the onset 
of labor, accompanied or not, by eclampsia. 
But, although we reject the induction of labor, and still more of abor- 
tion, it is not the same with interference after labor has once come on. 
In this case nature herself shows the way, and as soon as possible without 
danger to the mother, we hasten to end the labor. 
But we never interfere before dilatation of the cervix is complete, and 
if the contractions are energetic, and the woman a multipara, then we 
should leave the case to nature. If, on the contrary, the woman is a pri- 
mipara, and labor proceeds slowly, and the contractions are feeble, as soon 
as the dilatation is complete or the cervix largely dilated and dilatable, we 
end the labor by forceps or by version. It is finally a fact, confirmed by 
all accoucheurs, that labor generally proceeds rapidly in albuminuric 91 
DISEASES OF PREGNANCY. 
women, except in cases of dystocia, and this gives the child a better 
chance of surviving. 
Eclampsia. 
Eclampsia may declare itself during pregnancy, labor or the puerperal 
state. Authorities have been accustomed to describe it in the portion of 
their works which treats of Dystocia. We believe it more rational to ar- 
range it among the diseases of pregnancy, on account of the intimate re- 
lations which exist between albuminuria and eclampsia. As we have said, 
if all albuminuric women are not eclamptic, all eclamptic women, with 
few exceptions, are albuminuric, and eclampsia is only one of the manifes- 
tations of albuminuria in women during pregnancy, labor or the puer- 
peral state. We think that it is of advantage not to separate in our study 
these two diseases, of which one is the immediate consequence of the 
other. 
Eclampsia ^y itself does not impede labor, and if it is classified by 
authors with dystocia, it is not as an obstacle to delivery; it is an acci- 
dent that endangers the life of mother and child. Although eclampsia is 
more alarming, generally, after confinement, the risk which the mother 
and child incur during pregnancy are none the less serious, and it 
ought, as Cazeaux says, on account of the seriousness and nature of 
the convulsions, to be placed at the head of the diseases of pregnant 
women. It is one of the most alarming complications of albumin- 
uria gravidarum, and as such it should be studied immediately after 
albuminuria. 
Definition.-Under the name of puerperal convulsions, acute epilepsy, 
renal spasm, renal epilepsy, uraemic convulsions, acute cerebral uraemia, 
cerebral uraemia, cerebral albuminuria, epileptic dystocia, convulsive 
dystocia, eclampsia is described as an acute disease coming on during preg- 
nancy, labor or the puerperal state, and characterized by a series of tonic 
and clonic convulsions, affecting at first the voluntary muscles, and finally 
extending to the involuntary muscles, accompanied by a complete loss of 
consciousness, and ending by a period of coma or sleep, which may result 
in cure or death. 
Frequency.-As all authorities agree in regarding eclampsia as a rela- 
tively rare accident, it is difficult, according to their statistics, to establish 
an approximate estimate even, because the frequency of eclampsia appears 
to vary, not only from the statistics of certain authors, but also even in 
different countries, and in different years. Moreover, if eclampsia ap- 
pears more often in hospital than in private practice, it is because the 
cases are collected from different parts of the town, and brought to the 
hospital, which necessarily increases hospital statistics. Here are the fig- 
ures resulting from the practice in different countries: 92 
A TREATISE ON OBSTETRICS. 
In France, . . . 457 cases in 131,202 confinements. 
England, . . .161 " " 66,744 " 
Belgium, . . . 13 " " 1,750 
Switzerland . . . 11 " " 6,139 
Sweden ... 3 " " 502 
Russia, . . . 10 " " 2,014 
Germany, . . . 76 " " 50,558 
731 " " 258,969 " 
or about 1 case in 354 confinements. Peter has proved that the cases of 
eclampsia are becoming more and more frequent; indeed, taking the fig- 
ures given by Depaul in his clinic, and which represent all the cases ob- 
served in the hospital from 1834 to 1871, and dividing them into periods of 
ten years, Peter has arrived at the following result: 
From 1834 to 1843 ...... 17 cases 
1844 " 1853 . . : . . 27 " 
1853 " 1863 35 " 
1863 " 1871 54 " 
He thinks this result is due to the fact, that the habit of bleeding preg- 
nant women who suffer from this complication has been abandoned. Ac- 
cording to certain authors, finally, eclampsia becomes more and more 
frequent as we approach the equator. Barquissau quotes in connection 
with this, the personal observations of de Mahy, who has stated that at 
Bourbon eclampsia is frequently observed, and that it occurs more often 
in the higher classes and among the negroes than in the middle classes. 
Eclampsia, as we have seen, may appear at any time during pregnancy, 
labor or the puerperal state; but if authorities agree that it occurs by far 
most frequently at the moment of labor, they are not of the same opin- 
ion concerning its frequency during pregnancy and the puerperal state. 
Thus, while the majority of authors arrange the order of frequency as 
follows: Labor, puerperal state, pregnancy; Bailly proposes to substitute 
the following order: Pfegnancy, labor, puerperal state. Our own opin- 
ion would lead us to arrange the order of frequency as follows: Labor, 
pregnancy, puerperal state. 
In reality, there is only here a misunderstanding, and the difference of 
opinion is not as great as would seem at first sight. We consider eclamp- 
sia as closely allied to albuminuria. Now all authors agree on this point: 
that the albuminuria of labor is more frequent than the albuminuria of 
pregnancy, that it is at the same time more serious. It is not remarka- 
ble then that eclampsia shows itself more frequently during labor. But, 
on the other hand, under the name of albuminuria of labor, authorities 
generally mean that which appears during the two or three days before 
labor, days which correspond to the period which Millot calls the period 
of secret labor, and these days belong as much to pregnancy as to labor. 
As a rule, further, labor comes on at the end of a certain number of DISEASES OF PREGNANCY. 
93 
eclampsic attacks; and lastly, delivery does not always suppress these at- 
tacks, which are then seen to return either in greater or less numbers 
than before delivery. Hence the differences of opinion. Group the 
attacks together, and the eclampsia of labor becomes the much more fre- 
quent. If we separate, on the contrary, the three periods distinctly, 
Bailly gets nearer to the truth, which appears to us to be the division 
which we have given-Labor, pregnancy, puerperal state. 
This seems to be the result of the various statistics in the following 
table, which we have taken from Wieger. 
Before 
and during labor. 
Puerperium. 
Total 
number. 
Collins. 
28 
2 
30 
MacClintock 
3 
5 
13 
Rose 
3 
4 
12 
Before labor. 
During labor. 
Mauriceau 
7 
19 
16 
42 
Jaccoud .... 
18 
20 
9 
47 
Velpeau .... 
7 
5 
9 
21 
Desjardin .... 
0 
o 
2 
7 
Lever..... 
3 
10 
2 
15 
Ramsbotham 
17 
28 
14 
59 
Before 
labor. 
During 
1st stage 
of labor. 
During 
expulsion. 
During 
3d. stage. 
During 
puerper- 
ium. 
Schwartz .... 
2 
3 
5 
1 
11 
Arneth .... 
1 
7 
3 
2 
13 
Lachapelle.... 
4 
4 
4 
3 
1 
16 
Braun .... 
12 
11 
10 
3 
8 
44 
Devilliers and 1 
Regnault. J ' 
2 
6 
2 
0 
1 
11 
Blot 
1 
3 
2 
1 
7 
Divers .... 
36 
21 (17)1 
7 
4 
23 
108 
Thus, in a total of 455 cases of eclampsia, 109 occurred before labor, 236 
during labor and 110 after the birth of the child. 
Jacquemier found 99 cases during labor, 53 cases during pregnancy, 45 
cases after labor. Depaul confines himself to cases before and after labor, 
and in 133 cases there were 106 cases before labor, and 77 after labor. 
Of the 77 cases, in 9 only did the attacks appear first after labor, with- 
out giving any signs of eclampsia before labor. 
In 62 cases there were attacks before labor which continued after. In 
11 cases the attacks, which existed before and during labor, were not pro- 
duced after labor. The other cases refer to women brought to the Clinic, 
without information concerning the possible attacks before labor. The 
following then are the figures: 
In 133 cases attacks before labor, 106; after labor, 77; first commenc- 
1 The period of labor is not specified in these 17 cases. 94 
A TREATISE ON OBSTETRICS. 
ing after labor 9; ceasing after labor, 11; before, during, and after labor, 
62. 
It is rare before the sixth month; although Danyau has seen a case in 
the sixth week; Bach in the sixth week; Prestat in the second week; 
Morel d'Argentan in the fourth month; Carville in the fifth month; 
Charpentier in the fifth month; Cohen fifth and sixth month; Devilliers 
and Regnault sixth month. The rule is that eclampsia manifests itself 
from the seventh to the ninth month, particularly a few days before labor. 
As to the appearance of eclampsia after delivery, as a rule, the attacks 
are only the prolongation of those which existed during pregnancy, but 
even then the attacks may be immediate or a few hours after confine- 
ment. We have seen one case in which the attacks came on after a lapse 
of twenty-four hours. When the attacks come on for the first time after 
labor, they may be at a greater or less interval after labor. Wieger in 44 
cases has noted the following in regard to commencement: At the end of 
4 hours, 8; 12 hours, 2; 24 hours, 1; 48 hours, 3; 4 days, 2; 10 days, 1. 
The invasion may, however, be much more slow. Thus: Ramsbotham 
has seen it 7, 9, 10, 18 days after labor; Ducheck at 10 and 14 days after 
labor. The women remained hemiplegic. 
Cazeaux has seen it 8, 10, 12 days after labor; Charpentier at 17 and 
19 days; Tissier at 17 days; Bailly at 29 days; Simpson at 8 weeks. (Died.) 
In 1872, we analyzed 133 cases collected in the Clinic by Dr. De Soyre, 
and these are the figures for the time of pregnancy at which the attacks 
showed themselves. 
Primiparae eclamptic before labor. 
Multi parse eclamptic before labor. 
At 5 months, . . 2 
" . 1 
" 6 " . . . 6 
" 64 " . . . 2 
" 7 " . . . ' 6 
" 74 " . . * 3 
" 8 " . . .19 
" 8| " . . . 20 
" 8f " . . . * 1 
At 6 months, . . 1 
" 6| " . . . 1 
" 7 " . . . 5 
" H . 3 
" 8 " . . . 6 
" 81 " . . . 4 
20 
60 
Multipart eclamptic at term, 10 
Total. 133 
Primiparae eclamptic at term, 43 
Causes.-A great fact governing all causes of eclampsia, is the almost 
constant presence of albumin in the urine of the patient. Excepting, 
indeed, a certain number of cases of albuminuria, which we cited above, 
albumin is always found in the urine of eclamptic cases, and these cases 
are too few in number, compared with the others, not to be taken as ex- 
ceptions, and still, as Cazeaux says, all are not absolutely authentic. 
The quantity of albumin found in the urine increases a great deal dur- 
ing the attack, and diminishes usually afterward. 
Aside from this great primary cause, authors have noted the following: 
Manner of Living.-Young mothers are more subject to it than others, but, as Wieger observes, poverty may contribute to it, particularly grief, 
and the more so as the primiparae are young mothers. 
Epidemics.-This inference is admitted by Wieger, Mende and Man- 
sell, who base their judgment on the frequency of eclampsia at certain 
times, as observed by authors; but the epidemic influence of eclampsia 
seems to me to belong in the same category as the influence of seasons and 
imitation. 
Age.-This does not appear to have any great influence as a cause, 
although it is between twenty and thirty years that eclampsia is most 
frequent, but this is not surprising, since it is at this age that women are 
more likely to become pregnant. 
In 148 cases, Wieger found 37 cases from 15 to 20; 63 cases from 20 to 
25; 26 cases from 25 to 30; 20 cases from 30 to 40, and 2 cases from 40 to 
46. 
Primiparity. 
This is, without doubt, the most frequent predisposing cause. Most 
authors will agreo in this. Thus 
DISEASES OF PREGNANCY. 
95 
• 
Primiparte. 
Multipart. 
Total. 
Arneth, ..... 
8 
3 
11 
Blot, 
6 
1 
7 
Braun, ..... 
. 38 
6 
44 
Chailly, ..... 
9 
9 
18 
Clarke, ..... 
. 16 
3 
19 
Collins, ..... 
. 73 
12 
85 
Develliers and Regnault, . 
. 10 
2 
12 
Jacquemier, .... 
13 
4 
17 
Johns, ..... 
19 
2 
21 
Robert Let*, .... 
30 
16 
46 
Lever, ..... 
8 
6 
14 
MacClintock and Hardy, 
10 
3 
13 
Merriman, .... 
36 
12 
48 
F. Ramsbotham, 
. 43 
14 
57 
J. Ramsbotham. 
15 
7 
22 
Colles Rose, .... 
9 
3 • 
12 
Divers, ..... 
53 
23 
76 
Depaul, ..... 
. 103 
30 
133 
Scanzoni, .... 
. 23 
5 
28 
Totals, .... 
. 522 
161 
683 
161 multi parse against 522 primiparae, or 3.22 primiparae to 1 multi- 
para. 
This proportion would be too low for Madame Lachapelle, who puts it 
as high as 7 primiparae to 1 multipara. Usually women who have had 
eclampsia in their first confinement, are secured from having it in subse 
quent confinements, but it is not always so, for Collins, Devilliers, Schwartz, 
Johns, Braun, Dewees, Ramsbotham, Litzmann, have reported cases. 96 
A TREATISE ON OBSTETRICS. 
This is not surprising. If we admit the' relation of albuminuria to eclamp- 
sia, albuminuria does not always appear in subsequent confinements, and 
the women escape eclampsia; if, on the contrary, albuminuria does reap- 
pear, nothing is more natural than to have eclampsia also. This explains 
cases apparently irregular, in which the first pregnancy, being compli- 
cated by eclampsia, a second is passed without any accidents, which, how- 
ever, appeared in a subsequent pregnancy. Cases are seen in which a 
woman escapes eclampsia in her first confinement, and has it in her second, 
third, fourth and even the eleventh, as Dumont has stated. 
Distension of the Uterus.-Along with primiparity, which acts, accord- 
ing to many, through the great resistance of the uterine fibres, must be 
placed excessive distension of the uterus dependent upon the large size of 
the child, twin pregnancies, hydramnios; finally, different causes whose 
action is much less evident, i.e., erosions, fright, indigestion, and retention 
of urine. 
The Length of Labor.-Labor may be prolonged by the causes given 
above, by mechanical causes, deformed pelvis, uterine and abdominal 
tumors. The influence of the length of labor in the production of eclamp- 
sia is undisputed. But eclampsia, we have seen, is produced often dur- 
ing pregnancy, and, when labor comes on in these cases, it was gener- 
ally rapid, unless there was some mechanical obstacle; and one of the 
proofs that eclampsia is not always connected with labor, is, that there 
are a great many cases in which eclampsia, coming on during pregnancy, 
has not brought about confinement, which only takes place later. Most 
often the child dies, the eclampsia ceases, and the woman is delivered 
later of a dead child, changes in which are the more pronounced the 
greater the length of time between its death and its expulsion. We have 
had one case in our Clinic. The woman was confined eight days later; 
and to this case we can add those of Lever, Litzmann, Wegscheider, 
Lachapelle, Boer, Braun, Lauer, Mauer, Bodenstein, Baschwitz; and 
finally, Simon,Devilliers and Regnault, Blot and Wieger, have cited cases in 
which the eclampsia came on during pregnancy, did not bring about labor, 
and in which the women were delivered later of living children. In 
each of these cases the eclampsia was reproduced neither during labor nor 
after confinement. 
What are then the determining causes of eclampsia? We must remem- 
ber here all the causes we mentioned under albuminuria, i.e., alteration 
of the blood, increase of blood pressure and renal lesions, etc., but if those 
theories account for albuminuria, they do not suffice to show why eclamp- 
sia occurs in certain cases, and why it is wanting in others, and so the aim 
has been to discover the true cause of eclampsia; hence the new theories 
which Bailly classifies under the following heads: Eclampsia is due: 1. 
To a structural change in the nerve centres and their envelopes; 2. A 
cerebro-spinal congestion; 3. Eclampsia is a neurosis, caused by a reflex DISEASES OF PREGNANCY. 
97 
irritation of the spinal system, originating in uterine pain; 4. To a gen- 
eral or cerebral anaemia; 5. To a condition of the blood which renders 
this fluid less ready to stimulate regularly the nerve centres (uraemia, 
ammonaemia, urinaemia.) 
Depaul and Jlypolitte have endorsed these divisions of Bailly. All 
of them we think are open to objections more or less grave. As Cazeaux 
has stated, all these causes may act in producing an irritation of the nerve 
centres, and Scanzoni has already tried to show that this convulsive attack 
is due to an excitation, an irritation of the peripheral nerves, and of those 
of the spine or brain. 
It has been shown, he says, that the sensory nerves, extending into the 
walls of the uterus, may at once, by irritation excited in them during 
pregnancy and labor, produce a reflex action on the motor nerves which 
are given off from the spine. Admit this, and it is no longer doubted 
that this reflex action, under the influence of extreme congestion, (renal 
hyperaemia), which may increase the excitability of the general nervous 
system, may go beyond its normal limits and produce contractions, con- 
vulsions, of the muscles supplied by these nerves. If the excitation pro- 
duced in the sensory nerves of the uterus is not extreme, or even limited 
to a small part of the sensory nerves, these reflex movements will be pro- 
duced in the voluntary muscles only to a very limited extent. This is con- 
firmed every day by cramps that are observed in the lower extremities, 
where terminal spinal nerves are distributed. * If the irritation increases 
and extends, reflex convulsions may be seen in the muscles of the trunk. 
This increase of sensory uterine irritation during labor may be produced 
by all the causes which may make traction on or compress the nervous 
filaments during the uterine contractions. Thus we see these convulsions 
occur in parturient women, in cases of mechanical obstruction to labor, 
which exerts on the uterus a greater force than customary; when the uterine 
wall is in close apposition to the child, and makes considerable pressure. 
It is the same when it is an isolated part of the organ which is exposed 
to those causes of excitement, (inferior segment of uterus in the vicinity 
of the os internum.) All the causes 'which lessen dilatation may also 
provoke convulsions, partly because the inferior segment of the uterus is 
compressed in a marked degree by the uterine contents, and, partly, because 
the longitudinal fibres which produce the dilatation are exposed to in- 
creased tractions. This is one of the reasons which explain the greater 
frequency of eclampsia in primiparae. Finally, as a cause favoring con- 
vulsions, we must mention spasmodic contractions of the os externum, 
and all those causes which produce rigidity. Moreover, extraneous causes, 
foreign to the mother, may produce this excessive irritability of the uter- 
ine nerves, and lead to convulsions by reflex action, i.e., manual or in- 
strumental dilatations of the cervix. The central nervous irritation may 
react either on the spine or brain. 
Vol. IL-7. 98 
A TREATISE ON OBSTETRICS. 
As for the spine, we must consider hyperaemia of the cord and its mem- 
branes. A priori, it may be admitted, that the same causes which, dur- 
ing pregnancy and confinement, lead to congestion of the abdominal 
viscera, and particularly the kidneys, may prod uce congestion of the lower 
segment of the cord; and experience has shown that pregnancy is accom- 
panied almost always by congestion in the lower part of the cord. But 
no doubt, hypertemia in this part of the cord does not favor convulsions. 
We must admit that a woman, during pregnancy, confinement and the 
puerperal state, is predisposed more than in all other conditions to these 
convulsions. It is, however, understood that these congestions, to cause 
these convulsions, must not exceed a certain degree, and must not be ac- 
companied by exudations into the medullary tissue or the arachnoid sac, 
for otherwise we would not have convulsions, but paralysis. Finally, no one 
doubts but that the medullary irritation causing convulsions must have 
its origin in the brain. 
Eclampsia then may, according to Scanzoni, show itself in three forms: 
1st. Reflex convulsions arising from the peripheral extremity of the uter- 
ine sensory nerves; 2d. Spinal convulsions arising from the direct irrita- 
tion of the spinal cord, an irritation which is referred to the peripheral 
extremities; 3d. Cerebral convulsions, when the irritation arises in the 
brain, and is referred to the spinal cord. 
Cazeaux says that this last form may be controverted, and, according 
to him, spinal irritation is hl ways the origin of eclampsia. " It is a fact 
established by all physiologists, that the irritation of the cord, medulla, or 
tubercula quadrigemina, alone causes convulsions, while irritation of other 
points of the cerebrum or cerebellum produce nothing similar. Cerebral 
lesions may indeed destroy voluntary movements, but the involuntary con- 
tractions, those of which the excess and irregularity constitute eclampsia, 
are not affected. These last may still be produced by spinal irritation or 
of its nerves when the brain and cerebellum have been destroyed." 
In 1875 Cohen of Hamburg proposed two original ideas, of which we 
will speak in a few words. According to him there are two kinds of 
eclampsia: " Uterine eclampsia, which may be produced by irritation of 
the uterus, referred secondarily to the brain; cerebral eclampsia, which, on 
the contrary, originates in the brain, and is referred secondarily to the 
uterus, thus causing convulsions. These two forms are found clinically. 
Uterine eclampsia is divided into two classes, one which is called uterine 
eclampsia at term, which results in phenomena which occur during labor 
and confinement; the other eclampsia before term, which depends upon the 
contact, at the end of the sixth month, between the foetus and the inferior 
segment of the uterus, and on the distension and change of form which 
the lower uterine segment undergoes. This form will give a favorable 
prognosis for mother and child; the other, cerebral eclampsia, depends 
upon a cerebral affection, and presents some of these signs from the outset. DISEASES OF PREGNANCY. 
99 
In this case there is either abortion or premature labor, or labor at term; 
and this confinement may either lead to a favorable ending of the cere- 
bral affection, or, on the contrary, may aggravate and hasten the death of 
mother and child. The following are, according to him, characteristic 
symptoms, which enable us to differentiate these two eclampsias. 
Differential Diagnosis of Uterine and Cerebral Eclampsia. 
UTERINE ECLAMPSIA AT TERM. 
1. Begins at term. 
2. Each attack is accompanied 
by contraction of the uterus, recog- 
nized through the abdomen. 
3. Eclampsia disappears with 
birth of child and placenta, and 
after uterine contractions cease. 
4. Convulsions come on gradual- 
ly and increase. 
5. The remission resembles sleep 
without coma. 
6. Rotation of head only in very 
marked cases. 
7. Rarely is the protrusion of the 
tongue very marked, as well as the 
closure of the jaws. 
8. Excretions rarely involuntary. 
9. Dilatation of the cervix goes 
on continually. 
10. Obstetrical intervention acts 
favorably, particularly in hydram- 
nios. 
11. The convulsions are always 
preceded by nervousness, by groans. 
12. The duration rarely exceeds 
a day. 
13. The child is born alive, the 
mother usually recovers. 
14. Rarely in multipart does the 
os remain closed. 
UTERINE ECLAMPSIA BEFORE TERM. 
1. Begins at end of 6th month. 
2. No true coma, no involuntary 
excretions, no protrusion of the 
tongue. 
3. Caused by the descent of the 
child. 
4. Action of narcotics rapid. 
CEREBRAL ECLAMPSIA. 
1. Begins at any period of preg- 
nancy or puerperal state. 
2. Each attack conies on suddenly 
with uterine contractions. 
3. The attack may come on after 
labor or in the puerperal state. 
4. The attack reaches its acme 
suddenly. 
5. Coma profound; stertorous 
breathing. 
6. Rotation of the head very 
marked. 
7. Always protrusion of the tongue 
and spasmodic closure of the jaws. 
8. Excretions involuntary imme- 
diately after the beginning of the 
attack. 
9. The cervix remains closed 
during the attack, which lasts some 
hours or days; the cervix dilates 
suddenly. 
10. Obstetrical intervention while 
labor is not at hand is useless. 
11. No nervousness, no groans. 
12. The convulsions last a long 
time. 
13. The child generally dies, the 
mother often. 
14. As frequently in multipart 
as in primiparse. 
1. At any period of pregnancy. 
2. Cerebral symptoms very well 
marked. 
3. Caused by Bright's disease, 
fright, mental emotions. 
4. Narcotics often without action. 100 
A TREATISE ON OBSTETRICS. 
In making a division so well marked Cohen goes much too far, but, 
without sharing his views, one must confess that eclampsia is far from 
being always the same in its characteristics, and, while preserving its gene- 
ral characteristics, the attacks may vary in different women, or even in 
the same. How, on the one hand, can the attack, so frequent in some 
women, be explained, and so rare, on the contrary, in others? Why, in 
some women, does labor come on after a few attacks, while in others, 
who have a great many attacks, labor does not come on? Why does the 
child die so quickly in some cases, and in other cases survive so long? 
Why do certain women die after 8 or 10 attacks, and others have 30, 40, 
50, 60 or 100 attacks or even more, and still live, as has been shown by 
Pajot and Bailly? These questions are so numerous that it is impossible 
to answer them definitely. 
1st. Eclampsia is due to an Alteration of the Nerve Centres and their 
Envelopes.-Supported by Marchal de Calvi in 1851, this theory has against 
it, as Hypolitte has observed, the results of autopsies, for the lesions met 
with do not, as a rule, exist in the spine, the medulla, or the tubercula 
quadrigemina, which, according to physiologists, are alone capable of 
producing the convulsions. Coindet and Odier,Grisolle, Hardy and Behier, 
Graves, Oahours, explain the encephalopathy by hydrocephalus; Owen, 
Rees,Traube, as cerebral oedema due to Bright's disease, and the experi- 
ments of Munck (who injected water into the carotids, first having ligated 
the ureters and jugular veins), seems to confirm this view. Otto, Bidder, 
performing these experiments, without ligating the ureters or jugulars, 
have shown that the increase of pressure did not produce the convulsions, 
and that there must be concomitant hydraemia. It is on this fact that 
Traube bases his theory of cerebral oedema with subsequent acute anse- 
mia. To explain this cerebral oedema, Traube invokes first, the hydre- 
mia shown to exist by Andral, Gavarret, Devilliers and Regnault; and 
secondly, an increase of the intra-vascular pressure, due to the cardiac 
hypertrophy of pregnant women, and the increased tension of the cerebral 
vessels, produced by the pressure of the uterus on the abdominal aorta at 
the end of gestation. 
Hypolitte says, that there are certain forms of eclampsia, which seem 
at first sight to justify this theory. " Those, for instance, where the urine 
is diminished to 1500 grains per day. This urine is concentrated, and 
the dropsy (oedema) diminishes generally before the cerebral complications 
appear. Dropsy then spreads from the lower extremities to the brain. 
This is the mechanical uraemia of Jaccoud; but, as Hypolitte has observed, 
hydrocephalus, and oedema of the brain or its membranes, far from produc- 
ing excitement or twitchings, seem, on the contrary, to produce weak- 
ness. Convulsions are not the result, but paralysis." 
Nevertheless, Traube's theory, if it does not apply to all cases, may at 
least explain a great number, for it is supported by undoubted clinical DISEASES OF PREGNANCY. 
101 
facts, and we. can not compare, as Hypolitte has done, the acute oedema 
of Traube to the chronic oedema of the paralytic. 
2d. Eclampsia is due to a Cerebrospinal Congestion.-Originated by 
Mauriceau, defended by Levret, Broussais, Blot, Peter, this theory is 
denied by Hypolitte, Testut, Depaul, who consider the cerebral conges- 
tion and cerebral hemorrhage, which have been found on autopsies, the 
result and not the cause of convulsions. We will see further on that 
the course of the temperature, very different in cerebral hemorrhage and 
in eclampsia, justifies the opinion of the latter authorities. But is not the 
eclampsia due to a rachidian hyperemia, resulting from an irritation of 
the cerebro-spinal system, or the sensory terminal filaments ? This brings 
us to the third theory. 
3d. Eclampsia is a Neurosis, by a reflex Irritation of the spinal System, 
whose Point of Origin resides in the Uterine Pains.-This is the opinion, 
formally upheld by Tissot, Cullen, Vogel, Sydenham, Sennert, Jacque- 
mier, and revived by Dubois, Scanzoni, Axenfeld, Marshall Hall, Tyler 
Smith, Fleetwood Churchill, and refuted by Depaul, Bailly and Hypolitte. 
As Depaul observes with reason, if one admits, with the advocates of 
this theory, the irritation of the nerves of the uterus or pelvic cavity, by 
the increased growth of the uterus, or the action of the parturient state, 
" Why are not all primiparse eclampsic, since in them the uterus is en- 
larged for the first time? Why are not all rachitic cases eclampsic? We 
have already seen that this last cause is more rare than we generally be- 
lieved. That all these conditions may predispose to eclampsia, I grant; 
but there must be other causes added to produce convulsions. It is this 
other cause that I look for in this theory and do not find; and further, 
How explain an eclampsia which may occur during the puerperal state, 
when the irritation of the uterine nerves is not present ? If the Marshall 
Hall theory is rightly established, it must still fall to the ground, since 
this author pretends that no lesion of the brain or cerebellum can give 
rise to convulsions if the spine is secure from irritation. And so Tyler 
Smith believes convulsions to be due to a reflex irritation of the spine 
through the nerves of the uterus. I would answer him even as I have 
Axenfeld in regard to his theory. 
"I do not see what can be the cause of this irritation of the nerves of 
the uterus, when I remember that eclampsia may be developed before the 
beginning of labor, or even of the puerperal state. Some interesting ex- 
periments have lately been made on this reflex power, but every time 
that the convulsive movements were produced, they were partial and not 
general, aside from the fact that, where a like result has been reached, 
the point of origin is known, and one can localize the irritation on such 
or such point of the organism. Is it the same with eclampsia ? What is 
this pretended irritation of the nerves of the uterus ? Are not all women 
in a like situation? Labor produces in all very severe pains; the cervix 102 
A TREATISE OX OBSTETRICS. 
itself is irritated where we aim at the induction of premature labor; and 
ye't, is it common to produce eclampsic attacks? It is not then in the 
uterus that we must look for the causes of this accident, because, although, 
sometimes we see convulsions following on a severe pain, how many times 
under other circumstances, do we see the disease develop before the be- 
ginning of labor, or even after delivery. 
"Further still, much has been said about the accumulation of faeces in 
the rectum, of foreign bodies in the intestine, of worms, of emotions, 
etc. But I will not expatiate on this point. I do not think that simple 
sympathetic phenomena can be invoked to explain the etiology of eclampsia, 
and I reject as well the neurosis, by the reflex action on the cerebro- 
spinal system, as the neurosis essential to the acute stage/' (Depaul.) 
4. General or cerebral Anosmia is the Cause of Eclampsia.-According 
to Fournier, Traube, See, the phenomena of eclampsia (uraemic eclamp- 
sia, i.e., blood poisoning) are analogical, from the point of view of the 
particular mode of their production, with the pathological process, which 
Kussmaul, Tenner and others, assign to epilepsy. By the altered state 
of the blood, there is produced an irritation of the vaso-motor nerves of 
the cerebral arteries; these arteries contracting, there result, either con- 
vulsions from oligemia of the cord, or coma from oligemia of the brain. 
Testut, who is an advocate of the reflex action, admits that it produces 
anaemia of the brain. " Instead of being arrested in the cells of the sen- 
sory and motor columns of the cord, the irritation from the uterus is car- 
ried quickly toward the vessels of the mesophalon, and causes the elements 
of its muscular tissue to contract, and anaemia of this portion of the brain 
resulting, the conditions are evoked on which stress has been laid by 
Kussmaul and Tenner for the development of epileptic attacks." 
Before considering the last cause of eclampsia, the poisoned state of 
the blood, it is necessary here to return to the li renal theory,''the theory 
which we have spoken of in detail, in the chapter devoted to the study 
of albuminuria. Let us remember only that, while certain authors de- 
clare that there is no eclampsia without albuminuria, and no albuminuria 
without a renal lesion, others, whose authority is no less, do not share 
this view, and that the latter oppose to the first the relatively numer- 
ous cases where there has occurred eclampsia without albuminuria. These 
cases have been multiplied during the last years; and it will be sufficient 
to refer to 141 cases, which we have taken from the literature on the 
subject, and if some of the cases may be doubted, the greater number 
offer well-authenticated characteristics. Renal lesion is not, therefore, 
constant in eclampsia. Also certain authors have gone still further, and 
have declared, that it was not only not albuminuria which produced 
eclampsia, but eclampsia which predisposed the patient to albuminuria. 
Blot and Depaul have already noted the increase of albumin during the at- 
tacks, and often also, albuminuria, which did not exist before the con- 103 
DISEASES OF PREGNANCY. 
vulsions has shown itself, and disappeared with them. This th^y call 
nervous albuminuria, and three possible causes are assigned to it: lesion 
of the renal nerves, those of the splanchnic, and the floor of the fourth 
ventricle. The experiments of Wittich, of Herman, of Ludwig, of 
Stokvis, have only confirmed those of Cl. Bernard as to lesions of the 
floor of the fourth ventricle being sufficient to produce albuminuria; and 
Paul Dubois has said in his clinical lessons: " Since numerous experi- 
ments have proved that lesions of certain portions of the nervous system 
may suddenly produce various disturbances in the urinary secretions, it is 
not impossible that albuminuria may not be the cause of eclampsia, but 
the result of the same lesion which causes the nervous affections. " 
Hamon has shown albuminuria to be a neurosis of the central nervous 
system, cerebro-spinal and ganglionic. Tessier, to the renal alterations 
and to those of albuminuria of the blood, adds the influence of the central 
nervous system or the nerves which preside over the urinary secretion. 
But as Hypolitte rightly observes, the neuroses are of all affections those 
which are most rarely accompanied by albuminuria. This fact is particu- 
larly true of epilepsy, the most serious of all; and Hypolitte, who tries to 
explain these facts, supposes as an hypothesis, that eclampsia might lead 
to albuminuria, "first, from the nervous troubles which are of the same es- 
sence as it is by acting directly on the kidneys, then by the blood changes 
and the pseudo-asphyxia which immediately results, by preventing the 
intra-capillary combustion from taking place." 
This opinion is not sustained to-day, and Depaul, not considering it 
too radical, hastens to add: " If albuminuria does not certainly lead to 
eclampsia, I do not believe either in the necessary production of albumi- 
nuria by eclampsia, but I consider these two symptoms, as dependent 
upon the changes which pregnancy produces in the composition of the 
blood." 
Let us add, finally, that if albuminuria may be wanting in eclampsia, 
it is the same in anasarca and in oedema, and that in a still greater pro- 
portion. Thus the absence of oedema has been noted: In 27 cases, by 
Blot 13 times; in 62, by Wieger 10; in 44, by Braun 9; in 133, by Depaul 14. 
One can not be certain, therefore, from the absence of oedema, of the 
absence of albuminuria; and the necessity of examining the urine of all 
pregnant women cannot be too much insisted on. 
There remains, then, the last theory: 
5th. Eclampsia depends upon a poisoning of the Blood, which renders 
this Fluid unfit to stimulate regularly the Nervozis Centres.-What is the 
toxic principle ? Is it urea ? Is it the transformation of this urea into car- 
bonate of ammonia ? Is it the extractive or coloring materials of the 
blood ? Each of these theories have been sustained, and thence the three 
theories of uraemia, of ammonaemia, and urinaemia. 
1. Urcemia-Although Rostock, Christison and Gregory, first described 104 
A TREATISE ON OBSTETRICS. 
the presence of an excess of urea in the blood of eclamptic patients, it 
was Wilson who, in 1833, created the word, and the morbid entity, 
uraemia. (Hypolitte.) Adopted since by all authors, this word has re- 
mained in science, but if the word has remained, it is not so with the 
theory, which attributes the cerebral phenomena to the presence of an 
excess of urea in the blood. While Wilson, Hammond, Treitz, Lalesky, 
consider urea as poisonous, Babington, Bright? 0. Rees, Christison, Fre- 
richs, Schottin, Segalas, Hoppe, Gallois, Brown-Scquard, Cl. Bernard, 
Oppolzer, prove that urea is inoffensive, and the theory of Wilson was 
overthrown by the experiments of Cl. Bernard, who, injecting urea into 
the veins without producing convulsions, proved that urea is incapable of 
producing the nervous complications of albuminuria and eclampsia. 
The fact, itself, of the excess of urea in the blood during the eclamptic 
attacks, has been confirmed by the analyses of Devilliers and Regnault, 
Wurtz and Berthelot, Gubler, Ritter, Parkers, Schottin, Mosier, etc. 
Moreover, recent researches in regard to the temperature in eclampsia, en- 
tirely overthrows the theory of uraemia, because the temperature in 
uraemia is lowered gradually and considerably, while in eclampsia, on the 
contrary, it continues to rise. Let us add, finally, that in cholera, when 
an enormous quantity of urea is found in the blood, eclamptic convulsions 
are not observed. 
2. Ammonamia.-Impressed by the impossibility of explaining these 
complications by uraemia, Frerichs proposed the following theory: It is 
not urea by itself which leads to these complications, but they are due to 
the fact that urea, accumulating in the blood, is transformed, by a fer- 
ment, into carbonate of ammonia. It is to this carbonate of ammonia 
that the nervous complications are due. According to Mercier, it is not 
carbonate of ammonia, but urate of ammonia, which is the toxic agent. 
Finally, Treitz returned to the theory of carbonate of ammonia, but it 
is no longer, according to him, in the blood that the change of urea into 
carbonate of ammonia is made. " Whenever the urinary secretion is sup- 
pressed, the excretory matter, especially urea, accumulates in the blood. 
Now this urea passes from the blood into all the secretions of the econ- 
omy, but it is, above all, the intestinal mucous membrane which eliminates 
the greatest quantity of urea. Poured into the digestive tube, the urea 
is changed into carbonate of ammonia, and produces many lesions. At 
this time the ammoniacal salt has been reabsorbed, and it passes into the 
blood, and the more surely as the important function of the intestinal 
mucous membrane is exactly the absorption of the liquids which bathe it. 
It is the reabsorption of this ammonia contained in the intestine which 
produces ammoniacal intoxication or ammomemia. This theory, upheld 
by Christison, Jaksh, Brettet Bird, Oppolzer. Wieger, Braun, has been 
attacked by Richardson, Picard, Lalesky, and overthrown finally by Cl. 
Bernard, who has shown " that the blood of a well or sick person contains 105 
DISEASES OF PREGNANCY. 
almost always carbonate of ammonia; and that, if urea is found in the in- 
testinal fluid as an ammonia salt, and not as urea, it is only because when 
this substance appears in the intestinal canal, it dissolves in the fluids, in 
the midst of which fermentation goes on, which continually destroys the 
ammoniacal salts, as soon as they are found." 
3d. Urinamia.-Schottin has declared that the kidneys secrete not only 
urea, but other substances still little known, (creatin, creatinin, leucine, 
etc.), and designated under the vague name of extractive materials; these 
accompany urea, remain in the blood, and produce blood poisoning, and 
consequently convulsions. This theory, upheld by Reuling, Hoppe, Op- 
pler, Peris, Lalesky, Fabius, Fournier, Chalvet and Gubler, has received 
from the latter authors the name of urimemia, by which it is known to- 
day. The experiments of Challan, 1865, have confirmed it, and it is ac- 
cepted by Peter. 
" The pregnant woman, affected by eclampsia, is urinaemic. It is be- 
cause all the elements of the urine have accumulated in her blood, that 
she is a prey to the complication known as eclampsia. There occurs a 
great and complex disturbance of innervation, of which convulsions are 
only a symptom. There may be convulsions, coma or delirium, but 
always with a predominance of convulsions, and it seems best to designate 
the combination of symptoms by the term ' puerperal urinaemia. ' The 
analysis of the urine shows, without a doubt, that the woman excretes 
daily a greater quantity of urea. Quinquaud has shown that during preg- 
nancy, and on its account, a woman excretes daily one and a half times 
more urea than in the non-pregnant condition. If she excretes twice as 
much urea in twenty-four hours, she ought to do more work-i.e., more 
blood passes through the kidney, and there is an increased functional hy- 
peraemia. As a result of more blood, there is greater pressure; if greater 
vascular pressure exists, then possible filtration of the serum of the 
blood, nay even the blood itself-a phenomenon which is called incorrectly 
albuminuria, but it is serumuria." Now how does this serumuria, 
physiological when it is of slight amount, becoming greatly increased, ir- 
ritate, poison the organism, and cause eclampsic attacks ? 
One can, by the aid of the examination of the urine, judge of the state 
of the kidney. The more serum there is, the more the kidney is inert, 
so that the integrity of the kidney is in inverse proportion to the amount 
of albumin contained in the urine. With the microscope, the exact state 
of the kidney can be made out, by means of the presence of casts, granular 
and hyaline. These latter show that, at certain points, where this des- 
quamation has taken place, the kidney is totally useless, so far as secre- 
tion of urine is concerned. It is only a passive organ, through which the 
serum filters, as it would through a filter paper. It is necessary, there- 
fore, to look for serum in the urine; if it exists there, to examine the state 
of the nervous system for premonitory signs of eclampsia. There is not 106 
A TREATISE ON OBSTETRICS. 
present as yet eclampsia, but only a tendency toward urinfemia. There 
is not only an accumulation of urea, but the accumulation of all the 
constituents of the urine. 
Very exact analysis of the urine shows an accumulation of all the ma- 
terials of the urine in the blood of a woman inclined towards urimemia. 
In a first observation, in place of G parts of extractive matters in 15,000 
grains of urine, Quinquaud found 21 parts, i.e., 3| times more urea in 
the blood. These figures agree exactly with a second observation which 
gives 19.2 in place of G parts; a third gives 18.3. This makes three times 
more extractive material. I do not know of anything more convincing, 
and we need not say that it is only creatinsemia (Schbttin and Hoppe), but 
all the urinary extractives are present, that is to say, urinaemia. The 
pregnant woman no longer forms urine, no longer selects decomposed ele- 
ments which are the urine; they remain and accumulate in the blood, 
and therefore she is diseased. 
Contrary to Quinquaud, Hypolitte has not found urea increased in the 
blood of pregnant women, but diminished; and finally he says, that in cer- 
tain patients suffering from oligemia or anuria, as in cases of hysteria, or 
of retroversion of the gravid uterus, accompanied by compression of the 
bladder and oligemia, eclampsia is not observed. 
Hypolitte gives in the following table the examination of the urine of 
eclamptic women: 
Eclampsia. 
Temperature 
Axilla. 
Volume 
of 
Urine. 
Urea. 
Albumin. 
Process of 
Yvon. 
Process of 
Liebig. 
28 days before labor 
During labor and during 
an eclamptic attack 
Eclampsia during labor 
98.4° evening. 
102.° morning. 
Ounces. 
27 
15 
47 
Grains. 
108 
48 
375 
Grains. 
180 
<< 
C4 
Albumin. 
14 grains. 
Marked trace. 
From this table it results that urea is rather diminished than increased 
during pregnancy, and that it varies with the process employed. Thus 
between Yvon's and Liebig's methods, there may be a difference, varying 
between 15 to 75 grains. What do all these theories prove ? which is true ? 
It is at the present time impossible to say. 
It cannot be doubted, says Fournier, " that it seems rational to attri- 
bute these phenomena, observed during life, to an alteration in the blood. 
This alteration is not doubted; it does not consist in the retention of one 
principle alone, but the alteration is still poorly understood." 
Lately, practical researches in regard to the temperature in eclampsia 
have shown tlutt all these theories are useless. It was in France that the first 
authentic researches on the temperature in eclampsia were published, and 
Winckel is in error when, with the fairness and fidelity which charac- DISEASES OF PREGNANCY. 
107 
terizes the Germans, he tries to appropriate the credit of this discovery, 
(but this does not surprise us). " The French authors," says Winckel, 
"naturally do not recognize my works." This important work coniines 
itself to the following phrase, which is found in the " Clinical observations 
on the Pathology of Labor," 1869, Rostock, which he has reproduced in 
his second edition. " The temperature rises very considerably at each 
new attack. It may go as high as 104.5° F." From 1874 to 1875 and 
1876, in these observations and studies, he published various observations 
on eclampsia, in which he notes the temperature before the attack, but 
not during, and he takes it again only after two days, to find that it has 
risen to 105° F., under the influence of a new disease. It was only then 
in 1879, i.e., when he must have known of the French works for a long 
time, that he really began the study of the subject. This does not sur- 
prise us, for this appropriative method does not confine itself to scien- 
tific subjects. 
It was in France, in the Faculty at Strasburg, that the first observations 
on the temperature in convulsions were made. It is to Kien, a pupil of 
Hirtz, that they are due. For, although Quincque had, in Germany, 
in 1869, taken the temperature in eclampsia in a careful manner, he had 
drawn no conclusions, and confined himself to a simple statement; and 
the proof of this is, that Wunderlich, whose work appeared in 1871, col- 
lected all the thermometric observations acquired in medicine, and left 
aside entirely the course of the temperature in puerperal eclampsia. 
In 1869, at the suggestion of Charcot, his teacher, Bourneville under- 
took the study of the course of the temperature in diseases of the nervous 
system, and in 1871 to 1875, pursuing these studies, he arrived at the fol- 
lowing conclusions, based on 13 personal observations and 4 of Budin's. 
1st. In eclampsia, the temperature rises from the beginning to the end 
of the attack. 
2d. In the interval, the temperature remains high, and, at the time of a 
convulsion, there is a slight rise. 
3d. If the eclampsia is going to prove fatal, the temperature continues 
to increase and may be very high. If, on the contrary, the attacks dis- 
appear, and if the coma lessens or ceases altogether, the temperature falls 
gradually, and may become normal. 
4th. Finally, Bourneville, concerning the diagnosis between puerperal 
eclampsia and uraemia, adds: " Most authors class under the term uraemia 
both eclampsia and various forms of uraemia. Now of 31 cases of true 
uraemia which we have observed in men and in women, whether caused 
by an affection of the kidneys, or an obliteration of the ureters, (calculi, 
cancer, etc.), whether it be in the form of coma or convulsions, the tem- 
perature gradually falls, and at times below 93° F." 
Hence a very striking contrast between the thermometric curve of puer- 
peral eclampsia and that of uraemia, which we will sum up in the follow- 108 
A TREATISE ON OBSTETRICS. 
ing statement: In the beginning, a lowering of the temperature in 
uraemia is noticed, and an elevation of the temperature in puerperal 
eclampsia. In the course of uraemia, the temperature falls gradually, 
while in that of eclampsia it rises more and more, from the beginning of 
the attack, usually very suddenly. These differences are greater at the 
approach of and even at death. In uraemia the temperature falls very 
much below the normal; in puerperal eclampsia, on the contrary, it rises 
very high above the normal. 
Pinard and Budin have published a great many thermometric observa- 
tions of eclampsia. Also Dieude and llerbart have written on the subject 
(1875), also Buffet (1877), Lorain (1877), Deubel (Nancy, 1879) and 
lastly Hypolitte (1880.) 
In 1879 only, does Winckel report four cases of eclampsia, and 
reach the following conclusions: " The most striking thing is the un- 
usual course of the temperature, which, during sixteen hours without 
attacks, rose from normal to 102.4°, which, a little before the third attack, 
had fallen to 100.4°, and rose again at the beginning of the sixth attack 
to 102.3°, but fell, finally, from 1° to 5° until death, although duringthis 
short space of time the patient had still attacks of eclampsia." 
Dieude, from his observations, concludes that: " The first statement 
of Bourneville is too absolute, and that in eclampsia, not only does the 
temperature not rise continually, from the beginning to the end, but it 
may, rarely it is true, remain stationary or fall in spite of the attacks; 
but he is in accord with him in this, that, whenever the temperature, 
after having followed the ordinary course peculiar to puerperal eclampsia, 
falls gradually, a favorable termination can be prognosticated." 
Deubel similarly considers the statements of Bourneville as too abso- 
lute. 
Finally, Hypolitte, who bases his researches on thirty observations, has 
arrived at the following conclusions, which are those of Dieude slightly 
modified. 
"1st. In the great majority of cases, the temperature rises from the be- 
ginning to the end of the attack, but it may, though rarely, remain sta- 
tionary or fall in spite of the attack. The temperature rises most often 
to the highest point during the tonic convulsion, to fall slightly-two- 
tenths to three-tenths of a degree, during the clonic <convulsion. 2d. 
Between the attacks, the temperature remains high, and, on tire return of 
a spasm, the temperature rises. After several attacks, the temperature 
may remain normal or subnormal or over 1°, but the temperature does 
not remain there with subsequent attacks, or in the interval between the 
attacks, the temperature reaches the high point which is usually observed. 
3d. If the eclampsia is to end in death, the temperature continues to in- 
crease, and rises very high; if, on the contrary, the attacks disappear, 
and if the coma diminishes, or ceases altogether, the temperature falls DISEASES OF PREGNANCY. 
109 
gradually and becomes normal. It may happen, also, that the tempera- 
ture begins to fall before the end of the attack. 4th. In eclampsia, the 
temperature remains usually between 100.4° and 104°, and may go above 
105.4° after death, and even reach 106° to 107° and over. The pulse 
follows the course of the temperature exactly, 100 to 140, and at times 
160." 
As we will see, these thermometric researches have a great importance 
from a diagnostic and prognostic standpoint. 
Symptoms.-Although eclampsia sometimes developes suddenly and 
sharply, surprising the patient as an epileptic attack,this is not the rule,and, 
most commonly, the attacks come on after a prodromic stage, but the pro- 
dromata themselves present certain differences, occasionally being faint, at 
other times they come on just before the attack. They are cephalalgia, 
disturbances of vision, epigastric pain, dyspnoea, vomiting, insomnia, vei> 
tigo and excitement. 
Among the slight prodromata must be noted insomnia, or, on the con- 
trary, deep sleep, excitement, vertigo; the latter may be accompanied with 
a dullness of the intellect, more or less marked. The patient seems sim- 
ply to exist, scarcely interesting herself in things about her, answering 
questions more or less correctly. She seems to live in a sort of trance, a 
physical and moral apathy. She complains of vertigo, transient dimness 
of vision, and, above all, of head-ache more or less severe, situated gener- 
ally in the back part of the head, rarely in the occiput, sometimes in the 
temporal region. This head-ache, which is at first transient, and appears 
only occasionally, becomes day by day more persistent, more fixed, more 
intense, and finally continuous, add when the attack is near at hand the 
head-ache becomes so intense as to be unbearable. Then vomiting appears, 
which may be bilious or stercoraceous, and may reappear suddenly in 
some women who have been free from it for some time. 
Next appear the prodromata which indicate that the attack is immi- 
nent, i.e., disturbances of vision, epigastric pain with or without dyspnoea. 
The disturbances of vision, although being an indication of an impending 
attack, may come on beforehand, but then, usually, they are not well 
marked. They accompany then the head-ache, and are confined to a little 
disturbance of sight, and fatigue, which prevent the patient from read- 
ing or amusing herself. But when they come just before the attack, they 
are more marked, and the disturbances of vision are observed, i.e., am- 
blyopia, diplopia, and even complete blindness. At the same time, the 
head-ache becomes more marked, and the patient goes into a state of pro- 
found stupor, which had been slight up to this time. To the disturbances 
of vision are often added a sharp epigastric pain, sometimes so violent 
that the patient cries out. This pain, this epigastric oppression, may 
accompany dyspnoea, although this sometimes precedes the epigastric pain. 
Epigastric pain, disturbances of vision and dyspnoea, are the three 110 
A TREATISE ON OBSTETRICS. 
symptoms which announce the onset of eclampsia, and which may pre- 
cede it by a few hours, but sometimes come on only a few minutes before 
the attack. 
In spite of the disturbances of vision, the ocular media remain trans- 
parent, excepting a little congestion of the ocular conjunctiva, on a level 
with the oculo-palpebral fold, but it is only after an attack that we find 
retinal lesions, hemorrhages and congestion, which often, however, may 
be wanting. 
Wieger claims that the frequency of the prodromata is not the same, 
according as the eclampsia occurs before, during or after confinement. 
Eclampsia of pregnancy will have prodromata in 40 per cent, of the cases; 
that of labor in 30 per cent., and that of the puerperal state in 20 per cent. 
Attacks of eclampsia are not all alike, and if, in most cases, the move- 
ments are not increased, and do not require a great amount of power to 
restrain the patient, at other times, on the other hand, the patient is 
greatly excited, so that we can, with difficulty, prevent her from falling 
or throwing herself out of bed. 
The attack finally comes on and may be divided into three periods: 
1. The period of invasion; 2. The period of tonic convulsions; 3. The 
period of clonic convulsions.' 
1. The Period of Invasion.-All at once the eyes become fixed, there 
follows a moment of quiet, and the attack begins by convulsive movements 
of the face, which is contracted in a thousand ways and makes horrible 
contortions. The eyelids fall and rise through rapid twitchings, and the 
eyes, drawn by the convulsive movement of their muscles, roll in their 
orbits, drawn sometimes one way, sometimes another. The pupil is dilated, 
immovable, insensible to light, the ocular conjunctiva is insensible to 
stimulation and to light, and finally the eye, drawn upward by the levator 
muscles, partly disappears behind the upper lid, leaving in view only the 
lower segment of the sclerotic, and a very small part of the pupil. It 
lastly remains fixed on that side of the orbit toward which the commissure 
of the lips is drawn. These are not slow in taking part in the convul- 
sions; the mouth, more or less distorted, deviates strongly to the left side, 
as a rule, and the head being rotated, the face to the left side rotates 
back again to the right shoulder, and finally, it is directed to the left; the 
alae of the nose, strongly pinched and contracted, draw down, and 
towards the lower part of the nostrils. 
2. Period of Tonic Convulsions.-From the head, the convulsions 
extend to the muscles of the neck, of the body, and the limbs, which are 
greatly contracted. The extensor muscles of the neck and trunk produce 
a curve of the spine, with the concavity turned backward, and the patient, 
raised up by the contraction, only rests on the bed by the head and lower 
limbs, in a true state of opisthotonos, the whole body being rigid. At 
the same time, the arms are stretched and rigid, undergoing a marked DISEASES OF PREGNANCY. 
111 
movement of pronation, while the fists are closed, and the thumbs turned 
into the palm of the hands, which cannot be opened. The diaphragm, 
the muscles of the thorax, take their turn. Respiration is suspended, 
and the face, instead of the livid pallor which it has presented, becomes 
red, swollen and tumefied, as in asphyxia. At the same time, the mus- 
cles at the base of the tongue contract, the tongue projects out of the 
half open mouth, the jaws rise and fall spasmodically; the tongue is 
bitten and cut by the teeth, and the blood mixing with the saliva, forms 
a bloody froth which dribbles out of the mouth. The muscles of the 
larnyx, throat, pharynx, contract violently, and when respiration becomes 
re-established, it is noisy and whistling. At the same time, there is 
absolute loss of sensibility and intelligence, so that the patient may be 
pinched and pricked without being conscious of it. 
Such is the ordinary aspect of the eclamptic, during the tonic period, 
which is thus characterized by rigidity, immobility, and insensibility of 
the patient, with impeded respiration, all coming on suddenly and unex- 
pectedly. It is not always so, however, and with many patients, as Bailly 
has shown, the attack is preceded by a very short period of excitement, 
during which the patient, instead of stretching her arms along her body, 
raises them over her face, as if she wished to defend herself from an im- 
aginary enemy. The tonic contractions come on secondarily. This ex- 
aggerated tonic state of the muscles lasts generally for fifteen to twenty 
seconds, and then begins the third period of clonic convulsions. 
Third Period.-This general muscular rigidity is followed by shakings 
and twitchings, which agitate incessantly, and in turn, all the muscles of 
the face, body and limbs. As in the tonic convulsions, it is in the face 
that they begin, to reach finally the body and limbs. The face, also, is 
horribly disfigured, the jaws open and shut, cutting the tongue, which 
bleeds more and more, swells, and thus contributes to increase the hin- 
drance to respiration. It is, indeed, in the clonic convulsions, that respi- 
ration, suspended during tonic convulsions, reappears, but it is irregular, 
noisy and whistling, and is accompanied, at each expiration, by expulsion 
of a froth more or less bloody, sometimes even, when the tongue is very 
much cut, by almost pure blood. Generally, the shaking of the body and 
limbs makes itself apparent by slight twitchings, which pass off, and occur 
without the patients changing much in position. This is not always so, 
however, and in certain cases, as soon as the clonic convulsion comes on, 
they are very much excited, throw themselves from right to left, so that 
it is difficult at times to hold or restrain them. During this period, the 
cutaneous and visceral congestion increases, and the face is blue, red, livid, 
seems as swollen as that of a drowned person who has been long in the 
water. Sub-conjunctival hemorrhages take place, and, on account of 
contractions of the diaphragm, or the muscles of the abdomen, as Jacque- 
inier, Depaul and Bailly believe, or even on account of intestinal contrac- 112 
A TREATISE ON OBSTETRICS. 
tions, as Lachapelle and Tyler Smith and we are disposed to believe, ab- 
dominal evacuations frequently occur. Evacuations of urine are not very 
frequent, owing to the small amount of urine in the bladder of eclamptic 
patients. Vomiting is rare, and we have seen it generally in patients 
who have inhaled chloroform. 
This period of clonic revulsions is longer than the tonic period, but 
we have not seen it extend over one or two minutes. Bailly, who has 
given one to five minutes as the limit, appears to go too far; likewise, 
Tarnier, who has seen the attack prolonged twenty minutes by the watch. 
Ordinarily we would yield to the testimony of such a conscientious and 
careful observer as Tarnier, but we believe that he has taken the case of 
a woman in whom the attacks followed each other so- quickly that there 
was no intermission, and therefore the limit we have fixed upon for the 
duration of the attacks seems to be the rule. 
If we consider the congested and asphyxiated condition of the patient 
during a tonic and clonic convulsion, we can not understand how, when 
respiration is so impeded, the patient could long survive such a condition 
of things. 
While the limbs and body are so shaken by convulsive twitchings, the 
face, which was drawn to one side, returns to the middle line, but is still 
carried from one side to another by muscular twitchings. The twitching 
of the eyelids is still present, and also the movement of the eyes. Res- 
piration, for a while suspended, returns, but accelerated, and becomes 
more and more blowing and whistling. It is irregular, the muscles of in- 
spiration and expiration taking part in the clonic convulsion which in- 
volves the whole system. 
Tyler Smith states that the muscles of the larynx share in this spas- 
modic contraction, and it is the closure of the glottis that is the cause 
of the bruit produced in respiration. Asphyxia is the consequence of 
the suspension or diminution of the blood-producing process. Hence 
the bluish-black discoloration of the face, the swelling of the neck and 
face, the enlargement of the jugulars, and the violent beating of the 
carotids. He thinks also that the heart participates in the convulsion, 
and this would explain why the lividity and turgescence is not always 
limited to the face, but may extend sometimes all over the body. 
At the beginning of the attack, Cazeaux says, the pulse is full and 
strong, but we have, on the contrary, seen it always rapid and feeble, so 
feeble that it is sometimes difficult to count it; but, remarkable enough, 
however feeble, we have always seen it increase in cases in which vene- 
section has been practised, as in Depaul's clinic. 
When the end of the attack approaches, the skin, which was dry, be- 
comes covered with perspiration more or less abundant, the respirations 
become a little longer, more regular, the convulsions diminish in violence 
and frequency, first in the body and limbs, then in the face, the livid ap- DISEASES OF PREGNANCY. 
113 
pearance disappears gradually, lastly in the face, where it may remain for 
some time. The attack ends generally with a deep inspiration, followed 
by a slow and prolonged expiration. The patient sinks back in bed in a 
state of coma or stupor more or less pronounced. Whether there be one 
eclampsic attack or several, never does the patient regain her normal 
condition immediately after the attack, but she remains, for a given length 
of time, in a comatose state, with loss of intelligence and sensibility. But 
it is understood that this condition or state is less pronounced and long 
as the attacks are less violent, Qr as they have been few in number, and, 
finally, the further apart the attacks have been. 
Generally, after the first attack, coma and stupor do not persist a long 
time. In a few minutes the breathing, which was noisy, becomes calm 
and regular. The patient, quiet and motionless, moves frequently in bed, 
opens her eyes, looks vaguely about her, without knowing where she is, 
or why she is kept there, nor does she recognize those about her. Little 
by little consciousness returns, sensibility reappears, and, when the pa- 
tient is spoken to, she tries to reply, and is not able to do so, on account 
of the mental disturbance which exists, and also on account of difficulty 
of articulation caused by the swelling and sensibility of the tongue. 
Slowly consciousness returns, but memory is still at fault, so much so that 
the patient has forgotten her pregnancy, her address or her name, and 
it is only after several hours that consciousness is more completely re- 
stored, but memory returns only at the end of twenty-four to thirty-six 
hours or even more. At times, it is true, when there is only one attack, 
a normal condition is regained sooner, but this is rare, and usually the 
first attack is soon followed by another or several. The new attacks may 
be separated by shorter or longer intervals, and then, in the first instance, 
they come upon the woman when she is in the coma following the first 
attack; or, secondly, the woman may have regained consciousness, and 
have come out of her comatose state before the return of convulsions. 
Each new attack is preceded by a new period of excitement, and the scene 
is gone over again, with a severity proportionate to the number of the at- 
tacks. As these attacks are renewed, the coma becomes more and more 
profound, and, in cases where they are renewed again and again, the 
patient passes from a comatose state into new attacks, and vice versa to 
the last. 
But the attacks themselves vary in intensity. At times one or two vio- 
lent attacks are followed by a lighter one, then there follows a more vio- 
lent one. Sometimes two or three attacks follow each other in quick 
succession, then after an interval of half an hour or several hours; then 
the attacks are renewed with greater frequency and intensity. Sometimes 
the attacks come at regular intervals, five to ten minutes, every half hour, 
or every hour; at other times without regularity; at other times still, 
they are repeated with such violence and intensity that they do not* in- 
Vol. IL-8. 114 
A TREATISE ON OBSTETRICS. 
termit at all, but are continuous, and we believe these to be the cases, 
cited by certain authors, in which the attacks lasted ten to fifteen min- 
utes, as in Tarnier's case. The tonic period is obscured by the incessant 
clonic convulsion, and this will explain the error into which these ob- 
servers have fallen, when they give such a long duration to an eclampsic 
attack. The coma is always proportionate to the severity of the attack, 
and, when they are numerous, the woman, if she recovers, is always a 
longer time in coming out of the coma than when the attacks are few in 
number, and the interval between them long. On the other hand, if the 
attacks are long and repeated, the coma is profound and persistent. It is 
often only at the end of twelve, twenty-four or thirty-six hours that the 
patient becomes conscious of what is going on about her. 
The patient may be roused from her stupor for a moment, her eyes 
open, but shut again at once, the few words which can be drawn from 
her are incoherent, the movements, if any, are mechanical, and she soon 
relapses into the comatose state. The memory is the last to return, and 
this rarely takes place until three or four days have passed, the patient 
being only partially conscious of what is going on about her. As for the 
attacks, the patients are not at all conscious of them, and manifest some 
surprise at finding themselves in bed, and know nothing of their confine- 
ment, which, as we shall see, may have taken place during the convul- 
sion; and when they find themselves in the hospital, they ask why and 
how they have been brought there. When, on the contrary, they die, 
the coma becomes more marked, the breathing becomes stertorous, con- 
sciousness and sensibility is entirely abolished, and death takes place, 
either in a new attack or before the patient becomes conscious. In 
some cases, the coma is interrupted by a certain amount of excitement, 
by cries; it would seem that the patient was going into another attack, 
but this is aborted, and she passes into a stupor which may yield in its 
turn or end in death. 
Course and Duration.-Eclampsia, on account of the rapidity of its 
course and its gravity, should rank among the acute diseases. It is rare 
for it to last more than two days without ending in a cure, or in compli- 
cations which may lead to death; but the course of the disease may pre- 
sent numerous varieties. First, the number of the attacks, which in 
some women are limited to two or three or even one, may reach in others 
to 100 (Bailly, Pajot) or 160 as Crettet observed. The intervals between 
the attacks are not fixed, and the attacks themselves, which are renewed 
with a sort of mathematical regularity, may, on the other hand, be very 
irregular. At times, several attacks occur one after another, and a long 
interval passes without an attack, when they occur again with renewed 
violence. In some patients the attack appears over, when, at the end of 
twelve, eighteen, twenty-four, forty-eight hours, a new attack appears, 
and this explains why certain authors have described the startling and DISEASES OF PREGNANCY. 
115 
very sharp forms, and those relatively slow. Paul Dubois goes farther 
when he says that one of the dangers of eclampsia, once declared during 
pregnancy, is that it will reappear until term. But this must be very 
rare, for where eclampsia, which occurs before term, ceases in a few days, 
it reappears no more even at the time of confinement, or else, as a rule, 
it induces premature labor. The attacks themselves present many 
varieties; sometimes few, with long intervals, or at other times slight and 
frequent. Often they have this character during labor. The latter 
ended, there is an interval of repose, and the attacks are renewed with a 
fatal result. At other times, instead of beginning with the uterine con- 
tractions, the attacks come on before labor, cease when it begins; then 
labor is arrested, the attacks come on again; at other times there is an 
attack at each contraction. 
Termination.-Eclampsia may end in cure, in death, or in the develop- 
ment of another disease, the result of the convulsions. Cure, however, 
is happily the most frequent termination, although the mortality is very 
great. When the case is going to end happily, one of the signs that is 
noticed after the cessation of the attack is the progressive diminution of 
the albumin which the urine contains, and its complete disappearance at 
the end of a time which may vary from several hours to several days. Gen- 
erally it is in the first two or three days that this disappearance is noticed, 
and, at the same time, the urine, which was almost wholly suppressed 
during the attack, and likewise cloudy, takes on again, little by little, its 
normal quantity and appearance. Then consciousness gradually returns, 
but it is not rare to see it remain for some time, sluggish and troubled. 
It is the same with memory and disturbances of vision, but generally all 
complications cease in the fortnight after confinement, and the patients 
recover their health almost entirely, save a feeling of feebleness and 
fatigue, which may last much longer. 
Unfortunately it is not always so, and death is too often the end of 
eclampsia. At least statistics go to show it: 
General Mortality of Eclampsia.-Lachapelle and Romberg, 50 per 
cent.; Devilliers and Regnault, 55 per cent.; Brummerstadt, 37 per cent.; 
Dohrn, 29 per cent.; Merriman, 22 per cent. Churchill, 27 per cent.; 
Lever, 28 per cent.; Collins, 16 per cent.; Ramsbotham, 16 per cent.; 
Murphy, 24 per cent.; Blot, 35.5 per cent.; Wieger, 30 per cent. 
According to Kiwisch, one-third of the women attacked by eclampsia 
die during the convulsive period, and one-third of those who survive are 
carried off by secondary puerperal complications. In 318 cases collected 
by Wieger there were 96 deaths. In 60 the cause was as follows: 41 
women died from eclampsia, and 19 from complications. 
Death may occur in different ways. 1st. Death may come on before, 
during or after confinement, and then it is due, either to the attacks 
themselves or to the consequences of the attack, or to the sequelae. 116 
A TREATISE OX OBSTETRICS. 
When death comes on before labor, it is either during the attack, and 
although rarely, it has been observed by Baudelocque, Kiwisch, Prestat, 
Depaul; or else, and this is the rule, it may come on during the period 
of coma. Ordinarily, after a certain number of attacks, labor comes on, 
and then, indeed, death may hike place either during labor in an attack, 
or after labor in another attack, or, as a rule, during coma. Pulmonary 
complications are very common, and may carry off the patient; also pul- 
monary oedema, congestion or apoplexy; death, even, may result from 
cerebral apoplexy or paralysis produced by congestion, which in turn re- 
sults from disturbances of respiration and circulation, or by extravasations 
into the cranial cavity, which may be either serous or bloody. 
Litzmann and Braun attribute the cause of death either to uraemic 
poisoning, i.e., to the toxic influence of the blood on the nervous system, 
or to secondary lesions of the brain or lungs. The apoplexies into the 
cranial cavity or tissue of the brain have been noted by Chaussier, Vel- 
peau, Meniere, Larcher, Duges, Prestat, Bailly, Depaul, Charpentier, and 
Molas, who has in his thesis collected five to six cases. Blot and Molas 
have noted hemorrhages in the liver. These hemorrhages are not surpris- 
ing, for since Blot noted the frequency of hemorrhages in connection with 
albuminuria, all authors have noted similar cases. 
Hamilton, Baudelocque, Miquel, Scanzoni, Cazeaux have reported cases 
of rupture of the uterus during an eclampsic attack; and Bailly has seen 
death in one case due to the swelling of the tongue, produced by blood ex- 
travasation into the organ, the result of the deep bites inflicted during the 
convulsions. In these cases, death is no less rapid, and, in general, the 
women die in twelve or twenty-four hours or more after the last attack. 
2d. Death may be caused by complications which are frequent in eclamp- 
sia, but they are not all of the same gravity; and, if some are the imme- 
diate cause of death, others may be only a predisposing cause, and such 
are hemorrhages in general. Aside from the blood extravasations, such 
as sub-arachnoid or cerebral or hepatic hemorrhages, or pulmonary apo- 
plexies, which we have noted, Blot has called attention to a hemorrhagic 
tendency which eclampsic and albuminuric women have, a tendency which 
shows itself in epistaxis, otorrhagia, hematemesis, hematuria, but, above 
all, uterine hemorrhage, which comes on during the third stage of labor, 
and to which he attaches great importance, and which has been since 
observed by other authors. If these hemorrhages, indeed, are not serious 
in themselves, they weaken, exhaust the woman, and predispose her thus 
to puerperal complications. 
Authors are agreed in establishing the frequency with which puerperal 
complications follow eclampsia, and Blot has shown that these complica- 
tions are the more grave and serious as hemorrhages have been severe. In 
28 cases of albuminuria, with or without eclampsia, Blot has observed 15 
cases with hemorrhages, more or less abundant, with 6 deaths. DISEASES OF PREGNANCY. 
117 
These complications may be arranged under five heads: 1st. Women 
may suffer from puerperal complications (Blot, Depaul, Braun, Devilliers 
and Regnault, Litzmann, Krassnig, Dohrn, Grenser, Cazeaux). These 
accidents are classic, i.e., peritonitis, metro-peritonitis, phlebitis, lymphan- 
gitis, etc. 2d. Women may die from meningeal complications, (Cazeaux, 
Pelissier). 3d. The albuminuria was dependent upon Bright's disease, 
chronic or acute, which becomes increased, in passing into a chronic 
state, and may kill the patient. (Hoffmeier, Moricke). 4th and 5th. 
Eclampsia may end in paralysis, or puerperal mania, which will be treated 
of in a chapter devoted to that subject. 
We will only say here, that mania is much more frequent than paralysis, 
since Wieger saw 10 cases in 140; Grenser 4 in 19 cases; Braun 5 in 44 
cases, and Simpson much more frequently still. 
Pathological Anatomy.-The lesions which are found on autopsies of 
patients who die of eclampsia are so numerous and varied, that one might 
well ask, Is there a pathological anatomy of this disease ? The lesions are 
found in the brain, lungs and kidneys, but it is impossible, at present, to 
find one lesion which is characteristic of the disease, or constantly pres- 
ent. The kidney lesions may be often wanting, so it is not to be won- 
dered at that so many theories are advanced. The lesions themselves are 
in no respect constant, and in a great many cases, general congestion is 
only present to explain the convulsions. 
On referring to different authors, we find that Lachapelle, Cruveilhier, 
Baudelocque, Ramsbotham, Velpeau, Scanzoni, Cazeaux, Kiwisch, Jac- 
quemier, in a number of autopsies have found no appreciable lesion, it 
may be in the brain or adnexa. The following lesions have been dem- 
onstrated by others: 
Braun, in 10 autopsies, 1 case of meningeal apoplexy, 10 cases of anae- 
mia and oedema of the brain and its envelopes. 
Krassnig in 9 autopsies, 6 cases of anaemia and interstitial serous effu- 
sions, 1 case of congestion, 1 case of meningeal apoplexy; 1 case nothing 
was found. Devilliers and Regnault, Lever, Hardy, Collins, Mac Clintock, 
Ramsbotham, Kiwisch, Grenser, Martin, found in 42 autopsies: Hyperae- 
mia, 10; anaemia, 4; normal, 4; serous effusion of arachnoid, 7; serous 
effusion in ventricles, 5; apoplexies, 12. 
Depaul, Blot, Bailly, Mercier, Charpentier, have found cerebral hem- 
orrhages; Molas hemorrhages into the arachnoid. 
Helm, Kiwisch, Braun, congestion of the membranes and meningeal 
apoplexy. 
Bloff, serous effusion into the spinal cavity. 
Braun found the brain and its membranes sometimes anaemic or nor- 
mal, sometimes congested. 
The arachnoid and ventricles sometimes contain fluid. The eye, in 
spite of amaurosis, may be normal, or the aqueous humor may be in- 118 
A TREATISE OX OBSTETRICS. 
creased (Cucuel, Abeille, Crocq, Collard, Marchal); sometimes there may 
be hemorrhages in the retina (Turcq); the blood is slightly coagulable, 
and has a violet color. In the lungs there is always oedema, and emphy- 
sema may or may not be present, as Bar has stated. Usually they are 
congested and contain apoplexies. Delmas has shown that serum 
exists in the pleural cavity. The spleen and liver are more or less con- 
gested. Blot, Molas, have found hemorrhages. The changes that are 
most often met with are those in the kidneys, but, Bailly to the contrary, 
they are not constant, and if it is true that, in a certain number of cases, 
the lesions have escaped observation on account of the insufficient means 
employed in the search, the microscope is not always able to find them; 
and although we think that there is an almost constant relation between 
albuminuria and eclampsia, we believe that in many cases the renal lesions 
are very slight, and sometimes they cannot be found by the most careful 
research, because they do not exist. When the renal lesions do exist they 
may be met with in the three forms described by Frerichs. 
First Degree. Commencing Hyperoemia and Exudation.-The surface of 
the kidney is smooth, the capsule is easily removed, the venous plexuses 
are dilated and gorged with dark blood ; the cortex is reddish-brown, 
soft and friable. On cutting through this substance, a gelatinous bloody 
fluid oozes out which infiltrates the substance of the kidney. The pyra- 
mids are congested. The mucous membrane of the calyx and infundibu- 
lum is swollen, covered with congested vessels and contains a bloody fluid. 
Except for the hypersemia, the substance of the kidney does not appear 
very much diseased. Sometimes hemorrhages are found coming from the 
glomeruli, again from the vascular plexus, the uriniferous tubules, or 
even from the veins spread over the cortex. The epithelium of these 
tubules is not yet very much altered, but it is easily detached. The 
tubules are filled with an exudation, or fluid in the form of casts, trans- 
parent, bloody, constituting fibrinous casts. 
Second Degree. Exudation and commencing fatty Degeneration.-It is 
characterized by a dull, yellow color of the cortex, by vascular striae, by 
red spots and by the size of the kidney, the weight of which is above the 
normal. Then the kidney is softer, more friable, opaque and dull, its 
surface is sometimes smooth, sometimes granular, covered with little eleva- 
tions of the size of a poppy seed, an appearance which is due to the fact 
that the tubules, whose walls reach the surface of the kidney, are distended 
with fluid. 
The capsule of the kidney may with difficulty be separated. The pyra- 
mids are dark red, the mucous membrane of the infundibulum is a dirty 
red, the glomeruli are covered with fine granular material, and in places 
there are areas of fatty degeneration. Between the glomeruli and the 
capsule lies a thick bed of solid, granular matter, in which fat globules 
are found and sometimes cholesterine. When the disease is more ad- DISEASES OF PREGNANCY. 
119 
vanced, the interior of the epithelial cells, filled with fat globules, becomes 
cloudy. Finally, by the increase in granules, the cells themselves become 
disorganized, and then the epithelial cells themselves undergo fatty de- 
generation. 
Third Degree. Atrophy.-The kidneys may have returned to their nor- 
mal size, or even smaller, the capsule has a dirty white color, it is thick 
at certain points, and closely united to the cortex, and can with difficulty 
be detached without bringing away with it portions of the kidney. The 
surface of the kidney has lost its polish, is rough and nodular, studded 
with deep depressions or furrows, which divide it into lobes. The color 
of the surface of the kidney is dirty brown, the depressed portions seem 
like cicatrices, and are generally pale. They have at times a bluish black 
color, due to old extravasated blood. Generally, some parts of the organ 
retain their normal color. The friability which the kidney presented in 
the preceding stage gives way to a hardness like leather. On section the 
cortex has more or less completely disappeared. The uriniferous tubules 
are destroyed and the Malpighian capsules retracted, after the oblitera- 
tion of their vascular coat. There remains no more of the destroyed uri- 
niferous tubules than the basement substance, which in its turn becomes 
wrinkled and shrivelled. When, in the first two conditions, a part of the 
exudation has passed into the interstitial tissue, it becomes organized, 
more or less completely, into a tissue which surrounds the tubules and 
capsules of Malpighi, and, contracting like cicatricial tissue, becomes 
one of the chief causes of atrophy. The atrophy of the pyramids of Mal- 
pighi and of Ferrini, is less than is found in the cortex. There is found 
at their base, scattered between the straight tubules, fine granulations 
which compress them, and separate them one from the other. The calices 
are usually enlarged, their mucous surfaces are thick and studded with 
varicose vessels, which give them a bluish gray color. The mass of fatty 
matter about the kidney diminishes when the atrophy of the organ begins 
(Braun). But it is rare that this third stage is found in women who die 
of eclampsia. The first two stages are most commonly met with. 
Diagnosis.-The diagnosis of eclampsia may be difficult or not, depend- 
ing on the stage or period of the disease in which we see it. It is, how- 
ever, particularly during the period of convulsion and of coma that we 
are liable to be in error; for often, the patient is seen by the physician, 
suddenly, before he has gained any information in regard to the case, 
and it may sometimes be very difficult to reach a diagnosis at once. The 
first point which ought to arouse the suspicion of the physician is the 
fact of pregnancy. Convulsions come on generally in the sixth or seventh 
month, i.e., when the positive signs of pregnancy have existed for a long 
time. It is easy, hence, to determine pregnancy with certainty. The 
urine should be examined at once for the presence or absence of albu- 
min, and albuminuria once determined, the probability is that the convul- 120 
•A TREATISE ON OBSTETRICS. 
sions, if there are any, are true eclamptic convulsions, and that the coma 
may be the result of the convulsions. There are, however, a certain num- 
ber of morbid states independent of albuminuria, which may produce 
convulsions, followed by coma, either during pregnancy, labor or the 
puerperal state, which may lead to error. We will review them rapidly. 
It is Braun who has gone extensively into the diagnosis, but as Bailly 
remarks, he has gone much too far, when he has tried to establish the 
differential diagnosis of eclampsia, with the convulsions which may come 
on in poisoning by mercury, copper, silver, arsenious acid, hydrocyanic 
acid; by the use of the preparations of hemlock, belladonna, tobacco, strych- 
nine, etc., and even poisoning from snake bite. Only lead poisoning 
could lead really to error. We will limit ourselves here to those diseases 
which present phenomena like those of eclampsia, either during the period 
of convulsions or coma. 
1. Cholemic Eclampsia.-It is always joined to acute yellow atrophy of 
the liver, to typhoid icterus, to pyaemia and to puerperal diseases. It 
is always accompanied by fever, and the diagnosis ought always to be 
based on the diminished size of the liver, made out by percussion. 
2. Hysteria.-The convulsions of hysteria come on during very difficult 
labors. The urine never contains albumin. Consciousness is always pre- 
served, if not wholly, at least very appreciably; sensibility may be lessened, 
but preserved. Hysterical convulsions are always accompanied by other 
phenomena-globus hystericus, oppression, dyspnoea, etc., but there are 
neither il tonic nor clonic " convulsions. During the attack, there is a 
tendency to loss of consciousness, but there is no coma after the attacks, 
which end usually by the passage of clear urine, limpid, not albuminous. 
These attacks do not interfere with the course of pregnancy. 
3. Epilepsy.-The convulsions are chronic; they come on during preg- 
nancy, at intervals of several days or weeks, but very rarely several times 
in the same day. There is no albumin in the urine. The attacks are 
often preceded by an "aura epileptica." Epilepsy is, moreover, charac- 
terized by insensibility, and it is not rare to see consciousness return very 
quickly and rapidly after the attack. Further, in epilepsy, reflex sensibility 
coincides with loss of consciousness from the beginning to the end of the 
attack. But it is the disease which most nearly resembles eclampsia, for 
ir^ epilepsy the attacks have a period of tonic and clonic spasm, and also 
of coma; but the prodromata, and the absence of albumin in the urine, 
are the diagnostic peculiarities. We may add that, except the aura, epi- 
lepsy never presents the prodromata which are seen in eclampsia, and that 
the infiltration which is so frequently found in albuminuria and eclamp- 
sia is never present in epilepsy. 
4. When the woman is comatose, the diagnosis must be made between 
coma of epilepsy, apoplexy, cerebral hemorrhage, and the coma of alcohol- 
ism. 121 
DISEASES OF PREGNANCY. 
(A). Coma of Epilepsy.-It is very difficult, if one has no information, 
to make a diagnosis between coma of epilepsy and that of eclampsia. 
The examination of the urine may remove all doubt; besides, the coma 
of eclampsia always lasts longer, is more persistent than that of epilepsy. 
While in the latter consciousness may be recovered completely, in eclamp- 
sia consciousness comes back only slowly, at first incompletely, and the 
patient remains more or less time in a state of discomfort, which does 
not exist in epilepsy. Memory comes back much more slowly, and the 
persistence of disturbances of one or more of the senses are often noticed- 
hearing or sight. Finally, it is not rare to see mania, paralysis, etc., fol- 
low eclampsia, which does not happen in epilepsy. 
(B). Cerebral hemorrhage is accompanied by hemiplegia, no albumi- 
nuria. 
(C). Coma of drunkenness (alcoholism) is diagnosticated by the odor 
of the breath, and by the nature of the vomited material which is noted 
in these cases. There is no albuminuria. 
(D). But with epilepsy, which is the disease most commonly confounded 
with eclampsia, lead poisoning must be mentioned. The latter is accom- 
panied by nervous phenomena similar to those of puerperal eclampsia; 
attacks of convulsions, coma, albuminuria like that of nephritic albumi- 
nuria; but, as Depaul says, who has observed a remarkable case, the coma 
is not as deep-the loss of consciousness exists, but insensibility is not 
completely lost. The eyelids and the lips twitch, and there are convul- 
sive movements, but the head remains fixed, the other muscles of the face 
are not convulsed, and the tonic and clonic spasm are incomplete. Fur- 
ther, the lead line of the gums aids the diagnosis, which is furthermore 
assisted by the information drawn from the patient. In Depaul's case, 
the autopsy revealed the presence in the brain of fifteen grains of lead. 
In this case the diagnosis was facilitated by the absence of infiltration, 
and also the absence of albumin in the urine. 
We only mention here meningitis and chorea, which are distinguished 
by such characteristics that an attentive physician cannot be mistaken. 
The application of the thermometer to eclampsia gives to-day a much 
greater precision in the diagnosis, which is remarkably facilitated by the 
study of the temperature. Thus, in eclampsia the temperature rises 
gradually and rapidly from the beginning of the attack, and it continues 
to rise even after death. (109.2°.) In uraemia, the temperature falls 
from the beginning, and continues to fall gradually until death, when it 
may descend even to 98° F. In some cases, however, the temperature 
stays high at the beginning, but always falls the following day. 
In epilepsy, under the influence of an attack, the temperature rises 
slightly, but the highest point is 101.4°-the rule is 100.2°. The attack 
ended, the temperature falls, only to rise again at the beginning of a new 
attack. In epilepsy, the temperature curve is the same as that in puer- 122 
A TREATISE ON OBSTETRICS. 
peral eclampsia; it rises gradually, stops, and descends gradually after the 
attacks. It is then by the previous history, and above all by the absence 
of albuminuria, that the diagnosis is made. But when the epileptic attack 
presents the two periods, convulsive and meningitic, described by Dela- 
siauve and Bourneville, at the beginning there is an elevation of temper- 
ature, then a depression, which is succeeded by a sudden elevation to 104° 
to 105.3°. 
In hysteria and hystero-epilepsy the temperature rises during the at- 
tacks, but where the attack is over, it descends again gradually to the 
normal. 
In lead poisoning the temperature follows the same course as in epilep- 
sy, moreover the pulse is tricotic. In cerebral disturbances the tempera- 
ture does not rise. 
Cerebrospinal Meningitis.-The pulse is slow, and the temperature pre- 
sents morning remissions and evening exacerbations. Finally, in the coma- 
tose period of cerebral hemorrhage, there is an initial lowering of the 
temperature, and then a much greater elevation as the disease is going to 
end fatally. 
Cerebral Concussion.-There is always a lowering of the temperature. 
It is not necessary to quote a large number of statistics of the 
mortality of women in the puerperal state to establish the seriousness 
of this disease. We must, in order to make our prognosis, seek, in the 
circumstances which accompany eclampsia, or in which it is produced, 
the elements for our prognosis, and finally determine what may be the 
consequences for mother and child. We think that eclampsia shows 
itself in this order of frequency: 1st. During labor. 2d. During preg- 
nancy. 3d. During the puerperal state. Is eclampsia equally serious 
during these three periods, or is it more serious during one than during 
another ? 
First of all, it is a fact admitted by all authorities that death rarely 
tikes place during the attack, and that it is, generally, during the coma- 
tose period or in consequence of puerperal complications that the fatal 
issue manifests itself. 
Contrary to the opinion of Cazeaux and Ramsbotham, who consider 
eclampsia more fatal when it occurs during the puerperal state, Depaul 
and Mme. Lachapelle believe the mortality greater when the convulsions 
occur during pregnancy or labor. Here are the statistics of Wieger: 
Cases. 
Cured. 
Deaths. 
Before labor, .... 
. 65 
40 
25 
At the end of labor, 
. 51 
33 
18 
During labor (stage not indicated), 
. 50 
35 
15 
During the period of expulsion, 
. 25 
18 
7 
After labor, 
. 62 
42 
20 DISEASES OF PREGNANCY. 
123 
Wieger hence agrees with Depaul. If the mortality of eclampsic women 
before and at term be compared, we find: 
Cases. 
Cured. 
Deaths. 
Eclamptic before term, . 
. 50 
37 
13 
at term, 
. . 50 
38 
12 
The mortality is then about the same in each, and Wieger is still in 
accord with Depaul. 
Among the elements of prognosis, the number of the attacks must be 
considered. Our statistics give the following: 
In 45 women having had 1 to 10 attacks the mortality was 11. 
" 31 " " " 10 " 20 " " " " 10. 
" 24 " " " 21 " 50 " " " " 12. 
Beyond this last number, which varied from 50 to 100 or 160, accord- 
ing to Bailly, Cretet and Depaul, we can make no statement, the number 
of cases being too small; the patients of Bailly and Pajot were cured. 
We say, therefore, that the number of the attacks has a marked influ- 
ence, because the mortality is increased with the number of the attacks; 
and since it has been proved that the number of the attacks is far from be- 
ing proportional to the renal lesion, one is forced to admit that the at- 
tacks themselves have some influence. 
The information derived from the thermometer ought to be a help in 
making a prognosis. But it is not the maximum temperature which 
ought to guide us, although it has some importance. (All the women, 
indeed, who have died, have had a temperature as high as 105.4° or higher, 
except two. In women who have been cured, the temperature has re- 
mained below 105.4° except two, in which cases the temperature reached 
this point). It is the course of the temperature which enables us to 
make the following propositions: 1. Whenever the temperature, after 
having followed the ordinary course, i.e., elevated, which is usual in 
puerperal eclampsia, falls slowly and gradually, a favorable prognosis may 
be given. 2. If, on the contrary, the temperature continues, and gradu- 
ally increases and becomes very high, 105° to 106°, an unfavorable prog- 
nosis can be given, for, in these cases, the eclamptic attack usually ter- 
minates in death. 
The Influence of Eclampsia on the Course of Pregnancy, and conse- 
quently on the Foetus.-This influence is gloomy, and in the great major- 
ity of cases, women attacked with epileptiform convulsions are confined 
prematurely. (Depaul.) Cohen has gone too far in affirming that he 
has never found albumin in the urine of any pregnant woman, unless the 
pregnancy was interrupted in its regular course. Blot has proved how 
exaggerated this opinion is, by showing that in the albuminuric women 
examined by him, 34 went to term, 7 only had premature labors. But 
in those cases, it was a question of albuminuria and not of eclampsia, 
which has a differently marked influence. 124 
A TREATISE ON OBSTETRICS. 
Without speaking of the cases in which eclampsia comes on during 
labor, it is undoubted that in most cases, when eclampsia comes on dur- 
ing pregnancy, before term or at term, labor is induced, and almost always, 
when labor does not come on immediately, the child dies. It is delivered 
later, with alterations proportionate to the length of time which it has 
passed in the uterus after its death. The further from term eclampsia 
declares itself, the more danger there will be for the child; on the con- 
trary, the more advanced pregnancy happens to be, the more chance 
there will be for the child to survive, and these chances will be increased 
the more as the eclamptic attacks supervene in the few days preceding full 
term, and the more rapid the labor has been, or has allowed active inter- 
vention nearer to term. 
As to the cause of the death of the child, must we look, as most 
authors do, to the convulsions, to disturbances in the blood, i.e., to as- 
phyxia, to an altered state of the blood ? All these causes may act, be- 
cause a certain number of children born alive die soon afterward, some 
because they were born prematurely, others because the asphyxia was so 
pronounced that they could not be revived. Others, finally, only die at 
the end of some days, and then, as Depaul says, the death must be attri- 
buted to congenital weakness or to convulsions, which seem to resemble 
somewhat the eclampsia of the mother, although we are not able to say 
that the two conditions are identical. 
Van der Donckt admits that the death of the foetus may result: 1st, 
from asphyxia; 2d, apoplexy in the brain or cord. According to Grenser, 
Litzmann found in the bodies of twins born of an eclamptic mother, a 
great many blood extravasations between the dura mater and the inner 
surface of the skull. The pleura and the entire surface of the lung pre- 
sented others, about the size of the head of a pin, and the pericardium 
contained bloody serum. Grenser has found pin-head ecchymoses and 
blood extravasations of the size of a lentil seed on the pleura, pericardium, 
and peritoneum, in a case where there was a slight effusion of blood in the 
meninges; 3d, to blood poisoning; 4th, to non-albuminuric convulsions, 
coming on in utero or after birth (Cazeaux, Depaul); 5th, finally to peri- 
tonitis. (Grenser.) 
Kiwisch attributes the death of the child in part to an arrest of the 
circulation in the placental vessels, during the attack of eclampsia and 
the resulting asphyxia, but he does not think that death of the foetus re- 
sults from asphyxia. 
Braun, on the contrary, thinks that uraemia is the cause of the death 
of the foetus. After the first or second attack, the foetus is already af- 
fected, and dies almost always after a certain number of attacks. If the 
mother dies, the child, which is delivered by the Ctesarean section, is al- 
ways dead. If the child is born alive, we find considerable urea in the 
blood which flows from the cord. If it is dead, carbonate of ammonia is DISEASES OF PREGNANCY. 
125 
found mthe blood immediately after delivery. If the labor is premature, 
the child dies in two or three days. Uraemia alone can kill the child 
without eclampsia having developed at all. The children of eclamptic 
mothers are often themselves albuminuric. 
Now we have seen that the thermometer shows that the eclamptic at- 
tack is not uraemic, and also that the temperature reaches in eclampsia 
104°, 105°, and 106°, and it results from Runge's researches that the foetus 
dies whenever the maternal temperature reaches 104.2°. It is more 
than probable that, in the majority of cases, the death of the 
foetus is due to the high temperature of the mothers. In the cases where 
the maternal temperature does not reach so high a point, death may be 
attributed either to the frequency of the attacks, to blood changes which 
result from it, or to blood poisoning. 
Whatever the cause, the mortality of the foetus is very great. Thus: 
Blot, in 58 cases of eclampsia, . 39 children died. 
Moricke, " 104 " " " . .62 
Merriman, " 51 " " , " . . 34 
Scanzoni, " 25 " " " . . 16 
Champion, " 10 " " " . . 5 
Depaul, " 132 " " " . .64 
Wieger, " 368 " " " . 179 
748 399 
According to Braun: 
Mortality during labor, . . . . .51 per cent. 
" " expulsion, .... 15 " 
" " the attack and 3d stage, . .45 " 
Finally, Wieger gives the two following tables: 
Eclampsia before or during labor. Mortality. 
Children at term, 
32 per cent. 
40 " 
Average, 27 per cent. 
" before term, 64 " 
. Children , 
Living. Dead. Cases. 
Eclampsia before labor, 
19 
29 = 48 
u 
at the beginning of labor, 
28 
21 = 49 
tc 
during labor, . . . . 
7 
8 = 15 
tc 
" the period of expulsion, 
19 
3 = 22 
These figures confirm the propositions which we made above. 
The prognosis of eclampsia is also aggravated by the fact that it leads 
to puerperal complications, metritis, peritonitis etc. But along with 
these serious complications, there are two which, if they do not lead to 
the death of the patient, merit none the less serious attention. We refer 
to puerperal mania and paralysis. 126 
A TREATISE ON OBSTETRICS. 
In the following chapters we will treat in detail of these two condi- 
tions, and at present we will limit ourselves with what concerns the di- 
rect relations between puerperal mania and eclampsia, before entering 
more carefully into details in the chapter on puerperal insanity. 
It was Simpson who first noted the relation which exists between 
eclampsia, albuminuria and puerperal mania. Scanzoni lias seen 4 cases; 
Wieger has seen 10 cases in 100 eclamptic women; Grenser 4 times in 
19 women; Braun 5 times in 44 women; and it has also been observed 
by Gooch, Merriman, Esquirol, Sanchez Frias, Selade, Billod, Maree 
and all alienists. 
In cases of this nature, sometimes, the maniacal state immediately 
succeeds the coma which follows the convulsion. Sometimes the delirium 
does not break out for twenty-four or thirty-six hours after the cessation 
of the convulsions, when everything seems to indicate the end of all cere- 
bral complications. As a rule, cure follows at the expiration of more or 
less time, but it is not always so, and mania may be incurable or even 
end in death. But we must be careful not to confound these cases of 
true mania with the cases of puerperal meningitis with delirium, which 
Cazeaux has mentioned among the terminations of eclampsia. These 
may occur without albuminuria or eclampsia, and, although they are gen- 
erally fatal, there are exceptional cures, as we observed in consultation, 
several years ago, in a single case. 
Fritz, agreeing with Griesinger and Winckel, divides puerperal mania 
into three categories. 
1. Symptomatic mania, which is only of interest on account of the 
febrile delirium, which increases and diminishes with the affections which 
cause it* 2. Puerperal mania, which developes slowly and a long time 
before confinement, and gives rise to the furious delirium which labor or 
the puerperal state excites, by becoming the occasional cause; 3. Puer- 
peral mania, properly so called, which results from hemorrhages, eclamp- 
sia, violent physical and moral suffering, without hereditary predisposition. 
In this last class, Winckel distinguishes two kinds of mania. In one the 
affection is acute, the course rapid, and there is an increase in the tem- 
perature and acceleration of the pulse. The maniacal attack is preceded 
and accompanied for some time by head-ache, hotness of the head, photo- 
phobia, great susceptibility to noise, tinnitus aurium and insomnia. In 
the other, the same general symptoms are not observed; the pulse is nor- 
mal, or slightly accelerated; the life of the patient is not in danger, but 
the mental disorder is more or less chronic, and persists sometimes indefi- 
nitely. 
It is the first of these two forms which Simpson and Donkin Scott make 
dependent upon albuminuria. Fritz, on the contrary, declares that there 
is no relation of cause or effect between albuminuria and mania. Braun 
says that the mania which succeeds eclampsia is afebrile, but he has DISEASES OF PREGNANCY. 
127 
almost always had in his cases a very marked acceleration of the pulse and 
elevation of the temperature. If, generally, mania follows eclampsia, it 
is not always so, and it may come on before, during and after the con- 
vulsions, and he cites in support of his views four observations which 
were in part personal and in part reported by Leubuscher, Grenser, Don- 
kin, Scanzoni, Spiess, Devilliers and Regnault, Esquirol, Trousseau, Seydel 
and Bonifas. Often the mania has ended in a few days, and again it has 
become chronic; but in these there were hereditary tendencies; two cases 
ended fatally, one by puerperal fever, one in profound coma coming on 
after an attack of mania. 
From these observations Fritz has drawn the following conclusions: 
1. In whatever period eclampsia comes on, it may be accompanied or 
followed by mania; 2. Mental disturbances predispose the pregnant 
woman to mania and eclampsia, during and after confinement; 3. During 
labor, mania may appear either during the prodromic period of eclampsia, 
or during the interval of attacks, or else in the state following, or lastly 
even several days after the cessation of the attacks; 4. It is not rare to 
see an interval of health, more or less long, separate two of these periods. 
The mania is of short duration according as the attacks are feeble, and 
the interval between the attacks are longer; 5. The form of the mental 
disturbances which succeed almost always the eclampsic attacks is acute 
mania; 6. In all cases, a woman who has had eclampsia is predisposed 
more than all others to puerperal mania. 
Rocher does not believe with Fritz that eclampsia is, properly speaking, 
the cause of mania, and he is rather disposed to admit that the two dis- 
eases depend upon the same lesion, which we do not yet know. Never- 
theless, eclampsia constitutes a predisposition to puerperal mania, which 
may start up soon after the complete return of consciousness, and it is in 
the organic alterations, more or less serious, that we must seek the occasional 
cause. These having the same origin, sometimes they start up simulta- 
neously, sometimes succeed one another. To the cases already cited, he 
adds three of Plasse D' Einbeck, of which two were cured, and one died. 
Cortyl, 1877, considers puerperal mania following eclampsia as depend- 
ing on a true perversion of nervous action, which, after producing disorders 
of motion, ends by provoking outbursts of mental disorders. 
Finally, eclampsia may produce paralysis, either of the senses, blindness, 
or deafness; of the limbs, hemiplegia, paraplegia. We will refer again 
briefly to puerperal paralysis. 
Treatment.-In 1872, we concluded our article on this subject in the 
following way. " In presence of a disease so serious as eclampsia, it is 
the duty of the physician not to limit himself to one mode of treatment, 
but he should have a choice of several methods, without being a partisan 
of any one, to the exclusion of all others/' 
To-day, ten years later, we would give the same opinion, and although 128 
A TREATISE ON OBSTETRICS. 
numerous works have been since written on this subject, we repeat what 
we have just said: There is no specific treatment for eclampsia. But we 
are not on this account wholly helpless when brought face to face with 
this disease, and if we have no exclusive method for treatment, it is no 
less true that we have at our disposal a certain number of means, which, 
fortunately, have given good results in many cases. We proceed to refer 
to these. 
The treatment of eclampsia may be divided into two great classes: the 
preventive treatment, the curative treatment. The last may be divided 
into the medical and obstetrical treatment. 
1. The Preventive Treatment.-Does there exist a preventive treatment 
of eclampsia ? Since we consider eclampsia as almost always dependent 
on albuminuria, we do not doubt this, and the best way to prevent 
eclampsia will be to treat the albuminuria. It is necessary, then, in our 
opinion to resort at once to a milk diet, continued if necessary for 
weeks or months. But for this treatment to be of use, it must be tried 
in a thorough manner, and it will be necessary, often, to overcome the 
patient's prejudices, for they are easily induced to stop the treatment as 
soon as they become a little better. So long as albumin remains in the 
urine, the treatment should be thoroughly continued. As soon as the 
albumin disappears, it should be stopped at once, but the patients ought 
only to return slowly and gradually to their ordinary diet. The examina- 
tion of the urine should be continued every four or five days, and the 
treatment be renewed if albumin reappears, even in a small quantity. If 
the albumin has disappeared for eight days we can make use of tonics,- 
quinine, gentian, together with small doses of iron. We prefer the ex- 
tract of quinine, and we give it in the following way: 
B. Extract Quinire, 
Extract Gentianae, . . . aa 4 aa 31 
Ferri Subcarbonatis, ... 1 gr.xv. 
Pulv. Rhei. .... q.s. q.s. 
M. Ft. pil. No. 100. 
Sig. Take five or six pills during the day. 
At the same time, the patients should take every two or three days -a 
light purgative (Castor oil, mineral water or magnesia). Since we have 
employed this treatment, we have had only good results, and it has been 
used with success in cases seen by us in our own practice and also in con- 
sultation. Unfortunately, there are cases in which the patients have such 
a dislike for milk that they can neither take it or keep it down. In such 
cases venesection should be our choice, as recommended by Cazeaux, 
Peter, Depaul. We withdraw from 4500 to 6000 grains of blood, accord- 
ing to the case. Peter goes further, and advises wet cups to the lumbar 
region; i.e., he believes, "that the dreaded uraemic complications 
should be guarded against by general blood-letting; that the renal DISEASES OF PREGNANCY. 
129 
congestion should be relieved by local blood-letting, this renal con- 
gestion being the first and only cause of the disease. The congestion 
of the kidneys may also be relieved by purgation." Besides the means 
given above, others have advised numerous agents in which we have little 
confidence. 
Diuretics.-These are recommended with more or less reserve by Fre- 
richs, Braun, Pajot, Cazeaux. Bailly prefers vegetable diuretics. The in- 
fusion of triticum repens, adding or not some nitrate of potash, squills 
or digitalis. Braun advises the use of vapor baths and also seltzer water 
and Vichy. Frerichs, theoretically, advises benzoic acid, lemon juice, or 
tartaric acid, with the hope of neutralizing the carbonate of ammonia 
produced in the blood by the decomposition of urea. Tannin, iodide of 
potassium and extract of aloes have also been recommended; Johnson and 
Collins have recommended emetics. 
Unfortunately all these means have an uncertain action, and venesec- 
tion even, whether it be general or local, does not always suffice to pre- 
vent the attack. Therefore, with certain restrictions, we have seen that 
Tarnier recommends the induction of premature labor as a means of pre- 
venting eclampsia. We have given reasons which have induced us to reject 
it. We will not refer to them here. 
[Nevertheless, the induction of premature labor meets with the ap- 
proval of most American accoucheurs, provided that other means have 
been tried faithfully. It will be sufficient, in this connection, to quote the 
words of our distinguished teacher and writer, Lusk, of New York, who 
says, " My own convictions are clear that, so soon as grave cerebral symp- 
toms develop, the period of folded hands has passed. The relief to be 
obtained from chloral and catharsis is, as a rule, of short duration, and 
we cannot go on giving chloral and cathartics to the end of gestation. 
Moreover, it is necessary to take cognizance of the well-being of the 
fcetus, which is threatened by the continued circulation of urea in the 
maternal blood. The induction of premature labor is attended by but 
moderate risks, if resorted to after the uremic symptoms have been got 
fairly under control. If employed as a last resort, its use then partakes 
rather of the nature of a forlorn hope. So far as my own experience 
goes, however, the practice of waiting upon nature has proved uniformly 
disastrous, whilst the induction of labor has furnished me with a certain 
proportion of recoveries."-Ed.] 
During Confinement.-Bailly advises the use of baths, of chloroform, 
and the termination of labor as rapidly as possible. We endorse the 
opinion of Bailly, excepting the baths and chloroform. We prefer chloral 
to chloroform. But we are not agreed with him in regard to the prophy- 
laxis of eclampsia after labor. Bailly says that the rapid delivery of the 
placenta and blood clots is necessary. We cannot believe that he 
advises, by the words extraction of the placenta, the artificial de- 
Vol. II. -9. 130 
A TREATISE ON OBSTETRICS. 
livery of the placenta. He knows better than any one the dangers 
and difficulties of the operation, and, moreover, the manipulations 
which are necessary would in themselves be sufficient to produce an 
attack of eclampsia. On the other hand, although we are advised to 
deliver the placenta as soon as possible, this is only practicable when the 
placenta is detached. Nature alone should indicate when one could or 
should deliver the placenta. As to general blood-letting after labor, we 
think that it only should be resorted to in exceptional cases, for nature 
alone should interfere in these cases. All accoucheurs, since Depaul has 
called their attention to this point, have noted the frequency of uterine 
hemorrhage during the third stage, in albuminuric women. It must be 
one of two things. If the hemorrhage is useful, why should we be eager to 
stop it ? Or if it is useless, why should it be replaced by general blood- 
letting ? 
It is true that in the last case, the amount of blood wished td be with- 
drawn can be controlled; while, in the uterine hemorrhage, the loss may 
be considerable, but there will always be time enough to interfere and 
stop this hemorrhage before it reaches serious proportions. There is still 
another reason why we do not advise venesection after delivery. Albu- 
minuric women are, by the fact of the disease alone, predisposed to puer- 
peral complications, and those who have had hemorrhages, are even more 
apt than all others to suffer from complications. Certain authors have gone 
further, and said that puerperal mania has been produced by frequent 
and copious bleeding, and by the anaemia which is the result. In such 
cases we limit ourselves to medical treatment, and, above all, to a milk 
diet as long as albumin remains in the urine. 
II. Curative Treatment. 
Medical Treatment.-The eclampsic attack has appeared and the preg- 
nant woman, during labor or after delivery, is in its power, either because 
the albuminuria was not recognized or treated, or it may be because the 
milk cure, or preventive treatment has failed. What is to be done? 
Before entering into the discussion and into the valuations of the two 
great methods of treatment, the antiphlogistic and the anaesthetic treat- 
ment, there are a few little points that it will be best not to overlook, for 
they are applicable to all cases, and when they are disregarded, they may, 
sometimes, cause complications more or less serious. 
During an eclamptic attack, the patient becomes completely unconscious, 
suddenly, even in a moment. The horizontal position, both during and 
after the attack is indispensable, and this position will be of advantage, 
because, in general, during the attack, patients are not at all likely to 
change their position. Unfortunately, it happens too often that eclamptic 
women are taken by surprise and fall unconscious, and are thus exposed 131 
DISEASES OF PREGNANCY. 
to those lesions which are seen in epileptic cases (wounds and burns) which, 
although they have no influence on the attack, may retard the cure. 
Airing the room, loosening the clothing, in a word, every thing which 
facilitates the free movement of the chest, have a true influence, and there 
is another cause still which may aggravate the condition of the patient, 
the distension of the bladder. The urine, it is true, is not secreted 
abundantly in eclampsia (so little is secreted that sometimes it is difficult 
to procure enough to establish the presence of albumin), but, in some 
exceptional cases, the bladder is so distended with urine that it may be 
the cause of serious complications, and Lamotte has cited two cases in 
which the convulsions seemed to depend directly on this distension, since 
the evacuation of the urine by the catheter caused it to cease at once. 
One should never forget to see that the bladder is empty. 
Often, also, patients are worried by attendants who wish to restrain 
them. A careful watching of tiie patient is all that is necessary, because 
touching often excites a patient, and at times it may be the means of 
renewing the eclampsia. Auscultation and abdominal palpation should 
be resorted to only exceptionally, and only when it is necessary to be sure 
of the condition of the child. All the more is this true of the vaginal 
touch, which, whether the prostration of the patient is real or apparent, 
produces nearly always in her a feeling of revolt or repulsion, which makes 
itself known by a low groan or even by some excitement, and may pro- 
duce the eclamptic attack itself. This abstention, however, has its limits, 
and one should not forget that frequently labor comes on during 
eclampsia, that it may be extremely rapid, that dilatation, scarcely 
commenced when we first examine, may take place in a few hours 
or less, and that uterine contractions, continuing to take place in spite 
of the coma, may overcome the resistance of the cervix and of the perine- 
um, and expel a child which, if it survives, is exposed to all 'the risks 
consequent upon unexpected delivery. It is best then to assure ourselves 
from time to time, by examination, in regard to the progress of the labor 
in the interest of the child. Another reason is that thus we may know 
the time when intervention is possible, an intervention which, if it is not 
always in the interest of the mother, as we shall see, is so for the child 
in a certain number of cases. 
At the beginning of the attack the tongue hangs outside the mouth, 
and the spasmodic closure of the jaws exposes it to cuts and tears, which 
are accompanied by swelling, impeding respiration and deglutition, not to 
speak of hemorrhage. The tongue must be replaced and kept behind 
the jaws or teeth. It has been advised to place between the teeth a 
handle of a spoon, a cork, a piece of cloth or wood. These agents, how- 
ever, are not without their inconveniences, and Depaul has in his museum 
a piece of wood nearly 5.5 inches long, which did considerable damage. 
This piece of wood, first placed between the jaws, was displaced by one 132 
A TREATISE ON OBSTETRICS. 
end; it sank into the oesophagus, and injured the ranine artery under the 
tongue, from which there was a severe hemorrhage, which did not 
kill the patient, but was only stopped by the use of the cautery. The 
simplest way consists in replacing the tongue behind the teeth at the 
beginning of the attack, and to keep it there by the use of a cloth held by 
both hands during the attack. 
The two principal methods of treatment at present, are: 1st. The 
antiphlogistic. 2d. The ansesthetic method. Each of these methods 
has ardent admirers and violent opponents. Should preference be given 
to one, or will advantage be gained by using them together ? 
A. Antiphlogistic Method.-General and local blood-letting, purgatives, 
revulsives. 
(a). General Blood-letting.-This was formerly the prevailing opinion, 
and Mauriceau, Dionis, Sauvages, Dewees, Burns, Hamilton, Chaussier, 
Baudelocque, and also P. Dubois, Cazeaux, and above all Depaul and 
Peter, are the defenders of this theory, which counts among its adversa- 
ries such men as Braun, Maygrier, Peterson, Kiwisch, King, Blot, Camp- 
bell, Sedywick, Churchill, Litzmann, Williams, Miquel, Schwartz, 
Legroux, Thomas, etc. But even among its advocates there is a differ- 
ence of opinion. It is only necessary to cite the two professors of the 
French school: while Depaul favors copious and frequent bleeding, Pajot 
states that " he has seen the method employed so often without success, 
that he does not advise it. He has not, however, banished bleeding com- 
pletely in the treatment of puerperal eclampsia; in certain robust and ple- 
thoric women it is useful." 
Thus Depaul, does not hesitate to withdraw at least 30,000 grains of 
blood from a woman in a few hours. Dewees proposes to bleed at each 
attack. Hamilton proposes to withdraw three pounds of blood and repeat 
the operation if necessary. The bend of the knee is the situation most 
usually selected. A sufficiently large vein is opened to obtain a rapid 
and continuous flow, and this is not always easy on account of the move- 
ments of the patient. Bleeding is practised at any time when the convul- 
sions appear, before, during, or after labor, with this exception, that one 
ought to consider, in cases when the disease comes on during or after 
labor, the amount of blood lost at delivery. In acting thus, says Barquis- 
sau (1876) "one diminishes the general mass of the blood, one relieves 
the nerve centres, which have a tendency to become congested, and by 
making the spinal bulb anasmic we deaden reflex irritability, which keeps 
up the hypersemia, and by which the convulsive attack may be revived." 
The advocates of moderate blood-letting, compared with copious and 
repeated, believe that the advantages of extensive blood-letting are 
more than counterbalanced by the serious complications in the 
present and in the future. For the present, it is to be feared that 
depletion, carried beyond certain limits, would itself become a cause of DISEASES OF PREGNANCY. 
133 
irritation to the brain and spinal cord, as is the case after profuse hemor- 
rhages, of which the final symptoms are almost always convulsive. For 
the future, the bleeding impoverishes the blood of an eclamptic patient, 
whose blood is already very poor, and forces the unfortunate patient into 
a chloro-anaemic state, the intensity and persistency of which may give 
rise to great alarm. Lee, in 19 cases in which he withdrew a large 
amount of blood, has reported 19 deaths, and 35 cases cured in 35 patients 
where the blood-letting was moderate. Braun himself, who is so op- 
posed in a general way to bleeding, accepts moderate blood-letting in 
robust and plethoric women. There results from statistics at our Clinic 
the following: 
Cured. Deaths. Mort. 
58 women having been bled once with or without leeches, 34 24 41.3 per cent. 
24 " " several bleedings, . . . . 11 13 54 " 
General mortality by bleeding 45 " 
The conclusion to be drawn from these statistics is that moderate vene- 
section is always followed by a less mortality than the more copious bleed- 
ing. Therefore we prefer moderate bleeding, although, aside from the 
general action on eclampsia, we can state the following facts: 
First and most often, the pulse undergoes marked changes; although 
it may be very feeble, it becomes less rapid and stronger, being easily felt 
under the finger; this is one of the first and most evident effects of bleed- 
ing. But there is still another effect which it is well to state, although 
in many cases it is not constant, i.e., that nearly always there is a greater 
interval between the attacks. This is undoubted, for in a certain num- 
ber of observations, in those cases in which the attacks continued in spite 
of the bleeding, their violence was lessened and the intervals which 
separated the attacks was greater. In 297 cases gathered from various 
authors, we find: 
Cases. Cured. Deaths. 
Bleeding useless or inappreciable, .... 72 55 17 
Attacks increased in spite of the bleeding, . . 46 14 32 
" diminished or ceased after, bleeding, . . 92 86 6 
210 155 55 
155 cured; 55 deaths: mortality, 26.1 per cent. 
Cases. Cured. Deaths. Mort. 
One bleeding, Ill 66 34 30.6 per cent. 
Bleeding repeated and frequent, . 83 65 18 21.6 " 
In 54 cases at the Maternity, general mortality by bleeding, 34.7 per 
cent. 
Cases. Cured. Deaths. Mort. 
Repeated bleeding, .... 13 8 4 23.3 per cent. 
One bleeding, 13 7 4 36 " 
It is seen from these tables, which have a total of 494 cases, that a con- 
clusion cannot be drawn, for in comparing them we obtain: 134 
A TREATISE ON OBSTETRICS. 
General Mortality of Bleeding Compared. 
One bleeding. Repeated bleeding. 
Clinic, . 45 per cent. 41.3 per cent. 54 per cent. 
Observations, 26 " 30.6 " 21.6 " 
Maternity, 34.7 " 36.3 " 33.3 " 
While in the Clinic, where the repeated bleeding is used with greatest 
severity, the mortality has risen to 54 per cent., exceeding considerably 
the mortality of single bleeding, in our own observations and at the 
Maternity, on the contrary, the mortality of single bleeding exceeds that 
of repeated blood-letting. It is impossible, therefore, to draw any con- 
clusions in favor of one or the other method, and we can only state the 
favorable influence which blood-letting has on the course of the attacks. 
This is one reason why bleeding should not be discarded entirely. 
(b). Purgatives.-Together with this method, purgatives must be 
mentioned. Those which are constantly and with good reason employed 
(because they are easily managed) are calomel and jalap, to which we 
can add other purgatives, senna, sulphate of soda, etc. These only act 
as adjuvants. 
(c). Emetics.-We reject all emetics, in spite of the fact that Legroux 
advocates them. Collins classes them with bleeding and calomel, and he 
is supported in this by Lever, Johnson and John§. It is difficult to assign 
to each of these therapeutic agents the part which belongs to them. 
Revulsives.-We have entirely given up the use of sinapisms, blisters, 
etc. Besides the irritation they produce, they may cause ulcers, more 
or less severe, or gangrene sometimes so extensive as to alone cause the 
death of the patient. 
We believe the following are useless, if not dangerous: Fly blisters, 
sprinkling the abdomen with cold water (Denman), ice applied to the 
head, cold baths, anti-spasmodics, camphorated ether, valerian, assafcet- 
ida. Bromide of potash has seemed to be useful and efficient in some 
cases, and Trousseau has prevented an attack by compressing the carotids 
on each side. 
Jaquet has advised the use of a wet pack, and Porter seems to have 
had very good results from this treatment. 
Brummerstadt recommends opium, but it should be given freely to 
have the desired effect. According to him, at the first onset of the attack. 
1 to 2 grains of pure opium (or a corresponding amount of the tincture) 
must be given, and later | a grain taken after each attack until narcot- 
ism is reached. It must also be given after the last attack. Subcutaneous 
injections of morphine may be preferred. 
[In this country many observers have obtained better results in the 
treatment of eclamptic seizures, from the subcutaneous administration of 
opium, than from any other method. It acts as quickly, nearly, as chloro- 
form, and does not alarm the patient to such a degree. The in jection should DISEASES OF PREGNANCY. 
135 
be given in full doses at once, one grain of morphia at least, and boldly 
repeated with the recurrence of fresh attacks. For our part, if the con- 
vulsions did not yield to morphia, we believe that the immediate termi- 
nation of labor offers the patient the best chance.-Ed.] 
Lately, subcutaneous injections of pilocarpine have been tried in doses 
of | grain, repeated if necessary, and it has been tried to induce labor by 
means of it, and again as a means of treating the eclamptic attacks. We 
will confine ourselves here to this last effect, and reserve for further 
consideration the ecbolic effects of pilocarpine. Here are the results: 
Massmann, 2 cases 2 cures. 
Fehling, . 2 " (1 hopeless) 2 " Infus. Jaborandi. 
Prochownick, 2 " 2 " 
Bidder, . 2 " 2 " 
Ludwig, . 1 case 1 death. 
Strognowski, 1 " 1 cure. 
Schramm, 2 cases 2 cures. 
Boegehold, 3 " uraemic, 3 " 
Pasquali, 1 case 1 cure. 
Braun, . 1 " 1 " 
Barker, . 6 cases 6 pulmonary complications. 
Sanger, 3 " 3 " " 
Kleinwachter, 4 li albuminuric; 2 cures, 2 failures. 
Galabin, . 1 case, failure; success with chloroform. 
Nowitzki, 2 cases 1 cure, 1 death. 
Hamilton, 1 case 1 " 
In 34 cases where pilocarpine has been used for eclampsia, it acted well 
in 20 cases, 2 cases died; 9 cases had such pulmonary complications that 
it had to be given up. 
The results seem very encouraging; unfortunately, these cases prove 
very little, for pilocarpine has almost never been given alone, but it has 
been associated with venesection, chloroform, or other means, douches, 
sounds intended to produce an abortion. It is thus difficult to say what 
part pilocarpine alone had in the cure. 
Sanger, who has written the most complete work on pilocarpine, con- 
cludes that it is not an ecbolic primarily, that it cannot bring on uterine 
contractions, but only reinforce and regulate them. 1st. When the cervix 
is more or less dilated, even when there are no true uterine contractions 
(the period of false pains), pilocarpine may produce labor. 2d. When 
there are irregular pains, pilocarpine will regulate them. 3d. During 
the period of dilatation and expulsion, pilocarpine is a means of making 
the labor more rapid, by regulating the pains and making them stronger 
and more frequent; and when the head is delayed by the feebleness of the 
pains, pilocarpine, by shortening the confinement, may take the place of 
forceps. The danger and inconveniences are easily overcome by the use 
of atropine, which is the physiological antidote. 
As to eclampsia, pilocarpine by injection, is only successful in cases in 136 
which it will produce sweating and salivation, or at least the latter. In 
these cases alone can it replace other therapeutic means. 
In dangerous cases it ought not to be used exclusively. One of its ad- 
vantages is to accelerate labor. Barker, on the contrary, who has used it 
in six cases, has seen bad results from it in every case, either in the heart 
or lungs, and does not believe that it should be used in eclampsia, and 
accepts it only as an adjuvant. Kroner has always seen it fail, both as 
an ecbolic and as a cure of eclampsia. Finally Marti-Autet, collecting 
the observations of different authors, and the experiments of Hyernaux 
and Chantreuil, has arrived at the following conclusions: 
1. In a great number of cases, subcutaneous injection of pilocarpine 
has given a negative result. It has not brought on uterine contractions. 
(Welponer, Parisi, Hyernaux, Sanger.) 
2. There has been the same result in a number of experiments on ani- 
mals. (Hyernaux, Chantreuil.) 
3. Under special conditions, the subcutaneous injection of pilocarpine 
seems to cause uterine contraction, when the woman or animal experi- 
mented on is already in labor or has arrived at term. 
4. Under these conditions, the uterine contractions come on some min- 
utes after the injection of the pilocarpine; they increase in frequency for a 
time, then remain stationary, and finally diminish. Renewed injections 
give like results. (Kleinwachter, Sanger.) 
5. At times the action is sufficient to expel the foetus. (Schauta, San- 
ger, etc.) 
6. Now and then the action has been insufficient to expel the foetus. 
(Sanger.) 
7. Hence, it seems reasonable to assume, that if pilocarpine is given at 
term or during labor, it seems to have a real influence on uterine contrac- 
tions; before term, subcutaneous injections of pilocarpine are usually in- 
sufficient to produce premature labor. 
All these agents are really palliatives or adjuvants, and if they are 
useful in some cases, they fail in many others. They cannot then consti- 
tute, so to speak, a method of treatment. Generally, they have been com- 
bined with venesection, chloroform, chloral, and premature labor, there- 
fore, it is not possible to say just what has been useful. Eclampsia is es- 
sentially rapid in its course, and a great number of these drugs are slow 
in their action; therefore we think that they will be more successful if 
they are not employed alone, but are associated with other means, and 
in particular with venesection i.e., the antiphlogistic treatment. 
B. Anoesthetic Method.-Three agents are usually employed. Ether, 
which has given place to chloroform, and lately chloral. In 15 cases re- 
ported by us in which ether was employed:-influence none or not evident, 
2 deaths in 3 cases; aggravation of the course of the disease, 4 deaths in 
4 cases; diminution or cessation of the attacks, 8 cures in 8 cases. The 
A TREATISE ON OBSTETRICS. 137 
DISEASES OF PREGNANCY. 
general mortality, then, is about 40 per cent. But since the substitution 
of chloroform for ether, the anaesthetic method as applied to eclampsia 
has been thoroughly tried, and has given some authors most surprising 
results. Unfortunately, contradictory facts have been collected, and we 
think that anaesthetics, no more than venesection, can be considered an 
heroic remedy for eclampsia. Is the method rational ? 
The opponents of chloroform object to it on the grounds: 1. In a great 
many cases not only are the attacks not diminished under the influence 
of an anaesthetic, but they come on more frequently, and more strongly. 
2. Although chloroform arrests the attacks, they reappear in the in- 
terval between the inhalations, and the woman cannot be kept under 
chloroform for some time without danger. 3. Chloroform is irrational, 
because it produces congestion of the nerve centres, and may thus in- 
crease cerebro-spinal congestion, which is already so much dreaded in 
eclampsia. 4. Chloroform increases the asphyxia of eclamptic subjects 
already predisposed to this complication; 5. The use of chloroform in 
some eclamptic cases has been followed by the appearance of puerperal 
mania. 
Depaul, finally, who is one of the most determined opponents of chloro- 
form, admits that it does modify to a certain extent the attacks of eclamp- 
sia, but they exist, none the less, as well as all the complications that go 
with them-congestions, central hemorrhages, pulmonary congestion, etc. 
The opinions of authors are divided on this subject; while Bichet, 
Gros, Sprengler, Scanzoni, Braun, Spilth, Meinsinger, Blot, Charrier, 
Richardson, Bazin, Macario, Wittie, Liegeard, Maugenest, Fearnet, 
Derby, Kiwisch, Wieger, Chailly, Channing, Campbell, Schneiseson, 
Schroeder, Spiegelberg, are advocates of this method, others, as De- 
paul, Pajot, Tarnier, Jacquemier, Gueniot, Bailly, are more conservative, 
or even reject it all together. 
We believe that it is not at all necessary to accept it exclusively, nor 
reject it absolutely; and, if chloroform has failed in a good many cases 
(we have had in our own practice an unfortunate example), there are 
others where it has rendered excellent service. In one article we collected 
63 cases in which chloroform had been administered by inhalation or in- 
ternally, and the following are the figures: 
Cases. 
Cures. 
Deaths. 
Mort. 
Cases in which the influence has been nil or 
could not be noticed, .... 
8 
6 
2 
25 per cent. 
Cases in which the disease has not been 
arrested, 
6 
2 
4 
33.3 " 
Cases in which the attacks, at first modified, 
have ceased, 
49 
48 
1 
2.4 " 
The figures of the average mortality are only raised to 11 percent., but 138 
A TREATISE ON OBSTETRICS. 
this we believe is too small, and because the successful cases have been 
published and the unsuccessful ones not. Nevertheless, taking the highest 
figure of the mortality, i.e., in the unfortunate cases-33 per cent., and 
we have pretty nearly the figures obtained by us in the Maternity by 
•venesection-34 per cent.; and a much lower figure than at the Clinic-45 
per cent. This would seem to settle the question, but, on the other hand, 
if we compare all statistics at the Maternity, we find that the mortality 
by bleeding is 34.7 per cent.; by the use of chloroform, 50 per cent. The 
results, therefore, are somewhat contradictory. 
Bleeding. Chloroform. 
Clinic, 45 per cent 33.3 per cen 
Maternity, . . . . 34.7 " 50 " 
The use of chloroform once granted, how should it be administered ? 
It should be inhaled and carried to complete narcosis, but the use of 
chloroform must not cease when once it has been employed. Inhalation 
should begin the moment the nervous excitement commences before the 
attack; it should be given rapidly in order to get complete anaethesia as 
soon as possible. This once obtained, the inhalations should not be given 
up, but should be continued for several hours, six, eight, twelve, fifteen 
hours or even more if necessary. If the attacks are far apart, the amount 
of chloroform may be diminished or suspended altogether during the in- 
terval. Do not allow the patient to come out of the chloroform and 
regain consciousness; at the least sign of a return of an attack give the 
chloroform again to complete amesthesia. Tarnier, in one case which he 
cured, kept the patient under chloroform all night, and 6000 grains of 
chloroform were used. When once complete anaesthesia is produced, 
keep it up without regard to time. This is well in theory, but it cannot 
always be done in practice; for there are cases in which the use of chloro- 
form must be suspended after a certain time, although it need not be 
given up altogether, as in our patient. 
It is well then, to resort to other means; but in general, it is astonish- 
ing to see with what ease patients will endure a long-continued anaesthe- 
sia, and the length of time that they can be kept under its influences 
without inconvenience. There is still one other difficulty, i.e., how is 
one to know the exact time when it will be safe to give up chloroform ? 
This cannot be fixed exactly. It is not rare to have the interval between 
the attacks last for several hours, and we seem to have mastered it, when 
in reality there has been a short suspension. The question cannot possi- 
bly be answered absolutely. When the patient has gone several hours 
without an attack, it is best to withdraw the chloroform a little without 
giving it up altogether. We would keep the patient in a half-sleepy con- 
dition, so that, if necessary, we may produce by a few inhalations com- 
plete anaesthesia if there are any other symptoms of the attack. But it is DISEASES OF PREGNANCY. 
139 
only after some time that the chloroform can be entirely given up. 
Bailly goes still further, and advises in cases in which the attacks, con- 
tinue, and with greater obstinacy, not to keep up the chloroform more 
than twelve hours at once, but to stop it at the end of this time, to allow 
the blood to become purified, and to make use of chloroform again in case 
of a relapse. We do not accept this view, because we think that chloro- 
form acts only on condition that its influence is prolonged, and therefore 
it must be given continuously. Admitting the action of chloroform on 
the nerve centres, we believe that, in acting as Bailly would have us, 
patients would be exposed to all the dangers of chloroform without deriv- 
ing any advantage from it. 
But there is another agent, little known, or better, little used until 
1872, which has since taken a prominent place in the treatment of eclamp- 
sia, and we have reported already some marvellous cases in which it has 
been employed. This is chloral-hydrate. The use of chloral-hydrate in 
the treatment of eclampsia either by the mouth, rectum or subcutane- 
ously, only dates back a few years. It is only since 1869 that chloral has 
really taken its place in practice in the treatment of eclampsia. 
Employed for the first time, in 1869, by Saint Germain, it was not 
slow in taking its place in obstetric practice, and we limit ourselves to the 
following works on the subject: Lecacheur, 1870; Alexander, Sedywick, 
Demarquay, 1870; Campbell, Milne, Flok, Mackintosch, 1870-71; Ray- 
mond, Furley, Stearly, Mac Rae, Bookley, 1871-72; Windhorn, Mawsell, 
Phillips, Tarnier, Bourdon, Charpentier, 1872; Franco-y-Mazora,Pelissier, 
1873; Fanny, 1874; Beliere, Chouppe, 1876; Testut, 1877; Troquart, 1877, 
Delaunay, 1877; Pelissier, 1878; Tucoulat, Froger, 1879. Fanny, in 1874; 
collected 36 cases, 16 of which had been given chloral after other treat- 
ment, and 20 had received chloral alone. The following results are 
given: 
Cases. Cures. I 
Jeaths. 
Unknown. Percent. 
Chloral given after other treatment, 16 14 
2 
0 12.5 
" " alone, . . .20 19 
1 
Women treated by chloral alone, . 36 33 
2 
1 
Mortality, .... 
3.7 
Cliouppe has had good results from chloral, and adds one cure. Legroux, 
always a partisan, reports some cases of death by an over-dose of chloral. 
Depaul reports 3 deaths, and, without giving up chloral, is but little in 
favor of it. Lissonde rejects it entirely; but the best and most interest- 
ing papers on the subject are those of Delaunay and Testut, 1877, and a 
paper by Froger in 1879. 
Testut admits two kinds of eclampsia; the one from reflex irritation, 
and the other from cerebral oedema. "In the first, chloral is all powerful; 
(fl) in quieting the spinal nerve-centres in which arises all the muscular and 
motor excitement; (6) in paralyzing the vaso-motor centre in the medulla, 140 
A TREATISE ON OBSTETRICS. 
it thus renders the contraction of the vessels impossible, and also the ap- 
pearance of anaemia of the convulsive areas, and opposes at the same time 
outward manifestations of eclampsia." In eclampsia due to cerebral 
oedema, chloral would be powerless. 
Delaunay admits that chloral acts on the nerve-centres themselves: 
" The blood being unable to stimulate the centres regularly, produces, in 
some way or other, a general irritation, which leads to an eclamptic attack 
more or less long, which may or may not be repeated. Is this central-nerv- 
ous irritation due to cerebral congestion, to serous exudation into the 
ventricles and meninges of the brain, to oedema of the brain substance, 
or to an alteration in the nerve tissue itself? We do not know. In any 
event, if other lesions do exist, it is not on these that the influence of 
chloral is exerted. Its action must, of necessity, be exerted on the nerve- 
cells themselves, particularly on the nerve-cells of the spinal cord, which 
all regard as the seat and origin of all convulsive attacks of whatever kind. 
Chloral acts first as an hypnotic, and then stupifies the cerebral nerve-cen- 
tres, and makes them insensible to the cause of the attack." 
Froger has collected all the cases since 1879, i.e., 110 cases, in 51 of 
which chloral was alone used, with 49 cures and 2 deaths-4 per cent. 
Finally Testut, who has taken the statistics from our table and observa- 
tions, gives the following table, which comprises the results obtained from 
different methods of treatment. 
Mortality. 
1. Revulsive treatment, ..... 50 per cent. 
2. Blood-letting " . .... 35 " 
3. Purgative " . .... 56 " 
4. Blood-letting and purgative treatment, . . 17.3 " 
5. Anaesthetic treatment, . . . . . 17.8 " 
6. Surgical " . . . . . 29.7 " 
7. Chloral alone, ...... 4.0 " 
8. Chloral and bleeding, ..... 9.01 " 
9. Chloral and other treatment, . . . . 13.32 " 
The general or average result of the chloral treat- 
ment, ....... 8.49 " 
Admitting even that a certain number of fatal cases have not been pub- 
lished, the results given by chloral differ so much from those given by 
other methods, that they cannot be but striking, and Beliere was right in 
saying, in 1876, when speaking of our work of 1872, that perhaps later 
we would give a more decided opinion. Since that time, indeed, cases 
have increased and are multiplying every day, and, in our opinion, the 
treatment of eclampsia to-day may be summed up in two great classes: 
1. To bleed the patient moderately; 2. To give chloral in large doses, as 
we shall show. 
Before studying the different methods of giving chloral, let us say that 
Bourdon is not satisfied with giving chloral when the eclamptic attack is DISEASES OF PREGNANCY. 
141 
in full force, but he has employed it as a prophylactic agent in an albu- 
minuric condition. In these cases chloral was given in doses of 60 grains 
at the time of confinement, and the labor has ended without eclampsia. 
How and in what dose should chloral be given? Chloral may be given 
by the mouth, by the rectum, subcutaneously, or by intravenous injec- 
tion. Of these four ways, there are two which we discard at once, i.e., 1st. 
the intravenous injections, because they are dangerous, and therefore 
should not be employed except as a last resort. 2d. Subcutaneous injec- 
tions, because they expose the patient to abscesses, phlegmon, gangrene. 
There remains then the mouth and rectum. But eclamptic cases, besides 
that they swallow with difficulty, vomit often all that they take. This 
would leave the rectum for the administration of chloral. 
Bourdon begins with 60 grains of chloral, then he gives 15 to 30 grains 
every quarter of an hour, until 150 grains have been given. If the attacks 
do not cease, he waits some time before continuing the treatment. 
Chouppe goes as high as 180 grains. Testut at first gives 60 grains, then 
15 grains every hour until the enema is used up. The enema is made of 
150 grains of chloral and 5000 grains of distilled water. 
Our method differs slightly. At first we give 60 grains to our patient; 
if this is not retained or only partially, we give immediately a second, 
and if necessary a third until the medicine is borne. Whether the at- 
tacks continue or cease, we do nothing for a few hours, say five or six if 
necessary, and it is only at the end of this time that we give another 60 
grains of chloral. 
It is rare that we have to pass this limit, whichf represents ^80 grains of 
chloral, to be taken in eighteen or twenty-four hours. We do not fear to 
give a still larger dose, and in one case we have given as high as 240 
grains in twenty-four hours. If the attacks become farther apart, we 
make the interval between giving the medicine longer; if, on the contrary, 
the attacks persist, we do not wait as long. In one case which was cured, 
(by bleeding and chloral) we gave without inconvenience, 180 grains of 
chloral in 10 hours. We never stop the medicine suddenly, but we give 
the patient always, even when cured, 60 grains of chloral at the end of 
the first twenty-four hours after the attack. By separating the doses, 
and giving them in large quantities, we obtain greater quiet with less 
trouble and worry to our patients. We have never had to exceed this 
dose, but we would not hesitate to do so if necessary, even to go as high 
as 300 grains, as Delaunay and Froger have done. 
Does disturbance of cardiac innervation and organic heart-trouble con- 
tra-indicate the administration of chloral, as Gubler would have us be- 
lieve? The cases of Liebreich, of Davreux, of Waters, of Dunlap, of 
Meldola, of Smalmann, seem to justify this view. But Waters, Ogles, 
Peyers, Westrangle have, in spite of cardiac trouble, had good results from 
chloral. The cases of Lucas Championniere seem to justify these authors, 142 
A TREATISE ON OBSTETRICS. 
for not only does he not fear to use chloral in patients who have cardiac 
disease, but he does not even see any contra-indication to chloroform in 
cardiac disease. 
In all of his surgical operations, Lucas Championniere uses chloroform, 
whatever be the state of the patient's heart, and he has never had an acci- 
dent. It is true, that in these cases the prolonged action of chloroform 
is less than that of chloral. These facts, nevertheless, are very encourag- 
ing, but we will still resort to chloral only in these cases, although, per- 
haps in smaller doses. 
2. Obstetrical Treatment.-All accoucheurs are agreed on this one point, 
that, whenever one can terminate the labor either by the use of forceps or 
by turning without injury to the mother, it will be best to do so, as well 
for the mother as the child, i.e., whenever the cervix is dilated or dilatable. 
Depaul goes still further when he says, " if the cervix is already dilated, 
although insufficiently, and the child living, there is reason to fear that 
in the new attack the child may die. Auscultation will enable us to 
foresee this by the disturbances in the foetal circulation. If, at the same 
time, labor goes on slowly, if the cervix is rigid, the hope of saving the 
child would warrant a more active interference and furnish an indication 
for lateral incisions of the cervix." 
But when the cervix is neither dilated nor dilatable, when, in a word, 
labor has not commenced, ought one to artificially induce labor ? Authors 
are far from agreeing on this subject. While Kiwisch, Holst, Wieger, 
Grenser, Litzmann, Stoltz, Simon, Thomas, Schillinger, Legroux, Braun, 
declare that the prompt evacuation of the uterus is of the greatest impor- 
tance in the treatment of eclampsia, and that it is necessary to induce it 
as rapidly as possible, in cases in which labor has not already come on; 
others, with' Tarnier, Busch, Bailly, accept the induction of labor only 
under certain circumstances, and have recourse to it only when the 
medical treatment has failed absolutely, and, in spite of the convulsions, 
the labor does not come on spontaneously. Finally, P. Dubois, Pajot, 
Blot, Depaul, discard it entirely. We ally ourselves with those who hold 
this last opinion. Our reasons are as follows: 1. Eclampsia is only a 
symptom of a general disease which the emptying of the uterus cannot 
eradicate at once. 2. In a good many cases not only do the convulsions 
continue after labor, but even they are produced after confinement. 3. 
Eclampsia is an acute disease, rapid in its course, and the time required 
for the induction of labor surpasses often the duration of the eclampsia. 
4. When, on the contrary, labor does come on, on account of the eclamp- 
sia itself, it progresses rapidly, and allows generally of some interference 
without danger to the mother. 5. All irritation in or around the uterus 
is sufficient, sometimes, to cause a convulsion much more so will it be 
the same with processes which are employed to induce labor. If we for- 
mulate these objections, and if we discard the artificial induction of labor, DISEASES OF PREGNANCY. 
143 
with how much greater reason should we reject forced delivery. Of this, 
there cannot be question in any case. 
But to these theoretical reasons we can add others which result from 
figures collected in our article. Thus: in 127 cases the attacks have come 
on before labor in 105 cases, and they have continued in spite of delivery, 
or they have come on only at this period, in 75 cases. Of 75 cases at the 
Maternity, in 38 cases the attacks have persisted, or were produced after 
delivery. In 297 cases, 155 of them have had the attacks continue or ap- 
pear after labor, i.e., in a total of 478 cases, 278 times the attacks have 
continued or were produced after delivery, i.e., in more than half of the 
cases. We do not then believe in the absolute efficacy of labor in puer- 
peral eclampsia; therefore we discard the induction of labor. 
If now we resume the therapeutic indications of eclampsia, they may 
be stated as follows: 1. Albuminuria once established, put the patient 
at the beginning on a milk diet, bleeding if necessary beforehand to the 
extent of 4500 or 6000 grains without going beyond this limit; 2. If this 
preventive treatment fails, and if eclampsia develops, venesection must 
be performed and from ten to sixteen ounces of blood withdrawn. An 
enema containing from one to four drachms of chloral should be given, 
and, if necessary, during the paroxysm a few inhalations of chloroform; 
3. If labor begins, it is to be terminated as quickly as possible by forceps or 
version. We must, however, await the dilatation of the cervix. In excep- 
tional cases the cervix should be incised if the child is alive and the at- 
tacks continue unabated; 4. Premature labor is never to be induced, and 
still less abortion; 5. For post-partum eclampsia give chloral, and, if 
necessary, chloroform during the paroxysms. 
Convulsions not due to Eclampsia. 
Puerperal Convulsions.-Besides eclamptic convulsions, we find numer- 
ous cases referred to in literature, as puerperal convulsions. These are 
convulsions occurring in the puerperal state, and differ essentially from 
true eclampsia. Thus, Jacquemier, under the heading convulsions with- 
out determinate form, cites Baudelocque's case of a woman who fell into 
convulsions whenever her child moved. Deneux saw a woman who, im- 
mediately after conception, was seized with spasms of the whole left side. 
These spasms lasted without pain or functional derangement until the 
third month of pregnancy. Residence in the country afforded relief in 
three weeks. Dubois saw a woman, pregnant between five and six 
months, whose abdominal muscles contracted so violently as to force the 
uterus completely down into the pelvis. The organ then quickly re- 
turned to its place, rebounding like an elastic ball. Other little promi- 
nences, apparently due to spasmodic contractions of the viscera and of the 
abdominal walls, appeared in the loins, the epigastrium and the umbilical 144 
A TREATISE ON OBSTETRICS. 
region. This woman recovered without an abortion. Velpeau cites an 
analogous case. Delamotte has seen convulsions from retention of the 
urine. Hysteria, tetanus and catalepsy, may occur during pregnancy. 
Neuralgias. 
These are common in pregnancy. The most frequent form is dental 
neuralgia, upon which Lindner has recently written at length. It is one 
of the early symptoms of pregnancy, but puerperal tooth-ache is not always 
purely neuralgic; it is often due, as Pinard says, to gingivitis or even to 
caries. In these cases the teeth should not be extracted, but local meas- 
ures relied on. 
Pregnant women are also often the victims of migraine, head-aches, 
cramps, pains in the legs and of intercostal neuralgia. They often have 
hepatalgia, with or without biliary calculi. We have seen hepatalgia with- 
out calculi repeated in the same patient in three consecutive pregnancies. 
We have also recently seen,with Dr. Magnin, a case of inflammation of the 
gall-bladder, which ended in eight days, without inducing premature 
labor. We have seen six cases of hepatic colic, either during utero-gesta- 
tion or during labor. In neither of them was pregnancy interrupted. 
Quinine best relieves these neuralgias, but they are very rebellious, and 
only stop after a certain stage of pregnancy. Morphine, hypodermically, 
has rendered us some service. Neuralgias of the legs are most persistent, 
and sometimes do not disappear until after labor. Duprilot classifies 
neuralgias as follows: 
1. Nervous Troubles from mechanical Causes.-Abdominal Pains.- 
These correspond nearly to the points of exit of the lumbo-abdominal and 
sacral plexuses. Pectoral: at the waist or near the insertions of the ab- 
dominal muscles. Lumbar or inguinal: not very serious; sometimes 
prodromata of abortion. Crural: numbness and cramps. Uterine: 
uterine rheumatism. 
2. Nervous Troubles of central Origin.-1They are due to an alteration 
of the blood, or to a direct action of the blood on the nerve tissue. A. 
Abnormal distribution of blood due to pregnancy. 1. Whenever there 
is a determination of blood to one organ the others suffer from lack of 
blood. Compression of large abdominal veins by the foetus. B. Abnormal 
composition of the blood, during pregnancy. Plethora; anaemia. In the 
head: ringing in the ears; disturbances of the senses; muscae volitantes; 
irritability; change of disposition; vertigo; insomnia; headache. In the 
chest: palpitations; syncope; dyspnoea. In the stomach: anorexia; dyspep- 
sia; gastralgia. Various sensory derangements. C. Depreciation of blood 
by abnormal substances. Albuminuria. 
3. Reflex Troubles.-Tetanic, apoplectiform, hysterical, epileptic and 
eclamptic convulsions; emesis; cough; spasms; reflex vesical irritability; 
vascular spasms; spasms of the capillaries; hemiplegia; paralysis. DISEASES OF PREGNANCY. 
145 
Vertigo, Sparks before the Eyes, Syncope. 
Syncope is, certainly, the most frequent of these accidents, is inde- 
pendent of cardiac affections, and occurs from insignificant or from inde- 
terminate causes. It may be produced by emotion, joy, anger, fright, 
strong odors, repugnance for objects or persons, or movements of the 
child. Often it occurs at meals, but most often when the horizontal posi- 
tion is exchanged for a vertical one. Ordinarily occurring without precur- 
sory symptoms, syncope may be preceded by yawning, malaise and prae- 
cordial heat, but almost never induces complete loss of sensibility and 
intelligence. Generally short, syncope may still be protracted, and is then 
often accompanied, as Cazeaux remarks, by hysterical symptoms, such as 
oppression, hypogastric pain, constriction of the throat, and, sometimes, 
true convulsions. The best treatment is to stretch the patient out flat, 
with the head low, and then to employ tonics and antispasmodics. These 
purely nervous accidents are, generally, devoid of gravity, and do not dis- 
turb the regular course of pregnancy. 
Puerperal Paralyses. 
Paralysis may supervene during pregnancy or after delivery, as is the 
case with eclampsia. Hence their designation by the generic term, puer- 
peral paralyses. As the older writers especially noticed these paralyses 
after labor, they referred them to the two great theories then dominating 
puerperal pathology, retention and suppression of the lochia, and milk 
metastases. These paralyses are now better studied, and, having ascer- 
tained that they occur during pregnancy, we have been forced to attribute 
them to another source. These paralyses are very varied in their mani- 
festations, although they affect, particularly, three leading forms. There 
may be hemiplegias or paraplegias, which are complete or incomplete, local 
or general, i.e., affecting one limb or both limbs, on the same or on op- 
posite sides. The paralysis may be limited to the face, or affect the face 
and the limbs; it may particularly involve some one organ of sense or 
one part of the muscular or nervous system, but there is always a marked 
tendency toward hemiplegia or paraplegia. 
By complete paralysis we understand the forms in which, if the case be 
one of hemiplegia, the upper and lower limbs of the same side are both 
involved, or, if paraplegia be present, both lower extremities are impli- 
cated. The term partial paralysis is reserved for the cases in which a sin- 
gle limb is attacked. Among these paralyses there is one special variety 
observed only after labor. This is the traumatic paralysis seen after diffi- 
cult labors, with or without surgical intervention, and to which we com- 
pare the palsies of newborn children extracted by the forceps or by version. 
Frequency.-Although not extremely frequent,- paralysis is not very 
rare for, in our monograph of 1872, we had already collected 149 cases, 
thus classified: Hemiplegias, 57; paraplegias, 25; traumatic paralyses, 
Vol. II.-10. 146 
A TREATISE ON OBSTETRICS. 
12; partial paralyses, 21; paralyses of the senses, 34; total 149. We will 
now study these different varieties. 
Hemiplegia. 
The first and by far the most frequent form of puerperal paralysis is 
hemiplegia. Out of one hundred and forty-nine cases of paralysis, we 
found, in 1872, fifty-seven hemiplegias. Five years later, Darcy quoted 
ten new examples, and since then, all authors who have paid attention 
to this question have published new cases. 
The causes are numerous. Aside from the two old theories,retention and 
suppression of the lochia, and milk metastases,which could, at the best, only 
be applied to the explanation of paralyses occurring after labor,we mention: 
1. Cerebral hemorrhage, cited in 1848, by Meniere, who particularly 
insists upon the hypertrophy of the left ventricle and plethora. Darcy 
admits three forms: a. Apoplectic, in which the apoplexy is often so pro- 
found that the existence of hemiplegia can not be ascertained, b. Mixed 
form. Consciousness lost, but only for a short time, and eclampsia may or 
may not have preceded. This is not genuine apoplexy, c. Paralytic form. 
In these cases there is hemiplegia lasting at least several months, and un- 
dergoing a gradual cure. d. Pregnancy occurring in hemiplegic women. 
2. Cerebral Congestion.-This is particularly induced by the efforts of 
labor or by eclampsia. It produces torpor, slight or well-marked, after 
which more or less complete hemiplegia remains and disappears, ordina- 
rily, quite rapidly. 
3. Cardiac Affections.-Endocarditis.-This may be the acute, ulcera- 
tive, typhoid or pyohaemic form of Senhouses Kirke, Simpson, Hardy, 
Charcot, Peter, Bucquoy, Martineau, and Decornicre, or the subacute 
and chronic form of OHivier, to which recent researches on puerperal car- 
diac troubles lend new importance. Attacking by preference the mitral 
valve, as does rheumatic endocarditis, it advances progressively and in- 
creases with the number of pregnancies. Causing the growth of valvular 
vegetations, it may give rise to cerebral embolism. In this connection we 
should mention the arterial thromboses reported by Oke, Risdon, Ben- 
net, Turner and Simpson. This last author divides them into five kinds 
caused by: a. The detachment of old or organized cardiac concretions 
and their transportation into arterial channels. b. Entrance into the 
circulation of recent coagula formed in the heart or in the great arteries. 
c. Local arteritis, d. A lesion of the tunica intima of the arteries, e. 
Foreign bodies coming from the veins and lodged in the pulmonary artery 
or its divisions. 
4. Alterations in the Blood.-These changes play the leading r6le in 
producing endocarditis, acute or sub-acute, and arterial thrombosis. 
Hemiplegia is thus only the epiphenomenon of a cardiac affection devel- 
oped during pregnancy, or after numerous pregnancies, and reacting, in 
turn, on the central organ. DISEASES OF PREGNANCY. 
147 
5. Albuminuria.-Cases have been reported by Fleetwood Churchill, 
Latham, Romberg, Simpson, Lever, Imbert Gourbeyre, Johnson, Braun, 
Fournier, etc. 
6. Puerperal Septicoemia.-Hervieux and Charpentier, have reported 
cases. 
7. Anoemia.-Stork, Bataille, Ley, Churchill, Laurent. 
8. Reflex Action.-Whyt, Prochaska, Lever, Churchill, Imbert Gour- 
beyre, Pellegrini, Crosse and Stokes, have reported cases. 
The last two causes cannot be absolutely eliminated, but, in reality, 
two grand causes seem to us to dominate the pathogeny of puerperal 
hemiplegia. First, cerebral lesions, congestions, hemorrhages, thrombo- 
ses of the sinuses, whether primary (Meniere) or secondary, lead to cardiac 
affections, i.e., to the acute puerperal endocarditis of Simpson and Decor- 
niere, or to Ollivier's sub-acute progressive endocarditis, or to puerperal 
cardiac disturbances (Peter, Marty, Berthiot and Porak). These affec- 
tions act, in turn, either rapidly or slowly, in determining the sudden or 
the slow development of hemiplegias. Second, we place albuminuria with 
or without eclampsia. We place last, as quite subordinate, and perhaps, 
doubtful, anaemic hemiplegias, as well as those due to reflex action and 
to puerperal septicaemia. 
Frequency.-Although not rare, puerperal paralyses are not very fre- 
quent, but it is impossible to furnish reliable statistics, since many cases 
pass unobserved, owing to the coexistence of coma. The age of the 
patients does not seem to have a great influence, for, although there are 
more cases between twenty-five and thirty years, this is the age at which 
women generally become pregnant. Our outside figures were eighteen 
and forty-five years. Darcy gives twelve and forty-five years. Among 
thirty-five of our cases, twenty-four women were from eighteen to thirty 
years, and fourteen from thirty-two to forty-five years. Among thirty- 
six of Darcy's cases, twenty-one were less than thirty years, and fifteen 
were from thirty to forty-three years. The same obtains as regards 
primiparae and multiparse. Our statistics are thus as follows: 
Charpentier. 
Primiparae, . . .17 
Multiparae, . . .14 
Darcy. 
Primiparae, . . .15 
Multiparae, . . . 17 
which may be thus classified: 
1st pregnancy, . .17 
2d " . . .1 
3d ... 8 
4th " ... 1 
5th " ... 1 
6th " ... 1 
7th " ... 1 
10th 11 ... 1 
1st pregnancy, . . 15 
2d ... 3 
3d ... 3 
4th " . . . 2 
5th " ... 2 
6th 11 ... 3 
10th " . 1 
13th " ... 3 
Before " ... 3 148 
A TREATISE ON OBSTETRICS. 
Time of appearance. 
Charpentier. 
Darcy. 
Hemiplegias before pregnancy. 
. 3 
3 
" during " 
. 19 
23 
" " labor 
. 1 
1 
" after delivery, 
. 8 
23 
" not stated, 
. 8 
8 
Charpentier. 
1st month, ... 2 
2d ... 2 
2d and | months, . 
3d month, . . . 1 
4th " 1 
5th " 1 
6th " 1 
7th " 1 
7th and | months,. 
Sth month, . . . 1 
8th and | months,. . 1 
9th month, ... 4 
15 
Darcy. 
1st month, 
2d " . . . 2 
2d and months, . . 1 
3d month, 
4th " ... 1 
5th " ... 
6th " ... 3 
7th " ... 6 
7th and | months,. . 1 
8th month, ... 8 
8th and | months, . . 2 
9th month, ... 5 
29 
Thus, it is in the last two months of pregnancy that hemiplegias are 
the most frequent. After labor they appear, usually within ten days. 
Hemiplegias after Delivery. 
Charpentier. Darcy. 
Almost immediately after, .... 3 3 
2 days after, ....... 1 
3 " " 1 
4 " " 2 
y Cl it । 
8 " " '. '. *. . . : . 1 3 
9 " " 1 
10 " " 2 4 
14 " " 1 
15 " " 1 1 
16 " " 1 
One month after, ...... 2 
Six weeks " ...... 1 
As regards- the side on which the hemiplegia was located, Darcy has 
found: Right hemiplegia, 26; crossed hemiplegia, 2; left hemiplegia, 16; 
side not stated, 14. 
Signs and Diagnosis.-There may be prodromata or these may be 
absent. Hemiplegias due to cerebral lesions commence, most frequently, 
suddenly, like an apoplectic attack. In women with albuminuria, how- 
ever, headache, disturbances of vision, or even convulsions, generally 
precede the attack by a few hours or days. The characters of the paralysis 
are as follows: Often it developes quickly, simultaneously invading the 
two limbs and even the face. Often, also, the upper and lower limbs are DISEASES OF PREGNANCY. 
149 
successively attacked. Sometimes the hemiplegia is incomplete, now 
affecting the upper extremity, and being accompanied by facial paralysis 
or amaurosis; now attacking the lower limb of the same or of the opposite 
side; now being limited to the face. It simultaneously involves motion 
and sensation, but is rarely attended by vesical or rectal difficulties. More 
rarely yet the intelligence is impaired. Generally it remains perfect after 
the patient has recovered consciousness. Speech is, indeed, affected, but 
that is due to impaired motility of the tongue, and, excepting in one case 
of our own, and in two of Temoin, in which delirium persisted several 
days, the intellect was unimpaired. Paralysis seems limited, in short, to 
motion and to sensation. The lesions of motility are the predominating 
features. Sometimes there is simply weakness or numbness, accom- 
panied, in some cases by tremors, formication, or more or less acute pains 
in the limbs involved. Sometimes the limbs are absolutely motionless 
and remain inactive in any position, without the patients being able to 
move them at all. Mobility may be progressively restored, or even rap- 
idly, in a few hours or days. Sometimes the paralysis lasts several months 
before absolutely disappearing. In rare cases, death closes the scene, but 
patients generally recover, if not entirely, yet to such an extent as to re- 
sume some of their occupations. Disturbances of sensibility present 
greater variety than those of motility, but exist habitually. In the major- 
ity of cases, motility is notably impaired. There may be all kinds of an- 
algesias and of anaesthesias, which may be the first symptoms of the pa- 
ralysis. The patients notice that some part of their person first becomes 
insensible and then immobile. So the two symptoms, impairment of 
movement and diminution of sensibility, progress side by side, sensibility 
generally returning sooner in cases resulting in a cure. This change in 
sensibility, limited to the paralyzed side, or involving the other as well, 
is more or less profound, varies from the mildest analgesia to complete 
anaesthesia, and presents remissions and exacerbations accompanied by 
sensations of cold or heat, without these two agents locally applied pro- 
ducing appreciable phenomena. One may prick or pinch the patients 
without their knowledge. Again, there may be real hyperaesthesia, always 
attended by sensations of cold or of heat. 
This difference in the symptoms, may serve to farther facilitate the 
diagnosis and often reveals the source of the paralysis. Thus, in paraly- 
sis from cerebral affections, the inception is always sudden, and the pa- 
thological conditions rapidly reaching their maximum, are lasting and 
fatal. On the other hand, in so-called reflex paralysis, the beginning is 
insidious. The lesions of motility, at first consisting in weakness and 
numbness, gradually pass into complete hemiplegia. In the former case 
all the extremities are almost always simultaneously involved, while, in 
the latter case, partial paralysis is often seen. Moreover, in the latter 
case, the lesions of sensibility are various, while, in cerebral lesions, sen- 150 
A TREATISE ON OBSTETRICS. 
sibility is usually just as completely abolished as motility. In the variety 
due to albuminuria, there are usually prodromal symptoms, viz., headache, 
visual derangements, eclampsia, convulsions. In these cases constitutional 
symptoms, fever, peritonitis, phlebitis, and lymphangitis are absent, al- 
though they do occur in paralysis from puerperal septicaemia. These 
hemiplegias considerably resemble those occurring aside from pregnancy, 
but the puerperal state impresses a certain stamp upon their course and their 
termination. Puerperal hemiplegias, commencing often during the later 
months, increase as pregnancy advances, acquire greater intensity dur- 
ing labor, and subsequently disappear, either completely or by gradual 
subsidence. In some cases the hemiplegia does not entirely disappear, 
and if several pregnancies succeed each other, the paralytic symptoms are 
aggravated either at the time of a new conception, or during utero-gesta- 
tion. In these cases there is sometimes amelioration of the symptoms in 
the later months, but during parturition, or some days later, there is a 
real relapse from which the patient does not recover for some time. 
Again, in rarer instances, hemiplegia begins during labor, but it is then 
almost always the result of eclampsia, albuminuria having been super- 
added to the influences due to the puerperal state. In a third class of 
cases, which are, at least, as frequent as the first, the paralysis does not 
begin until after labor, and, strangely enough, generally after a natural, 
easy and short confinement. 
Prognosis.-This is very variable, and depends chiefly upon the cause 
producing the paralysis. Hemiplegia due to organic lesions is quite often 
fatal, but the other forms of hemiplegia are not. Hemiplegias may be 
divided into two large classes: those due to extensive, and those due to 
transient or slight cerebral lesions. In fatal cases, death usually occurs 
very soon, within two or three Jays, and the autopsy reveals considerable 
cerebral lacerations and hemorrhages. When death ensues more gradu- 
ally, we find meningitis, or much less important hemorrhages, or a com- 
bination of lesions which suffice of themselves to cause death, inde- 
pendently of the cerebral affection. When recovery occurs, it is gener- 
ally very rapid, taking place in a few hours or days, thus showing the 
lesion to have been transient. In some cases, if long protracted, the in- 
tellect has been impaired. Heath does not occur so frequently as might 
be expected. We find it to have taken place in twenty of our fifty-seven 
observations. Another peculiarity of these hemiplegias is that, in some 
cases, before permanently disabling a limb or a side, they may alternately 
disappear and reappear. This characteristic feature is not always a proof 
of benignity, for two such cases resulted fatally. These hemiplegias 
exert hardly any influence upon pregnancy and labor. The majority of 
hemiplegic women almost or quite reach full term. Among fifty-eight 
of Darcy's cases, thirty-two reached the full term. In ten cases labor 
occurred prematurely, but this hardly happens except when albuminuria DISEASES OF PREGNANCY. 
151 
is present. In the cases referred to, eclampsia preceded labor, and the 
paralysis was consecutive to these attacks. In only two or three in- 
stances, has labor been slow and prolonged. In all the others parturition 
was normal, easy and rapid. 
The treatment varies with the cause, the nature and the form of the 
paralysis. Venesection, friction, mineral baths, strychnia, and electricity 
have been employed, sometimes with success, and sometimes without 
any favorable effect upon the patient's condition. 
Paraplegias. 
These are not less frequent than hemiplegias, and here we find, after 
labor, the two chief ancient theories regarding suppression of the lochia 
and milk metastases. The causes are numerous, as in hemiplegia, but 
we find here two new and important causes; reflex action, which we 
admitted with some reserve as a cause of hemiplegia, and traumatism. 
We mention, therefore, in the first place: 
1. Paraplegias from medullary Lesions.-In this case the medullary 
lesion sometimes exists before conception, and pregnancy only modifies 
its original action. On the other hand, the lesion may be developed under 
observation during pregnancy, the physician thus witnessing the series of 
morbid results terminating in death, and ascertaining the existence of the 
lesion, post mortem. 
2. Paraplegias from Albuminuria.-Some authors admit this cause, 
without reserve, while others regard it as exceptional, and still others re- 
ject it. We reject it, in common with Lasegue, Fournier, Addison, See 
and Hervieux. Lasegue, in the Archives de Med., 1852, studying the 
cerebral disorders which occur in Bright's disease, mentions coma, con- 
vulsions, delirium, and disturbances of the senses, but insists upon the 
absence of coma, in the following terms: " The absence of paralysis and 
the peculiar condition of respiration almost suffice to banish doubt. No 
matter at what period of the disease the case is observed, or what the in- 
tensity of the stupor, we do not find the slightest paralysis. Whenever 
concomitant paralysis is reported, it may be referred to a local cause, and 
is not due to Bright's disease. Bright himself emphasized this distinction, 
which experience fully confirms." 
3. Paralyses from reflex Action.-These are the functional paraplegias 
of Jaccoud, which were formerly called peripheral paraplegias. This is 
the prevailing cause of puerperal paraplegias. The relation between 
paraplegia and certain morbid conditions of the genital organs was men- 
tioned by Churchill, Romberg, Hunt, Stanley, Lisfranc, Esnaut, thesis 
1857, Vallin, thesis 1858, and Nonat. Now, as Hervieux remarks, " if 
the diseased uterus is capable of producing paraplegias, why may not the 
gravid uterus or the uterus in its post-partum state, exert the same patho- 
logical influence ? " Jaccoud gives the name of functional paraplegias to 152 
A TREATISE ON OBSTETRICS. 
all those whose distinctive feature is the absence of all material conditions 
producing paraplegias of his first three classes (spinal lesions, ischaemia 
and dyscrasiae), and he classifies functional paraplegias as follows. 1. The 
paralysis results from a more or less prolonged abnormal excitation trans- 
mitted to the medulla by the peripheral nerves, from the genito-urinary 
organs, the abdominal viscera or the skin. This is peripheral paraplegia. 
2. Paraplegia follows pyrexia? and acute diseases. 3. Paraplegia appears 
during the coma of a constitutional or cachectic disease. 4. Paraplegia 
developes from a neurosis. 
For him, therefore, puerperal paraplegia does not belong among reflex 
paralyses. Making a careful distinction between the paralysis of pregnancy 
and puerperal or post-puerperal paralysis, he places the former among 
the paraplegias due to anaemia, attributing it to chloro-ansemia and to a 
nervous state, and the second class of cases among organic paraplegias, 
from compression of peripheral nerves, thus attributing a predominating 
influence to traumatism. Jaccoud, disputing the propriety of the term 
reflex paralysis, insists that the paraplegia is not reflex, but due to the 
contraction of the medullary vessels, and that we should designate the 
paralysis as paraplegia by reflex vascular contraction or reflex ischaemia. 
But he does not even admit this contraction, for then it should be per- 
manent, or ought, at least, to last as long as the paraplegia, i.e., weeks or 
months, which is contrary to all the principles of nervous action, for pas- 
sive dilatation tends always and everywhere to active contraction of the 
vessels. If there really existed a permanent ischaemia of the medulla, the 
organ ought, after a time, to present the material lesions characteristic 
of ischaemic degeneration. Rejecting, therefore, the opinion of Willis, 
Why th, Prochaska, and Brown-Sequard, he formulates the following 
theory: " An abnormal excitation is transmitted to the medulla by the 
sensitive nerves of the uterus, the kidneys, the bladder, the bowel, etc. 
It exhausts, at the end of a variable time, the peculiar excitability of the 
corresponding region of the organ, and the inertia of these nervous ele- 
ments under encephalic stimulation, interrupts the channels of the motor 
impulses. The paralysis of all the parts situated below the affected point 
is the necessary result." Froge, thesis 1868, admits that, in certain cases, 
the gravid uterus may react upon the nervous centres by the physiological 
phenomena located in it, to such an extent as to precipitate disturbances 
of innervation, among which is reflex paralysis. Hervieux adopts the 
theory of reflex paraplegia outright, and the observations cited in our 
own monograph seem to leave no doubt on the subject. 
4. Chloio-anoemic and posi-h^morrhagic Paralyses.-These two forms 
of paralysis may, we think, be arranged under one heading, the anaemic 
paraplegias. They embrace what Jaccoud describes under the title dys- 
crasic and ischaemic paraplegias. Some paraplegias from dyscrasiae de- 
pend on a qualitative alteration of the blood, i.e., are produced by modi- DISEASES OF PREGNANCY. 
153 
fications in the normal elements of the blood, as Regards proportions and 
quality. Some are due to the presence, in the blood, of some foreign 
substance. Now, the composition of the blood is changed during preg- 
nancy, and hemorrhages occurring during or after labor, and even during 
pregnancy, alter the blood by reducing its quantity, and thus themselves 
sometimes cause paraplegias. 
5. Paraplegias from Blood-poisoning, in puerperal Septiccemia.-These 
are admitted by Hervieux, but we think that they should be included 
among paraplegias due to organic lesions. They are usually secondary to 
inflammatory lesions, of which they are only the results. 
6. Traumatic Paraplegias.-These will be separately Studied, and will 
serve as transitional forms between complete and partial paraplegias. 
Frequency.-Paraplegias seem less frequent than hemiplegias, since we 
found only twenty-five among our one hundred and forty-nine cases. 
They therefore bear to hemiplegias the approximate relation of one to two. 
Age.-They are encountered, most frequently, between nineteen and 
thirty years, but we have noted six cases between thirty-one and fifty 
years. The number of pregnancies is indicated in only a few of the cases: 
1st pregnancy, . 6 cases. 
2d " . . 2 " 
3d . 3 " 
4th pregnancy, . 1 case. 
6th " . . 1 " 
10th " . . 1 " 
In four cases, a paraplegia which existed before pregnancy, or during a 
preceding pregnancy, relapsed owing to conception. In the cases of Riviere 
and of Etcheveria, paraplegia followed abortions. 
Time of Appearance.-Like hemiplegias, they may appear before or dur- 
ing pregnancy and during or after labor. 
Paraplegias existing before pregnancy, 2 cases, six years before. 
" beginning during " 5 11 at 2, 4, 7, and 8 mos. 
" during labor, . . .1 case. 
A few hours after, 1 case. 
31 hours, . . 1 " 
7 days, . . 1 " 
8 " . . 1 " 
11 " . 1 " 
17 " . . 1 " 
1 month, . . 1 " 
7 months, . . 1 
Date not given, . G cases. 
Paraplegias after labor, 14 
Paraplegias are thus much more frequent after labor than during preg- 
nancy. 
Symptoms and Course.-These paraplegias do not differ from those not 
dependent upon the puerperal state, and may be either complete or in- 
complete. There are three types of the latter variety: " 1. The patient 
cannot take a step, nor even stand upright, but, when she is lying down, 154 
A TREATISE ON OBSTETRICS. 
she can either move tly? whole limbs or execute partial movements. 2. 
The patient can stand without support, and can even take a few tottering 
steps, but walks without raising the feet. She executes this - kind of 
progression by the alternate gliding of the whole sole upon the ground, 
or the heel being lifted, it is only the anterior extremity of the foot which 
glides along the ground. 3. The patient may sometimes walk quite a 
long time without support, except that of a cane, but she feels early and 
unusual fatigue, which is, most frequently, not in accord with the devel- 
opment of the muscular system." (Jaccoud.) 
These three types generally succeed each other, the disease rarely sud- 
denly reaching its maximum intensity. It is, at first, an awkwardness 
and an enfeeblement of the limbs, or of one limb, succeeded by complete 
paralysis after a variable time. Paraplegia shows another peculiarity in 
some cases. It oscillates, as it were, in such a way that if, for example, 
the left leg were first attacked, the right leg would be in turn affected 
after a few hours or days. In the meantime the left leg might have 
partly or entirely recovered. A few days later the latter would be again 
attacked, and from this time on the affection, being equally or unequally 
developed in the two legs, would pursue its regular course. Sometimes 
paraplegias, limited to the lower extremities, seem to have no effect upon 
the general system. Sometimes, however, they prostrate the patients 
considerably, and are attended by bladder and rectal disturbances, par- 
ticularly the former. Sometimes the urine is slowly expelled, and some- 
times there is complete retention, followed by incontinence from paralysis, 
with erythema and eruptions. The rectum is more or less paretic, which 
occasions constipation, or, if diarrhoea exist, involuntary defecation. 
Again, the paralysis involves even the abdominal muscles, and the women, 
not feeling foetal movements, and thinking the child dead, can only per- 
suade themselves that it is alive by seeing the movements. 
Sensibility-is differently affected. In some cases there is slight, but in 
others, profound anaesthesia. There are, sometimes, sensations of tick- 
ling, prickling and creeping in the paralyzed limbs. In spinal paraplegias 
there is, at the seat of the lesion, constant pain, which may radiate either 
toward the pubes, the thighs, the legs or the loins, or may encircle the 
body, producing cramps and sensations of heat and coid. But these sen- 
sations have nothing characteristic, and motility inay be alone affected. 
These paraplegias pursue a special course. Beginning in a gradual 
fashion, they rapidly become complete, but generally disappear quite rap- 
idly. This is not always true, and sometimes there is a sort of transition 
in the disease, which Jaccoud has well described. Anaemia of the spinal 
cord may lead to more or less severe organic lesions. Then paralysis 
persists, or, becoming general, it kills. In these cases other symptoms 
appear, which prove that it has changed. 
These symptoms are spinal pains, spasms, pains in the paralyzed limbs, DISEASES OF PREGNANCY. 
155 
which radiate to different points, and sometimes give the patients no 
peace. The muscles are wasted, and even complete atrophy may occur. 
Under the influence of repeated pregnancies, these paraplegias increase 
in extent and in gravity. 
Prognosis.-This varies with the cause. If the paraplegia is reflex, 
anaemic or post-hemorrhagic, the cause being transient and capable of en- 
tirely disappearing under proper treatment, the prognosis is favorable, and 
we may expect a cure, unless a transformation in the type of the disease 
appears. If the paraplegia be organic, the importance and the gravity of 
the lesion will decide the prognosis. If the cause is a congestion or a 
slight hemorrhage, we may hope for a cure, although it may be tardy. If 
the case involves vertebral caries, myelitis or medullary softening, the 
lesion will be grave in proportion to the extent of the disease. 
Diagnosis.-The chief point in the diagnosis is to decide whether the 
cause of the paraplegia be organic, or functional and reflex, and this is 
not, generally, difficult. If the paraplegia is of organic origin, it is gen- 
erally slowly progressive, accompanied by radiating pains in the spine, by 
formication, numbness in the legs, cramps, spasms, veritable contrac- 
tures, analgesia and anaesthesia, or marked hyperaesthesia, vesical and 
.rectal disorders, all of which are persistent. The puerperal state is lost 
sight of in these cases, and the organic lesion is the dominating pathologi- 
cal feature. When paraplegia begins after labor, and is not due to trau- 
matism, which plays a special role, this paraplegia is only developed after 
puerperal diseases, and is due to disease of the lumbar and sacral plexuses, 
dependent on inflammatory changes in the soft or the bony tissues of the 
pelvis. In this case inflammation is propagated from these tissues to the 
nervous plexuses. The resulting paraplegia follows in its development 
the evolution of the original disease, and, if the patients recover, the par- 
alysis disappears, either at the same time as the disease which occasioned 
it, or at the end of a longer period. In such case, the piyaplegia, al- 
though organic, is dependent upon a local condition which owes its origin 
directly to the puerperal state. Our view is thus quite different from 
that of Hervieux, who considers these paraplegias to be the result of a real 
poisoning by what he calls the puerperal miasm. 
Reflex paraplegias are never accompanied by spinal or lumbar pains. 
Beginning insidiously, i.e., with simple enfeeblement, perhaps of a single 
limb, they do not fail to speedily attack the other limb, and to become 
more or less complete (sometimes in a few hours). The peculiar changes 
of sensibility noted among the symptoms, are particularly prominent in 
these cases. The bladder and the rectum are, most frequently, unaffected 
and the paralysis supervenes, sometimes without known cause, and some- 
times as the result of an exposure to cold, of a hemorrhage, or of preg- 
nancy alone. It occurs just as readily after an easy as after a difficult 
labor, and is generally of short duration. If it persists, it is because its 156 
A TREATISE ON OBSTETRICS. 
type has been transformed. Although these paraplegias have no effect 
upon pregnancy, it is not so with labor, although this influence varies with 
the cause and the intensity of the paraplegia. If the disease, for exam- 
ple, is slight, and limited to the legs, its influence upon the course of labor 
is of no moment, but it rather seems to hasten labor by diminishing the 
susceptibility to pain. The same does not hold when the paraplegia extends 
to the abdominal muscles. In this case, labor is arrested at the very 
end, by failure of the expulsive power of the abdominal walls. (Garnet, 
Depaul, Bracket.) 
Treatment.-This varies with the nature of the disease. In the former 
case revulsives and stimulants to the legs, and nux vomica, meet the indi- 
cations. In the second case, a tonic regimen and rest will usually suffice 
to cure a disease, the natural tendency of which is toward recovery. If 
the disease, even in the second instance, proves a little rebellious, electri- 
city and baths, particularly sulphur baths, may be useful. 
Traumatic Paralysis. 
There is another class of paralyses, not less interesting, viz., those in 
which the lesion affects only a single limb, the upper or the lower, and among 
these paralyses, traumatic paralyses merit particular attention. Inciden-. 
tally mentioned by Campbell, Ramsbotham, Scanzoni, Romberg, Jacque- 
mier, Imbert Goubeyre, Bedford, Burns, Tarnier, Siredey, Jaccoud, 
Axenfeld, Simon, Hervieux, Depaul, Maringe, Rosier and Froge, these 
paralyses were carefully studied by Bianchi in his thesis of 1867, and we 
were able to collect eleven cases. Since then, in 1867, Lefebvre has 
cited four new examples, and Brivois, thesis 1880, two new cases, one 
personally observed and one borrowed from Winckel. The total number 
is seventeen, not great to be sure, but important in view of the clearness 
and precision of the facts. Bianchi, first recalling the cases of paraly- 
sis produced by tumors pressing against sacral nerves at their origins, 
compares the foetal head to a hard, voluminous tumor, which exerts ener- 
getic, although brief pressure, causing paralysis, generally temporary, but 
sometimes persisting after delivery. Reducing the question to a mechani- 
cal problem, he states that there exists: 1. An active agent or force 
(uterine contraction). 2. A compressing body (foetal head). 3. A re- 
sisting surface (maternal pelvis). 4. Organs exposed to compression. 
These are the foetal head, the pelvis, the perineal muscles, the hypogas- 
tric vessels, the bladder, the rectum, the nerves, particularly the obtu- 
rator, and the sacral plexus, particularly the great sciatic nerve. Incom- 
pletely protected against puerperal traumatism, this nerve is necessarily 
compressed in all labors, but to a variable extent. Generally, the only 
results are, at the end of labor, cramps in the calves and the great toes. 
If the nerve is, however, too long and too forcibly compressed, bruised by 
the foetal head or by instruments, disturbances which are often serious DISEASES OF PREGNANCY. 
157 
and lasting, or even trne paralyses, may develop in the inferior extremi- 
ties, where the terminal branches of the nerve are distributed. To-day 
these traumatic paralyses are universally admitted, and with Bianchi we 
may cite among their determining causes all conditions augmenting the 
duration and the intensity of the compression. Thus: the length of 
labor, whether due to weakness of uterine contractions or to considerable 
resistance, large size of the child, posterior positions, pelvic deformity, 
perineal resistance, first labors, particularly the use of forceps, and finally 
the patient's age. The majority of cases occur in women over thirty years 
old, and especially in primiparae. These paralyses are, nevertheless, rare, 
and one might assume a certain individual predisposition, which would 
be favored in some cases by the patient's age, the fact of not having 
borne children, and the situation of the foetus. 
Symptoms and Diagnosis.-These paralyses always occur after labor, 
but, in certain cases, are preceded by some phenomena which we might 
consider precursors almost like the first stage of a disease. These 
are very violent pains, which some patients experience in the sciatic 
nerve, during labor. Noted by all obstetricians, these pains, which 
occasion in many women cramps, formication and numbness of the 
limbs, are sometimes so pronounced as to give the labor a pathologi- 
cal aspect. Generally moderate, they assume, in some cases, an extreme 
severity and impede labor. Sometimes they specially affect the crural 
nerve (then they are felt on the anterior surface of the thighs), sometimes 
the obturator (and then they are felt on the internal aspect of the thighs), 
most frequently the great sciatic nerve, occasionally all the nerves at once, 
but, generally, various nerves in succession, thus indicating the progress 
of foetal engagement. Thus, the pains due to compression of the crural 
and of the obturator are felt before those of the sciatic nerve, and at an 
earlier period of labor. It is, in fact, upon this last nerve that all the 
compression exercised by the foetal head is concentrated, and this is par- 
ticularly true at the end of labor. If this compression has been too long 
continued or too energetic, these pains, which generally disappear very 
rapidly after labor, may last a longer or shorter time and paralyses may 
succeed them. This particularly happens when this contraction has been 
farther augmented by tractions upon the forceps, especially when these 
tractions are wrongly directed and either too violent or too long continued. 
Whether these original pains exist or not, paraplegia is developed in all 
the cases, very nearly at the time for labor. Paralyses appear after 
twenty-four or forty-eight hours, or after some days, at the latest. They 
might appear later without our being able to deny that they were due to 
traumatism, (Niemeyer, Follin, Velpeau, Bastien, Tillaux.) 
Sensation may be abolished, diminished, augmented or perverted. This 
abolition of sensation may be complete or partial, and may consist of anal- 
gesia, anaesthesia or, most frequently, of the two combined. There may 158 
A TREATISE ON OBSTETRICS. 
even exist thermo-analgesia, i.e., insensibility of the skin to different 
temperatures. Sensibility may, ou the contrary, be augmented, now con- 
stituting a true, traumatic, diffuse, disseminated neuralgia, without deter- 
minate limits, and often extremely severe, now corresponding to the course 
of the compressed nerve, or localizing itself in certain points. Sensibility 
may be perverted, and then the patients experience prickling, tickling 
and painful formication, symptoms which may announce the beginning 
of a true hyperesthesia, and may only be transitory, or may lead to a par- 
alysis of sensation. Motor disturbances may, in the same way, vary from 
a simple impairment of motility, awkwardness, torpor or weakness, up 
to complete loss of motility. The prolonged absence of innervation re- 
sults, generally after a long time, in a certain amount of muscular atrophy. 
The disturbances of secretion and vital heat are more directly dependent 
upon the sympathetic system. The lowering of the temperature in the 
diseased limbs is referable to local retardation of the circulation, due to pa- 
ralysis of the vaso-motor filaments derived from the cerebro-spinal system, 
which results in vascular contraction. 
This description, borrowed from Vulpian,Bastien and Tillaux,is perfectly 
applicable to traumatic paraplegias. Commencing moderately, the disease 
progressively reaches its maximum, but is almost always unilateral, which 
shows that the compression has been more strongly exerted on one of the 
sacral plexuses. The paralysis is generally incomplete and limited, for, 
since the compression affects particular nerves, the paralytic symptoms 
show themselves in the muscles which these nerves supply. Thus, in one 
of Bianchi's cases, paralysis was especially well marked in the muscles 
supplied by the external popliteal nerve. Limited to one limb, or to one 
part of a limb, the paraplegia never invades the rectum or the vagina, 
which remain intact and preserve the integrity of their functions. Elec- 
trical excitability is diminished or even abolished. 
The only conditions which are liable to be mistaken for these paraple- 
gias, are the pseudo-paraplegias of Jaccoud, and the relaxation of the pel- 
vic symphyses, succeeding a difficult labor, but the differential diagnosis 
is easy. Schmidt had a curious and rare case, in which paraplegia devel- 
oped in the course of an extra-uterine pregnancy. These paraplegias al ways 
disappear, but sometimes only after months or even years, and in these 
tedious cases, we find atrophy of the diseased limbs. 
Treatment.-This is preventive, consisting in wise intervention, calcu- 
lated to prevent compression of the nerves from prolonged contact with 
the head, and curative, consisting in efforts to retain the remaining exci- 
tability of the injured nerves, and to prevent or to arrest fatty degenera- 
tion of the muscles. Electricity, locally applied, cutaneous revulsion, dry 
or wet frictions, mineral waters, baths and sulphur douches are indi- 
cated, besides a tonic and roborant treatment. DISEASES OF PREGNANCY. 
159 
Partial Paralyses. 
These paralyses, whether hemiplegic or paraplegic, may affect now an 
upper and now a lower extremity, and may either simultaneously invade 
the face and one upper limb or be limited to the face. Again, they may 
involve a limited muscular area. Although the causative influence of the 
puerperal state is evident in some cases, yet these paralyses may acciden- 
tally develop in a pregnant woman without there being an evident con- 
nection between the palsy and pregnancy. Aside from traumatic paral- 
yses, we have collected the following twenty-one cases: 
Crossed hemiplegia, ...... 1 case. 
Paralysis of the upper extremity, .... 5 cases. 
" " lower " .... 2 " 
" " face " . . . . 8 " 
" " " and arm, .... 1 case. 
" " shoulders, ..... 2 cases. 
" " extensor muscles of the neck, . . 1 case. 
Hemiplegia with contractures, . . . . " " 
One striking fact is the comparative frequency of facial paralysis. 
Next to this comes paralysis of the arm. The hemiplegic type largely 
predominates over the paraplegic in these cases of partial paralysis, and 
these palsies are rarely isolated, i.e., they are complicated by impairment 
of the senses, as of hearing and sight. Amaurosis, most frequently par- 
tial, may exist. Instead of always assuming a typical course, these paral- 
yses tend to develop in one single region, as in the muscles of the face, 
the shoulders, or the neck. They therefore belong to the class desig- 
nated as rheumatic. On the other hand, all authors have noted the 
relation existing between albuminuria and rheumatism. Among our 
twenty-one cases, in six albuminuria existed, and in four others, the pa- 
ralysis coincided with a more or less complete amaurosis. These usual 
impairments are among the most frequent complications of albuminuria. 
We, thus, believe that partial paralysis are due to three chief causes: 1. 
Albuminuria; 2. Rheumatism; 3. Reflex action. 
Frequency.-Rare as regards absolute frequency, partial paralyses are 
frequent as compared with complete paralyses. Thus, if we add these 
twenty-one partial paralyses to the seventeen traumatic paralyses, we ob- 
tain the following figures: Hemiplegias, 57; Paraplegias, 25; Partial pa- 
ralyses (traumatic or otherwise), 38; total 120. 
After hemiplegia, this is, 'therefore, by far the most frequent form. 
Partial paralyses may occur as well during pregnancy as after delivery, 
after an abortion as well as after labors at term, and may be recurrent. 
This happened once in three, once in four, and once in eight successive 
pregnancies. Motility and sensibility are alike affected, and we may 
have all the varieties noted above. Sometimes the palsies begin sud- 
denly, and, sometimes, are preceded by discomfort, head-ache and visual 160 
A TREATISE ON OBSTETRICS. 
troubles. Occasionally the paralysis has been preceded by weakness, 
numbness and pains in the limbs, and has slowly and progressively grown 
more marked until sensation and motion have been entirely lost. Occasion- 
ally, however, it has begun suddenly without premonitions. It may present 
the same varieties mentioned under the head of complete paralyses, which 
enable us to make the diagnosis, to which we need not revert at present. 
Let us only mention hysterical paralyses, which are distinguished by the 
concomitance of other hysterical phenomena which render the diagnosis 
clear. 
Paralyses of the Senses. 
These paralyses are almost always dependent, it is true, upon albumin- 
uria, but they may, in rare instances, be attributed to hysteria, anaemia 
or dyscrasiae. The fact of their persistence shows that albuminuria is 
not their only cause. Rarely isolated, they are often accompanied by 
paralyses of several other special senses, particularly of hearing and sight. 
Again, they may coexist with paralyses of the face or of the limbs. 
Disturbances of vision are by far the most frequent. These troubles may 
present various degrees. Sometimes the sight is, at first, clear and only 
grows dim after use. Sometimes there is complete loss of vision. Some 
patients become color-blind, others become myopic, and others present, 
at the same time, exophthalmos, strabismus and prolapse of the lids. 
The cornea and the sclerotic are healthy, the pupils are not very contrac- 
tile and are often dilated. The retina and the choroid may present nu- 
merous and varied alterations, but often are in a normal state. In cer- 
tain cases, the amaurosis coexists with lesions of motility and of sensi- 
bility in the limbs. Besides these visual troubles, referable to albumin- 
uria, we must mention those following large puerperal hemorrhages, 
those due to toxic doses of lead or quinine, (we have seen one such case 
which lasted four months) and those referable to syphilis or to other ca- 
chexiae. We, finally, see these impairments of sight accompanying the dis- 
eases of the post-partum state, whether inflammatory or not. Lastly, in 
Lebreton's, Boulley's and Landry's cases of hysterical paralyses, there 
were marked visual difficulties. We believe albuminuria is the chief path- 
ological agent. The same applies to deafness, although it may be more 
generally connected with general depression of the system. Although, 
indeed, deafness sometimes depends upon albuminuria, it is oftener due 
to the adynamia attending puerperal septicemia, and, in one of our own 
cases, we found albuminuria to be wanting. The observations of Capu- 
ron, of Liegey and of Prestat regarding paralyses of smell, of taste and of 
the voice, seem to us at least doubtful. 
Must puerperal mania, which Imbert Gourbeyre considers to be a 
paralysis of the intellect, be classed with these? We do not think so, and 
we hold that the following resume from our monograph states the essen- 
tial points regarding puerperal paralysis: DISEASES OF PREGNANCY, 
161 
1. Puerperal women are subjected to the same causes of paralysis as 
non-puerperal subjects. 
2. The puerperal state, nevertheless, constitutes with them a predis- 
posing and, in certain cases, even an exciting cause. 
3. These palsies may occur at any period of the puerperal state, whether 
during pregnancy, labor or the puerperium, but are much more frequent 
in the first and the last named periods. 
4. There are three forms of these paralyses: hemiplegia, paraplegia 
and paralysis of the special senses. Each of the first two may be accom- 
panied by the third, particularly the first. 
5. These paralyses may be complete or incomplete, partial or general, 
i.e., they may affect one side (hemiplegia) or only the lower limbs (para- 
plegia), and involve either one member or both simultaneously. 
6. These palsies may exist in clearly distinct forms by themselves, or 
may be accompanied by paralysis of the special senses, as of sight and hear- 
ing, which latter may, of themselves, constitute the sum total of paraly- 
tic symptoms. 
7. The hemiplegias and the disorders of special senses are often ac- 
companied by facial paralyses, which are rarely isolated, but generally 
combined with either partial paralysis of the limbs or with paralysis of 
the special senses. 
8. These palsies, of whatever form, affect both motility and sensibility, 
and present every possible variety from simple paresis to complete paralysis. 
9. These paralyses may be separated into two chief groups: A. Paraly- 
ses from organic lesions; B. Paralyses from reflex action. The paralyses 
from organic lesions may be subdivided into two classes: a. Primitive 
organic lesions ; congestions, hemorrhages, meningitis, and lesions of the 
cranial bones or of the vertebrae; b. Secondary or consecutive organic 
lesions; congestion, hemorrhage, meningitis, heart affections, cerebral 
thromboses, albuminuria, uterine affections and compressions of the 
nerves. Reflex paralyses are due to peripheral irritation. 
10. The puerperal state not only does not protect women against the 
causes of paralysis other than those which we have mentioned, as rheu- 
matism, chloro-anaemia and hysteria, but seems to predispose the patients 
to palsy from these causes, by producing abnormal haemic conditions. 
11. Puerperal paralyses are generally slight and transient, but this is 
particularly true of reflex paralyses, for hemiplegias, paraplegias and pa- 
ralyses of the special senses may be of indefinite duration. 
12. Organic paralyses borrow their character, as regards gravity, from 
the nature of the causative conditions, being either temporary, perma- 
nent or even fatal, as the case may be. 
13. The lesions most frequently reported are: cerebral hemorrhage, 
cerebral or spinal meningitis, whether alone or accompanied, as they fre- 
quently are, by renal degenerative changes. 
Vol. IL-11. 162 
A TREATISE ON OBSTETRICS. 
14. The frequent coexistence of these renal lesions, and of cerebral or 
medullary lesions, shows how important albuminuria is in the pathogeny 
of puerperal palsies. 
15. It is possible, within certain limits, to establish a precise diagnosis 
of the cause of these puerperal paralyses, and this cause once being 
known, to establish a prognosis which will be surer in proportion as the 
cause of the paralysis is better known. 
16. The treatment must depend on the causes, some of which are per- 
manent, the others being transitory and temporary. 
Intellectual Disturbances. 
These are, as Maree says, of two kinds. One consists in simple moral 
tendencies, which do not deprive the patient of free-will, but impart a 
peculiar character to her manner and her physiognomy. The other is a 
state of mental alienation, variable in type but well-marked. In the first 
instance, the disorders are very different, as caprices, whimsicalities, 
changes of disposition, variable moods, new tastes, unreasonable antipa- 
thies-disorders, in short, affecting either the whole of the mental facul- 
ties or only one of them, (understanding, sensibility, will. Boudrie.) 
Thus, one sees women who, having been remarkable for the sweetness 
and amenity of their character, become sad, morose, sour, violent even, 
and unable to endure the presence of persons hitherto dear to them. 
Others, inclined to be naturally sad, melancholy, grave or serious, de- 
velop an activity and a gayety surprising to their friends. Still others, 
particularly primiparae, await their confinement with terror, and are per- 
suaded that they will not survive the trial which is before them. Hence 
they grow melancholy, and conceive fears regarding the proper develop- 
ment of their children. Maree quotes, from Vandermonde, the history 
of a woman who had a horror of water during the first four months of 
each of her eleven pregnancies. In certain cases, the nervous distur- 
bance eventuates in true mental alienation, or puerperal mania. On this 
subject, however, authors do not agree. Insanity may, indeed, manifest 
itself, not only in pregnant women, but during labor in the puerperium, 
and even in lactation. So, while some authors describe the mental 
alienation occurring at these different periods under the generic term, 
puerperal mania, others reserve this name exclusively for those cases of 
insanity developed during the puerperium. Others add the insanity of 
lactation, making the mania of pregnant women a variety by itself, viz., 
sympathetic insanity. Aside from the emotional character peculiar to 
pregnant women, there is an undeniable sympathy between uterine dis- 
turbances and intellectual disorders. 
These conditions have been found by Lisfranc, Azam and others when 
pregnancy did not exist. Much more should they obtain when there ex- 
ists a long-continued irritation, such as is produced by the presence of DISEASES OF PREGNANCY. 
163 
the fcetus in utero. But this sympathy, existing in pregnancy, is not un- 
derstood in the same way by all authors, and is even rejected by some. 
Thus, while Falret, Georget and Scanzoni deny it, Le Grand du Saulle, 
Tarnier, Dagonet and Rocher positively admit it. Others, like Maree, 
Brierre de Boismont, Baillarger and Morel admit it with certain reserva- 
tions, and although they admit the sympathy, consider it to be imperfect. 
Maree expresses himself thus: " If we considei* it proper to exclude from 
the class of sympathetic manias, (taking this term in its strictest accept- 
ation), those which are developed after labor, during lactation or after 
weaning, we reserve the term for those causes of transient insanity occur- 
ring during labor, and disappearing so soon as confinement is terminated; 
for those mental affections which, beginning at conception or during the 
early days of pregnancy, cease after the termination of the puerperal 
state; and, finally, for those rare cases in which a delirium of a few hours' 
duration accompanies the milk fever and disappears with it." 
This sympathy cannot be absolutely denied, and the material proof of 
its existence has been furnished by Voisin, who discovered, by the aid of 
the microscope, a large number of embryoplastic nuclei, particularly in 
the semilunar ganglion, and at a more advanced period, fusiform bodies 
and distortion of the nerve-cells, which, filled with fatty and pigmentary 
granules, are mingled with healthy cells or with other atrophied cells. 
Nor do authors agree as to the significance of the term puerperal state, 
or as to the limits which should be assigned to the term puerperal mania. 
While Griesinger reserves this title for intellectual derangements mani- 
fested during and after labor, Monneret and Maree consider all derange- 
ments occurring from conception to weaning as puerperal insanity. We 
think that the puerperal state includes, at once, both narrower and broader 
limits, and while admitting Raymond's classification of minor puerperal 
state, (pregnancy) and major puerperal state (post-partum state) we be- 
lieve that the true puerperal state begins with pregnancy and terminates 
with the post-partum state. It is unnecessary to include lactation, but 
since some authors compare the mania of women just delivered with those 
of nursing women, we think that the insanity of pregnant women should 
be included in the same category, and that the phenomena of mental 
alienation occurring in pregnancy, labor, the puerperium, and lactation 
are all intimately connected. Sympathy, if one will, but the puerperal 
state and the exhaustion due to lactation, impress peculiar characters 
upon this alienation. We might, perhaps, make three special chapters of 
the subject, as Maree does, but to our mind, Rocher went too far when 
he said: "It is well enough to treat of the mania of women who are preg- 
nant, but it must not be called puerperal mania." True puerperal mania, 
we admit, will manifest itself three or four weeks after labor, but it seems 
impossible to us to separate it entirely from the insanity of pregnant or 
of nursing women. We therefore include these forms in our study. 164 
A TREATISE ON OBSTETRICS. 
Frequency.-It is difficult to collect trustworthy statistics regarding 
puerperal mania, for it often does not appear until after the patients have 
left the hospital. The following figures have, therefore, only a relative 
value. Thus: 
Women Delivered. 
Reid, among 3,500 found ..... 9 cases. 
Gream, " 2,000 " 11 " 
Behier, " 1,000 " . . . . .1 case. 
Leidesdorff," 200 " 
during pregnancy, 6 
u puerperal state, 14 
20 cases. 
Among the fourteen cases occurring in the puerperal state, Leidesdorff 
saw eight develop from the sixth to the tenth day, five from the third to 
the eighth week, one at the twelfth week. 
On the other hand, the proportion of cases of puerperal mania compared 
with the total number of the insane, furnishes much more positive data. 
Thus: 
Puerperal origin. 
Esquirol 
. . among 
1,119 insane, found 
92 
cases. 
" (private practice) " 
144 
CC 
CC 
21 
CC 
Reid, . 
cc 
899 
cc 
cc 
111 
cc 
Haslain, 
CC 
1,644 
cc 
cc 
84 
cc 
Han well, . * 
cc 
703 
cc 
cc 
79 
cc 
Macdonald, . 
cc 
691 
cc 
cc 
49 
cc 
Parchappe, . 
cc 
596 
cc 
cc 
33 
cc 
Zeller, 
cc 
97 
cc 
cc 
11 
cc 
Webster, 
cc 
282 
cc 
cc 
17 
cc 
Kirkbride, . 
cc 
2,752 
cc 
cc 
116 
cc 
Marco, 
cc 
242 
cc 
cc 
9 
cc 
Hence, " 
9,179 
cc 
there are 
622 
cc 
That is, about 1 out of every 14.7. 
The following table shows the relative frequency of the cases in preg- 
nancy, in the puerperium, and in lactation. 
Number 
of cases. 
Pregnancy. 
Puerperiuni. Lactation. 
Palmer, 
19 
1 
6 
12 
Esquirol, 
. 92 
0 
54 
38 
Han well, 
. 43 
4 
26 
13 
Macdonald, . 
. 66 
4 
44 
18 
Maree, . 
. 310 
27 
180 
103 
Tnke, . 
. 155 
28 
73 
54 
Leidesdorff, . 
. 20 
6 
14 
0 
Insanity during pregnancy is, therefore, much the most rare. 
Causes.-In the first place: 1. Heredity, i.e., a predisposition which 
Griesinger calls a psychopathic diathesis, transmitted by ancestors affected 165 
DISEASES OF PREGNANCY. 
by insanity, diverse neuroses, hysteria, epilepsy, etc., in brief, by phreno- 
and neuro-pathies. Thus: 
Esquirol, . . among 28 cases, found 10 hereditary ones. 
Helft, of Berlin, . " 131 " " 51 
Weill, . . . " 30 " " 14 " 
Maree, . . . " 56 " " 24 
Robert Lloyd, . " 63 " " 13 " " 
Reid, " 111 " " 45 " 
Webster, . . " 131 " " 51 
Macdonald, . . "66 " " 26 " " 
2. Altered blood states-the Dyscrasite.-a. Anemia, which may ante- 
date pregnancy or be its result. Its causes may be repeated pregnancies, 
hemorrhages either during pregnancy or during and after parturition; 
exhaustion from lactation, and, in the poorer classes, bad or inadequate 
food, fatiguing work, unhealthful dwellings, lack of sleep-in brief, all the 
causes of debility, b. Ilyperaemia; active or passive congestions; Laserre's 
serous congestions. 
3. Repeated Pregnancies.-Thus: 
Patients. 
Primiparse. 
Multipart. 
Maree, 
. among 57 
14 
43 
Tuke, 
" 101 
17 
84 
Robt. Lloyd, . 
11 63 
10 
53 
Macdonald, 
66 
29 
37 
- 
- 
- 
287 
70 
217 
Thus, among 287 patients, 70 were primiparae and 217 multiparae. 
4. Age.-Maree, among 55 cases, found: At 18 years, 1 case; from 30 
to 35 years, 13 cases; from 20 to 25 years, 13 cases; from 35 to 41 years, 
5 cases; from 25 to 30 years, 17 cases; at 40 years and upward, 6 cases. 
Reid, among 1771 cases, found: Under 20 years, 69 cases; from 40 to 
45 years, 54 cases; from 20 to 30 years, 1,100 cases; from 45 to 50 years, 
6 cases; from 30 to 40 years, 542 cases. 
Tuke found, among 155 cases: 
Pregnant women, . . 28 
From 15 to 29 years, . . 17 
" 31 " 44 " . . 11 
Women already delivered, . 73 
From 20 to 30 years, . . 44 
" 31 " 43 " . . 29 
Nursing women, . .54 
From 19 to 30 years, . . 39 
" 31 " 42 " . . 24 
5. Consanguinity.-This cause has no effect, according to Brierre de 
Boismont, Lagneau, Peter and others, unless the related parents are them- 
selves insane or suffering from the psychopathic diathesis. In this case, 
they transmit to their progeny a double predisposition. 
6. Sex.-A certain influence is attributed to the generally fuller devel- 
opment of boys, but this is not proven. * 166 
A TREATISE ON OBSTETRICS. 
7. Moral Causes.-These are beyond question, and act both as predis- 
posing and as exciting causes, particularly the latter. Rocher, although he 
attributes to them an important part, yet makes this reservation, that one 
ought always to assign to the temperament its share of the responsibility. 
The emotional nature of the pregnant women justifies the fear that her 
extreme nervous excitability may, under the existing special physiological 
circumstances, be the avenue for the entrance of intellectual disorders. 
He, however, willingly admits that this nervous state is not the indispen- 
sable auxiliary of moral shocks, and that a sudden, violent emotion, may 
immediately precipitate an attack of mania. 
Berard, Esquirol and others, have noticed that moral.causes exercise 
their pernicious influence, particularly among the higher classes of society. 
The lower classes are more affected by physical causes. Nevertheless, the 
part played by moral causes in the evolution of puerperal insanity, is per- 
ceptibly greater than that of the physical causes. Esquirol estimated the 
relation as 4 to 1; Weil as 12 to 6. Maree alone reverses the proportions. 
8. Physical Causes.-Writers have mentioned dystocia, obstacles to 
delivery and obstetrical operations. Marc6, however, remarks that insan- 
ity shows itself as frequently after prompt and easy labors as after long 
and painful ones. 
Return of Menstruation.-The mania may appear before or during the 
first menstruation, or hemorrhages. There is another cause, the influ- 
ence of which cannot be disputed, in view of the frequency with which 
puerperal mania succeeds it, viz., eclampsia. All authors agree in con- 
sidering puerperal mania as a relatively frequent termination of eclampsia. 
Chloroform has been accused, but authors do not agree about it. Webster 
admits this cause, basing his views upon five of his cases, while Simpson 
opposes to these cases three of his own, where the women, being predis- 
posed by heredity, had most happy deliveries after the use of chloroform, 
but were attacked by mania in their next confinements when chloroform 
was put aside. Waters not only does not regard chloroform as a cause of 
puerperal insanity, but proposes it as the best means of preventing and 
curing mania. Finally, we should mention prolonged lactation, forced 
weaning and abscesses of the breast, and will recall, as matters of histori- 
cal interest, the old theories of the suppression of lochia and of milk 
metastases, besides Esquirol's view regarding the etiological effects of cold, 
which, in ten of his cases, is said to have been the cause of insanity. 
2. Mania of Pregnant Women. 
Melancholia is the most frequent of all the forms of insanity in pregnant 
women. Mania is the next most frequent. The insanity may begin at 
any time, from the commencement of conception, which is rare, up to 
the end of the ninth month, i.e., up to some weeks before delivery. The 
number of cases increases after the eighth month, attains its maximum DISEASES OF PREGNANCY. 
167 
frequency at about the seventh or eighth month and then diminishes. 
Sometimes the disease bursts out suddenly, which is rare. As a rule, 
it appears slowly and increases gradually. The intellectual disturbances 
which attend pregnancy grow more and more marked, and disorders of 
volition and of observation are soon added. The disposition is altered, 
sleep first becomes agitated and then is replaced by insomnia, and the 
patients complain of head-ache and digestive troubles. Then true mental 
alienation, generally of the melancholic type, makes its appearance. In 
other cases, the maniacal form predominates, and then generally suddenly 
explodes, either without prodromata or after attacks of eclampsia. Some- 
times there is simply weakness, languor and inertia, a sort of stupor with 
suicidal ideas, and, sometimes, there is excitement with ideas of murder 
and hallucinations. Again, there may be, in the maniacal form, excite- 
ment, insomnia, irritability and paroxysms of furious mania. There is, 
sometimes, albuminuria, but this is sometimes absent. Garcia Ri jo has 
reported inequality of the pupils. 
Prognosis.-Generally, the sinsanity disappears after labor, but it is 
not always so. Among the nineteen cases of Maree, the disease proved 
incurable in nine, or only disappeared long after labor; in seven cases, 
labor was the point of departure for the cure. In two of our own cases 
the insanity ceased abruptly, once with the expulsion of the child, even 
before the expulsion of the placenta. In the second case insanity ap- 
peared at the sixth month, disappeared at the ninth, reappeared five 
weeks after labor, lasted six months, and then disappeared but not com- 
pletely. In one case, Maree saw the insanity aggravated by labor, and 
death rapidly supervene during the confinement. 
Among Leidesdorff's six cases were four women who had presented 
psychical troubles before marriage. The insanity became serious during 
pregnancy, and melancholia followed labor. Of the two others, in whom 
insanity began during pregnancy, one saw her mania augmented by labor, 
and one recovered immediately after delivery. Esquirol saw one case in 
which insanity reappeared in five consecutive pregnancies, disappearing 
each time after confinement. 
Among the twenty cases of Leidesdorff, during pregnancy and the 
puerperal state, there were ten cures and one fatal case. In eight cases 
insanity remained. Esquirol saw only six deaths in ninety-two cases; 
Webster five in one hundred and eleven cases. After labor the insanity 
seems much more serious and the maniacal form has by far the worst prog- 
nosis. Thus, there were, among fifty-seven patients seen by Burrows: 
Cures (28 in the first six months), 35; deaths, 10; incurables, 1; suicide, 1. 
Among eight cases of insanity developed during labor or after delivery, 
seven of which had hereditary antecedents, Burrows saw: Melancholia 
and homicidal monomania, 1 case, cure in 9 months; mania and melan- 
cholia, 1 case, cure in 14 months; melancholia, 1 case, cure in 1 year; mel- 168 
A TREATISE ON OBSTETRICS. 
ancholia, 1 case, cure in G months; melancholia, 1 case ended in incurable 
dementia; abortion at four months, 1 case, suicide; abortion at three 
months with six attacks of mania before marriage, 1 case; incurable in- 
sanity developed at four months. Among Leidesdorff's twelve cases dur- 
ing the puerperal state, from twenty to twenty-nine years, there were: 
Melancholia, 8 cases; mania, 3 cases; dementia, 1 case. There were 
eight cures: five in four months; two in six months and one in a year. 
It, therefore, appears that sometimes the cure follows closely upon 
labor, but that it sometimes occurs only after a certain number of months. 
In general, there is notable improvement after the first weeks following 
confinement. It is rare to see insanity develop and disappear during 
pregnancy. Sometimes the patient is improved considerably, and a 
happy termination is expected, when a sudden relapse destroys this hope, 
and only confinement can change the aspect of the disease. In the ma- 
jority of cases, labor has no influence or a very doubtful one. Finally, 
acute mania may develop, and death result more or less speedily. 
Treatment.-This should be, above all, hygienic, and, with Maree, we 
absolutely reject the induction of premature labor and of abortion. 
What is, then, the influence of insanity upon pregnancy and of pregnancy 
upon insanity ? The effect of insanity upon pregnancy is nil, and women 
affected by puerperal insanity carry their children to full term. Burrows, 
however, has cited the two cases of abortion alluded to before. Does 
the same statement hold true regarding the influence of pregnancy upon 
insanity? What are the consequences of pregnancy occurring in an in- 
sane person ? It is a popular notion that pregnancy cures insanity, but 
this view has no actual basis in fact, and if, in exceptional cases, pregnancy 
and labor happily modify insanity, there are innumerable cases in which 
there is no such modification. One cannot too strongly condemn the 
practice of some physicians in recommending pregnancy for insane women, 
not amenable to the ordinary therapeutic agents. In some rare cases, 
however, pregnancy has had the singular effect of checking the advance 
of mental alienation, but, labor being once completed and the patient re- 
stored to her ordinary condition of health, the nervous troubles reappear 
with equal intensity. There are still other cases in which parturition has 
had a plainly beneficent influence in aiding the cure of a paroxysm of 
insanity. Maree has collected five such cases. Generally, the course of 
pregnancy is not interrupted by distressing incidents. A remarkable fea- 
ture, observed in our two patients, was the slight intensity of the labor 
pains. In certain cases, several of which Maree mentions, the patients 
are not aware of their delivery. There seems to be a difference between 
the children whose mothers were insane at the time of conception, and 
those whose mothers became insane during pregnancy. In the former 
case, the children are born healthy, but in the second case, they arc often 
still-born or die soon after birth. In our two cases the children were born DISEASES OF PREGNANCY. 
169 
in perfect health. In these cases, the children are certainly subjected 
to that hereditary influence which plays so important a role in the etiology 
of mental diseases, but it is not true that their intellectual condition need, 
necessarily, be affected by that of their parent. 
Even in 1826 Bouchet noted, in twenty-two cases, this absence of ame- 
lioration in the mental state from pregnancy and labor, while See and 
Montgomery reported a temporary aggravation during cervical dilatation. 
Temporary Insanity at the Time of Delivery. 
Sometimes labor does not limit itself to the production of the agitation, 
anxiety and irritability which all accoucheurs have observed, but attacks 
the intelligence or even leads to the development of maniacal delirium. 
These cases, wdiich are rare, may be classed in two categories, as Maree 
has done. " In one variety, the actions and words are of constant inco- 
herence, while in the other, the delirious actions instigated by the severe 
pains of labor are logically related to their point of origin. Thus, some 
women, in real frenzy, seek to inflict violence upon themselves or the 
child, to abridge their sufferings. In many cases, the intellectual trouble 
assumes the characters of acute mania. There is complete incoherence; 
patients have no appreciation of their condition, and nothing in the symp- 
toms betrays the physical and moral causes which occasioned the deli- 
rium. " It is, therefore, a sympathetic phenomenon, encountered most 
frequently in difficult labors, but also, sometimes, in natural ones, when 
it coincides with the expulsion either of the foetus or of the placenta. In 
spite of its apparent gravity, this delirium has no serious consequences. 
It ceases spontaneously when labor ends, and in the cases where it is pro- 
longed after delivery, it rarely lasts more than a few days and hardly ever 
ends in mania. The most rational treatment consists in terminating labor 
as rapidly as possible, and in then adopting expectant measures. 
Insanity of Women just delivered and of nursing Women: 
The types of insanity observed in these cases are: Mania, melancholia, 
lypomania, partial involvement of the intellect, hallucinations, intellec- 
tual or instinctive monomania, alternate insanity or duplex insanity, and 
simple dementia. These forms are far from being equally frequent. 
Among forty-four cases Maree found twenty-nine of mania, ten of melan- 
cholia, five of partial insanity, and only two cases of temporary intellec- 
tual enfeeblement. In nursing women melancholia is, at least, as com- 
mon as mania. The number of monomanias is hardly equal to one-fifth 
of the cases of mania. 
Among forty-four cases, the insanity appeared within the first ten days 
in thirty-three cases. Sometimes the delirium appeared on the first or 
second day, but most often did not develop or attain its maximum until 
the fourth or fifth day. The inception of insanity on the tenth day is 170 
A TREATISE ON OBSTETRICS. 
quite rare. In eleven cases insanity developed at about the sixth week, 
i.e., at the return of the menses. (Maree.) 
I. Mania. 
The attack is sometimes sudden, but generally gradual, and accom- 
panied by precursory symptoms, lasting from some hours to several days. 
The women are sad, morose, but more often excited. Their manners 
and behavior become modified, the senses grow more acute, the slightest 
noise dr too bright a light causing suffering; the agitation is aggravated 
day by day, and violent mania developes. Insomnia becomes complete, 
the tongue is coated, the mouth slimy, the head more painful and the 
pulse, accelerated during the moments of agitation, beats more quietly so 
soon as the woman grows calmer. Hallucinations of sight and hearing 
are now developed, and put the patients into a state of violent agitation, 
during which they become dangerous to themselves, to those around them, 
and particularly to their child. Some of the most important symptoms 
are the fancies of the patients, the odor which they exhale, and the pres- 
ence of albumin in their urine. Some observers, as Maree, attach im- 
portance to the presence of erotic ideas. Puerperal mania, thus, has 
nothing peculiar to itself, either in the delirium or in the physical symp- 
toms. 
Mania terminates in recovery, incurability or death. Recovery is much 
the most frequent, and occurs more or less rapidly, within a few days or 
several months. Among the complications which may prove fatal, we 
should accord the first place to acute delirium, which sometimes begins 
with the attack, but sometimes is not developed until after several weeks, 
or after a paroxysm of duplex insanity. Instead of ceasing in a few days, 
acute delirium may be prolonged, entering a new stage. Then typhoid 
symptoms develop, syncope occurs and the patients succumb, either sud- 
denly from syncope, or slowly with all the symptoms of profound nervous 
exhaustion. To recapitulate: Patients who die during acute puerperal 
mania, succumb either to an intercurrent disease or to violent agitation 
and acute delirium. 
Treatment.-Authors have recommended venesection, nauseating doses 
of tartar emetic, prolonged warm baths, purgatives, narcotics, antispas- 
modics, camphor and the milk diet. Maree advises prolonged baths, the 
expectant treatment, tonics and hydrotherapeutics. 
II. Melancholia. 
This is less grave than mania. The moral state of the woman, during 
pregnancy, seems to exert a special causative influence. 'It begins, like 
mania, either within a few days after delivery or near the sixth week. It 
is rapidly developed, or occasionally sad ideas may precede the invasion of 
the delirium, and of the melancholic depression. In certain cases, there DISEASES OF PREGNANCY. 
171 
is, for some days, a general excitement bordering on mania, and, later, the 
delirium becomes habitual. Ideas of persecution, fear of death, dread 
of punishment, and ideas of suicide form the basis of the delirious concep- 
tions. There are hallucinations of sight and of hearing, and the patients 
may grow dangerous to themselves or to their children. Maree reports 
analgesia, hysterical attacks and catalepsy among the symptoms. 
Prognosis.-This is, generally, not very grave, but the duration is long, 
from one month to six months. 
Treatment.-It consists in prolonged warm baths, cold affusions, opium, 
chloral, hygienic measures and constant surveillance. 
Together with these two chief forms must be mentioned the partial 
lesions of intelligence, the hallucinations of sight and of hearing, impul- 
sive religious monomania and homicidal monomania. Maree mentions a 
special variety of intellectual enfeeblement, which is prone to follow abun- 
dant puerperal hemorrhages, may be general or partial, and particularly 
affects the memory. Dementia also occurs, and lastly, cyclical or duplex 
insanity, characterized by two regular periods, one of excitement, of 
mania, and the other of depression, of melancholia, the association of 
which constitutes a paroyxsm. It sometimes follows mania, and may be 
intermittent. It is a secondary, chronic form of puerperal insanity. 
III. Insanity of Nursing Women. 
This form of insanity developes during the first six or seven weeks after 
labor, or later, after eight, ten or twelve months of lactation or even a few 
days after weaning. The disease begins in two ways, either suddenly, 
after exciting events, chills, etc., or gradually. The prevailing types are 
mania, melancholia, monomania and duplex insanity. The prognosis is, 
generally, not bad. Maree saw twenty cures among twenty-six cases. 
The cure may, however, be slow, occurring only after several months or 
years. The first indication is to stop lactation. To accomplish this, 
dieting, purgatives, the iodide of potassium, and after suppression of the 
secretion, a tonic regimen may be useful. 
Diseases of the Skin. 
Besides the regular eruptions of pregnant women, there is often ex- 
tremely severe itching of the skin, without visible lesion. This itching, 
which may commence at the beginning or not until the second half of 
pregnancy, may reappear during consecutive pregnancies, (cases of Mas- 
lieurat Lagemard.) Sometimes temporary and passing, this itching is, in 
other cases, rebellious to all treatment, and only disappears after labor. 
Although not grave, it becomes the source of annoyance and even of 
weakness. Being aggravated by warmth and by rest in bed, it thus de- 
prives the patients of sleep. In some cases, the suffering is so severe that 
the women scratch off the epidermis, thus adding to their torture. Often, 172 
the itching is confined to certain regions and reappears with each preg- 
nancy, so regularly that the patients recognize the beginning of pregnancy 
by this sign. Hebra cites the case of a woman who saw this itching develop 
upon her fingers after the fecundating coitus, in seven consecutive preg- 
nancies. 
The real cutaneous eruptions usually appear in the first months, and 
then either disappear before labor, which is the exception, or at variable 
periods after labor. 
The most common of these skin diseases are the so-called chloasma of 
pregnant women-the mask, and pityriasis versicolor. The favorite seats 
are the forehead, the cheeks and the chin. The eruption consists of yel- 
lowish spots, more or less extended, but not reaching beyond the limit 
of the hair. Cazeaux believes that light is one of the chief necessities 
for their development, and that the shadow of the hair suffices to arrest 
their formation. 
Hardy and Hebra separate these spots into two species: the ephelides 
and the pityriasis. 
Hardy says that the ephelides are not projecting, and are not attended by 
pruritus or desquamation. They are composed of an accumulation of 
pigment in circumscribed areas. The ephelides often develop in women 
at the time of menstruation, and particularly during pregnancy. They 
generally disappear after labor, but not always, to the despair of the 
patients. 
Hardy advises the application, twice daily, of the following solution: 
Aquas destillat. . . . . . . . fl. f iv. 
Hydrarg. chlorid. corrosiv. ..... grs. vii ss. 
Zinci sulphat. ....... grs. xxx. 
Plumb, acetat. ....... grs. xxx. 
Alcohol, qs. ad. sol. 
If this is not sufficient, one may advantageously employ sulphur waters, 
particularly those of Luchon and Bareges, locally applied. 
Pityriasis versicolor, although resembling the ephelides,differs essentially 
from them in that it is papular. The papules are covered by little scales. 
This eruption is always accompanied by slight itching, and is a parasiti- 
cal disease occupying, according to Hebra, the hair bulbs. The micro- 
scope facilitates the diagnosis, showing some spores and numerous ramifi- 
cations in the scales. 
The treatment consists in sulphur lotions, douches, and sulphur oint- 
ments. Hardy advises sublimate lotions and citrine ointment. Jeannin 
believes in an intimate relation between menstrual troubles and this erup- 
tion. It is, according to him, due to the arrest of the menses, and preg- 
nancy is not indispensable for its occurrence, since it is observed in 
women or girls who have not conceived, when their menstruation is dis- 
turbed. lie does not believe that the parasite, microsporon furfur, is 
A TREATISE ON OBSTETRICS. DISEASES OF PREGNANCY. 
173 
indispensable, but it may be observed, which justifies the classification of 
Hardy. Parrot is opposed to Jeannin, in that, while he admits that 
chloasma may be related to menstrual disorders, he attributes it to a neu- 
ropathic condition, finding expression in certain general pigmentations of 
the skin. 
Hebra mentions acne, or inflammation of the hair-follicles, or of the 
sebaceous follicles. It may be common acne or acne rosacea. The latter 
resists all treatment until after labor. In some women, the nose is the 
part attacked, and it becomes red, tumid and covered with the pimples of 
acne. Again, a true eczema may be developed in the early stages of 
pregnancy, and may become terribly severe, as in one case of our own. 
Urticaria is another eruption affecting pregnant women, and may reap- 
pear at certain hours of the day, after meals or in the evening. We have 
seen a case which yielded to alkalies and quinine. * Hebra has seen two 
cases of puerperal pemphigus. In one case it appeared two days after 
labor, and there was no relapse in later pregnancies. In the second case, 
the eruption appeared in three consecutive pregnancies, in the same 
woman. The first time it came at five months and disappeared after 
labor. The second time it appeared at three months, and did not disap- 
pear until a month after labor. The third time it became chronic and 
did not disappear. The woman was delivered of a dead child. Klein has 
seen a persistent pemphigus, which reappeared in two pregnancies. He 
also observed impetigo herpetiformis, which showed itself, in five cases, 
during pregnancy and labor. The eruption was pustular. The pustules 
appeared on the inside of the thighs, either discrete or in groups, and 
thence invaded the legs, the abdomen, the chest, the arms, the forearms, 
the hands, feet, neck, face and scalp. The eruption came out in crops 
and was attended by burning fever and great prostration. Before each 
eruption there was a chill with a pulse of 104° and a temperature of 105°, 
which then slowly subsided. There was diarrhoea which was once bloody. 
The urine was acid, dark-colored and contained a little pus, much urea 
but no albumin. Of the five women, three were delivered from two to 
five weeks before the eruption, two were attacked in the last months of 
pregnancy, and were delivered at the hospital. The symptoms remained 
unchanged after labor. Among the five women four died. They had 
no puerperal disease, and showed no trace of syphilis. Vrain reports one 
case of erythemato-tubercular scrophulide of the face, and one case of stru- 
mous lupus during pregnancy, and aggravated by subsequent pregnancies: 
Eczema of the face and hands, 3 cases; of the scalp, 2 cases; zona 
and eczema impetiginosa, 1 case. 
The most common skin disease, wyith pregnant women, is certainly 
prurigo. 174 
a treatise on obstetrics. 
Lesions of the Pelvic Articulations. 
Relaxation of the Symphyses. 
After having been admitted, then contested, then demonstrated by 
Severin Pinaud, in 1869, upon the body of a woman recently confined, the 
softening of the inter-articular cartilages and the consequent relaxation 
of the pelvic symphyses is to-day granted by all obstetricians But this 
softening is usually moderate, and remains, so to speak, within physio- 
logical limits. Sometimes, however, it is so extreme as to become patho- 
logical. Going still farther, Zaglas has recently demonstrated that there 
is, in man, a perceptible movement of the ossa innominata, antero-poste- 
riorly, or around an imaginary transverse line traversing the second sacral 
vertebra. So we may consider the sacrum as having a movement of 
rotation around an imaginary transverse axis, the promontory advancing 
forward and downward, while the apex moves in an opposite direction 
and vice versa. 
Matthews Duncan calls attention to the presence, on the posterior arti- 
cular surface of the iliac bones, of an irregular bony prominence, which 
often has the form of a massive angle in relief. There is a cavity corre- 
sponding to this eminence upon the opposite side of the sacrum, and the 
cavity is analogous, as regards some of its functions, to a cotyloid cavity. 
The movements of the iliac bones occur at the level of these surfaces, which 
are, generally, opposite the upper part of the second sacral vertebra. 
While they offer no resistance to the movements of flexion and extension 
of the ilia upon the sacrum, they oppose vertical movements between the 
bones, such as would necessarily be prejudicial to stability in the erect 
posture. In the latter half of pregnancy, the soft parts entering into the 
formation of the joints are always softened, and the articulations are con- 
sequently relaxed. The softening of these tissues is generally accompanied 
by increase in their thickness, which produces separation of the bony sur- 
faces and widening of the pelvic diameters. In some cases, this thicken- 
ing is extraordinary. Boyer, Chaussier, Bovin, Smellie, Dimerbroeck 
and Denmah, have reported separations of the bones, even to the exten- 
of from one-half inch to an inch. Matthews Duncan, thus regards the 
softening and thickening of the ligaments as the cause of separation of the 
joint surfaces, as a wedge of dry wood, becoming moistened by the absorp- 
tion of water, splits stones into which it is driven. Lenoir thinks that, 
at a later stage, the relaxation depends solely on the serous infiltration of 
the pelvic ligaments, due to pregnancy. This does not produce separation 
of the articular surfaces, but renders it possible under the influence of 
an effort tending to produce it. In the late stages, a hypersecretion of 
synovia is added to the softening, distends the cavities and separates the 
bones. Then, the mobility is very great, and if, in the cadaver, one opens 
the joints, a viscid abundant fluid escapes, as Morgagni saw in one case. DISEASES OF PREGNANCY. 
175 
Trousseau, Ferdinand Martin, and Tarnier have again called attention to 
this relaxation of the pelvic joints, and Bourhis and Dubois have studied 
it with care. 
For Stoltz, this relaxation is either the effect of softening of the liga- 
ments, or of violence exerted upon the tissues holding the pelvis together, 
during operations undertaken to deliver the woman: He thus makes two 
classes of relaxations. 1. The slow and progressive relaxation; 2. The 
violent and sudden relaxation. This latter also bears the name of rup- 
ture of the symphyses. 
Korsch, in the laboratory of Professor Slavjansky, at St. Petersburg, 
examined thus forty-five pelves, of which there were: Pelves of women 
dead after labor at term, 18; before term, 8; after an abortion, 3; before 
labor, 1. Pelves with uterine and ovarian tumor, 4; pelves of women 
not pregnant, 6 ; pelves of men, 5. The following are his conclu- 
sions: 
1. The influence of pregnancy and of large uterine and ovarian tumors 
manifests itself, not only by softening of the ligaments of the joints, but by 
enlargement of the dimensions of the inlet, and, particularly, of the out- 
let. 
2. At the inlet, the greatest enlargement occurs in the transverse diam- 
eter. The reverse obtains at the outlet. The longitudinal diameter is 
less elongated than the transverse. 
3. To produce enlargement of the superior strait, almost double the 
force is necessary as for the inferior strait. 
4. The elongation of the transverse diameter of the inlet involves the 
shortening of the conjugate. However, the elongation of the conjugate 
does not modify the transverse diameter (in some cases we obtain a short- 
ening of about one twenty-fifth of an inch). 
5. The maximum elongation of the transverse diameter of the inlet 
always slightly enlarges the conjugate. But the maximum elongation of 
the conjugate does not, generally, enlarge the transverse diameter. 
6. The simultaneous enlargement of both diameters of the inlet never 
elongates them so greatly as a successive enlargement of each diameter. 
7. The widening of the outlet always slightly shortens the conjugate, 
and slightly elongates, or leaves intact, the transverse diameter of the 
superior strait. 
8. The same holds true of the outlet when the inlet is widened. 
9. In most of our cases we noticed greater mobility in the ligaments of 
the sacro-iliac and sacral articulations. 
10. In the most mobile joints, the quantity of synovia was always in- 
creased. 
11. The elongation of the longitudinal diameter depends on the mo- 
bility of the sacrum, but the mobility of the symphysis particularly aids 
increase of the transverse diameter. 176 
A TREATISE ON OBSTETRICS. 
12. The larger the crevice or cavity of the symphysis pubes, the greater 
the mobility of this articulation. 
13. The number of labors seem to have no influence upon the mo- 
bility of the pelvic articulations. 
Causes.-The temperament of the patients has been mentioned as a 
cause. Feeble and delicate women a?e supposed to be more predisposed 
than others (Munro, Smellie), and Roederer has even said that debility, 
rickets, venereal diseases and profound cachexise were themselves capable 
of producing relaxation of the pelvic ligaments. Morgagni opposed this 
exaggerated opinion. The influence of scrofula is not more manifest. 
Other assumed causes are extreme youth or age of the women, and the 
primiparous and multiparous condition. The contradiction of these 
opinions deprives them of value. Jacquemier holds that the relaxation 
of the symphyses is due to the development of the uterus, particularly 
when this development surpasses ordinary limits, as in large size of the 
foetus, twin pregnancy and hydramnion. (But there are cases in which 
the relaxation appeared in the second or the third month.) 
Excessive exercise, bodily fatigue and anchylosis of the knee are causes. 
Too sudden getting up after confinement has been accused of an etio- 
logical relation. 
All these causes are problematical, for one observes relaxation of the 
articulations in women belonging to all classes of society, and the eti- 
ology is, really, very obscure. 
Relaxation of the symphysis always begins during pregnancy, and, in 
general, in the seventh, eighth and ninth months, but it may commence 
much earlier. Moreau has seen it in the second month and Desormeaux 
in the fifth. In two cases of our own, the disease began once at six 
months and once at seven and a half. The disease always begins insidi- 
ously, by a feeling of lassitude and weakness, accompanied by pains in 
the lumbar region, whicli, at first dull, soon grow more intense, and in- 
volve the buttocks, the groins, and the symphysis pubes. The patients at 
first only feel them when walking, then in the standing or sitting pos- 
ture, and, finally, in some cases, they become so pronounced that they do 
not cease even when the patients assume the dorsal decubitus, and 
the least movements become so painful as to be almost impossible. The 
pains are always more marked at the sacro-iliac joints than at the pubic 
symphysis. They are often accompanied by numbness in the abdomen. 
When the patients rise, the pains become very violent and assume a 
peculiar character. It seems to the women as if the pelvis was spreading 
apart, their bones becoming dislocated, and as if they were sinking 
between their haunches. The gait becomes almost pathognomonic. It 
consists in a balancing from one leg to the other, a sort of oscillation. 
The women waddle like ducks. In walking, the women sustain their 
loins with their hands, now bending forward and now backward. At DISEASES OF PREGNANCY. 
177 
such times we can feel the bones being displaced, and when we attempt 
to make them move upon each other, the woman resting on her back, 
this is successful up to a certain point. If we feel of the different joints, 
we excite a sharp pain in them, and sometimes can observe a notable dis- 
placement of the bones at the symphysis pubis. Trousseau related a 
case where one could introduce the end of the finger. When the sepa- 
ration is not appreciable to the touch, we may recognize it by a proceed- 
ing which we often saw used by Depaul before Budin again called atten- 
tion to it at the Biological Society. It consists in placing the woman in 
the erect posture, against a resisting object, and in placing two fingers 
horizontally beneath the symphysis and therefore introduced a little way 
within the vagina. The woman is now made to stamp the feet or to walk 
a few steps, whereupon the fingers applied below the symphysis, distinctly 
feel the oscillation of the iliac bones at this level, and thus ascertain 
the mobility and the widening of the articulation 
When (pee begun, the relaxation of the joints goes on increasing 
until the time of delivery, but if the women keep quiet, they only have 
their movements impaired; their general health is unaffected. It is not 
always thus, for in one of our cases the pain was such as to deprive the 
patient of sleep, and thus to induce notable weakness and exhaustion. 
Generally, this articular relaxation disappears after labor, but sometimes 
it persists at least a short time, and, rarely, for months or even years. 
Courty quoted a case which lasted two years, and Baudelocque one of nine 
months' standing. Lenoir and Robert have seen the malady persist- 
through life. In one of our cases the duration was eighteen months. 
Sometimes the relaxation becomes complicated after labor, with in- 
flammation of the joints. These results are rare in slowly progressive 
relaxation, but usual in the sudden relaxation of labor, where the so- 
called rupture of the symphyses occurs. Only one affection can be 
mistaken for relaxation of the joints. This is inflammation of the artic- 
ulations, and we will soon revert to that subject. 
Prognosis.-This should always be considered serious, although not 
absolutely grave, for the disease predisposes to inflammations of the sym- 
physes, and to their rupture during labor. It may, moreover, persist a 
long time, thus constituting a real cause of infirmity. 
Treatment.-This must not be neglected. Although rest suffices 
most of the time in slight cases, the patients should be carefully watched 
after confinement. To keep the patients in bed for a very long time, say 
one month, six weeks or two months, if necessary, and to maintain im- 
mobility of the articulations are the first indications. In many cases a 
towel, a body bandage, a roller bandage, suffice. In others, more ener- 
getic restraint is necessary. Boyer advised a leather girdle, and Martin 
a complete metallic girdle, quite strong and large enough to encircle the 
entire pelvis. The spring, the height of which is about one third of an 
Vol. II.-12. 178 
A TREATISE ON OBSTETRICS. 
inch, padded and trimmed like those of trusses, is interrupted, anteriorly, 
and furnished on one side with a strong strap, and on the other with a 
buckle, by which means the two ends are approximated and firmly held 
in contact. We saw a so-called gymnastic girdle used with advantage 
in one case, and followed by a plaster dressing. But, as Cazeaux properly 
says, we must, above all, be certain that there is no inflammation of the 
joints, and must not resort to restraining measures until all inflammation 
has been dispersed by revulsives. It is well, afterward, to use sulphur 
douches, which rendered us great service in one case. Patients must be 
careful not to leave off their apparatus too soon, and must not incur 
fatigue by taking too much exercise. 
Inflammation of the Articulations.-Inflammation of the Symphyses. 
Although generally observed after labor, inflammation of the pelvic 
symphyses may appear during pregnancy, and to the cases cited by Hiller, 
Monod, Danyau, Hayn, Joyeux and Kiwisch, we can add two observed by 
ourselves. Dubois reported three more, in 1879, and we are convinced 
that it would be easy to find a larger number still 
Causes.-According to Fodere, these are, particularly, the puerperal 
state, scrofula, rheumatism, and traumatisms incident to labor 
Symptoms.-Generally, the disease begins a few days after labor, from 
the third to the tenth day, sometimes even earlier, in grave cases. In 
some cases, the characteristic symptoms of relaxation are observed toward 
the end of pregnancy, and inflammation manifests itself after delivery, 
and we may sayas a result of it. Usually, a chill opens the scene, a fever 
follows and then the characteristic symptoms appear. The first is pain, 
which, slight at first, grows rapidly worse, is increased by movements and 
is localized in the joint attacked. Generally, the sacro-iliac joints are at- 
tacked, and the pain is then usually more violent and lasting. From the 
joint the pain spreads to the loins and the buttocks, radiating also into 
the legs. Sometimes it remains fixed in the articulation, or, at least, is 
augmented by slight pressure in this region or upon the iliac crests. 
When the symphysis pubis is attacked, the pains are less severe, and are 
located in the front of the pelvis. When the pain radiates into the legs, 
it there produces sensations of formication and of numbness, and the sensi- 
bility of the limb may be impaired (cases of Joyeux and Pigeolet). 
Sometimes the pain radiates into only one limb, and thus simulates sci- 
atica. This happened in one of our cases. The urinary function is often 
impaired when the symphysis pubis is affected. Sometimes there is 
dysuria, and sometimes incontinence. The skin over the joint keeps its 
normal Color for some time but often becomes red, tense and shiny. 
Soon, a little tumefaction and oedema appear, but these are not constant, 
and, generally, vaginal palpation is necessary to detect swelling of the 
articulation. In rare cases the tumefaction fluctuates, an abscess forms. DISEASES OF PREGNANCY. 
179 
grows large and breaksits way into the pelvis or outward. In the former 
case death may result, and at the autopsy we find the articular surfaces 
altered and denuded of their cartilage. 
Prognosis. -This is, thus, serious enough, although, even in these 
cases, a cure may be effected and the disease end in anchylosis. Gener- 
ally, these inflammations cease after a time. 
Treatment.-This embraces local revulsives and venesections, with ab- 
solute repose and opiates. 
Rupture of the Symphyses. 
Sudden relaxation of the symphyses may occur and constitute rup- 
ture of the symphyses. 
As Bach said, in 1832, "In order that the separation of the sym- 
physes may occur, there must be a great expansibility of the articulations. 
If this expansibility does not exist, and if the force causing- the relatively 
large foetal body to pass through the pelvis is sufficient to separate the 
pelvic bones, rupture will occur. In ordinary cases, the pelvis resists 
longer than the head, but often, the overlapping of the cranial bones 
does not suffice, and we meet with many more cases of rupture of the 
symphysis in labor than of fractures of the skull. The symphysis 
pubes is less susceptible to rupture than the posterior articulations. 
We meet many more examples of rupture of the sacro-iliac articula- 
tions than of the symphysis pubes, while relaxation of the latter is oftener 
seen. ' ' 
In rare cases, spontaneous rupture may occur (Duverney, An- 
siaux), but generally, rupture follows the use of the forceps. De Lamotte 
quotes a case of rupture from version, and Chaussier has cited a similar one. 
Bach does not believe that rupture can occur without predisposition, and 
it is also necessary that relative narrowness exist without which only 
separation would take place. Among the predisposing causes, he cites 
failure in the cohesion of the ligaments of the symphyses, found in 
cachectic persons and in rickets, osteomalacia, scrofula, scorbutus, gout 
and syphilis. Most frequently, the rupture takes place on the descent of 
the head into the pelvis, but it may occur at the time of the extraction or 
expulsion of the head from the inferior strait. When rupture occurs in 
the posterior symphyses, it is due to backward displacement of the sacrum. 
Hence the tendency of the pubic bones to approach each other in front, 
and to separate behind. When the rupture is at the symphysis pubes, 
the surfaces are separated, leaving an interval between them, and there 
is, also, always a separation of the sacro-iliac joints at their anterior part. 
The sudden stretching of the ligaments of the posterior symphyses, by the 
separation of their articular surfaces, the retrocession of the sacrum, 
the separation of the ilia, cause a rupture of the ligaments maintaining 
these bones in contact. The anterior ligament is raised and made tense, 180 
A TREATISE ON OBSTETRICS. 
but does not tear. A part of the posterior ligaments is torn or loosened, 
when the separation is sufficient. 
When the symphysis pubes is involved, the inter-articular fibro-cartilage 
and the anterior ligament are torn, the posterior ligament is elongated; 
sometimes the cartilage of incrustation is separated from one of the bones, 
or is torn off. Bach, who has seen this arrangement at the symphysis 
pubes, does not consider it possible at the sacro-iliac joints. 
Signs and Diagnosis.-If rupture occurs, the woman feels an acute 
pain, a sense of laceration, at the moment when the head passes through 
the inlet or outlet of the pelvis. Often, there is a cracking sound, per- 
ceptible to the assistants, and louder when the symphysis pubes is rup- 
tured. This is not a pathognomonic sign, however, for this cracking 
sound is often heard without rupture, when the head passes a contrac- 
tion of the pelvis. The obstetrician then, has an articular sense of re- 
sistance overcome, which is noticed when forceps are applied at the inlet, 
in pelvic contractions. It is then due to the depression of a parietal 
bone by the promontory. In rupture, there is always acute pain, which 
is lacking in the other cases. The separation is never so marked in the 
posterior articulations as at the pubic symphysis, but the pain is more 
severe. At the latter joint, the separation is often considerable. The 
pain is intensified by pressure and by movements of the legs. Some- 
times there is a real crepitation. After from twenty-four to forty-eight 
hours, sometimes later, inflammatory reaction ensues, and the symptoms 
of inflammation of the symphyses, with their sequela?, make their ap- 
pearance. 
Puerperal Rheumatism. 
As early as 1866 and 1867, Lorain stated, in a communication made to 
the Medical Society of the Hospital's, that "there exists in pregnant 
women a morbid state of the genito-urinary passages, which may pre- 
dispose to attacks of arthritis, analogous to blenorrhagic arthritis. There 
is a certain amount of urethritis as well as of cervicitis and vaginitis. 
The urethral pus, as well as the pus which escapes from the cervix and 
bathes the vagina, is the natural result of pregnancy. There is always 
disease of the genito-urinary organs in the pregnant woman. Genital 
rheumatism is, thus, as little surprising in her case as in that of a man 
who has just had the sound passed." 
Lorain's ideas have been reasserted by two of his pupils, in their in- 
augural theses. Vachee gives the name of uro-genital rheumatism to this 
form of rheumatism, and states that it may occur in four forms: 1. As 
hydrarthrosis; 2. Rheumatism, proper; 3. The form characterized by 
vague pains; 4. The nodular form. 
Vaille, in 1867, takes a broader view than Cruveilhier, who considers 
the rheumatism of pregnant women to be akin to puerperal rheumatism DISEASES OF PREGNANCY. 
181 
propei- (i.e., the rheumatism which is developed a few days before Or after 
labor), and adds to this class, menstruation, which he considers to be a sort 
of miniature puerperal state, and lactation. He describes two varieties 
of puerperal rheumatism-muscular rheumatism and articular rheuma- 
tism. Under the term muscular rheumatism he describes tetany or con- 
tracture of nursing women, and ordinary muscular rheumatism, which 
seems to have nothing special about it, excepting its causative relation to 
the puerperal state. The conclusions he arrives at are the following: 
1. There is a rheumatism peculiar to the puerperal state, developed 
under its influence and modified by it. This rheumatism is, perhaps, 
constantly accompanied by leucorrhceal or other discharges, and is, 
therefore, analogous to blenorrhagic rheumatism. This is Lorain's geni- 
tal rheumatism. 
2. Puerperal rheumatism attacks the same organs as ordinary rheu- 
matism. It may be muscular or articular and may provoke other 
arthritic diseases, cardiac affections, meningitis, ophthalmia, erythemata, 
etc. 
3. During pregnancy it tends to follow the subacute course of gon- 
orrhoeal rheumatism. It is prone to produce hydrarthrosis, and may, 
rarely, end in suppuration or white swelling. 
4. Immediately after labor, particularly when epidemic influences are 
prevalent, articular rheumatisms of exceptional gravity may be devel- 
oped, and are remarkable for their tendency to suppurate and to pro- 
duce articular changes. 
5. Endocarditis may develop, sometimes, in the puerperal state, even 
when there is no joint trouble. • 
Braunberger, in 1870, stated that the puerperal state is only one of the 
phases of Lorain's genital state, and that the rheumatoid symptoms of 
pregnancy are localized in the joints and synovial sheaths, with or without 
the coincidence of cardiac affections. This local trouble is tenacious, re- 
bellious, aggravated as time elapses after conception, and is not improved 
or cured until after parturition. These joint troubles of pregnancy have 
a special stamp. They are quite analogous to gonorrhoeal arthritis. 
Peter does not so absolutely admit the influence of these causes. "He 
thinks that everything is an exciting cause of rheumatism, as well cold, 
which is a general traumatism, as a contusion which is a local one; as well 
urethral gonorrhoea as uterine gonorrhoea; as well pregnancy as parturi- 
tion. " 
Tison, in 1879, admits that pregnancy acts in two ways: 1. By the 
profound changes which conception produces in the general condition 
and in the woman's health; 2. By the discharges which exist in most 
cases. 
We fully concur in Peter's opinion, and although we admit that 
rheumatism presents some peculiarities in pregnancy and the puerperal 182 
A TREATISE ON OBSTETRICS. 
state, we do not think that it can be regarded as identical with gonor- 
rhoeal rheumatism, and we believe, much more, in the general influence of 
the puerperal state than in a local influence brought about by the vaginal, 
urethral and uterine discharges of the pregnant woman. 
Symptoms.-The disease often begins with chills, which may be several 
times repeated and which are generally slight. In some cases, on the 
contrary, they are very violent. At other times they are absent. 
Pain generally succeeds the chill. Sometimes very intense, it is, so to 
speak, the initial symptom. Sometimes it is dull and only excited by 
movements or pressure. In cases of great intensity it has been observed 
to persist during several weeks, with the same severity, thus depriving 
the patients of all repose and of all sleep. It then corresponds to the 
painful form of Vachee and of Fournier. Now fixed in one joint, now 
migratory, it is soon accompanied by marked swelling of the affected 
joints, due to the serous effusion into these and to inflammation of the 
peripheral fibrous tissues and of the bones themselves. Generally, these 
pains are more migratory than the swelling, which, once fixed upon a 
joint, lasts much longer than the pain and seems to persist for a certain 
time after the cure. 
Seat.-The disease may affect many joints, to a variable degree. It is, 
however, rarely erratic and generally fixes itself upon one joint, particu- 
larly the knee, the elbow, the wrist or the ankle. There is, ordinarily, 
neither redness nor heat, but the articulations attacked are swollen, pasty, 
shiny, of a pale or violet color, or sometimes devoid of color. There is 
a sort of characteristic obscure oedema, accompanied, where the serous 
effusion is pronounced1, as in the knee, by an elevation of the patella and 
a real fluctuation. At the same time the febrile reaction, which exists 
at first, yields quite rapidly, and the disease more resembles a hydrar- 
throsis than a true rheumatism. The temperature rarely exceeds 102° F. 
The sweats are not profuse, and, although the patients lose some strength 
and grow pale, pregnancy still pursues its regular course, except in rare 
instances. Generally, the rheumatism of pregnancy is subacute, in- 
vading, at first, three or four joints and then settling in one of them, 
while the general symptoms disappear. The swelling and pain on pres- 
sure constitute the disease. Often, rheumatism is chronic from the 
first. The fever is hardly noticed; at first, the swelling and discomfort are 
confined to a single joint, the swelling is pasty, and the color of the skin 
unchanged. We have noted two or three examples. In these cases, the 
disease is indefinitely prolonged. 
Among the twenty-three cases reported by Tison. the disease lasted 
from 1 month to 1| months, 5 times; from 2 to 3 months, 4 times; from 
4 to 5 months, 4 times; from 5 to G months, 4 times. 
In one of his cases, Tison saw three attacks of rheumatism developed in 
the same woman, the first before, the second during and the third after 183 
DISEASES OF PREGNANCY. 
pregnancy. The first lasted fifteen days, the second five months with 
endocarditis, the third, also with endocarditis, several weeks. 
Terminations.-Among Tison's twenty-three cases, there was only one 
death, and in that case there was metro-peritonitis. Recovery is the 
rule, but recovery with anchylosis. Tison has seen it eleven times out of 
thirteen cases, three of them with nodosities; in four cases, stiffness and 
swelling remained; three times the patients left the hospital uncured; in 
only five cases was the cure complete. Sometimes labor causes great im- 
provement, but at other times it has no influence on the rheumatism. 
Whatever Vaille says, the termination by suppuration is rare in preg- 
nancy, but not rare after labor. 
Prognosis.-This is grave, for although life be not endangered, anchy- 
losis follows in two-thirds of the cases, and complete recovery occurs in 
only one-quarter of the cases. It is graver in proportion as the disease 
■was localized, at first, and has lasted a long time. 
Treatment.-This must be energetic, consisting of quinine, salicylate 
of soda, narcotics locally, and, especially, fixation in splints or immovable 
apparatus, perforated so as to allow of the application of medicinal sub- 
stances. When the fever has passed, revulsives are to be used. The tinc- 
ture of iodine, cotton saturated with iodine, vesicatories and the actual 
cautery may be employed. Trouseau used a poultice composed of four 
pounds of bread, six and a quarter ounces of camphorated alcohol and 
thirty grains of the extract of henbane. A poultice is thus made upon 
which is spread one hundred and fifty grains of the extract of belladonna, 
with which the limb, reposing on a splint, is enveloped. The poultice is 
only renewed once in eight days. To prevent it from drying, it is 
covered by a sheet of oiled silk. The whole is covered with cotton-batting 
and held by a bandage. 
Alkaline baths and sulphur douches are useful, when swelling and 
stiffness of the joints are the only remaining symptoms. The patients 
are not to be kept quiet too long. It is, therefore, good, although the 
limb be left in the splint most of the time, to take it out morning and 
evening, when the acute attack has once passed, and to subject it to a 
few slight movements, limited to the joint. 
One sometimes sees, in pregnancy, true gonorrhoeal rheumatism, syphi- 
litic rheumatism, such as Dubois and Fournier have reported, and white 
swellings. White swellings may exist before pregnancy, or, as in a case 
of Labbe, quoted by Dubois, the white swelling developed in the left 
knee during the puerperal state of a preceding pregnancy, pursued its 
course and necessitated amputation during a subsequent pregnancy. 
The patient, already pregnant three months, submitted to amputation 
and recovered without an abortion. In another case, quoted by Bichet, 
there was white swelling of the wrist and of the right knee. Richet em- 
ployed igni-puncture. A month later the patient was attacked with 184 
A TREATISE ON OBSTETRICS. 
acute tuberculosis. She was delivered at eight months and died forty- 
eight hours afterward. 
After Confinement.-Braunberger is very wrong in uniting, under a 
single heading, rheumatoid symptoms occurring after labor, although 
he carefully divides them into three distinct classes: 1. Articular locali- 
zations in subacute infectious puerperal troubles; 2. Articular localiza- 
tions in acute infectious puerperal troubles; 3. Localizations in non- 
infectious chronic puerperal troubles. Here we have incontestable con- 
fusion. 
We must, indeed, carefully distinguish rheumatic disease-developed 
in the normal course of the puerperal state, and the arthritis of puer- 
peral fever, which Lorain and Quinquaud have called the infectious puer- 
peral state. This arthritis, we consider, as do Lorain and Quinquaud, 
as the manifestation of puerperal septicaemia which attacks the joints as 
well as the lymphatics, the veins, the serous membranes, the heart and 
all the other organs, and is either primarily or secondarily developed. 
But these symptoms have no relation to rheumatism. This arthritis may 
become purulent, the same as puerperal peritonitis and pleuritis, but 
has no connection with puerperal rheumatism. Rheumatism may, of 
course, be developed in the puerperal state, just as in pregnancy, and, 
when it does so, it has characteristic features. It may be muscular, 
which is rare, or articular, which is common. 
Muscular Rheumatism. 
This form attacks the muscles of the upper or lower limbs, localizing 
itself in the muscles of the arms or of the calves. To the two cases 
cited by Warmont and observed in Legroux's service, we can add two 
seen by ourselves, one of which is now under observation. Confined to 
the calf, in our two cases, the disease showed itself, each time, from the 
twentieth to the twenty-fifth day after labor, and we might have considered 
'A phlegmasia alba dolens had not the absence of fever and of oedema, and 
the limitation of the disease to a small area, removed all doubt. We 
should prefer to call the trouble myodinia of puerperal women, as War- 
mont and Legroux do. In our first case every symptom disappeared at 
the end of five days, by the application of belladonna and indulgence in 
rest. Our second patient has only been sick three days. We have just 
seen a third case, wherqthe rheumatism had settled in the muscles of the 
left shoulder after having affected the corresponding muscles on the right 
side for forty-eight hours. The patient had been confined twenty-four 
days before. The disease disappeared in eight days, under quinine and 
local narcotics. 
Articular Rheumatism. 
The characteristic of these cases is their tendency to suppuration. The 
joint symptoms, appearing from the second or third to the tenth or 185 
DISEASES OF PREGNANCY. 
fifteenth day after confinement, are generally accompanied by a claret red, 
a blue, or a pale rose color, disppearing on pressure, to soon return. The 
swelling,unlike that observed during pregnancy,is generally slight,although 
the effusion be more abundant. The pain is excruciating. The pulse is 
very rapid, from one hundred and ten to one hundred and thirty-two 
per minute. The temperature usually keeps pace with the pulse, rising to 
104° or even 106° F. Chills are frequent and recurrent. In fatal cases, 
there is adynamia and delirium, while meningitis is a frequent complica- 
tion. Pericarditis and endocarditis are, also, complications. 
Fonsart and Bourdon have reported teno-synovitis, involving both the 
extensors and flexors of the fingers and toes. In many cases peritonitis, 
peri-metritis and metritis have been observed. It is not only after normal 
labor at term that puerperal rheumatism may manifest itself, for Peter 
has reported a fatal case which followed an abortion at three months. 
The prognosis is rendered grave, of course, by the tendency to suppura- 
tion already alluded to, and the outlook is more serious in proportion as 
the disease has developed rapidly after labor. But, although the prog- 
nosis is more favorable in the cases occurring later than the tenth or 
twelfth day after labor, it is still very serious, for, in these cases, the 
arthritis tends to chronicity, and the termination by transformation into 
strumous arthritis is frequent. In the most favorable cases, anchylosis is 
the rule. This is not always the result, and in one case which we ob- 
served at the clinic, the patient recovered without suppuration of the 
articulations and without anchylosis. 
Treatment.-This is often inefficacious. Quinine seems to have yielded 
the best results, thus far, but large doses must be used, as twenty-three 
grains per diem, and must be continued during the whole course of the 
disease. The treatment should not be suddenly but gradually suspended. 
Revulsives and narcotics are only uncertain palliatives. 
Chorea. 
Chorea may occur during pregnancy or after labor, but is infinitely 
more common during utero-gestation, and this relation between chorea 
and pregnancy had been already noted in the eighteenth century when 
Borsieri advised the use of quinine. 
Frequency.-The disease is rare, for Mosier, in 1862, had only been 
able to collect twenty cases. Barnes, in 1869, collected fifty-six, and 
Fehling, in 1874, sixty-eight cases. Schroeder and Spiegelberg consider 
it as very rare. The latter has only seen two cases, in a very large 
practice. Among 1600 patients, observed by ourselves at the clinique, 
we only discovered two cases, and we have recently seen our third case in 
a woman after labor. 
Causes.-1. Primiparous state.-All authors agree on this point. 
Scanzoni, Dreyssig, Schneider, Bezold, Wirke, Bodo, Wenzel, Sieckel, 186 
A TREATISE ON OBSTETRICS. 
Weber, Russell and Spiegelberg are unanimous on this question. But 
the only authors who have given figures are: 
Primiparae, . . .8 
Multiparae, • . .7 
Unknown, . . .5 
Mosier, . . .20 cases, 
Primiparae, . . .28 
Multiparae, . . .15 
Unknown, . . .13 
Barnes, . . .56 cases, 
Fehling, . . .58 cases, 
Primiparae, . . .33 
Multiparae and unknown, 35 
Charpentier, . . 3 cases, 
Primiparae, . . .2 
Multiparae, . . . 1 
2. Age.-Mosier, among twenty-one cases, found sixteen in which the 
age was exactly known. This table exhibits the ages: 
17 years, . . .1 case, 
18 " . . .2 cases, 
19 " . . . 2 " 
From 17 to 20 years, 5 cases. 
20 " . . . 5 " 
23 " . . . 3 " 
24 " . . .3 " 
From 20 to 24 years, 11 cases. 
Barnes found among fifty-six cases 
17 years, . . .3 cases, 
18 " . . . 4 " 
19 " . . . 4 " 
From 17 to 20 years, 11 cases. 
20 " . . .10 " 
21 " • . .1 case, 
22 " . . .2 cases, 
23 " . . . 7 " 
24 . .3 " 
From 20 to 24 years, 23 cases. 
28 " . . .1 case. 
32 " . . . 1 " 
35 " . . . 1 " 
From 28 to 35 years, 3 cases. 
Chorea is, therefore, most frequent between 20 and 25 years. 
3. Constitution.-There is no uniformity. Sometimes the women are 
feeble, small and delicate, and sometimes are robust and strong. 
4. Heredity.-Romberg has only quoted one case in which this cause 
can be really assumed. 
5. Previous Chorea.-Mosier saw, among his twenty-one cases, five who 
had had previous attacks. This was noted by Senhouse Kirke, Eliscrhe 
and Fehling, fifteen times among thirty-three primipara?. Barnes reports 
nine out of his fifty-six cases. Spiegelberg, without giving statistics, in- 
sists on this point and the same is true of Franck and Duncan, whose 
patients had had chorea either during infancy, as in the preceding cases, 
or during previous pregnancies. Chorea may, however, appear suddenly 
during the second or third pregnancy, or as a relapse, having existed DISEASES OF PREGNANCY. 
187 
during a first or a second pregnancy. Again, it may not appear until 
after labor whether at or before term. Pregnancy may commence during 
an attack of chorea, as in a case of John Hirks. 
Among the seven multiparae cited by Mosier, the previous pregnancies 
had been normal in three, and in two there had already been chorea 
during the first pregnancy. In the other cases there had been vertigo, 
intense headache, and marked anaemia. 
6. Emotions, as anger, fright, mental trouble, delirium. 
7. Rheumatism.-Spiegelberg insists on rheumatism, combined with 
cardiac affections. In some cases, albuminuria or glycosuria has been 
noted. In many cases the cause is not discovered, and Spiegelberg regards 
these cases as reflex neuroses, which, given a predisposition on the patient's 
part, suddenly develop under the influence of inadequate nutrition of the 
nervous centres by impoverished blood or under the influence of peri- 
pheral irritation of the genital system. It is, in fact, not rare to find 
choreic patients poorly nourished, feebly developed and anaemic. Barnes, 
Copland, Roger, See and Chambers also mention rheumatism, and Ogle 
embolism. 
Period of Development.-Chorea may appear at any stage of pregnancy 
and after labor, but it is particularly in the earlier part of pregnancy 
that it is most often observed. It then persists, generally, until the be- 
ginning, or even to the end of labor. More rarely, it yields before labor, 
and more rarely still (only three times out of Spiegelberg's sixty-nine 
cases) does it persist during the post-puerperium. In our own case, the 
chorea did not appear until three weeks after labor. On the day follow- 
ing her. confinement the patient, a multipara who had been four times 
pregnant, was seized with a left crural neuralgia which resisted quinine, 
injections of morphia and vesicatories for twenty-one days. On the 
twenty-second day, after a severe annoyance, the patient was attacked by 
left hemichorea of a typical character, involving the whole left side, more 
marked in the upper extremity and involving the muscles of the face. 
This attack disappeared at the end of thirteen days and gave place to 
genuine hysterical attacks, which were repeated two or three times daily, 
at first, but which are nevertheless now diminishing. There is now only 
one daily hysterical attack, and this is less violent, although accompanied 
by very plain erotic sensations, which lead to free secretion of the vulvo- 
vaginal gland, and they have tended, ever since their diminution, to be 
replaced by an incessant hysterical cough. Bromides, valerian, cold 
douches and chloral have been, hitherto, absolutely powerless, and the 
same has been true of quinine, arseniate of iron, etc. We may add that 
the patient has had an intense catarrhal metritis for some years, and an 
ulceration of the cervix for which she is now being treated. She had 
an attack of chorea in her infancy, but not in her other pregnancies. 188 
TREATISE ON OBSTETRICS. 
one cases: 
In the first 2 months, . . . . .7 times. 
" " 3d and 4th months, . . . . 8 " 
11 " 5th " 6th " 3 " 
" " last months, ...... once. 
Unknown, ....... 2 
Regarding the exact date of the attack, Mosier has seen, among twenty- 
Among fifty-seven cases, Barnes found: 
In the 1st month, 3 times. 
" " 2d " 3 " 
11 11 3d " 10 11 
il " 4th " 7 " 
" " 5th " 7 " 
In the first five months, 30 times. 
" " 6th " 4 " 
" " 7th " 3 " 
" " 8th " 2 " 
" " 9th " 2 " 
In the last four months, 11 times. 
41 
Early, without exact date, 6; late, 3; unknown, 6. 
Our three cases appeared as follows: Twice during pregnancy, at the 
fourth and the sixth month, and once, twenty-two days after labor. 
In Fehling's fifty-five cases, chorea began in the first half of pregnancy 
in thirty-nine instances. In only three did the chorea persist during the 
puerperium. In only twenty-nine cases did pregnancy reach full term. 
Symptoms.-These vary according as the chorea appears slowly or sud- 
denly. If the inception is gradual, the friends of the patient,, or the 
patient herself, first perceives involuntary movements of the limbs or of 
the face, and in some cases, such as Kiwisch, Scanzoni and Romberg "have 
observed, there is also head-ache, vertigo, a queer facial expression, ex- 
cited speech, and, rarely, excitement of the whole psychical system. 
Then these movements grow marked, and the chorea is progressively de- 
veloped. At other times, the chorea begins rapidly, the incoordination of 
the movements is marked and rapidly extends to several parts of the body. 
Among the twenty-one cases of Mosier, the disease began in the right 
arm alone, twice; in the left arm and leg, twice; in the legs only, twice. 
The attacks returned at a fixed time. In four cases the disease began in 
the face, and, in one case, in the tongue muscles. 
When the attack is sudden, several parts of the body are simultane- 
ously involved, as the face, limbs and tongue. There are evening exacer- 
bations, delirium and insomnia (Helfft). In the majority of cases, the 
chorea is bilateral (Mosier, Fehling, Barnes). In sixteen of Mosier's 
cases, the disease affected besides the limbs, the face, the eyes, the tongue, 
and the muscles of the neck and trunk. Speech was affected. But even 
in these cases, the chorea is not always of equal intensity in all parts of 189 
DISEASES OF PREGNANCY. 
the body, and the movements are now violent, now quite slight. In 
many cases there seem to come crises or exacerbations of the disease. 
Almost always, save in two cases of Franck and Ingleby, the movements 
ceased during sleep, but often-times the sleep is disturbed, and ac- 
companied by night-mare. The patients talk aloud and are restless. 
The movements reappear in the morning when the patients awaken, and 
sometimes it is the reappearance of the movements which puts an end 
to sleep (Scanzoni). There are, sometimes, diurnal remissions, of which 
Mosier has noted four distinct cases. Hand has observed an aggravation 
of the movements under the influence of movements of the child and of 
vaginal touch. Often, the chorea is accompanied by epileptiform con- 
vulsions and hysterical fits which seem to return at fixed hours (Mosier, 
Duncan). One of Duncan's patients, and one of our own, had ulceration 
of the cervix. Other complications are headache, sharp pains in one 
limb, cardiac and renal diseases. Generally, there is little or no fever, no 
digestive difficulties and no disorder of the intellect. In a case of Lever, 
however, there was weakening of the memory and the intelligence seemed 
impaired at the time of the crises. 
Course, Duration and Terminations.-The influence of chorea upon 
pregnancy is very marked. Abortion or premature labor are common. 
The sooner the chorea begins, the greater the chances that pregnancy will 
end before full term. 
Among twenty-one cases, Mosier observed four abortions, at four, five 
and six months. In three cases, the chorea had lasted three, four and 
five months, for it began in the first month. In three cases it disap- 
peared immediately after abortion. Once, it lasted six weeks after 
labor (Romberg). 
In three cases there was premature labor, twice at the beginning of 
the ninth month and once in the seventh. The chorea had persisted, in 
one case, nine months, in one case five, and, in one, only one month. 
In three cases the chorea ceased abruptly. Once (Aran), the patient had 
a still-birth and died delirious the next day. 
Barnes, recapitulating his fifty-seven cases, reaches the following results: 
Spontaneous labors at term. 
. . 22 cases. 
Abortions at three months, 
1 ) ' 
" " five " ... 
6 8 
11 " six " ... 
1 ) 
Premature labors at seven months, . 
2[ 3 
► 19 " 
" 11 eight " 
1 f 3 
11 " date not given, 
6 
Abortions, date not given, 
2 
Women dead before delivery, . 
• • 
3 
Abortion induced, ..... 
1 
Premature labor, induced at seven months, 
1 
Unknown, ...... 
• 
11 
57 190 
A TREATISE ON OBSTETRICS. 
In five cases of Mosier, the chorea continued until the end of preg- 
nancy; in three cases, from the third to the tenth month, and once, from 
the fourth to the tenth. 
In Ingleby's case, (the fifth of Mosier,) the disease reached its maximum 
in five days, premature labor occurred, and the patient died twenty-four 
hours later. In some cases the disease ceased before labor. 
On the other hand, in the cases of Barnes: 
Recovery occurred rapidly, . . . . in 1 case. 
" " in 19 days, . . . . " 1 " 
" " " 37 . . " 1 " 
" " " 2£ months, . . . . " 3 cases. 
" " " 3| " . . . . " 1 case. 
The disease ceased before the end of pregnancy, . "8 cases. 
" " " after abortion, . . , " 2 " 
" " " " labor, . . . . " 2 " 
" " ended in an attack of rheumatism, . "2 " 
" " continued during the whole of pregnancy, " 12 " 
" " ended in mania, . . . . " 1 case. 
Death occurred seventeen times in the days following delivery, the next 
day or the one following that. Twice mania occurred and once eclampsia. 
Among the seventeen cases, there were only six primiparae against eleven 
multiparae. 
Among sixty-eight cases collected by Fehling, there were nineteen 
deaths. Among these, that of Senhouse Kirke is one of the most 
curious. A patient attacked with chorea at fourteen years had two mis- 
carriages and one labor at term. In a fourth pregnancy she was attacked 
with severe chorea four days before her confinement, and died four days 
after labor. 
When chorea develops late, it seems to be more severe as well as when it 
occurs in a second or third labor or wdien it relapses. When, on the 
other hand, it begins from the third to the fifth month or before, it 
rarely persists up to the ninth month. In these cases there is either abor- 
tion or premature labor and a cure generally results. 
Chorea is more serious in multiparae than in primiparae. Spiegel berg, 
who among sixty-nine cases noted twenty deaths, saw pregnancy go to 
full term in only twenty-nine cases. Death of the child, however, does 
not always precede the interruption of pregnancy, even in cases of abor- 
tion. The child is often born alive and has never been seen affected with 
chorea. The disease has no influence on the post-partum state. 
Mosier and Barnes find the causes of death in the complications, not 
in the chorea itself. Fehling has noted intestinal ulcerations and cardiac 
affections five times, albuminuria once, and cerebral affections (mama and 
eclampsia) ten times. Cerebral complications ought not to occasion sur- 
prise, if one accepts Barnes' opinion, which locates the disease in the cor- 
pora striata. DISEASES OF PREGNANCY. 
191 
In his remarkable study on chorea, Germain See states that it has not 
been positively shown that chorea is more common with pregnant women 
than in others, but he considers gestation as more or less favorable to the 
development of nervous, choreic phenomena. Among the fourteen cases 
which he collected, he finds thirteen primiparae. The chorea began three 
times within the first two months, seven times from the third to the fifth, 
three times from the fifth to the ninth. But he thinks that pregnancy 
is not the real cause, and that it acts only through the usual causes, the 
production of which it favors. In his view, the chorea of pregnancy de- 
pends on no cause save choreic antecedents. Five of his patients had al- 
ready had chorea in their youth, and only relapsed during their preg- 
nancy. With the others chorea was only secondary to rheumatism, chloro- 
sis, chronic dysmenorrhoea, hysteria or hydrsemia, which so often attend 
both chorea and pregnancy. The chorea of pregnancy is more stubborn 
than ordinary chorea, and > if it is improved by labor, the cure is not gen- 
erally effected for some days, or even for more than a month. Chorea 
does not produce abortion itself, nor does it demand artificial premature 
delivery. 
Treatment.-This should embrace general tonic measures, narcotics, 
quinine, bromide of potassium, and particularly, chloral. Spiegelberg, in 
cases where the chorea gets worse and resists all treatment, advises artifi- 
cial premature labor and even abortion. He especially recommends early 
interference. 
Diseases of the Vulva and of the Vagina. 
Pruritus Vulvce. 
This disease, although not peculiar to pregnant women, sometimes as- 
sumes especial intensity with them. By the term is understood a severe 
itching of the external genitals, which sometimes extends to the introitus 
vaginas, and amounts to real torture. Generally, there is no visible lesion. 
In other cases, the women produce erosions, superficial fissures, and some- 
times redness by scratching and thus augment their sufferings. Hardy 
has seen some superficial ulcerations in these cases, from which serum 
exudes, as in eczema. Cazeaux has quoted a case in which the itching 
was such that the woman was in a state of general irritation almost pro- 
ducing convulsions. In another case the friction had been so often re- 
peated that it had caused swelling and inflammation of the labia majora 
and minora, one of which was of twice its natural age. Although devoid 
of gravity, pruritus vulvas gives so much suffering that it claims active 
treatment, which is often inefficacious. Rest, alkaline baths, separation 
of the inflamed surfaces, and lotions of vegetable and mineral waters some- 
times succeeds, as do solutions of borax, chlorate of potassium and weak 
carbolized water. Meigs recommends ablutions of the parts with soap 192 
A TREATISE ON OBSTETRICS. 
and water, and then the application, thrice daily, of the following solu- 
tion: 
Sodii borat. . . . . . 3 ij- 
Morph. sulphat grs. iv. ss. 
Aquae rosae destill. . . , . fl 3 x. fl 3 ijss. 
We have often successfully used either just as hot water as the pa- 
tient can endure, or tar water. In obstinate cases, we employ the follow- 
ing: 
G Hydrarg. bichlorid gr. xxii. ss. 
Aquae destill. . . . . . . 3 iv 3 vss. 
Ammon chlorid. . . . . . Q. s. ad. sol. 
Sig. One teaspoonful, in a glass of hot water, as a lotion, three times a 
day. If the case resists, we use the solution undiluted, applying it with 
a brush morning and evening. 
[In any case of pruritus vulvae, a very common cause must be borne in 
mind, and this is endocervical catarrh, and the resulting erosion of the 
external os. The diagnosis is readily made by the finger-patency of the 
external os and cervical canal, velvety softness of the external os, and these 
signs are confirmed by the examination through Sims's speculum, which 
reveals the eroded cervix and the gaping os. As for treatment, applica- 
tions to the canal and the os, by means of cotton wrapped applicators, of 
a solution of nitrate of silver, 30 to 60 grains to the ounce, are the most 
effective, and if made gently, will not induce miscarriage. In case of 
vaginitis a similar solution should be swabbed over the entire vaginal 
mucous membrane. The most effective of all means for the relief of the 
symptom-pruritus-is painting the external organs,the skin of the thighs, 
nates, etc., with a solution of silver nitrate, gr. x- 3 j.-Ed.] 
Dubois recommended cauterization with nitrate of silver, which we have 
never employed. We have seen one case of marked pruritus, the patient 
being a young woman, at the beginning of her second pregnancy, which 
resisted all treatment, and ended at two months and a half by an abor- 
tion. During a third pregnancy, the pruritus reappeared during the first 
two weeks of the second month, but yielded to astringent lotions, (Goulard's 
extract) and to separation of the surfaces. The pregnancy pursued its 
regular course to full term. 
Leucorrliaa. 
Almost all pregnant women have leucorrhoea. Generally it is mild, but 
sometimes is severe, being then connected with granular vaginitis. A 
mass of granulations develop in the vagina, particularly during the latter 
half of pregnancy, forming a rough surface and coexisting with erosions 
and with superficial ulcerations of the cervix. In this case the discharge 
becomes very abundant, yellow or greenish, and, producing painful inflam- DISEASES OF PREGNANCY. 
193 
mation and superficial ulceration of the external genitals, and of the inner 
aspect of' the thighs, causes great suffering. The best means of relief 
consists in separation of the surfaces with bits of fine linen dipped in a 
solution of sub-acetate of lead, in careful injections, in alkaline baths, and 
particularly, in tampons of cotton. These tampons enclose equal parts 
of alum and sub-nitrate of bismuth, and are tied by a thread, which is 
allowed to hang between the legs, and serves to withdraw the tampon. 
We leave the tampon in place three days, at the end of which time the 
patient withdraws it, takes an alkaline bath, and during her bath, injects 
some of the alkaline water. A new tampon is then inserted, and so on. 
Fig. 8.-Vegetations of the Nympho.-(McClintock.) 
Generally after three or four tampons, notable relief ensues, if not a 
complete cure. We have never seen accidents due to the tampons. 
[Owing to the well-known property of the tampon, of exciting uterine 
contractions, we should not care to resort to it here. The means above 
described by us, for the relief of pruritus, will answer for the symptom 
leucorrhcea. -Ed. ] 
Vegetations. 
These are common in pregnant women (Fig. 8). These vegetations, 
for a long time considered syphilitic, are not due to syphilis and are de- 
veloped by pregnancy, as Thibierge has so well shown. Cullerier, Boys 
de Loury, Costilhes and Ricord, noted the coincidence of pregnancy and 
vegetations. They appear at all stages of pregnancy, in the shape of tufts, 
Vol. IL-13. 194 
A TREATISE on obstetrics. 
pediculated at the attachment and swollen like cauliflower. They are 
roseate, pale, red, brown or livid. Sometimes they are isolated, and some- 
times aggregated into large masses. We have seen one case in which they 
were almost as large as a child's head. They have an odoriferous dis- 
charge, and occasion sharp pains and pruritus. Their favorite seat is 
the mucous membrane of the vulva, the borders of the labia majora and 
the space between these and the labia minora, which their growth sepa- 
rates, and through which they protrude between the thighs, partly obli- 
terating the vulva. They may extend into the vagina and up to the cer- 
vix uteri. Again, they may extend to the furrow between the buttocks, 
to the anus and the groin. Although they constitute a source of great 
annoyance, they are not serious, and generally resist all treatment up to 
the time of labor, when they wither and fall off. In two cases, however, 
in one of which they were as large as an apple, we have seen them disap- 
pear during pregnancy, owing to separation of the surfaces and the use of 
compresses, dipped in Labarraque's solution. We consider more energetic 
measures useless,and strongly disapprove of all radical operations (excision, 
crushing, etc.). 
Abdominal and Uterine Pains. 
Abdominal, Lumbar, and Inguinal Pains. 
These pains, to which Cazeaux has particularly called attention, hardly 
appear before the last months of pregnancy. They are generally circum- 
scribed and limited to the lower part of the thorax, to the origins and 
insertions of the abdominal muscles or the groins. The pains are due, as 
Tarnier says, and as Beau had already remarked, to lumbo-abdominal neu- 
ralgia, and we may find the maximum point, as in all neuralgias, by fol- 
lowing the course of the nerves. They generally yield to hypodermic 
morphine injections. Again, there are cramps or severe pains in the 
thighs and the legs. These may be due to compression of the sacral 
plexus by the foetal head, but as Tyler Smith says, there are cases in 
which this explanation does not serve. They are then attributed to irri- 
tation of the large intestine or of the uterus, and are considered reflex. 
In some cases the uterus itself is the seat of pains which come on at 
variable intervals, and the nature of which can not be discovered. Now 
continuous, now irregularly intermittent, they occur in paroxysms which 
are excited by pressure, a cough or by foetal movements. They are almost 
always the manifestation of a uterine contraction which is appreciable to 
the touch. Finally, in some cases, the sensibility of the uterus is exag- 
gerated by incessant, violent foetal movements. This sensibility is some- 
times so extreme that each foetal movement is accompanied by acute pains, 
the repetition of which greatly exhausts the patients. 195 
DISEASES OF PREGNANCY. 
Uterine Rheumatism. 
Cazeaux and Gauthier have particularly called attention to this disease. 
Cazeaux considers it true rheumatism, but Gauthier regards it as identi- 
cal with uterine neuralgia, which may also occur aside from pregnancy. 
Gestation produces modifications, however, in its course. Spiegelberg 
and Braun do not believe in uterine rheumatism and consider it as a re- 
sult either of endometritis or of metritis. 
Symptoms.-Among twenty-nine cases collected by Gauthier, eighteen 
commenced during pregnancy, before labor, and eleven began during 
parturition. The attack is never sudden. Before the appearance of 
uterine pain the patient complains of pains and contractions in the limbs 
and the trunk, of vertigo, palpitations and of syncope. Shortly after- 
ward, or at the same time, a continuous, dull pain, of variable intensity, 
is felt in the sacrum, the hypogastrium and the lateral abdominal regions. 
This pain is exaggerated by movements of the mother or of the foetus. 
At the end of a few hours or days, the pain becomes suddenly violent, 
sharp, lancinating, and lasts from a few seconds to several hours, begin- 
ning at the uterus, radiating into the lower limbs, and extending to the 
bladder and rectum. On applying the hand to the abdomen, we find 
that its walls are not the seat, and that the pain is uterine and not so limited 
as in ordinary neuralgias. Almost always one of the surfaces or sides of 
the uterus is the chief seat of the pain. The pain is generally fixed, 
but may be mobile, the fundus uteri being usually less affected than the 
othei- regions. The women experience a sensation of spasmodic constric- 
tion, due to uterine contraction, and perceived by the patients and the 
obstetrician during the earlier months. The uterus, in fact, grows hard. 
Sometimes it is smooth and sometimes nodular, from partial contractions. 
When the organ is large, we can appreciate these changes in form, which 
may, in certain cases, produce an annular transverse constriction. The 
latter may be partial, and involve different parts of the uterus, including 
the cervix, and may occasion, according to the case, either rigidity or 
rapid dilatation of the cervix. 
Gauthier admits two forms, one acute, febrile, and one chronic, apyretic 
form. The former may succeed the latter or may present momentary 
acute exacerbations. Uterine rheumatism occurs most frequently at term 
and during labor, at which time it may become the cause of dystocia. It 
may be developed after labor, either immediately or after a few hours. 
It then causes spasmodic uterine contractions, which lead to retention 
of the placenta. Finally, it may occur later yet, after fifteen days, as in 
a case of Neucourt. 
The usual complications are neuralgic or rheumatic pains in certain 
viscera, in the muscles or in different nerves, particularly the vesical and 
rectal nerves. Luroth has seen a case of rheumatic' meningitis, and 196 
A TREATISE ON OBSTETRICS. 
finally, there may be muscular pains in the face, the neck, the arm, the 
shoulder, the thoracic walls and in the lower limbs. 
Very prone to relapse, this affection may recur several times, during or 
after pregnancy. The intervals vary from two or three days to several 
weeks. An individual attack varies from a quarter of an hour to twelve 
days, at the longest, but in general, it does not exceed twenty-four or forty- 
eight hours. The disease may reappear in successive pregnancies. Tlie 
disease may end in recovery, which is the rule, in a chronic condition, in 
metritis and in eclampsia. 
1. Influence upon Pregnancy.-When the attacks have lasted a certain 
time, and have been violent, they are followed by uterine contractions, 
and may thus provoke labor. But it is not always so, and Wigand quotes 
a case where the cervix dilated, and the bag of waters formed; when 
everything was arrested, labor ceased, the os closed, the cervix regained 
its former length, and pregnancy went on its course. Sometimes the 
pains simulate labor without inducing it, and they may occasion faulty 
presentations. 
2. Influence upon Labor.-Uterine rheumatism impedes labor, and 
sometimes even renders the spontaneous expulsion of the foetus impossi- 
ble by interfering with the pains, by producing spasm of the cervix, and 
by preventing the woman from making voluntary expulsive movements. 
3. Influence upon the Puerperal Functions.-By causing tetanic uter- 
ine contractions, it may produce dystocia or may occasion hemorrhage by 
inducing uterine atony, which may be followed by metritis or by perime- 
tritis. 
Causes.-1These are difficult of detection. The disease may appear 
under all circumstances and at any stage of pregnancy. Gauthier saw 
it begin in twenty-nine cases, as follows: 
In the 2d month, 1 
" " 3d " 3 
" " 4th " 1 
" " 5th " 1 
In the first five months, 6 times. 
" 6th " 2' 
" " 7th " 4 
" " 8th " 5 
" " 9th " 12 
Ill the last four months (twelve 
occurring in the last month), 23 times. 
Meissner regards rheumatism as a neurosis of uterine sensibility and 
motility, caused by peripheral irritation, and particularly by cold. 
The predisposition increases as the full term approaches, and is nota- 
bly augmented near the time of labor. 
Prognosis.-Although not fatal to the woman, uterine rheumatism is 
still serious because it may occasion abortion or premature labor, or by 
retarding and complicating labor it makes the condition of both mother 
and child much less favorable. It is particularly disagreeable when de- DISEASES OF. PREGNANCY. 
197 
veloped at the end of pregnancy, because of its tendency to recur several 
times before confinement, even when it does not interrupt pregnancy. 
In these cases it almost always recurs during parturition, which it renders 
long and difficult. 
Treatment.-This consists, during pregnancy, in venesection, revulsion 
through the intestine and in narcotics, either internally, subcutaneous- 
ly, or by enema. Chloral has proved very useful in these cases. 
During Labor.-We give the preference to chloral and to chloroform, 
and we hasten the termination of labor as much as is compatible with the 
mother's safety. 
After Labor.-We prefer to use laudanum enemata, twenty drops in 
three ounces of water, to be repeated two or three times in twenty-four 
hours. In a stubborn case, we pushed the dose to one hundred drops in 
twenty-four hours, without causing any results, aside from marked relief, 
except head-ache and somnolency. 
Displacements and Deviations of the Uterus. 
Prolapse of the Uterus. 
Prolapse of the uterus, during pregnancy, may be either incomplete or 
complete. In the latter case the whole organ escapes from the genital 
Fig. 9. Fig. 10. 
Fig. 9.-Complete Prolapse of Uterus, the result ' of Elongation of the Cervix.-a, 
Urinary meatus, b, Invaginated ant. vag. wall, c, Ext. os. d, Vag. portion of cervix. 
Fig. 10.-Complete Prolapse of Uterus, without Cystocele. Rectocele and Enterocele.- 
a, Urinary meatus, b, Uterus, c, Rectocele. 
canal, and hangs between the thighs. (Figs. 9 and 10). This form is 
very rare. These displacements may develop slowly or suddenly, in cases 
where prolapse pre-existed or not. Spiegelberg believes that a certain 
amount of prolapse always precedes the pregnant condition. 
The accidents, according to Cazeaux, which result from this displace- 
ment, vary in intensity, according to the degree of displacement and the 198 
A TREATISE ON OBSTETRICS. 
period of pregnancy at which it occurs. When the pelvis is too roomy, 
but the straits of normal size, the uterus remains in the true pelvis much 
longer than under other circumstances. The uterus then presses upon 
the rectum and the bladder, irritating them. The woman experiences a 
sensation of weight at the anus and of painful traction at the groins, the 
loins and the navel. There is a fetid discharge. The patient can neither 
stand up nor walk easily, and she falls, gradually, into a state of marasmus. 
If pregnancy has just begun and the uterus is either very large or has de- 
scended to a greater extent, the accidents are more deplorable still. Com- 
plete retention of urine and obstinate constipation may result. The irri- 
tation resulting in the uterus itself may lead to abortion. These compli- 
cations generally cease when, at the fifth month, the uterus is unable to 
develop farther within the pelvis and rises above the superior strait. 
Hiiter who, in 1860, collected all the cases up to his time, divides 
them as follows: • 
1. The gravid uterus being prolapsed, reduces itself during the first 
months, and pregnancy and labor follow their usual course; 5 cases. 
2. The prolapse is not spontaneously reduced. Its artificial reduction 
and support must be undertaken; 8 cases. 
3. Reduction cannot take place on account of incarceration; 3 cases. 
4. The prolapse causes labor before term; 7 cases. 
5. Prolapse occurs in the second half of pregnancy, and persists up to 
term and during labor; 3 cases. 
6. Prolapse takes place shortly before, or during .abor, at term. In 
this case, prolapse may not have existed before labor, or, having existed 
before, was spontaneously reduced during the first months of pregnancy, 
or the prolapse was reduced and the uterus maintained by a pessary; 16 
cases. 
7. Prolapse occurs during labor and delivery; 15 cases. 
8. Prolapse existed before pregnancy, but only became pronounced 
during labor; 16 cases, making a total of 73 cases. 
Causes.-It was impossible for Hiiter to divide the cases into those of 
complete and incomplete prolapse. Among sixty-nine cases, there were 
ten primipane, twenty-seven multipart and thirty-two unknown. In 
thirty-five patients, seven of them being primiparae, prolapse existed 
before pregnancy. In thirty-four patients, three being primiparse, this 
was not noted. 
Hitter concludes that antecedent prolapse is the cause of prolapse dur- 
ing pregnancy, since it exists in one half of the cases. Hitter states: 1. 
That in sixteen cases, the uterus prolapsed before pregnancy, remained 
prolapsed during this pregnancy. 2. That, in five cases, prolapse which 
did not exist during a certain period of pregnancy, resulted from efforts 
and traumatism. 
Among twenty-four women in labor, eleven of them being primi- DISEASES OF PREGNANCY. 
199 
parae, the prolapse which existed before pregnancy recurred with it. 
Among fourteen women in labor, three of whom were primiparae, the 
prolapse occurred for the first time during labor, owing solely to the 
uterine contractions; in eight cases it already existed before pregnancy. 
In two primiparae it was due to traction with the forceps. One had 
already had a prolapse before pregnancy, the other not. 
In two cases, the pelvis was extremely large, and in one case the vulva. 
The most active causes, however, are the efforts of labor. 
To recapitulate the causes: Multiparous state, pre-existence of pro- 
lapse, efforts, traumatism, uterine contractions, the forceps, justo-major 
pelvis, large vulva, efforts during labor. 
Fritsch attributes a powerful influence to arrest of uterine involution, 
after first labors. The enlarged uterus will have a better chance to de- 
scend if the perineum has been lacerated. Labor has a particularly pre- 
disposing influence when the membranes are ruptured before complete 
dilatation of the cervix. The fcetus pushes forward the rigid cervix, 
which may thus be protruded through the vulva, dragging the vagina 
after it. If uterine involution is incompletely accomplished, the uterus 
will remain low down, for the over-stretched peritoneal ligaments will no 
longer sustain this organ. 
Course.-Ordinarily, pregnancy proceeds undisturbed to full term. In 
only ten cases did premature labor occur. In two cases death resulted 
from incarceration of the uterus. 
In thirty-four cases the child presented by the vertex; in nine by the 
pelvic extremity. 
In five cases the feet were brought down by version. (Fig. 11). 
In only six cases was labor normal, and four of t'.ese labors were pre- 
mature. 
In seventeen cases the presentation was not noted. 
In two cases there were twins, which presented, in one instance, by the 
breech. 
In all the other cases, save the six referred to above, intervention was 
necessary either because of tedious labor, due to slow dilatation in spite 
of good pains, or to inefficient action of the abdominal muscles, or because 
of serious complications (rupture in three cases, from excessively strong 
contractions and gangrene of a part of the prolapsed uterus). 
Prognosis.-This is favorable, for the prolapse is almost always sponta- 
neously reduced in the first months, and pregnancy and labor generally 
take their normal course. The prognosis is even good for the con- 
tinuance of pregnancy, when artificial reduction and the introduction of 
a pessary are necessary (nine cases). But the outlook is much more 
serious when incarceration occurs (two deaths). Among the seven cases 
of premature labor or of abortion, there was one death. 200 
A TREATISE ON 
OBSTETRICS. 
For the child, the prognosis is bad in proportion to the rapidity of 
labor. 
Among fifty-six women at term, six died, one in labor, and five during 
the puerperium. 
Among the fifty-six children, nineteen were born alive, fourteen dead, 
and the fate of twenty-four was not noted. 
Treatment.-This consists in favoring spontaneous reduction by ap- 
propriate postures on the patient's part. If it does not occur, the 
Germans, more audacious than Cazeaux, advise artificial reduction as 
early as possible, and support by means of a pessary. Iliiter, going still 
further, recommends these measures even at eight months. 
Fig. 11.-Complete Prolapse of Uterus at Term.-Presentation of a foot: (multipara, aged 
thirty-eight.) a, Meatus urinarious. b, Prolapsed uterus, c, Cervix at term, through which a foot 
projects. 
If reduction fails, the uterus is to be sustained by a suspensory bandage 
and removed from all causes of irritation. 
If symptoms of incarceration are developed, artificial abortion is justifi- 
able. When labor is protracted, artificial delivery is to be carefully per- 
formed by the forceps or version. The uterus is subsequently reduced. 
Uterine Deviations. 
The uterine deviations are lateral, the obliquities of the older writers; 
anterior, or anteversions; posterior, or retroversions. That is to say, 
there are deviations en masse or partial deviations; anteflexions, retro- 
fiexions, latero-flexions. All are not of equal importance. DISEASES OF PREGNANCY. 
201 
1. Uterine Obliquities; Lateral Deviations. 
The older writers attached great importance to these, but in reality they 
are not well-marked and never cause serious complications. They only 
affect labor, and this by retarding cervical dilatation. We shall return to 
them in the chapter on Dystocia. 
2. Partial Deviations; Flexions. 
Conception is, according to Holst, not so rare as it is thought to be in 
cases of uterine flexion. He collected eight cases in point, and it must 
not be supposed, because conception occurs while the flexion is being 
treated, that the flexion is cured. If flexion often induces sterility, it is 
because the flexion is generally complicated by chronic inflammations of 
the mucous membrane and of the parenchyma; by Cervical catarrh, by 
erosions, by granulations and by amenorrhoea. But these are not positive 
obstacles. When the flexed uterus is healthy, the cause of sterility 
resides in the faulty position of the cervical orifice,which is directed either 
backward or forward. It is, therefore, no longer in contact with the end 
of the urethra at the moment of ejaculation, and, moreover, the bend in 
the uterus prevents the penetration of the spermatic fluid. Holst justly 
objects to this latter cause, as there should, otherwise, always be retention 
of the menstrual blood, which does not occur. That which renders con- 
ception possible is the disappearance of complications, the ability of the 
cervix to retain its normal position and the preservation of the uterine 
cavity. 
[The shape of the cervix is more likely to impede conception than the 
mere fact of flexion. The conical shape, usually accompanied by pin- 
hole os, is a frequent accompaniment of sterility. To refer only to the 
data of the late James Marion Sims, he found this conical shape in nearly 
85 per cent, of the cases of sterility which he investigated.-Ed.] 
W hen conception has taken place, pregnancy has Jit tie chance of reach- 
ing an end, as abortion very frequently occurs. 
Hitter reverts to the frequency of abortions in uterine flexions, and 
considers the larger part of those abortions, which take place in the early 
months of pregnancy, and the cause of which escapes observation, to be 
occasioned by these flexions. He thus explains the occasionally frequent 
recurrence of abortion, without known cause, in the case of certain 
women. He cites three cases in point, the first one being extremely in- 
teresting: 
First abortion, tenth week of pregnancy. 
Second " " " 11 
Third " seventh " ? " 
Fourth " tenth " " ■ " 
All these abortions occurred without appreciable cause. Anteflexion 202 
A TREATISE ON OBSTETRICS. 
was found to exist when pregnancy did not. In a fifth .pregnancy there 
was anteflexion and anteversion. The uterus was replaced at times cor- 
responding to the second and third menstruation. The pregnancy was 
not interrupted. Labor occurred at term and the post-partum period 
was normal. [We believe it very doubtful if abortion was ever produced 
by simple flexion. There are so many, often latent, causes of miscarriage, 
that we are scarcely warranted in laying this to flexion. We do not refer 
here, of course, to cases where version accompanies flexion.-Ed.] 
He concludes from his observations, that this supposed predisposition 
to abortion does not, in reality, exist, and that abortion is always occa- 
sioned by a cause which may momentarily escape observation because it 
is not always easy to discover at once. 
Flexions disappear during abortions, so that the diagnosis of these cases 
is only possible before the beginning of abortion or some time after its 
termination. 
It is not uterine flexion itself which produces abortions, but the ante- or 
retro-versions which accompany them. 
Treatment must, therefore, be directed against anteversions and retro- 
versions. 
Philips adopts, without reserve, the opinion of Iliiter as regards the 
frequent recurrence of abortions. 
3. Anteversion. 
Uterine anteversion is merely an exaggeration of a normal state, and 
becomes really pathological only when it exceeds a certain limit or when 
it occurs in the true pelvis, i.e., in the first months of pregnancy. Dur- 
ing the last months, it constitutes what is called pendulous abdomen, and 
it is well known under what circumstances this is produced. The mul- 
tiparous state, relaxation of the abdominal walls, eventration and rachitis 
are causes. It is not'rare, in these cases, to find women whose abdomens 
rest, as it were, upon the thighs, the fundus uteri forming the lowest 
part of the abdomen, the cervix being carried upward and backward. 
The patients, of course, suffer from renal pains and dysuria. The foetus is 
not within reach and delivery is difficult. 
But anteversion may occur during the first months of pregnancy (Fig. 
14,) before the uterus has risen from the true pelvis, and it is in these 
cases that it really becomes pathological. 
Iliiter has examined it, particularly from this point of view. 
Recalling the observations of Baudelocque, Chopart, Ashwell, Boivin, 
Hachmann, Welcke, Godefroy and adding two cases of his own, he distin- 
guishes three degrees of anteversion. 
First Degree.-This is about the normal state. The longitudinal uter- 
ine axis forms a very acute angle with the pelvic axis. DISEASES OF PREGNANCY. 
203 
Second Degree.-The fundus approaches the symphysis but does not 
reach it. The angle formed by the two axes is less acute. 
Third Degree.-The fundus reaches the symphysis. The angle is al- 
most a right angle. The portio vaginalis of the cervix is carried more or 
less backward toward the posterior pelvic wall. It is very rare to see the 
Fig. 12.-Anteversion of the Uterus. (After Legendre.)-A, Bladder. B, Rectum. C, Body of 
uterus. D, Vaginal orifice. E, Symphisis pubis. F, Anus. G, Sacrum. H, Left labium minus. 
I, Clitoris, root of corpus cavernosum, cut across. J, Left labium majus. K, Meatus urinarius. 
L, Pyramidalis muscle. J/, Rectus abdominis. N, Anterior peritoneal cul-de-sac. O,Vesico-uterine 
cul-de-sac. P, Retro-uterine cul-de-sac. R, Levator ani. S, External sphincter. T, Internal sphinc- 
ter. U, Anterior lip of cervix. V, Posterior lip. X, Coccyx. V, Venous plexus of Santorini. Z, 
Venous plexus of vagina, a, Muscular tunic of the bladder and urethra, b, Muscles of tectum, d, 
Fibro-cellular vaginal tunic, e, Fifth lumbar vertebra, f, Uterine cavity, g, Section of uterine 
veins, h, Rachidian canal. 
cervix remaining in front, except in the case where there is, simultane- 
ously, anteversion and anteflexion. It is, usually, during labor that this 
result is brought about by the influence of the pains. At the same time 
that it inclines forward, the uterus undergoes a torsion upon its transverse 
axis. As a result, the anterior vaginal wall is distended by the uterus 
and pushed forward. The posterior wall does not look directly toward 204 
A TREATISE ON OBSTETRICS. 
the rectum but becomes oblique and almost horizontal. The uterus com- 
presses both the rectum and the bladder, causing difficulty in micturition, 
in defecation and in the introduction of the sound. 
Causes.-Lohineier, Kiwisch and Scanzoni do not believe in primary 
anteversion. Hiiter shows that, the uterus being already normally ante- 
verted, if the pelvis is wide and larger than usual, and if the pelvic axis is 
more inclined, the posterior surface of the uterus has a greater and greater 
tendency to become superior. It follows that the pressure exerted by the 
intestines becomes more considerable and thus tends to produce and to 
Fig. 13.-Anteversion of the Uterus. (After Legendre.)-A, Bladder. B. Rectum. C, Body of 
uterus. D, Vaginal orifice. E, Symphysis pubis. F, Anus. G, Sacrum. H, Left labium minus. 
L Clitoris, root of corpus cavernosum, cut across. J, Left labium majus. K. Meatus urinarius. 
L, Pyramidalis muscle. M, Rectus abdominis. A', Anterior peritoneal cul-de-sac. O, Vesico-uterine 
cul-de-sac. P, Retro-uterine cul-de-sac. R, Levator ani. S, External sphincter. T. Internal sphinc- 
ter. U, Anterior lip of cervix. F, Posterior lip. X, Coccyx. U, Venous plexus of Santorini. Z. 
Venous plexus of vagina, a, Muscular tunic of bladder and urethra, b, Muscles of rectum, d, 
Fibro-cellular vaginal tunic, e, Fifth lumbar vertebra, f, Uterine cavity, g, Section of uterine 
veins, h, Rachidian canal. 
increase the anteversion. Ovarian or other tumors, ascites and peritoneal 
adhesions act in the same way. If there be superadded to this a relaxa- 
tion of the vaginal wall and of the uterine ligaments, particularly of the 
round ligaments, and, finally, vaginal cystocele, it is plain how the accu- DISEASES OF PREGNANCY. 
205 
mulation of urine in the bladder will produce ante-version. It may be de- 
veloped slowly or suddenly and be particularly favored by a sudden and 
exaggerated pressure of the bowels, by sudden contractions of the abdom- 
inal muscles and by sudden depression of the diaphragm. When the an- 
teversion has reached a certain degree it .may thus pass to a more advanced 
stage from the slightest cause. 
Signs.-So long as it is moderate, anteversion passes unnoticed, but, 
when it is exaggerated, there soon follow dysuria, frequent micturition, 
constipation, tenesmus, and pains in the loins and sacrum, which attain 
their maximum in the third degree of anteversion. The lumbar and 
sacral pains are constant, and are due to traction upon, or, according to 
Huter, even to laceration of the retro-uterine folds. Constipation be- 
comes complete, and there is a constant desire to urinate, although the 
Fig. 14.-Vertical Section of the Pelvis, representing Anteversion of the Uterus in the 
early stages of Pregnancy.-a, Right pubis. 6, The sacrum, c, The bladder. d,The urethra. 
ec, The rectum, f, Section of the tube and of the left broad ligament, p, Body of the uterus, h. 
Lateral portion of the uterus, not covered by peritoneum, i, Os tinea', k, The vagina. {Boivin & 
Duges.) 
bladder contains very little urine. The patients feel a sense of weight in 
the pelvis, as if there were something to be expelled by the anus. The 
abdominal walls and the diaphragm accordingly contract, and, tending to 
further depress the fundus uteri, increase the trouble. Then follow fever, 
nausea, emesis and spasms. 
Authors do not agree about the condition of the bladder. While God- 
efroy and Huter have always found the bladder empty, Kyll, Hachmann, 
Boivin and Duges admit that urine may accumulate in that part of the 
bladder which is above the point compressed by the uterus. 
Course and Prognosis.-Most cases pass unobserved, and the grave 206 
A TREATISE ON OBSTETRICS. 
symptoms disappear when the uterus rises out of the pelvis, between three 
and a half and four months. If it remains incarcerated in the true pelvis 
serious symptoms may appear, and first pregnancy and later the life of 
the mother may be endangered. But this is not absolute, for the incar- 
ceration is never complete as in retroversion. 
When anteversion occurs suddenly, pregnancy is less secure, but all de- 
pends, in this case, on the time which elapses before the reduction of the 
uterus. Generally, all the grave symptoms disappear when the uterus 
is once replaced, and pregnancy pursues its regular course. 
Treatment.-This consists, first and foremost, in reduction of the dis- 
placed organ. Complications must then be met by appropriate means, 
but especial care must be exercised in providing for evacuation of the 
bladder and of the rectum. 
Fig. 15.-Retroversion of the Uterus, early in Pregnancy.-a, Right pubis, b, Os tinea", c. 
Canal of the urethra, d. Vagina, e, Body of the uterus, f. The bladder at its maximum develop- 
ment. g. The rectum, h, The sacro-vertebral angle. /, Section of the tube and of the left broad 
ligament. (Boivin & Duges.) 
[A so-called supra-pubic pad abdominal supporter, will ordinarily cor- 
rect the anteversion after the uterus has risen above the brim. Before 
this period, the symptoms are rather due to downward sagging of the 
uterus, and traction, in consequence, on the neck of the bladder. In this 
case, the open cup-pessary of Thomas may be tried, often with relief to 
the main symptom-vesical tenesmus.-Ed.] 
4. Retroversion. 
Uterine retroversion consists in the complete displacement of the organ 
in the pelvic cavity, so that the fundus is contained in the hollow of the DISEASES OF PREGNANCY. 
207 
sacrum while the cervix is carried forward beneath the symphysis pubis 
(Salmon) (Fig. 15). 
We thus at once eliminate what the Germans call a partial retroversion, 
and what Depaul styles a sacriform dilatation. This we will study in the 
following chapter. 
Frequency.-"Although one cannot say that retroversion is a very rare 
accident, the cases are still so few that it is difficult to collect more than 
forty or fifty examples from all medical literature. For my part, during 
a practice of thirty years, which has afforded me the opportunity of ob- 
serving nearly everything unusual in obstetrics, I have only seen eight or 
ten cases of retroversion during pregnancy. P. Dubois had hardly seen 
more, and his father had never seen a case in his long practice." These 
are the words of Depaul. 
Fig. 16.-Retroversion of the Uterus. (After Schultze).-I, Intestine. U, Uterus. U, 
Bladder. 
Since Baudelocque, two kinds of uterine retroversion are described and 
based upon their respective causes. 
The first form is slow and progressive, the second form sudden and 
accidental. 
Causes.-1. Gradual Retroversion. All authors admit that the uterus 
is lowered in the first months, and that it is originally developed at the 
expense of its fundus and of its posterior wall. 
But, while Denman, Merriman, Desormeaux, Paul Dubois, Danyau 
and Jacquemier consider the retention of urine to be the occasional cause 
of retroversion, William Hunter, Burns, Moreau and Cazeaux think that 
the retention of urine is the effect and not the cause of retroversion,which 208 
A TREATISE ON OBSTETRICS. 
is, itself, produced by another mechanism. Depaul, in 1853, resolutely 
took his stand with the former class of authors. He held that retention 
is an occasional cause of retroversion (Fig. 1G), and he is the more justi- 
fied in holding this opinion as he has seen the bladder distended by an 
enormous quantity of urine in cases of retroversion not occurring during 
pregnancy. Jacquemier had already stated, to explain these facts, that, 
when the distension of the bladder by the urine is long continued, the 
organ can contain a large quantity of the liquid without being over-dis- 
tended. Then, its walls being partially dilated, and particularly behind, 
it forms a large sac which displaces the fundus uteri towards the hollow 
of the sacrum, while the cervix is retained in its ordinary position. De- 
paul adds that, in this case, the bladder, in subsequently rising into the 
abdominal cavity, draws the cervix upward and this increases the dis- 
placement already begun. This is the explanation of Boivin and Duges, 
of Desormeaux and of Dubois, and we adopt it in its entirety. 
The accumulation of faeces in the intestine, above the iliac fossa, 
has been assumed as a cause. Desormeaux, Dubois and Depaul, although 
accepting this cause, think that it must be preceded by a certain degree 
of retroversion. 
Other assumed causes are curvature of the sacrum, justo-major pelvis, 
insertion of the placenta at the fundus Or on the posterior wall of the 
uterus, deformed pelvis, uterine prolapse, fibroid uterine tumor, ovarian 
tumors, abnormally wide vagina, adhesions due to old peritonitis, the 
multiparous state, feebleness of constitution, etc. 
2. Sudden and Accidental Retroversion.- Besides the predisposing con- 
ditions cited above, the following are given by different authors: efforts, 
blows, falls, pressure on the abdomen, sudden backward displacement of 
the cervix in prolapse, and emotions. Salmon quotes two cases of 
Bolland and Godefroy, in which it was due to violent and unavailing 
efforts to urinate. 
Time of Appearance.-Retroversion is a disease of the first half of preg- 
nancy. It occurs, generally, between the third and the fourth month 
(in nineteen out of Salmon's twenty-seven cases). It rarely takes place 
before the third month (only five cases). It may occur from the fourth 
to the fifth month (five cases). It may, very exceptionally, occur after 
the fifth month (three cases). 
Signs. -;The authors of to-day only admit two degrees of retroversion, 
although Hunter admitted three. 
First Degree.-The uterus is inclined backward, so that its fundus is 
in contact with the upper part of the sacrum, the cervix resting behind 
the symphysis pubis, but being accessible to the finger. 
Second Degree.-The fundus has executed an almost complete revolu- 
tion and has descended so far into the hollow of the sacrum as to become 
accessible to the finger, or even, when the labia are pressed open, to be DISEASES OF PREGNANCY. 
209 
seen distending the posterior vaginal wall. The cervix is so high behind 
the pubes that the finger no longer reaches it. Ordinarily the second de- 
gree succeeds the first, and this is particularly true of the chronic or slow 
form. But the physiological backward inclination of the uterus, during 
the first three months, must not be mistaken for a retroversion. After 
the third month, the uterus tends to quit the true pelvis, straightening 
itself, and approaching more nearly to the axis of the superior strait. 
But, if it encounters an obstacle, whether this be a too prominent sacro- 
vertebral angle or a sigmoid flexure filled with faeces, the fundus is pushed 
backward while the cervix tends to approach the symphysis. Intestinal 
and vesical disturbances now appear, (Fig. 17) accompanied by feelings 
of weight, of traction and of pains in the loins, while examination enables 
Fig. 17.-Retroversion of the Uterus. Gangrene of the Detached Mucous Membrane of 
the Bladder and of a Part of the Muscular Coat.-I, Intestine. U, Uterus. V. Bladder. W, 
Vagina. MV, Gangrenous mucous membrane of the bladder. 
one to discover uterine displacement. Women walk and stand with diffi- 
culty, and these symptoms becoming aggravated and retention of urine 
becoming complete, the disease passes into the second degree. 
Salmon thinks that an effort or some injury is necessary, in this case, 
on which point Depaul does not agree with him. When, however, retro- 
version is suddenly produced, observation shows it to be always due to 
violence, to efforts, to fatigues or to traumatism. Then the acute symp- 
toms are speedily developed, and more or less intense pain occurs at the 
moment when the displacement takes place. 
The chief symptom of retroversion is retention of urine, and it is never 
wanting in the second degree. The retention is generally complete, and 
the bladder may be much distended. Sometimes there is incontinence 
Vol. 11-14 210 
A TREATISE ON OBSTETRICS. 
from overflow. The urine is red, strong-smelling, and, sometimes, colored 
with blood. There is usually, also, retention of fseces, but it is less 
marked, and we often feel faecal tumors through the abdominal wall. 
The patients complain of acute pain in the loins, the groins and the ab- 
domen, and of weight at the perineum. Fever, anorexia, thirst, insom- 
nia, emaciation and general debility then ensue. 
Palpation shows, above the umbilicus, an elastic, fluctuating tumor be- 
neath the abdominal wall, in which no foetal member can be distinguished 
and in which ballottement is not present. If the catheter is used, which 
may be difficult, the tumor disappears and we reach the uterus, but it is 
impossible to bound it or to map out the fundus. On palpation, we some- 
times feel only a single tumor, formed by the retroverted uterus pushing 
backward the posterior vaginal wall. More rarely, there are two tumors, 
Fig. 18.-Retroversion of the Gravid Uterus. 
one behind, which is the uterus, and the other in front, which is the 
bladder (Fig. 18). Generally the finger does not find the cervix, and, 
sometimes, we only find it with great difficulty above the pubes, and then 
one can often only feel one of the lips of the cervix. Finally, one some- 
times finds the fundus of the retroverted organ presenting the character- 
istics of the pregnant uterus. 
In some cases there exist, simultaneously, retroversion and retroflexion, 
and then another difficulty arises for the diagnostician, because the cervix 
may be displaced, and the facility with which one reaches the cervix dis- 
arms the suspicion of a retroversion. Ordinarily it is almost inaccessible, 
but rectal touch allows us to examine a large part of the uterine tumor 
and to appreciate the characters of this tumor. What is most striking, at 
first, is the slight depth at which we encounter this tumor, and, in exam- 
ining with care, we see that it is not continuous with the uterus, which is DISEASES OF PREGNANCY. 
211 
only displaced and flattened by it. Besides, in combining vaginal and 
rectal palpation, we feel that the finger in the rectum is only separated 
from that in the vagina by the thickness of the folded and swollen vaginal 
wall. It is only in exceptional cases that the finger can reach beyond the 
end of the tumor. 
In view of the existing stage of pregnancy, auscultation gives no in- 
formation, but we generally discover the uterine souffle. In exceptional 
cases, on separating the labia, we have been able to perceive the tumor, 
but, in general, that which is striking in these cases is, often, the swelling 
of the labia majora and minora and the presence of a vaginal prominence 
large enough to pass for a prolapse of the vagina. 
When the affection has reached its acme, and incarceration has taken 
place,.all the above symptoms are aggravated. The pain becomes intoler- 
able, the fever is more and more intense, and to retention of the urine and 
of the faeces are joined emesis, singultus, delirium, irregularity of the 
pulse and a state of prostration and adynamia, more or less pronounced, 
with emaciation and exhaustion of the patient. If abortion does not set 
a limit to these accidents, gangrene of the bladder and rupture of the 
uterus aggravate the situation, or even result in death. 
Diagnosis.-This embraces, according to Salmon, five problems. 
First.-1The diagnosis between retroversion of the gravid uterus and 
intra-uterine fibrous tumors, in a healthy or in a retrovertcd uterus. 
Fibroids are distinguished by the hemorrhages, the slow progress of the 
disease, the resistance of the cervix compared to the softness of preg- 
nancy, and the statements of the patients relative to the existence of an 
old tumor. 
Second.-The differential diagnosis between retroversion of the preg- 
nant uterus and tumors of the pelvis or of the abdominal cavity. This 
is> sometimes, very difficult, as the diagnostic errors, reported by various 
authors, demonstrate. The characteristic which deserves particular at- 
tention is the retention of the urine and the possibility of generally pass- 
ing the finger behind the pubes. The concomitant symptoms of preg- 
nancy, but especially the character of the cervix, will often make the 
diagnosis. Retroversion has also been confounded with extra-uterine 
pregnancy, ovarian tumors and retro-uterine hematocele. 
Third.-The differential diagnosis between simple pregnancy, with 
retention of urine, and pregnancy with retroversion. 
Fourth.-The diagnosis between retroversion during normal pregnancy 
and retroversion in cases of hydatidiform moles. In Salmon's case there 
was no retention. 
Fifth.-Finally, the diagnosis between retroversion of the gravid uterus 
and retroversion of the unimpregnated uterus. 
The differential diagnosis of extra-uterine pregnancy really presents the 
greatest difficulty, and we shall return to the subject under that heading. 212 
A TREATISE ON OBSTETRICS. 
Prognosis.-This is always very grave, but is more so in proportion as 
pregnancy is far advanced, for the complications are then more grave and 
develop more rapidly, and the treatment is more difficult of application. 
Although the affection often ends in recovery, it may also end in abor- 
tion and in death from peritonitis, from gangrene of the bladder, from 
rupture of the uterus and from partial gangrene of that organ. In some 
cases, the fundus uteri has contracted adhesions to the rectum, a com- 
munication has formed between these two organs, and the disintegrated 
foetus has been expelled piece-meal through the bowel. In a very inter- 
esting case, which we saw at the Clinique, the diagnosis was doubtful, and, 
in spite of two examinations, Depaul hesitated. An examination to de- 
cide regarding intervention was appointed for the following day, when, 
during the night, the woman fell out of bed. The disturbances ceased 
as if by magic, but the patient was confined in the forenoon. This was, 
probably, a case of spontaneously reduced retroversion. 
Treatment.-1There are, according to Depaul, three methods. 
First: Expectation-i.e., leaving the uterus in its acquired position, 
treating complications, destroying probable causes of retroversion, or, at 
least, removing obstacles opposed to reduction. Thus: 1st, catheterism, 
which is not always easy and sometimes demands the use of the fine elas- 
tic sound in place of the ordinary catheter, and is to be repeated three 
or four times in the twenty-four hours. 2d, combatting constipation, 
by enemata given through a long canula, but particularly by laxatives, 
especially castor oil. Depaul does not believe that the position of the woman 
has any influence, at least in severe cases. If complications occur, resort 
to the second method. 
Second: Manual Reduction.-This is effected either by the rectumor 
the vagina, with one or two fingers or even the whole hand. Gosselin 
used the first. All these measures have been successful, but the result 
is sometimes only obtained by their combination and by repeated at- 
tempts. 
Third: Ihe Instrumental Method.-The best known instrument is 
Evrat's baguette, introduced by the rectum. Then come the spatula of 
Petit, Roederer's spoon, pessaries, bladders introduced empty and then 
distended, and the lever. If these means fail, recourse must be im- 
mediately had to artificial abortion. [The simplest and most effective 
method of replacing the retroverted, flexed uterus, is to make the 
patient assume the knee-chest position, lift up the perineum by 
means of Sims's speculum, and then, very exceptionally, pneumatic 
pressure and gravity will replace the uterus. If not, pressure may 
be made on the fundus in the posterior cul-de-sac, by a sponge pro- 
bang or roll of cotton held in the dressing forceps. Occasionally, especially 
near the end of the third month and after, it will be necessary to dislodge 
the fundus from under the sacral promontory before it can be replaced. DISEASES OF PREGNANCY. 
213 
This is accomplished by hooking a tenaculum in the anterior lip of the 
cervix and pulling downwards. Unless the fundus is adherent or the sacral 
promontory very projecting, these measures will suffice. After reposi- 
tion, a suitable retroversion pessary should be worn till the end of the 
fourth month.-Ed.] 
Sacculation of the Uterus. 
Partial retroversion, or sacculation of the uterus, is an unusual form 
assumed by the pregnant uterus, which has furnished Depaul the occa- 
sion for a very complete work from which we have borrowed the following 
description. 
Depaul keeps the name sacciform dilatation of the posterior wall, for this 
modification of the shape of the uterus has a special origin and depends 
neither upon a simple flexion, nor upon any other change in the uterine 
axis. The explanation is found in the unequal growth of different parts 
of the organ. The cases collected by Depaul, from his private practice, 
and from different authors, are not numerous, for they are only a dozen, 
and one of these was erroneously diagnosticated. So it is a rare phenom- 
enon, but it only deserves the more attention on this account, because of 
the difficulties of the diagnosis and of the dangers for both mother and 
child which it entails. Depaul begins by stating that certain parts of 
the uterus grow proportionately much more than others, and that, gener- 
ally, the anterior wall developes much more fully than the posterior one. 
But, exceptionally, this abnormal development may occur in the posterior 
wall. In this case, if the presenting fcetal part is engaged in the pelvis, it 
must push before it this posterior wall of the inferior uterine segment. 
The cervix, instead of being directed backward, is turned forward toward 
the symphysis which it touches. It is much higher in the pelvis than the 
posterior part of the inferior segment of the uterus, which descends 
toward the vulva, forming a tumor which is in contact with the hollow 
of the sacrum, and variable in form, in accordance with the part of the 
fuetus which it encloses. In the case of Parise and Depaul, hypertrophy 
and tension of part of the circular fibres of the external os were super- 
added. 
Pathogeny.-Depaul denies any causative relation between this condi- 
tion and retroversion, for the lattei' occurs in the first months, and saccu- 
lated dilatation in the last two months. Without denying that kyphosis 
may have some etiological influence, as some authors say, he states that 
nothing of the sort existed in the cases he has seen. He further rejects 
constipation, and the consequent straining efforts, invoked, as causes, by 
Billi, and partial retroversion, suggested by Frank. lie shows that Mende 
first adopted the idea of primary dilatation of the posterior wall, suggested 
by Kiwisch and Scanzoni, and that the opinion of Chailly and Hyernaux 
relative to abnormal insertion of the cervix into the inferior uterine seg- 214 
A TREATISE ON OBSTETRICS. 
ment, rests upon no anatomical basis. Depaul believes that the deformity 
depends upon uterine flexions, particularly anteflexions which antedated 
pregnancy. If pregnancy occurs in thpse cases, the posterior wall, no 
longer in its normal state, will become much more hypertrophied than 
the anterior, because, owing to the character of its tissues, it cannot 
respond so fully to the stimulus of fecundation. The disproportion ex- 
isting before pregnancy will persist and even be increased. The posterior 
wall will be more and more depressed into the pelvic cavity, the anterior 
will rise in the same proportion, and thus the cervix will come to be 
placed against the upper border of the symphysis or even several finger- 
breadths above it. 
Signs and Diagnosis.-Abdominal palpation shows that the anterior 
wall is not so prominent or so uniformly rounded as usual, and that it is, 
sometimes, a little flattened. If the bag of waters is broken, one may see 
the outlines of the foetus. If the lower foetal part has not engaged, which 
is the exception, it forms a prominence above the pubes, in front. On 
palpating in front, we see that the posterior part of the uterus is largely 
developed, and has occupied all the available space in the corresponding 
part of the abdominal cavity. Generally, even when the patients reach 
full term, which is not always, the volume of the organ does not seem to 
correspond to the period in question. The finger introduced into the 
vagina shows the posterior vaginal wall to be very short, which is the 
reverse of the normal state. The corresponding cul-de-sac is effaced, and 
this wall drawn forward seems to end in the prominent part of the foetal 
tumor. The finger, instead of entering deeply to encircle the tumor, 
passes obliquely from below upward, and from behind forward, and is con- 
ducted, in spite of itself, toward the centre of the pelvis. Here, again, 
the shortness of the posterior vaginal wall is not real. The upper part 
covers the foetus and the cul-de-sac is lifted above the symphysis, with the 
cervix. In following the anterior vaginal wall, we seek long and vainly 
for its upper end, and therefore for the anterior cul-de-sac. Sometimes 
we do not succeed, even with two fingers, and it is in these cases that the 
utility of introducing the whole hand is apparent. But this is not always 
possible, even with chloroform, and the deep position of the tumor ob- 
structs the movements of the hand. It has, in some cases, been impossi- 
ble to reach the anterior cul-de-sac, and it has been necessary to use a 
flexible rod passed upward, behind the pubes. When we have once reached 
z the os, we find it closed or partly opened, softened or indurated, directed 
forward or downward, and more or less mobile. The bladder, being for- 
cibly drawn upward and forward, occupies an unusual position, and to 
penetrate its cavity, the sound should be exceptionally long. The stretched 
urethra is in close proximity to the posterior wall of the symphysis, and 
to find its external orifice, it must be sought much higher, for it is, as it 
were, hidden behind the anterior pelvic wall. The differential diagnosis 215 
DISEASES OF PREGNANCY. 
must exclude osseous or fibrous tumors attached to the anterior sacral 
wall, fibromata, cysts of the recto-vesical septum, fibrous tumors of the 
posterior lip of the cervix, pelvic hematocele, retroversion, ovarian cysts, 
uterine fibromata affecting the body and the upper part of the organ, 
fibromata of the abdominal wall, or of abdominal viscera, extra-uterine 
pregnancy and complete obliteration of the cervix. The last-named con- 
dition led Depaul into error, in his second case. 
Prognosis.-This is very serious, but there is a difference between 
cases in which the cervical dilatation is moderate, And those in which it 
is excessive. In the former case, labor is longer and the cervix dilates less 
easily, but the deviation may correct itself, little by little, until the child 
can enter the pelvis, particularly if the pelvic extremity presents. The 
life of the foetus is almost always sacrificed, Frank's case forming the sole 
exception. But, when the cervix is drawn forward and above the sym- 
physis, the difficulties are much greater. The part of the foetus contained 
in the sac formed by the posterior wall, receives the force of the uterine 
efforts, which cause the tumor to descend even to the vulva. The uterine 
tissue becomes inflamed, thin and painful, and may even be lacerated or 
become gangrenous. The cervix, placed beyond the sphere of uterine 
action, does not dilate, even at the end of several days of labor. Some- 
times the posterior lip becomes rigid and opposes a new obstacle to explo- 
ration. Metritis and peritonitis may be the results of this forced labor. 
The women are quite exhausted, and putrefaction of the child being 
super-added, when the membranes have been ruptured some days, aggra- 
vates the situation. Still, the majority of the mothers have survived. 
Treatment.-The conditions under which we are called are very varia- 
ble, hence the impossibility of prescribing a line of conduct applicable to 
all cases. The indications are to reach the cervix, and to draw it down- 
ward. If the child presents by the feet, to draw them down and to seek 
to have them engage; to seize them with a noose and to extract, so soon 
as dilatation is complete; to see if the tumor can be displaced; to incise 
the cervix^ if it is rigid; and finally, as a last resort, to do vaginal hyster- 
otomy, i.e., to open the inferior segment, through the vagina and to thus 
extract the foetus. CHAPTER III. 
DISEASES OF THE OVUM. 
/CONSIDERED as a whole, the ovum represents a membranous sac com- 
posed of two membranes peculiar to it, the amnion and the chorion, 
and of one membrane of uterine origin, the decidua, a sac which contains 
the foetus, the cord,the placenta and the amniotic fluid. Each of these parts 
may be the seat of lesions forming the subject of this chapter, and consti- 
tuting the pathology of the ovum. We shall commence by the study of 
changes in the decidua. 
Diseases of the Decidua. 
Metritis proper is rare in pregnancy, as all authors admit, except when 
there is retroflexion or retroversion. Inflammations of the decidua are, 
however, frequent, and maybe acute, as in the infectious diseases, cholera, 
typhus and variola, leading through apoplexy of the membranes to early 
abortion, to destruction of the ovum, and to the degeneration called fleshy 
mole. Again, the inflammation may be chronic, and then presents the 
three following essential varieties: 1. Chronic diffuse endometritis; 2. 
Polypoid endometritis; 3. Catarrhal endometritis, or hydrorrhoea gravida- 
rum. 
1. Chronic diffuse Endometritis. 
This consists in the development of connective tissue, partly white and 
partly yellow, forming a granulation tissue and causing thickening and 
induration of the decidua. There is hyperplasia of the mucous mem- 
brane, in which the subjacent muscular fibres are involved, with the for- 
mation of cysts. (Spiegelberg). Schroeder considers it to consist in 
chronic diffuse proliferation of the decidua vera and reflexa. The mu- 
cous coat is thickened by the aggregation of the large cells, of the deci- 
dua; or, as a result of their proliferation, the mucous membrane, particu- 
larly the deeper layers, presents a cavernous or cystic structure. These 
changes cause the death of the foetus, and abortion may even occur from 
the irritation of the uterine nerves, occasioned by the inflammation of the 
mucdus membrane. In other cases the inflammation is more chronic, 
the nutrition of the ovum is unaffected, pregnancy advances to full term, 
and inflammation is only recognized by examination of the membranes. 
M. Haschewarowa found, in the thick membranes of a foetus at term, not 
only proliferating connective tissue and decidual cells, but also newly- DISEASES OE THE OVUM. 
217 
formed, smooth muscular fibres. Often this inflammatory thickening is 
merely partial. 
Ilofe described some deciduae in which inflammation had caused pro- 
tuberances as large as a grain of wheat, or larger. In some cases, accord- 
ing to Schroeder and Spiegelberg, the proliferation of the decidual cells is 
secondary to death of the foetus. This happens, according to Duncan, 
particularly in those cases where, after the death of the foetus, the ovum 
is retained. This is the adhesive endometritis of Braun. According to 
him, the proliferation of Friedlander's large cells does not occur in the 
decidua proper, and is accompanied by hyperaemia and extravasations in 
the placenta. The disease, he says, is characterized during pregnancy 
by the fact that the foetal movements are painful, and that the women 
experience violent, colic-like pains described under the name of uterine 
rheumatism. It is chiefly caused by exposure to cold. When the disease 
mainly attacks the utero-placental mucous membrane, it is much more 
dangerous for the foetus, and in these cases abortion is generally caused 
by the persistent irritation and by the destruction of the mucous mem- 
brane through hemorrhages. At the moment of delivery it may occasion 
difficulty by causing adhesions of the placenta. M. Haschewarowa has 
given, as causes, syphilis, or a chronic endometritis antedating pregnancy, 
efforts and difficult labor. 
2. Polypoid Endometritis. 
This condition, which is only a more advanced degree of the cases 
reported by Hofe, is characterized by thickening of the mucous mem- 
brane, which may attain double or triple its normal thickness, and 
by prominences of different form and size, sometimes from one-fifth to 
one-half an inch high, but smooth, which are situated on the surface of 
the mucous membrane. (Fig. 19.) The excrescences are sometimes 
pediculated and sometimes sessile. Sometimes they form thick kernels. 
The uterine surface is rough and covered with coagula. According to 
Schroeder, the uterine glands are absent on the bright red surface of these 
excrescences, but are very apparent on all other parts of the mucous mem- 
brane. The whole mucous membrane, particularly in the papillae, is very 
vascular. Spiegelberg admits, as does Schroeder, that the outgrowths 
are more vascular than the rest of the membrane. The glandular ori- 
fices are not numerous, are sometimes absent, and, particularly at the ex- 
tremity of the prominences, have a small diameter. According to Vir- 
chow, the microscope shows that the proliferating tissue is the interstitial 
tissue of the mucous membrane. In the midst of a slightly fibrillary 
tissue, we see large stellate cells which, on vertical section, appear as 
thick fasciculi. According to Spiegelberg and Dohrn, the characteristic 
elements of the proliferation are the decidual cells, which are remarkable 
for their large size and their large nucleus. They are concentrically ar- 218 
A TREATISE ON OBSTETRICS. 
ranged around the vessels and cause constriction of the glands. In some 
isolated cases, where the decidua vera was absent, the change has been 
seen in the reflexa. (Dohrn.) It has never been observed, save upon 
young abortive ova. Almost always the villi are secondarily changed. 
The embryo has, usually, disappeared. Upon an ovum, observed by Vir- 
chow, they constituted long epithelial projections, generally very fine. In 
Gusserow's case they ended in club-shaped extremities, while the ova 
seen by Dohrn and Muller showed the beginning of a multiple myxoma 
of the villi. 
Fig. 19.-Polypoid Endometritis. (After Virchow.)-Foetal surface of decidua, a, Openings 
of the glands, b, Larger openings, c, c, Projections or vegetations. One of them is cut open. 
The etiology is obscure. In Virchow's case there was a syphilitic his- 
tory, but in the other cases there was none. In some of the cases it seems 
that the lesion was only the result of an endometritis, of an irritation of 
the mucous membrane, preceding pregnancy. The changes in the cho- 
rion, as those of the foetus, are only secondary. Speigelberg, even, rather 
considers this alteration secondary. 
3. Catarrhal Endometritis.-Hydrorrhcea. 
The opinion, entertained to-day by the German authors Schroeder, Spie- 
gelberg and Braun, is that chronic inflammation of the decidua may, 
aside from cellular proliferation, produce an abnormal secretion called 
hydrorrhoea gravidarum. But this opinion is not yet accepted by all 
authors, and Stapfer, after reviewing and discussing all the opinions, con- 
cludes that there are, perhaps, two forms of hydrorrhoea, the traumatic 
and the catarrhal. His work is the most recent and complete. We bor- 
row, from it, the following description. DISEASES OF THE OVUM. 
219 
The aqueous discharges during pregnancy have been considered, now 
as uterine dropsy, now as dropsy of the membranes, now as premature 
rupture of the membranes, and have been described, under the titles false 
waters, hydrorrhoea and metrorrhoea. Several hypotheses have been sug- 
gested regarding the seat, the source and the nature of the liquid. 
. Seat.-I. Between the Uterine Walls and the Membranes.-A case of 
Duclos, quoted by Basset, seems conclusive. Here two full sacs and one 
empty one were found, as well as the channel leading from the latter to 
the os, and this in a woman who, three weeks before, had suddenly lost a 
glassful of liquid, and had, subsequently, had a discharge, drop by 
drop. This is the anatomical explanation of the clinical fact reported by 
Naegele and Geil. A secretion occurs and accumulates. The membranes 
are detached, progressively, as far as the os, and at this moment, probably 
owing to a painless uterine contraction, the pocket is suddenly emptied. 
In this case there has been found, on the internal surface of the uterus, 
an opaque, whitish plaque. Is this the first or the second'degree of the 
catarrhal endometritis of Schroeder, Spiegelberg and Braun ? 
II. The Water collected between the Membranes.-According to Mattei, 
in two out of three cases the amnion is separated from the chorion by 
liquid, not only in the early weeks, but even up to the end of gestation, 
He has called this space, thus filled with liquid, the pocket, the amnio- 
chorial sac. According to others, this pocket only accidentally exists in 
cases of hydrorrhoea. But Naegele, Basset and Chassinat have denied 
the existence of this sac, and shown that, even in hydrorrhoea, there is 
complete adhesion of the membranes. Duclos had already reported that 
in his case. Geil overturned this opinion, and maintained that all the 
water escaping from the uterus during pregnancy or immediately after 
labor, comes from the space separating the concavity of the uterus from 
the convexity of the chorion. Stapfer states that, in a case seen by him, 
at the moment when he was palpating, some liquid escaped which could 
only come from the internal surface of the uterus, for the cervix was not 
dilated, and, during labor, two pockets were successively formed and 
ruptured by Stapfer. The membranes were intact. In a case of Bat- 
bedat, however, the chorion and amnion were entirely separated on one 
side, and incompletely on the other. The amnion on its external sur- 
face, and the chorion on its internal surface, were covered by a slight 
plastic exudation, such as is seen in pleurisy. That seems to prove that 
Naegele and Geil were too positive. Duges stated that the liquid accu- 
mulated in the cavity of the allantois! ! ! The older writers held that the 
liquid gathered between the two deciduae. In these cases, hydrorrhoea 
occurred in the first weeks of pregnancy. The two deciduae do not, in- 
deed, become united until after the third month. 
III. The water collects in an hydatid. 
IV. The water collects in a cyst. 220 
A TREATISE ON OBSTETRICS, 
V. The collection occurs in a supernumerary ovum. 
These three opinions do not admit of discussion, so that only three 
opinions remain: 1. The hydrorrhoea of the first weeks (Tarnier) occurs 
in the cavity of the hydroperion. The liquid collects between the decid- 
ua reflexa and the decidua vera. 2. The hydrorrhoea of the last months 
is due to an accumulation of liquid between the decidua and the chorion. 
3. The accumulation is between the chorion and the amnion. 
Origin of the Liquid.-I. The Liquid comes from the Amniotic Cavity 
by Transudation.-Tarnier and Pinard have shown that this transudation 
of amniotic liquid is possible at a certain stage of labor under the influ- 
ence of the pains. Is the same true of pregnancy ? Stapfer does not 
think so, for the anatomical conditions are not the same. 
II. The Liquid comes from the Uterine Walls.-This is the view of 
Naegel^ and Geil, who have seen these escapes of water persisting after 
labor, as well as of Chassinat, Chailly and Mackenzie. It is the classical 
opinion. But does the liquid come from the glands or from the vessels? 
1. The Liquid comes from the Glands.-This is the opinion of Hegar 
and of Retzius, who have seen hypertrophied glands on the membranes of 
the ova of two women who had had hydrorrhoea. The decidua vera is an 
organ of secretion, and hydrorrhoea is a hypersecretion. This is the catar- 
rhal endometritis of Spiegelberg, Schroeder and Braun. 
2. The Liquid comes from the Vessels.-a. The liquid is serous and es- 
capes from the capillary vessels, torn by the separation of a part of the 
membranes of the ovum. This is the opinion of Chassinat and of Depaul, 
but the separation of the membranes is not explained, b. The Liquid 
comes from the Lymphatics.-Stapfer believes that the fluid is not pure 
lymph, but that other liquids from the vascular capillaries or the amniotic 
cavity are mixed with the lymph. 
III. The Liquid comes from the Amniotic Cavity, whence it escapes 
through a Tear in the Membranes, above the Uterine Orifice.-The only 
cases are those of Ingleby, Biesing and Graef. In all the others the 
membranes were intact. 
Nature of the Liquid.-This is very little understood. Chassinat found 
it thin, limpid, transparent and viscid from albumin. He found no odor 
of spermatic fluid. The color is not always yellowish. In a case which 
we reported to Stapfer, the liquid had a slight spermatic odor, was not 
viscid, was but slightly turbid and contained no vernix caseosa. Boiling 
caused slight turbidity but not nitric acid ; hence there was no albumin. In 
Gomes' case the fluid was not albuminous, but was markedly acid and con- 
tained much epithelial detritus. After evaporation, crystals of chloride 
of sodium were found, but no nitrate of urea. With a little hydrochloric 
acid, no uric acid formed even after twelve hours. A little ammonia 
caused crystals of ammonio-magnesic phosphate to appear at once in the 
field of the microscope. DISEASES OF THE OVUM. 
221 
Frequency.-The affection is rare. Stapfer could only collect seventy 
cases. It has been particularly seen in multiparae, and appears at inde- 
terminate periods. It, however, seems more frequent in the last two 
months. 
Signs.-Typical hydrorrhoea has the following symptoms: A woman 
after the sixth month suddenly loses, at different intervals, a jet of trans- 
parent,colorless liquid, slightly tinging the linen, making it stiff, like ascitic 
fluid, giving a more or less abundant albuminous precipitate, and fol- 
lowed by an oozing more or less marked and prolonged. All this happens 
without prodromal symptoms and without painful uterine contractions. 
Labor occurs at term, and the fcetus is healthy. The membranes are 
intact, adherent, opaque in one, two or three places. 
Local Symptoms.-The hydrorrhoea begins suddenly, without known 
cause, at night. At other times, the abdomen becomes distended before 
the discharge, the patient feels tired; then painful uterine contractions 
follow; a jet of liquid escapes from the vulva; the pain ceases at once, and 
the abdomen subsides. Geil disputes this preliminary increase in the size 
of the abdomen noticed by Hegar and Chassinat. Generally the escape 
of the liquid is sudden, but sometimes there is simple oozing. Some- 
times there is a single discharge, or there may be a repetition which may 
become periodical. The quantity of liquid varies from one to twenty 
ounces. Naegele has seen the discharge continue thirteen weeks. In 
some rare cases the liquid has been colored by blood, and sometimes a 
slight sanguinolent discharge has preceded the aqueous one. There are 
no constitutional symptoms. 
Diagnosis.-This depends on the source of the liquids. The only avail- 
able symptoms are: The repetition of the discharge, the non-appearance of 
abortion, the existence of a catarrhal metritis at the time of conception. 
In one case we observed an effacement of the cervix, coincident with an 
escape of liquid, which lasted four days. Then the flow ceased, but the 
cervix remained obliterated, and the labor took place after sixteen days, 
twenty days after the accident. The bag of waters formed and broke 
spontaneously, while the membranes and placenta showed nothing par- 
ticular. Another sign is the presence, in the liquid, of debris of vernix 
caseosa, which shows the presence of amniotic liquid. 
Prognosis. -This is good, neither pregnancy nor health being compro- 
mised. 
Treatment.-This consists in keeping the patients quiet and watching 
uterine contractions, if they occur. 
Diseases of the Placenta. 
1. Placentitis. 
The disease, described by Geoffroy de Montreuil, Brachet, Simpson, Fer- 222 
A TREATISE ON OBSTETRICS. 
dinand Robert and Cauwenberghe, under the title of placentitis, is an 
endometritis, but a distinction must be made between inflammation of 
the foetal and of the maternal placenta. Indeed, excluding the observa- 
tions of Brachet, Stratfordt, Dance, Simpson, Cruveilhier, Wilde, Dubois 
and Desormeaux, Ramsbotham and Geoffroy de Montreuil, inflammation 
of the foetal placenta has not been demonstrated. But inflammation of 
the maternal placenta has been observed and constitutes the organized ad- 
hesions of Brachet; the placentitis of the second degree with effusion of 
coagulable ly/nph on the uterine surface of the placenta of Simpson; and 
the metamorphoses of plastic inflammatory exudation on the uterine pla- 
cental surface of Ferdinand Robert. This is the acute inflammation of 
Meckel; the chronic inflammation, the primitive or secondary chronic 
endometritis of Braun, Schroeder and Spiegelberg; the ipterstitial endo- 
metritis of Hegar and Maier, in which the villi are agglutinated and com- 
pressed by the hypertrophied decidua serotina, and a new connective 
tissue. 
Here is their microscopical description, after Cauwenberghe: The fusi- 
form cells which, with little amorphous intercellular substance, form the in- 
terstitial tissue of the decidua serotina or maternal placenta, are larger 
than normal, but in various stages of retrogressive metamorphosis. In 
the points where the change is most recent, the cells are alone. They 
are now regularly arranged, side by side, fusiform as in their normal state, 
and only slightly degenerated; now deformed, rounded, distended by 
finely granular matter or by a fatty granular substance, they either possess 
a plain nucleus or have none. Their arrangement is less uniform, and 
between them is free fat in globular masses or in scattered granules. 
As the affection advances, we see new elements appearing between 
those of the interstitial tissue. The new tissue is now fibrillary, finely 
reticulated, its meshes being filled with nuclei and cells, now fibroid, 
striated or homogeneous. It displaces the older cells, deforms them or 
leads to their degeneration, so that a few fatty granules alone testify to 
their previous existence. In many places, the new connective tissue quite 
displaces the old. The utero-placental vessels undergo various changes, 
the constant result of which is atrophy and degeneration from compres- 
sion, so that there finally remain only hard and whitish foci, comparable 
to old connective tissue, imbedded in the spongy mass of the placenta. 
This progressive formation of connective tissue, on the uterine surface 
and in the placenta, produces induration, the plainest result of which is 
obliteration of the foetal and maternal vessels, with more or less extensive 
thromboses and apoplexies. 
As early* as 1842, Devilliers, in 1849, Dance, and later, Lesauvage, 
Breschet, Dubreuilh de Montpellier and Jacquemier, reported congestions 
of the decidua, leading to thickening and the production of white, pseudo- 
membranous concretions, analogous to pleuritic false membranes. (Dance DISEASES OF THE OVUM. 
223 
reported a layer of thickened pus, between the uterus and the placenta). 
Congestions of the uterus may lead to apoplexies, that is hemorrhagic 
extravasations, either partial or general, in the decidual tissue or in its 
cavity, transforming the abortive ovum into a sort of coagulum, as almost 
all observers have noticed. If the hemorrhage is violent, the extravasa- 
tion may occupy not only the thickness of the deciduae and their cavity, 
but may also rupture the membranes and penetrate their interior. 
Devilliers has reported a case which he considers a hypertrophy of the 
two folds of the decidua greatly congested around the hypertrophied pla- 
centa, the first cause of which was an active congestion or some state 
peculiar to this membrane. The result is congestion of the uterus fol- 
lowed by a granulo-fatty degeneration (interstitial endometritis of Hegar). 
He adds that, if one finds pus on the surface of the decidua, it can only 
come from the inflamed uterus. 
Hegar states that the changes in the decidua may affect all parts of it, 
and that one may find, successively: 
Fig. 20.-Ovum with Atrophied Decidua. External Surface of the Decidua Vera. (After 
Spiegelberg). 
Atrophy, which is not serious, except when it affects the decidua re- 
flexa and the serotina, for simple atrophy of the decidua vera has no harm- 
ful result. Muller calls attention to the fact that the external surface of 
the ovum is often thickened, but smooth. Now, detachment of the de- 
cidua in the first half of pregnancy cannot take place without numerous 
lacerations which give a spongy, rough aspect to the detached surface, 
the uterine surface being thickened while the foetal surface preserves a 
soft and spongy look. Now, in certain abortions, the two surfaces are 
alike, being formed of a friable tissue. The glandular spaces are widened 
and, later, there is fatty degeneration. There is atrophy and deficiency 
of the decidua reflexa, which may also affect the serotina. In this 
case, says Spiegelberg, the ovum is in contact with only a small part of 
the uterine surface and we find the serotina notably elongated, as it were 
pediculated, and invaginated into the decidua reflexa (Fig. 20). In the 
latter, the ovum is sustained by the uterine wall. It may then become 
detached either by its own weight or by uterine contractions. 224 
A TREATISE OX OBSTETRICS. 
If the decidua reflexa is originally lacking, the villi of the chorion pro- 
liferate over the whole area of the decidua vera, and then we may have 
either the placenta spread out, or, as the uterine development is not reg- 
ular, a placenta praevia. Arrest of development in .the decidua reflexa, 
or its premature destruction, is more frequent. The ovum is then only 
covered by the chorion and is suspended to a pedicle of the serotina. 
The pedicle may be elongated, producing cervical pregnancy (Rokitansky). 
Hegar also mentions hypertrophy, which may affect either the glandular 
tissue (with cyst-formation) or the interstitial tissue. Finally, there may 
be congestions in the decidua, with hemorrhages, as reported by Devilliers, 
Jacquemier, etc. They are seated, at the same time, on the external sur- 
face, the internal surface, and in the thickness of the mucous membrane, 
as well in the decidua vera as in the reflexa and in the serotina. 
Scanzoni assumes a communication between the two surfaces through 
the widened glandular orifices. The same may occur between the decidua 
reflexa and the chorion. When they are seated in the serotina they ex- 
tend between the reflexa and the chorion, then invaginate the chorion 
and amnion into the cavity of the ovum, and the foetus dies from com- 
pression, unless it was dead before. Sometimes, even the cavity of the 
ovum bursts and the blood penetrates into the amniotic cavity. If the 
ovum does not burst, the amniotic fluid is reabsorbed after the death of 
the foetus, which is macerated and disappears. The only remnant of the 
ovum is debris of the funis. This is Montgomery's false germ, ova two 
months old. If the ovum bursts, the foetus may be expelled without, 
one's knowing it, and then the clots and membranes are expelled later. 
If expulsion is long delayed, the clot may become more solid, undergo 
the changes usual in effused blood and be expelled, later, as the so-called 
carnified mole. The decidua is often thickened, hypertrophied and very 
adherent to the uterine wall. This accounts for the long sojourn in utero* 
of the carnified mole, which may undergo pigmentary and other changes. 
When the chorion and the amnion, or the amnion alone, after rupture of 
the chorion, have been thus dilated by the extravasation, they form 
what is called hemorrhagic cysts (Fig. 21), which enclose a sero-sanguinolent 
fluid or a clear fluid colored and derived from the blood serum. Carnified 
moles are usually expelled at the fifth month and rarely are larger than an 
orange. Sometimes part of the mole remains in utero and may become 
the origin of fibrous polypi. 
We thus see that, although inflammation of the maternal placenta is 
to-day undoubted, the same is not true of foetal placentitis. Cauwen- 
berghe regards it as doubtful; Duchamp admits its existence, with the 
reservation that, although the suppurative form is doubtful, the chronic 
or sclerotic form is real. It shows itself in fibrous degeneration of the 
villi. The cases of so-called abscess of the placenta, numbering ten in 
scientific literature, are questionable, for not one of the authors remem- DISEASES OF THE OVUM. 
225 
bered to analyze the pus, and it is more than probable that it was not 
genuine pus but what Robin has called pseudo-fibrinous pus. 
2. Changes in the Chorion. 
The maternal placenta is formed by the decidua serotina. The foetal 
placenta is formed by the villi of the chorion which, having originally 
covered the entire surface of the ovum, atrophy over the major part of 
the surface, while they ramify and develop, ad infinitum, at the point 
corresponding to the serotina, where they become imbedded and consti- 
tute the vascular mass known as the placenta. To study changes in the 
Fig. 21.-Bloody Mole, with Extravasations and Blood-cysts on the Fcetal Surface. 
(After Spiegelberg.)-CS, Clots. KH, Blood Cysts. 
chorion amounts to studying the lesions of the placenta and the reverse. 
Now, these changes may relate to each of the placental elements, i.e., 
the vessels and the villi. Let us successively study these lesions. 
I. Atrophy of the Villi of the Chorion. 
This atrophy occurs, normally, in all the villi not destined to form the 
placenta, i.e., in all not in contact with the serotina, and these villi may 
present three different conditions: 
1. They are vascular. 
2. They are well-formed and hollow but non-vascular. 
3. They are mal-formed, and this has prevented their vascularization. 
The atrophy is different in the vascular and in the non-vascular villi. 
Ch. Robin has best described this atrophy: 1. If the villus is non-vas- 
cular, it is obliterated and undergoes fatty degeneration; 2. If the villus 
is vascular, the vessels are obliterated and the villus transformed into 
fibrous tissue, composed of longitudinal parallel bundles not continuous 
Vol. 11-15. 226 
A TREATISE ON OBSTETRICS. 
with the tissue of the wall of the villus. There is, also, a little amorph- 
ous connective tissue and fine granulations, besides narrow and long 
nuclei, longitudinally directed and only made visible by acetic acid. 
This obliteration occurs in the villi of different cotyledons indifferently. 
In many villi, after obliteration, we find that the parietes contain fatty 
granulations, and real drops of oil, mostly spherical or oval. They are 
bright yellow at the centre and dark at the periphery. They are insol- 
uble in acetic acid but soluble in liquor potassse. They are either irregu- 
larly dispersed or collected into groups. 
The villi of the decidua serotina are developed, ad infinitum, and form 
the placenta. But as Cauwenberghe justly remarks, the disorders of the 
circulation, manifested during the development of the villi, differ greatly 
from those obtaining after the perfect formation of the placenta. Au- 
thors, although agreeing about the former, disagree about the latter period. 
Eigenbrodt and Hegar have noted apoplectiform destruction of the 
uterine mucous membrane, both in pseudo-membranous dysmenorrhoea 
and on abortive ova of the early months. During this time the mucosa 
is thickened, its vessels grow' large and numerous, their walls are thinned, 
they coalesce and form vascular labyrinths gorged with blood as the re- 
sult of physiological congestion. The gradual penetration of the vessels' 
walls, thinned by the villi, also favor rupture of the vessels and extravasation 
(Cauwenberghe). Hemorrhage is very frequent during placental devel- 
opment, and may be primary or secondary to morbid maternal or foetal 
states. The blood comes, then, from the mother's circulation, and is sit- 
uated in the decidua serotina. 
When the placenta is once formed, one may observe either simple con- 
gestion, the villi presenting no changes, or hemorrhages, apoplectiform 
extravasations, always due to changes in the villi. But these hemorrhages 
undergo changes greatly altering the appearance of the lesion, hence di- 
verse descriptions and different opinions, held by authors, not only as to 
the existence of such or such lesions but as to the connections between 
them. Some consider the lesions of the villi as merely secondary to the 
extravasations. Others consider the disease of the villi the chief element, 
and attach secondary importance to the hemorrhages. Some see the 
source of the hemorrhages in the maternal circulation and others in the 
fee till. 
II. Extravasations. 
Jacquemier's work on this subject is the most complete. He claims 
that, unless arterial lesions exist, the hemorrhages are always due to tear- 
ing of the veins, either in the placental tissue or in the decidua, outside 
of the placenta. 
The seat of the extravasations depends on the development of the pla- 
centa and the time of the hemorrhage, and the hemorrhages are either DISEASES OF THE OVUM. 
227 
true extravasations or what are called by Jacquemier and others placental 
apoplexies. 
When the placenta is fully formed, the blood, extravasated in the pla- 
centa, cannot extend between the decidua and the chorion, but accumu- 
lates on the external surface of the chorion and is limited to the lobe in 
which it wTas first extravasated. Later, the placenta forms a compact 
mass, and the blood, not being able to reach so far, forms superficial foci 
rarely reaching the external surface of the chorion. Occasionally, lesions 
of the umbilical vessels are merely consecutive to those of the utero-pla- 
cental vessels. 
The extravasations may present themselves in three distinct forms: 
1. The blood is contained in a very irregular cavity. The neighboring 
tissues are infiltrated and colored red. The hemorrhagic foci often com- 
municate with the external placental surface, which is torn. They are 
irregular, being sometimes on the placental border, and sometimes in its 
centre. In the latter case, they generally extend to the external surface 
of the chorion and to the cord. If they are at the points where the chief 
branches of the funis traverse the chorion, the blood sometimes infiltrates 
the tissues around the umbilical Vein and artery. The hemorrhagic foci 
may be single or multiple and of the same or different dates. 
Millet is opposed to these views and thus expresses himself in his thesis: 
"a. The extravasations in the centre of the cotyledons come from rup- 
tured umbilical vessels, and not from maternal vessels. 
"b. The supposed false membranes, referred to by certain writers, on 
the uterine surface of the placenta, and regarded as an inflammatory exu- 
dation, are only heaps of epithelial cells, which have undergone a real 
hypergenesis, or hypertrophy, at certain points." 
Certain microscopists have found aneurisms of the umbilical vessels, at 
the entrance of the latter on the foetal side of the placenta, which would 
explain the apoplectiform extravasations. 
2. There is no proper focus. The blood is infiltrated in one or more 
lobes. It may, however, be more abundant at some places. 
3. The blood is in regular, circumscribed foci, the number of which 
may vary from two or three to twenty. The placental tissue around them 
is healthy. Being first decolorized at their circumference, they seem en- 
veloped by a new cyst. There are, sometimes, very numerous small and 
regular foci, containing coagula, which closely resemble seeds of black 
grapes, and which, being in different stages of transformation, indicate 
recent and old coagulations. 
These extravasations may coexist with the lesions of ordinary uterine 
hemorrhages, internal or external, but they often occur alone or only lead 
to the lesions in question at a late date. Dubois and Desormeaux make 
two different degrees of the disease, congestion and apoplexy of the pla- 
centa. The congestion may lead to extravasations in the placenta, on 228 
A TREATISE ON OBSTETRICS. 
either placental surface or between the decidual membranes and the 
chorion. The congestion may result from disturbances of either the ma- 
ternal or of the foetal circulation. Simpson holds this view and Jacque- 
mier rejects it, believing that hemorrhage is always the result of rupture 
of utero-placental veins. 
The surface of the placenta is violet or livid, its tissue of a deep pur- 
ple color, its vessels full of venous blood. The organ is larger and heav- 
ier. A little effort on the patient's part, and extravasation occurs from 
the torn vessels. 
In the first three months it occurs between the chorion and the de- 
cidua, later in the placenta, and nearer the foetal surface as pregnancy is 
less advanced. This is the placental apoplexy of Cruveilhier, the utero- 
placental of Jacquemier. 
In true placental apoplexy, is it the rupture of the umbilical vessels, 
the placental parenchyma or the utero-placental vessels, ■which causes 
extravasation? We never find, except in the case of Cazeaux and 
Grisolle, even when the foci are near the foetal surface, any torn umbilical 
vessels. 
Is there rupture of the parenchyma or laceration of the utero-placental 
vessels? This is the sole cause, according to Jacquemier and Simpson. 
Their seat is determined by the very structure of the placenta, ■which 
is less close on the side of the chorion. 
These extravasations, almost always multiple, present themselves as 
foci, generally rounded and circumscribed. Sometimes their form and 
outline are irregular. When they are near the foetal surface of the pla- 
centa, and the blood is extravasated between the decidua and the 
chorion, the latter and the amnion are elevated and form on the side of 
the cavity of the ovum an hemispherical or conical prominence. The 
adhesion of the clot to the chorion is then, sometimes, very intimate. 
Near recent extravasations, the placental tissue is redder, darker, and 
this state, dependent, perhaps, upon the infiltration of a certain quantity 
of the extravasated blood, may result, also, from the presence of a num- 
ber of diminutive foci around the chief focus or of little clots formed in 
the vessels. The color of the blood is ordinarily of so deep a brown as 
to simulate melanotic degenerations. 
In other cases the blood is decolorized, becomes successively chocolate 
colored, yellow, reddish or brownish, deep yellow, and dirty white when 
the coagulum contains only fibrin. 
The shrinking of the clot, and the expression of the serum into the 
cavity left by the contraction, might simulate a serous cyst. 
Finally, the tissue near the extravasations becomes changed. It is ex- 
sanguine, atrophied, and the atrophy may become general if the foci are 
multiple. 
Joulin, 1867, thinks the foci have two distinct seats: 1, the utero-pla- 
cental mucous membrane, and 2, the placenta. DISEASES OF THE OVUM. 
229 
lie ascribes the effusion to fusion of the vessels and to partial destruc- 
tion of their original walls. If the solution of continuity be considerable, 
the pressure of the liquid may cause separation and the blood may then 
enter the spaces between the cotelydons or escape externally. The pla- 
cental hemorrhages are seated further in the capillaries, but their mechan- 
ism is different. He ascribes them to traction on and laceration of the 
capillaries from their displacement and their change of direction during 
the enlargement of the organ. Perhaps there is a disease of the capil- 
laries which causes the hemorrhage. However it be, the hemorrhages 
are rarely exactly the same and the quantity of blood is very variable. 
The effusion may cover the whole surface of the ovum, as an irregular 
layer, sending prolongations into the depressions hollowed out by the sep- 
aration. It may, in other cases, be in smaller, more numerous, isolated 
and circumscribed foci. It always stops at the inner surface of the organ, 
without rupturing the epithelial covering of the uterus. 
The appearance of the clots is variable, according to the date of extra- 
vasation. They are black, like thin jelly, or whitish, or in yellowish-white 
resisting plaques, which have been inappropriately compared to scirrhous 
tissue. 
III. Changes in the Villi. 
Ch. Robin considers these changes as the consequence of the natural 
development of the villi of the chorion accidentally affecting the villi of 
the placenta. 
A. According to him, we sometimes find parts of different cotyledons 
depressed, hard, friable and with a shreddy irregulai- surface. This tis- 
sue is formed of villi in an advanced state of fibrous degeneration. The 
substance of the chorion proper is very granular and often thin. The 
nuclei are less numerous than in the normal state. The granulations are 
small and not all of them are fatty. The villi are adherent, and between 
them is a little amorphous tissue and a few granules. 
B. In some placentae the cotyledons are separated by deep furrows. 
The tissue is harder than normal, yet friable, is gray, yellowish-gray or 
yellowish white, and less moist than normal. At a deeper level the tissue 
is more normal but denser, less red and less moist. These parts of the 
tissue are composed of villi obliterated by cellular tissue, but many of the 
villi have their own normal substance or contain only a few fatty granu- 
lations. 
The nuclei are generally partly or entirely absent where these fatty 
granulations are in contact, but this is not constant. 
The diseased cotyledons are more involved on the uterine surface than 
on that of the chorion, where they have their normal softness, humidity 
and reddish tint. 
The fatty deposit is, thus, only a complication of the obliteration of the 230 
A TREATISE ON OBSTETRICS. 
villi, which is accidental. The term fatty degeneration is, therefore, not 
exactly correct. 
Barnes thus describes the lesion, in the cases observed by him: The 
maternal placental surface is deeply divided by furrows, resembling cere- 
bral tissue in color and lobulation. All the lobes are yellow and shiny, 
like fat. At the bottom of the furrows the color is red, elsewhere the 
placenta is pale. The fatty aspect is more marked near the uterine pla- 
cental surface, and the microscope shows the villi there to be more ex- 
tensively changed. The villi are, however, nowhere perfectly healthy, 
but in the firmest lobules are fragile and poorly outlined, and their ves- 
sels are ruptured. The chorion is largely destroyed, and the nuclei in the 
walls of the vessels are enlarged and filled with granules. In the less 
diseased parts the vessels preserve their normal volume. 
D'Outrepont, Wilde and Kilian regard this lesion as a fatty degener- 
ation of the placenta. 
So soon as the investigations of Robin were published, observations were 
multiplied, but it was soon noticed that the facts were not so simple as 
they appeared from these clear and precise descriptions; and mixed cases, 
i.e., cases characterized by both placental apoplexy and fatty degeneration 
of the villi, were cited. 
The first was reported in 1854 by Hiffelsheim and Laboulbene, after 
that of Ch. Robin, who maintained that these lesions are independent of 
each other, although sometimes coinciding. He held that obliteration 
of a few placental vessels or of a cotyledon may modify the whole pla- 
cental circulation and thus cause hemorrhage, but that the lesion itself is 
independent of the hemorrhage. 
Laboulbene and Hiffelsheim came to the following conclusions: 
1. There may be, at the same time, apoplexy and obliteration of villi; 
2. Apoplexy does not cause obliteration, but rather the reverse; 
3. The two lesions are independent of each other. 
The appearance of the diseased cotyledons has sometimes been wrongly 
attributed to retrogressive changes in coagula about which the authors 
do not agree. 
Jacquemier says that the serum is reabsorbed, while the coagulum 
grows dense by contraction. The pigment gradually disappears, being 
first lost at the circumference, unless the clot has been formed by succes- 
sive additions. Sometimes the coagulum is so changed as to be unrec- 
ognizable or to simulate cartilage, cancerous growths or tubercles, nodu- 
lar or diffuse. 
Sometimes the coagula enclose cavities containing blood, and sometimes 
they are soft like adipose tissue and seem to be encysted. Often the um- 
bilical vessels penetrating the coagula are obliterated. When the blood- 
clot is large, the placental tissue is firm and white around them, and one 
or more lobes of the placent-a are obliterated. 231 
DISEASES OF THE OVUM. 
When the hemorrhage lias led to detachment of the placenta, the circu- 
lation cannot be restored. If, however, the extravasation is small, the 
blood may be taken up and the serotina reproduced. The latter then has 
new vessels, adherence between the placenta and uterus is not disturbed, 
and the umbilical circulation is not suspended. 
Ch. Robin states that fibrin appears in two forms, according to the man- 
ner of its coagulation. The first is the thrombus, formed while the blood 
is still circulating, as in the case of cardiac vegetations and in aneurisms. 
The thrombus is stratified and pale in color, and may look like organized 
tissue, but never has fasciculi as does fibrous tissue. It has no capillaries 
and never grows, but either enlarges by the deposition of new laminae, 
or becomes granular and is reabsorbed. Now, it is not even this form of 
fibrin which is found in the placental coagula. 
The second form of fibrin, called a clot, is produced during life, when 
extravasation, apoplectic or otherwise, takes place, or when the current 
of blood in some normal or pathological cavity is interrupted. The clot, 
proper, is formed of fibrin and red and white corpuscles, is softer than a 
thrombus, is friable and non-striated. 
These are the coagula found in the placenta, and some writers speak of 
their organization because the fibrin resembles formed connective tissue. 
Verdier states that coagula may either contract and become permanent, 
be destroyed or become organized. The contraction and permanence of 
coagula is simple and undisputable. The destruction of the clot consists 
in several stages. The fibrin, when first deposited, gives a yellowish, 
lardaceous look, and a firm yet friable feeling. It soon, however, becomes 
granular and presents two kinds of granules. One kind is proteid, dis- 
solving in alkalies and in acetic acid, the other fatty, resisting these re- 
agents. The mass then becomes soft and liquid, resembling pus, and 
regarded as such by earlier writers. In these pyoid masses one finds, 1, 
innumerable fibrinous and fatty granules; 2, some liquid; 3, *fatty white 
corpuscles; 4, granular bodies formed either by simple adhesion of fatty 
molecules or by their accumulation in a white corpuscle; 5, hematoidin 
crystals. 
It was once held that the clots could become organized. 
Hunter's theory of organizable plastic lymph was soon abandoned. 
Cruveilhier denied that coagula are organized, and so did Robin, but Vul- 
pian reaffirmed the old theory, and Weber describes the organization of 
extravasated blood. In the coagula of ligated vessels the white corpuscles, 
in a few days, change their shape, the nuclei divide, they send out slen- 
der prolongations and form a reticulum like that of connective tissue. 
Then capillaries form and anastomose with neighboring vessels, the red 
corpuscles disappearing. 
Bustamente, adopting Dalton's ideas, says that the villi, with their 
arterial and venous channels, plunge into the maternal blood from which 232 
A TREATISE ON OBSTETRICS. 
they are not separated at all. The placenta, according to him, is contin- 
ually bathed in the mother's blood, which extends into the interstices of 
the cotyledons like liquid into a sponge. 
Without defining the nature of the lesion in question, the author des- 
cribes its gross and microscopical appearances. 
a. External Appearance.-The lesion occurs either in scattered foci or 
in more or less extended plaques, which may be far separated, near to- 
gether, or confluent. The color varies from yellowish-white to blackish- 
red or black. These colors are due to metamorphoses of the blood. 
b. In the diseased parts, the tissue is firmer, yet more friable, particu- 
larly in cases with multiple foci. 
c. The extent is variable. Sometimes the foci are scattered and vary 
in size from a pea to a nut; sometimes there are plaques, which may be 
a few lines broad or may rarely occupy nearly the whole placenta. 
d. The most frequent seat is the border or the neighboring parts. The 
next is the foetal surface, and then, in order, the whole thickness of the 
organ, the uterine surface, the centre and one third or one half of the 
entire organ. 
e. The state of the tissues varies. Now we find the placenta filled 
with numerous and recent clots; now their number has diminished, they 
are decolorized and include the agglutinated villi. Again, older clots are 
soft and their centre looks like broth, varying from reddish-brown to yel- 
low, which may, according to Billroth, be true pus, which is denied by 
Virchow and Robin. 
In other cases the coagula are stratified, particularly if on the foetal 
surface. The tissue may be so hard that it cannot be broken up, in 
which case it is of a dirty white or gray. The vessels in the diseased 
parts are generally diminished in calibre (Jacquemier), but they are 
sometimes obliterated and atrophied, either primarily or secondarily. 
The microscopical appearances, according to Bustamente, are due to 
changes more or less advanced in the blood, and to secondary changes in 
the villi. 
A. When the lesion is recent, we find coagulated blood around the villi, 
and, later, fibrin with blood corpuscles in its ipeshes. • The villi in the 
clot are intact, but their vessels are filled with clotted blood. 
B. At a later stage the fibrinous meshes are closer and the red corpus- 
cles fewer, and so changed as to be recognized with difficulty. 
The white corpuscles change to connective tissue corpuscles, and the 
new tissue is very dense. The villi undergo fatty degeneration. The 
blood in the vessels becomes granular, and the connective tissue nuclei 
begin to proliferate. Compound granulation corpuscles appear in the 
clot. At the most advanced stage of the change, the white corpuscles 
present one, two or three nuclei. Yellow elastic fibres appear, cross 
and increase, while the blood corpuscles disappear. The vessels of the DISEASES OF THE OVUM. 
233 
villi become, finally, obliterated. The walls of some of the villi become 
fatty. 
The mechanism of the lesion is as follows: The maternal blood current 
is retarded in the placental sinuses, the blood clots surround the villi 
and the above changes occur. According as the coagulation is rapid or 
slow, the coagula are amorphous or striated. Bustamente proposes the 
name placental thrombosis for this condition. Cauwenberghe says that 
the blood undergoes the most diverse changes in different parts of the 
same or of different placentae, just as in vascular thrombi. 1. The decol- 
orized fibrin may remain stratified without other change; 2. The throm- 
bus is transformed into connective tissue; 3. Retrogressive changes occur 
in the blood, the red corpuscles disappearing and the white undergoing 
fatty degeneration and being carried away. The fibrin is changed to a 
pulpy mass like pus, the fibrinous pseudo-pus of Robin, the true pus of 
Billroth. 
The microscope presents the following appearances in these lesions: 
1. Transformation of the Blood.-In some cases red corpuscles pre- 
dominate, in some the fibrin. The white corpuscles may be few and scat- 
tered, or grouped and in layers. The red corpuscles become deformed 
and decolorized. The pigment may disappear or remain a long time. 
At this time the fibrin is still fibrillary and the white corpuscles are un- 
changed. Later, the red corpuscles break up, the fibrin becomes gran- 
ular and the white corpuscles become fatty and are disintegrated. When 
the foci do not enclose villi, the clot may be changed to pseudo-pus. The 
fibrin may remain unchanged. But may the clot form organized connec- 
tive tissue? This is admitted by Billroth, Virchow, Cohnheim and 
Bustamente, but denied by Robin, Cauwenberghe and Maier. Maier says 
that new connective tissue, when found, is the result of hyperplasia in the 
decidua-serotina or interstitial placentitis. 
2. Cauwenberghe considers the changes in the villi and the umbilical 
vessels as secondary, and repeats Bustamente's views, but he agrees with 
Hegar and Maier that the walls of the large vessels, on the foetal placental 
surface, are thickened from hypertrophy of the tunica adventitia, the 
lumen of the vessels being contracted and the capillaries empty. 
Ercolani, 1876, considers the villi to be formed of two parts, the par- 
enchyma, (chorial tissue of Robin; mucous tissue of Virchow), in com- 
munication with the chorion and the external part or epithelial envelope. 
He distinguishes, among diseases of the villi, hypertrophy or myxoma 
of Virchow; hydatigenous placenta; myxoma of the serotina or of the 
glandular organ surrounding the villi. The first two lesions correspond 
to the vesicular mole of the books. Here is his description of myxoma 
of the serotina: The placenta belonged to an abortive foetus of three or 
four months. It was normal and completely developed. The supposed 
placental parenchyma was composed of an intricate net of villi, between 234 
A TREATISE ON OBSTETRICS. 
the chorion and the serotina. The microscope showed in the pedicles 
and tufts of the villi, irregular swellings formed by a layer of the cells of 
the serotina. In the cells the development of the glandular organ was 
arrested and little pediculated bodies, generally pyriform, had appeared. 
Some of these, Virchow's physwlides, contained liquid such as we saw in 
the epithelial proliferations of the villi. The parenchyma of the villi had 
undergone atrophy and fibroid degeneration at the beginning of its devel- 
opment. 
Ercolani considers the fibro-fatty degeneration of the placenta a cellular 
hypertrophy of the parenchyma of the foetal villi, simple or complicated 
by vascular obliteration and glandular atrophy. He considers the hyper- 
plasia of the cells in the mucous tissue of the villi, to be peculiar to the 
disease. 
Dilatation of the vessels seems to be the result of the obstacle opposed 
to the circulation by obliteration of vessels in some of the tufts of the 
villi. The reason for the obliteration is the pressure exerted on the ves- 
sels by the neighboring cells, which are greatly increased in number and 
in volume. The volume of the diseased villi is augmented and they form 
compact, grayish masses, because they have no vessels and because the 
maternal blood cannot circulate around them. This is the lesion des- 
cribed by Bustamente and Neumann as sclerosis of the placenta. 
Ercolani also describes fibroma of the villi and of the serotina. Called 
fibro-fatty degeneration by Robin, and designated as syphilitic by Virchow, 
this lesion is frequently found, according to Ercolani, on abortive pla- 
centas expelled after the third month or on placentas at term. In the 
latter it is less extensive. In the beginning of the transformation of the 
mucous tissue of the villi into fibrous tissue, the cells become more elliptical 
and numerous, and the surface seems firm and almost vitreous. Ercolani 
regards this really as a hyaline transformation and not as a fibroid one, 
because amorphous transparent matter abounds in the cells. 
The fibrous transformation is now partial, now general. Obliteration 
of the vessels in the villi is secondary. The fibrous change may affect 
the villi alone, or also involve the glandular organ. The change may 
occur simultaneously in the villi and the serotina, before the glandular 
organ is formed. When the cells of the serotina assume the character 
of fibrous tissue, they remain round but get smaller, arrange themselves 
in series, lose their granules, and their nucleus is rapidly colored red with 
carmine. 
Later, the nyaline substance exudes through the cell walls, and the cells, 
losing their round form, take on that of the connective tissue corpuscles, 
having numerous inter-communicating poles. The vessels of the villi are 
mostly obliterated. The fibrous tissue of the serotina is fused with the 
new fibrous tissue of the villi. 
Ercolani and Beluzzi also mention melanosis of the placenta, consisting DISEASES OF THE OVUM. 
235 
in the deposition of pigment granules around the utero-placental vessels 
or in the villi. The pigment is hematoidin. 
Ercolani states that there may be thrombosis of the sinuses and hem- 
orrhage. The decidual vessels may rupture in the early months, and 
cause hemorrhage between the decidua and the chorion. The chief cause 
of the clots and hemorrhages is fatty degeneration of the cells of the 
serotina. The cells, thus altered, support, but poorly, the pressure of the 
blood in the lacunas, and hemorrhage results. He has never observed 
the transformation of the coagula into pyoid matter, pus or neoplasms. 
He, however, remarks that the diversity of coloi- in apoplectic centres, 
does not only depend on the time and character of the changes, but also 
on the quantity of lacunal blood and on the relative rapidity of coagu- 
lation. 
Finally, Duchamp, in 1880, returning to Robin's view, considers fatty 
degeneration secondary to fibrous degeneration. 
From an examination of these different opinions we conclude that the 
subject of placental lesions may be summed up thus: 1. Hemorrhages 
occur in the placental tissue, and the extravasated blood undergoes great 
change; 2. The villi may undergo a fibro-fatty degeneration; 3. There 
may be, simultaneously, extravasation and degeneration of the villi. 
But the questions already asked by us, in our thesis of 1869, now pres- 
ent themselves again, viz.: 1. May there be placental hemorrhage or 
thrombosis without change in the villi? 2. May there, conversely, be 
changes in the villi without hemorrhage or thrombosis? 3. In mixed 
cases, with both lesions, are they dependent upon each other, and which 
is the initial lesion ? 
The facts reported by Hiffelsheim, Laboulbene, Depaul, Ercolani and 
de Sinety show that the first question may be answered affirmatively. 
The same is true of the second question, as is proved by the cases of Robin 
and of Depaul and de Sinety. 
The solution of the third problem is far harder. Less positive than 
formerly, we no longer say, as in 1869, that the lesion is one. There is, 
first, fatty degeneration and obliteration of the villi, and then extravasation 
of blood which undergoes transformations; these two lesions being, in 
reality, successive degrees of one and the same change in the placenta. 
We do not, however, adopt the exaggerated ideas of Bustamente. His 
anatomical considerations on the structure of the villi are not conclusive. 
Indeed, the researches of the Germans and of Dastre tend to show that 
the villus is not hollow, as Robin thinks, but formed, externally, by a 
layer of polyhedral epithelial cells enclosing fatty globules and crystalline 
rings, or rods beneath this layer, and by a parenchyma of connective tis- 
sue arranged in planes parallel to the surface and forming a more or less 
dense felt-like tissue. Stellate cells are interposed between the groups of 
fibres. The villus is formed by a displacement of the chorion when the 236 
A TREATISE ON OBSTETRICS. 
vessels enter, but no central canal is formed. At the point where the 
displacement of the chorion is to occur, the fibres of connective tissue, 
parallel to the surface, become erect to enter the villi, the centre of which 
they form. 
There is, here, nothing comparable to what Ch. Robin understands by 
the fibrous degeneration of the villi, which is a well-ascertained lesion. 
Besides, if, at the beginning of pregnancy, the extravasation of blood can 
only come from the maternal circulation, it may, later, come from the 
umbilical vessels. Millet expressed this opinion and certain microscopists 
have seen aneurisms on the umbilical vessels, near their entrance to the pla- 
centa, the rupture of which would explain the apoplectic extravasations. 
The facts quoted by Cauwenberghe, himself, and by Hegar and Maier prove 
the changes in the umbilical vessels. We reserve our decision, for both 
explanations can be maintained while neither is absolutely proven. This 
is, moreover, Duchamp's opinion. 
IV. Calcareous Changes in the Villi. 
By the terms ossification, ossiform concretions, placental calculi and 
calcareous degeneration, authors understand deposits of lime, either on 
the surface or in the interior of the placenta. Sometimes there are iso- 
lated grains or needles, sometimes calcareous masses. The grains contain 
amorphous carbonates and phosphates of lime and magnesia, and are 
found, most frequently, on the uterine placental surface. Carestia has 
reported some on the foetal surface. Lobstein, Meckel, Adelon and Cru- 
veilhier, thought that they were in the capillaries. Robin has shown that 
the grains are especially found in the cotyledons whose villi are wholly or 
partly obliterated. They adhere, strongly, to the surface of the villi, 
surrounding and sometimes obscuring the villi, always deforming them. 
They are, then, in the maternal placenta, as Ercolani also believes. 
Etiology.-The causes of the changes of the placenta mostly elude us. 
Hegar has observed, in a great number of ova, coexistent anomalies of 
the decidua and of the embryo which we have mentioned before, and this 
may explain the abortions occurring in the first months. This is not 
true of the important placental lesions which we have just considered. 
The advocates of the theory of blood changes have sought the explana- 
tion of these phenomena in placental thrombosis. But what are the 
causes of this thrombosis? Cauwenberghe finds them in the conditions of 
the placental circulation, the modifications of which seem to tend to one 
and the same end, viz., augmentation of the quantity of blood, and ex- 
cessive slowing of the circulatory current, or changes in the composition 
of the blood. 
Finally, the following occasional causes have been noticed: Extreme 
youth, or, on the contrary, extreme age; the predisposition of certain 
women who menstruate very abundantly; acute diseases which affect the DISEASES OF THE OVUM. 
237 
circulation, and the respiration; the eruptive fevers; pneumonia; cholera; 
typhus; the diatheses and cachexias (among which latter, syphilis is the 
most prominent), and, finally, syncope, gravido-ca diac troubles, trauma- 
tisms, or, in one word, all the causes of abortion. 
1st. Influence upon the Mother.-All authors agree that whatever the 
lesion, it exerts no influence upon the mother. The sanguineous effusions 
may possibly, it is true, compromise her health, and exceptionally endan- 
ger her life; but, as a general rule, she suffers from nothing more than a 
more or less pronounced state of malaise, which has only a passing influ- 
ence upon the material health. According as the disease is more or less 
intense, and according as it has or has not accidental complications, the 
mother suffers more or less; but the placental malady seems to have hardly 
any pathological influence upon her. 
2d. Influence of Placental Lesions upon the Foetus.-Here, on the con- 
trary, all authorities agree as to the direct influence of the lesion. How 
can it be otherwise ? The placenta is the essential organ of foetal devel- 
opment; through it all its functions of nutrition and assimilation are ac- 
complished; through it it respires and is nourished, and from it draws 
the elements necessary for its development. Is it not natural that the 
foetus should suffer when it is affected with disease? We may con- 
clude with Dubois: "If a portion of the placenta still preserves its struc- 
ture and its functions, the foetus will not only continue to live, but its 
nutrition will suffer little or nothing. On the other hand, if it does not 
die, it will be born feeble, thin, and wizened. If the placental disease is 
progressive, it will cause, in spite of our efforts, a gradual enfeeblement 
of the foetal movements and heart-beats, until both stop completely; and 
the mother and the accoucheur, not unfrequently, help on the agony and 
death of the foetus in these unfortunate cases." 
3d. Influence of Diseases of the Foetus upon the Placental Lesion.-Is it 
not possible for the state of health or the life or death of the foetus to react 
upon the disease of the placenta ? We are entirely dependent upon hypoth- 
esis for an answer. It is true that placental oedema, atrophy, and hyper- 
trophy, appear to be lesions which are peculiarly prone to follow death of the 
foetus; but we know nothing certain about it. If we could recognize and 
diagnosticate disease in the foetus, we might obtain more precise data. The 
only thing that we can determine, and that but rarely, is the condition of the 
heart-beat, that is to say, the life or death of the foetus. It is only after the 
beginning of the second half of pregnancy that even this is possible, 
and the first cause of the death of the foetus escapes us. One fact only 
can be appreciated at the time of the death of the foetus, and that is the 
almost constant tendency to abortion which follows that accident. But 
how often do wTe not see this accident occur without there being either in 
the placenta, the membranes, or the foetus, anything to explain the death, 
and we are forced to ascribe it to general causes, to diatheses. Even when 238 
A TREATISE ON OBSTETRICS. 
we find a placental lesion, is the placenta diseased because the foetus is 
dead? or has the foetus died because the plaoenta is abnormal? The 
question is still entirely unanswered. 
John Bremmer has studied the pathological alterations of the pla- 
centa, in connection with their influence upon the course of labor. He 
claims that placenfal alterations cause, by contiguity, a state of torpor and 
debility of the uterus, which manifests itself at the time of labor, by a 
more or less marked paralysis of the organ. Certain symptoms during 
pregnancy enable us to foretell this condition; these are a pale, thin, and 
pining facies, flaccid breasts, loss of flesh, frequent pains in the back and 
in the uterus, but above all, a continuous and unbearable state of malaise, 
lasting day and night, and often resisting even narcotics; a soft or com- 
pressible pulse, and a slight lowering of the uterus. At the time of labor, 
its slowness and difficulty, in women who have had other easy deliveries, 
are markedly in contrast with the continuous and severe pains, and soft- 
ness and facidity of the os. The child is born feeble and almost asphyxi- 
ated, or it may be covered with livid blotches. Others again, though 
born at term, are only half the average weight of new-born infants; they 
may live a few days. 
The amount of alteration m the placenta does not appear to bear any 
direct relation to the infant's condition as regards life or death. 
Finally, the escape of meconium, if not always a sign of the death of 
the foetus, indicates a state of. such great weakness that relaxation of the 
sphincters has occurred. Nevertheless, the diagnosis is only certain after 
the expulsion of the placenta. The cord looks dirty, and the vessels are 
yellowish green in color; the placenta exhales a foetid odor, and may be 
smaller than usual, but its texture seems to be but little changed. 
Hypertrophy. 
Hypertrophy and (Edema of the Placenta.-These two lesions, which 
are inseparable, are due to an increase in number and volume of the 
elements constituting the villosities, together with an exudation of fluid 
material between these elements. The epithelial covering remains in- 
tact, though it is hypertrophied to cover the enlarged villi; but the other 
structures may be profoundly modified. The cells of the mucoid tissue 
are hypertrophied and increased in number, and are closely aggregated 
together, one or two vessels still retaining their normal calibre. In more 
advanced degrees of change, the vessels disappear entirely from the mu- 
coid tissue. Within the epithelial layer are a large number of round 
cells, dentate, and with fusiform prolongations, and even star-shaped; in 
other words, we find a true myxoma of the mucoid tissue. De Sinety 
considers this the first stage in the development of the vesicular mole. 
Ercolani, as we have seen, regards this lesion as a hyaline transformation, 
because few cells thus changed can be found in the parenchyma of the DISEASES OF THE OVUM. 
239 
villus, while the amorphous and transparent element is abundant; and 
Wilde has seen the trunks that were not dilated by fluid undergo a fatty 
degeneration. In a case of acute hydramnion in a twin pregnancy, de 
Shirty, who examined the placenta, found in it the following alterations: 
''Even with the naked eye it was possible to distinguish two different parts 
of the organ; the one being violet red and filled with blood, and the 
other looking pale yellow and thin. The fluid appeared to be everywhere 
between the membranes, though the contents of the amniotic cavity did 
not seem to be increased. The membranes were easily detachable from 
one another. Histological examination of hardened sections showed that 
the red portion exhibited a considerable dilatation and engorgement of the 
blood spaces, while the villosities appeared normal. In the white part, 
on the other hand, the walls of the maternal vessels were hypertrophied, 
and there was no blood in them. The villosities had but few vessels, and 
they were bloodless. There were seen certain dilatations of the mucoid 
tissue reticulum, which contained an amorphous material not colorable 
by either picro-carminate of ammonia or by purpurine. 
" Some of these spaces contained a large cell which almost entirely filled 
it. In most villosities of the white portion of the placenta, the cellular 
elements were much more numerous than is normal. Some villosities 
had become fibrous, or, more rarely, fatty. The epithelial covering 
was notably hypertrophied, and was thus much more apparent than in 
the red part. The cord was apparently normal. The vein and one of 
the arteries contained blood-cells; but the other artery was contracted, 
and almost obliterated, and contained no blood; it only had a few small 
round elements, which were colorable by reagents, and appeared to be due 
to endothelial proliferation. The intima was infiltrated with these same 
elements, showing the existence of endarteritis. In the healthy artery we 
could see, in the midst of the blood globules, a certain number of giant cells 
of various shapes. They appeared also in the vein, but less abundantly, 
and mostly rounded. The stroma of the cord and its covering were nor- 
mal. In short, the lesion consist 3d of a partial oedema of the placenta, 
together with complete anaemia of that region, probably of maternal 
origin. Although I do not consider the lesion a specific one, I must add 
that I have seen similar lesions in cases of syphilitic placenta." There was 
no syphilis in either the patient or her husband. 
Atrophy of the Placenta. 
This lesion has been attributed by various authors to hemorrhages, to 
fatty degeneration, or to consecutive blood changes. It may be partial 
or general. But atrophy does not always appear to be due to the above 
causes, since placentae have been found whose dimensions are much re- 
duced, though the tissue of the organ itself shows nothing peculiar. This 
is an anomaly, and if very pronounced, may interfere with foetal nutri- 240 
A TREATISE ON OBSTETRICS. 
tion, though not to the extent that it does in cases of consecutive atrophy, 
involving the whole or a great portion of the placenta. 
Sclerosis of the Placenta. 
This, according to Bustamente, causes the placenta to appear as a red- 
dish, flesh-like, lobulated, and smooth mass, bearing some resemblance to 
the thymus gland. It is homogeneous and dense to the cut. The altered 
portion adheres partly to the villosities of the healthy part. Towards the 
sides, and especially upon the foetal face of the placenta, the normal tis- 
sue is encroached upon and compressed; as may easily be seen if the 
altered portions be removed. The mucous coat, on the uterine portion of 
the placenta, is detachable over the abnormal parts. 
On microscopic examination, the villosities of the morbid tissue are not 
well defined. The section is homogeneous, and shows very small arterial 
vessels at the centre of the lobules. It is composed of fibro-plastic ele- 
ments arranged in regular order in concentric layers, almost like the vas- 
cular tissues. 
Cysts of the Placenta. 
According to Millet, who has seen two cases, the walls of placental cysts 
are formed of layers of tissue very like that which we find interposed be- 
tween the chorion and the amnion. The fluid they contain resembles, 
both in consistence and in composition, the gelatine of Wharton. The 
cyst is, in fact, developed in rneshes of the cellular tissue, just as are those 
cysts of the cord which Ruysch has described under the name of hyda- 
tidiform degeneration of the umbilical cord. 
Bustamente describes a kind of cyst which is sometimes found upon the 
foetal surface of the placenta, of a regularly rounded or elongated shape, 
and varying in size from -? of an inch to 2 or 2f inches. They are placed 
below the amnion and chorion, which form their superficial or foetal boun- 
dary, being limited below by the placental tissue itself. 
The contents of these cysts are solid and liquid. The fluid is usually 
lemon-colored, lactescent, and contains blood globules. Nitrate of silver 
causes a curdy precipitate; heat and nitric acid show the presence of al- 
bumin. Underneath this liquid portion of the contents is a whitish or 
slightly yellow substance, from | of an inch to | of an inch in thickness. 
Under the microscope, this tissue is seen to consist of reticulated fibrin, 
perhaps containing in its meshes some placental villi. Close inspection 
reveals the fact that it is disposed in layers. The greasy masses of which 
it is apparently composed, are usually found towards the centre of the 
placenta, in the intervals between the large vessels. Finally, it is not 
unusual to find plates on the surface in which we find a small quantity 
of fluid, having the same characters as the liquid of the cysts. 
How are these cysts formed ? A coagulation has taken place against DISEASES OF THE OVUM. 
241 
the chorion, forming the plate which is the deeper layer of the cyst. The 
fluid may be produced in one of several ways: 1st. A certain quantity of 
blood may have been included between the coagulum and the chorion; 
or the blood may have appeared later, after the formation of the first 
layers of the plaque, from rupture of the layers. 2d. Or a little bleeding 
point may be left open, and the blood then tears a cavity between the 
chorion and the plaque of coagulated fibrin. We cannot attribute rhese 
to the rupture of a vessel, since in the cases examined there was no such 
thing. The fibrinous parietal layer also shows evidence of having come 
from the maternal blood of the placenta. 
Ercolani has seen two cases of placental cyst. In one the entire foetal 
surface of the placenta was sown with round tumors, covered by the cho- 
rion, the largest being about the size of a cherry. Some had been opened, 
and the chorional wall torn, showing a solid material filling the depths 
of the cyst. They were in fact like the variety described by Bustamente. 
Others again were more solid, and were filled with coagulated fibrin, in 
which rounded masses of granular haematin could be seen. 
In the second case three hemorrhagic centres could be easily distin- 
guished upon the foetal surface; they were round, red in color, and about 
the size of small peas. Others were less prominent and more irregular 
in shape. In those that were cyst-like, Ercolani proved that the interior 
wall was formed by the chorion, which covered the whole bloody mass, 
of which half projected above the placental surface, while half dipped 
into the placental tissue, and lay in immediate contact with the effused 
blood. The term cyst is therefore inexact. At the placental depths of 
these tumors, the villosities, more fibrous than usual, formed a compact 
layer, certain spots in which turned out to be cells of the serotina, some 
of which plainly showed fatty degeneration of the nuclei. Small irregular 
calcareous concretions were scattered through the mass. 
Tumors of the Placenta. 
The following is the description, by A. Danyau, of a tumor occurring in 
a healthy woman, and after a normal pregnancy, the only effect of the 
mass being to cause considerable abdominal distension, so that labor oc- 
curred at the seventh month. " Near the margin of the foetal portion of 
the placenta, is an oval tumor 4f inches long by 3^ inches broad, and 
covered by the membranes, which are partly detached from its surface. 
Several large venous and arterial branches of the umbilical vessels run 
over its surface and penetrate its substance to the centre. The tumor is 
lobulated, and, besides the membranes, has a proper envelope, thin super- 
ficially, thicker over the portion covered by placenta, easily torn, and ap- 
parently formed of plastic lymph more or less condensed. Divided longi- 
tudinally, the tumor appears to be composed of intimately adherent lobes, 
some being of a dead white, and others of a pale or deep rose tint; its 
Vol. II.-16 242 
A TREATISE ON OBSTETRICS. 
tissue is homogeneous, very dry, like schirrhus in appearance, and crying 
under the scalpel; its color and consistence reminding one in some places 
of the cortical substance of the kidney, and appearing in others to be com- 
posed of layers of fibrin; vascular orifices are apparent, some of which 
are still filled with clots." 
The author describes a second similar but smaller tumor, and adds, 
that the portion of the placenta upon which they rest is depressed; that 
the tumors can be nucleated; that the placental tissue is then very com- 
pact, and that a neighboring cotyledon contained a blood clot about the 
size of a filbert. The second tumor was observed under circumstances 
similar to the rest; it differed only by a greater homogeneity of the tis- 
sue out of which it was formed, and by the absence of the layer of plastic 
lymph which almost entirely covered the first one. 
The author then discusses the nature of these tumors, whether they 
are monstrosities or moles, or perhaps due to degeneration of the decidua, 
or whether of cancerous nature. Danyau comes to what appears to us 
the well-founded conclusion, that they are due to anterior sanguineous 
effusions. In conclusion, he states that the tumors appeared to have no 
evil influence upon either pregnancy, delivery or the puerperal state, and 
that they cannot, at present, be diagnosticated before birth. 
Syphilitic Lesions of the Placenta. 
It is only recently that syphilitic affections of the placenta have been 
studied. Duchamp has given the best reszime of the subject. He shows 
that while Astruc, in 1796, recognized abortion as a consequence of syph- 
ilis, Murat first, in 1820, noticed certain black spots upon the organ, due 
to hemorrhage, though Paul Dubois, Putegnat, and d'Outrepont denied 
their significance. Simpson and Lebert, in 1822, Virchow, Barensprung, 
Wilk, Biervliet, Slavjansky, Kleinwachter, Mayer, Adamson, Birne, Ver- 
dier, Hennig, and ourselves, have noticed these lesions in the placentas 
of syphilitic children. Frankel, in concert with Waldeyer and Kolaczek, 
was, however, the first to bestow serious attention on the subject. 
He could collect fifteen observations of syphilis transmitted from the 
father, in which nothing more than hypertrophy of the villi could be 
found; but when the mothers were diseased, the lesions were more com- 
plex. His conclusions were as follows: 
1st. There is a syphilitic placenta, with characteristic features. 
2d. It is only found in cases of congenital or hereditary foetal syphilis. 
3d. The seat of the lesion is different when the mother is affected, or 
when the virus is simply transported by the zoosperm to the egg. 
a. In the latter case the placenta is degenerated and the foetus is dis- 
eased, and the villi of the foetal placenta are filled with fatty granulations; 
their vessels are obliterated, and their epithelial coverings thickened or 
absent. DISEASES OF THE OVUM. 
243 
b. The mother being infected, one of three conditions may be present: 
1. If the mother is infected during the generative act, at the same 
time as the foetus, syphilitic foci will often develop in the maternal pla- 
centa (placental endometritis.) 
2. If the mother is syphilitic before conception, or becomes so shortly 
after, the chances of the placenta remaining healthy are about even. In 
the latter cases the endometritis gummosa of Virchow is observed. 
3. If the mother is not infected until after the seventh month of preg- 
nancy, both foetus and placenta escape entirely. 
4. Infection of the foetus during delivery has not been proved. 
Macdonald, in 1875, noticed hyperplasia of the villi in cases of paternal 
origin. The vessels are especially affected, and there is considerable peri- 
vascular hyperplasia, followed by vascular atrophy and disappearances of 
the villous tissue. The rest of the placenta is the seat of congestions and 
bloody effusions. In cases of maternal origin there is hyperplasia of the 
elements of the decidua, with compression and atrophy of the villi-in 
fact, the'endometritis of Virchow and of Slavjansky. 
When both mother and father are syphilitic, the lesions are mixed. 
Nevertheless, Tarnier and Depaul doubt the existence of specific lesions 
of the placenta. De Sinety, if he has not found lesions in every case, has 
proved that the following three important changes may occur. 
1. Hypertrophy of the villi, which may be doubled, or even tripled in 
size. 
2. Fibroid degeneration of the villi. 
3. Nodules of cheesy-degenerated granulations. 
The coincidence of the fibroid and caseous degenerations is found in 
syphilitic gummata, and notably in those of the liver, and although de 
Sinety has not found this ensemble of lesions in any other disease than 
syphilis, he does not enter upon the question of the specific nature of the 
lesion; he does not deny that a disease other than the pox may cause them, 
but he suspects syphilis when he finds all three lesions. In two cases his 
surmises have been clinically confirmed. (Duchamp.) 
Albuminuric Changes. 
Chantreuil has found, m a certain number of albuminuric women, pla- 
cental lesions consisting of whitish plaques, some of which the micro- 
scope showed to be tissue in a state of fibro-fatty degeneration. Others 
again were merely collections of fibrin. They were fatty degenerations of 
the placental villi, and apoplexies. There was a placentitis albuminurica, 
analogous to the retinitis albuminurica. 
Adhesions of the Placenta. 
The two most complete works upon this subject are those of Van Lyn- 
seele, and of Hegar. The latter found adhesions in cases of abortion, of 244 
A TREATISE ON OBSTETRICS. 
premature labor, and of delivery at term, and showed them to be due to 
such pathological processes as degeneration of or hemorrhage into the pla- 
centa, and inflammations of its parenchyma, of the decidua, and of the 
tissues about the uterus. 
1st. Tn cases of abortion and premature labor there is an arrest in the 
process of involution of the placenta. Retention of the placenta occurs 
from the intimate union between the maternal placenta and the uterine 
parietes, from separation of the maternal from the foetal placenta, from 
the want of energy in the uterine contractions due to incomplete develop- 
ment of the muscular layer, from the resistance of the cervix, and from 
pathological processes of the uterus, of the appendages of the egg, and 
of the organs in the neighborhood of the womb. 
2d. In cases of vesicular mole, to which we shall presently return. 
3d. In case of exudative processes, and of extravasations into the pla- 
centa. 
That adhesions from primary exudations from the uterine wall do occur, 
has been anatomically demonstrated. (Obs. of Stradfort, Chiari, Clay, 
Braun, Wrisberg, Hegar, Simpson, Meckel, Hiiter, Siebold, Stoltz). The 
placental tissue may appear solid, anaemic, and white, or, on the contrary, 
it may be soft, friable, and brownish, but it is firmly attached to the 
uterus by the uniting layer. Thus the placenta is easily torn, and frag- 
ments remain in the uterus at the time of delivery. 
Some authors have described adherent placentas in a condition of 
atrophy; they were dry, small, and anaemic. 
When the adhesions are secondary, they occur in consequence of exu- 
dations and extravasations into the parenchyma of the placenta, or be- 
tween it and its membranous covering. The uniting layer of the mucosa 
participates in the lesion by extension of the morbid process, by the irri- 
tation which the pathological product causes in its vicinity, and by the 
modifications of the circulation which it effects. The effusions poured out 
between the membranous coverings and the foetal surface of the pla- 
centa most often extend to the periphery, following the ramifications of 
the umbilical vessels along the external surface of the chorion, and with 
prolongations extending to the decidua. 
These placental adhesions may be spread out as membranes or may 
form bands and cords. They rarely extend over the entire uterine sur- 
face. 
Causes.-These may be diseases of the, foetus, of the umbilical vessels, 
of the amnion, or of the chorion; or they may be obstacles to the umbi- 
lical circulation, hemorrhages and effusions, or endometritis. 
Hegar believes that he can recognize them during pregnancy, but the 
symptoms that he gives are of very doubtful value. DISEASES OF THE OVUM. 
245 
Moles. 
Mole was the name formerly given to the fibrinous masses which women 
sometimes pass during menstruation, and also to the altered products of 
abortion. Hence the distinction between true moles and false moles, 
which were further classified according to their appearance as fleshy, ves- 
icular, and watery moles. Now-a-days, under the name of the hydatid or 
vesicular mole, or the designations of cystic degeneration of the chorion 
and the placenta, dropsy of the chorional villi, myxoma of the placenta, 
all authors describe a peculiar placental alteration, characterized by the 
production of more or less pedunculated vesicles, and sometimes forming 
a very considerable mass. 
Madame Boivin distinguishes four kinds of moles: 1st. The red, fleshy, 
and vascular mole, due to abnormality of the sanguineous system of the 
embryo. 2d. The white, hydatid or vesicular mole, due to lesions of the 
membranous shell of the egg. 3d. The complex, fleshy and vesiculai' mole, 
due to lesions of both portions. 4th. The embryonal mole, composed of 
an embryo and a mole, due to the partial degeneration of one germ, and 
the complete degeneration of another. 
Madame Boivin insists that the vesicular mole is always the product of 
sexual intercourse, and states in proof thereof, that its enveloping mem- 
brane is entirely analogous to the epichorion or decidua. This enveloping 
membrane is sometimes expelled entire with its hydatid contents, and it 
is, like the decidua, the bond of communication between the body which 
it encloses and the matrix to which it adheres. 
If the decidua is adherent, it may not be expelled with the vesicular 
mass; it may putrefy and exfoliate and gradually break down and flow 
away, exactly as occurs after ordinary delivery. 
Time of the First Hemorrhage, and its Duration in Hydatid Gestation. 
Names of Authors. 
Time of first 
hemorrhage. 
Time of 
delivery. 
Duration 
of flow. 
Dumancean, . 
. at 45 days. 
at 8 months. 
6| months. 
Mme. Boivin, . 
qq 
45 
QQ 
" 4 
QQ 
Bi 
QQ 
Littre, . 
Qi 
2 months. 
" 6 
QQ 
4 
QQ 
Crawfort, 
qq 
3 
QQ 
QQ ry 
QQ 
4 
QQ 
Sonville, 
QQ 
3 
QQ 
" 7 
QQ 
4 
QQ 
Percy, . . 
QQ 
3 
QQ 
" 8 
QQ 
5 
QQ 
Mme. Boivin, . 
QQ 
3| 
QQ 
" 8 
QQ 
QQ 
Pichart, 
QQ 
4 
QQ 
" 4 
QQ 
Millot, . 
QQ 
4 
QQ 
" 4 
QQ 
Delamotte, 
qQ 
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A TREATISE ON OBSTETRICS. 
Duration of Hydatid Gestation. 
Observations in 28 Cases. 
Woman delivered at 14 months, .... 1 case. 
" " " 11 .... 1 " 
" " " 10 " .... 3 cases. 
" " " 9 " .... 3 " 
" " " 8 .... 4 " 
"7 " and 8 days . . 1 case. 
" 7 . 1 " 
" " "6 11 . . . . 5 cases. 
" " " " . . . . 2 " 
Ci iC 4 Ci 2 Ci 
" " " 3 " .' .' '. 4 " 
28 cases. 
Dubois and Desormeaux describe three varieties of hydatid mole: 1st. 
The embryonal hydatid mole. 2d. The hollow hydatid mole. 3d. The 
hydatid mole en masse. 
The first variety consists of a membrane, vesicular on its outer surface, 
with an internal cavity containing a foetus or parts of one, and possibly 
fluid. 
The second kind is like the first, save that its cavity contains only fluid, 
and possibly a remnant of the umbilical cord, the foetus having been dis- 
solved. 
The third variety is distinguished by the enormous development of the 
hydatid bodies, and the more or less complete effacement of the central 
cavity formed by the amnion, the place of which is taken by a mass of 
soft, yellowish, spongy tissue. 
Moles of all kinds are covered by a thick membrane, which is in imme- 
diate contact with the uterus, and which is nothing but the decidua. 
Cayla has sought to prove that the hydatid moles are only uterine vil- 
losities, modified in shape and size by the accumulation of fluid within 
their cavities. He thus describes what he calls dropsy of the chorional 
villi. " The pedicle of the villus forms a membranous tube filled with 
serosity, and some | to one inch in length. At the point where the pedi- 
cle begins to branch, the dilatations or hydatid vesicles begin to develop. 
They may be as large as a hazel-nut, or so small as to be hardly visible, 
smaller vesicles often springing by a short pedicle from the larger ones; 
the pedicle being the non-dilated portion of the branch. The flow of 
fluid is free from one vesicle into another. Curious groups of vesicles 
of varying size and shape are thus formed. Each vesicle is oval, spheri- 
cal or pear-shaped. Occasionally one will be found triangular, or even 
cylindrical in shape. A few are more irregular, and have prolongations 
in various directions. The microscope shows small cysts upon the pedi- 
cles or on the walls of the vesicles; these are vesicles in process of forma- 
tion. DISEASES OF THE OVUM. 
247 
a Texture of The Hydatid Bunches.-They are usually easily isolated, 
though they may be more or less intimately interlaced, when they form a 
mass of cysts as thick as the placenta, in the centre of which nearly nor- 
mal villi may be found. 
" Contents of the Vesicles.-The walls are thin, semi-transparent and 
resisting. The contents consist of a transparent, reddish, serous fluid, 
albuminous and coagulable by alcohol and nitric acid. There is no trace 
of cysticerci or echinococci. 
Fig. 22.-Hydatid Mole.-This mass, which-weighed 2 pounds 2 ounces, preserved the shape of 
the uterine cavity in which it was enclosed. On opening it, a certain quantity of the hydatid 
vesicles that it contained escaped. Two membranous layers could be distinguished; the first, a, the 
external or uterine membrane, analogous to the epichorion or decidua; the second, b, thin and 
transparent and apparently consisting of the remains of the chorion, c.c.c, Granular vesicles, d. 
Free vesicles, e.e, Oblong vesicles. /./, bud-like vesicles. (Mme. Boivin.) 
11 Two varieties of special cells were found in equal and limited numbers 
in this fluid. 
"The first are spherical, transparent and regular with one or two round 
nuclei, and contain fine gray molecular granulations. The nuclei con- 
tain a small brilliant nucleolus. They are unlike any known anatomi- 
cal element. 
" The second variety belongs to the class of pavement epithelium and 248 
A TREATISE ON OBSTETRICS. 
are exactly like the cells of that tissue save for the brilliant, yellowish, 
molecular granulations that they contain. It is difficult to understand 
the origin of these cells if we admit that the cysts were formed, after the 
penetration of the vessels; for there is no pavement epithelium in capil- 
laries. 
" The walls of the vesicles are formed by the chorional tissue. They 
contain a large number of brilliant molecular granules, or sometimes, in- 
stead of that, very fine grayish grains. Thus the hydatid vesicles are 
nothing but dilatations of the chorional villi." 
We have seen that the dropsy may occur when the placenta is com- 
pletely organized, but that it may take place much earlier is shown by the 
isolated vesicles, and by the examples of eggs expelled entire, whose 
whole chorional surface was covered with groups of vesicles, proving that 
the alteration occurred at a time when the chorion was entirely villous. 
Clots of varying consistency and color are almost invariably found in 
the midst of the vesicular mass, which may explain the coloration of the 
vesicles. Amnion and chorion showed no lesion. The weight varies, 
and may reach eleven pounds. 
Depaul, accepting the division of Dubois and Desormeaux, seeks to ex- 
plain the nature and occurrence of the various elements encountered in 
the vesicles thus: 
4 ' The vesicular liquid is, at first, transparent, and any reddish tinge is 
due to blood temporarily in contact with the vesicles, the haematin of 
which has been dissolved and has reached the fluid, for Robin found no 
blood globules in the fluid he examined. The rupture of the allantoic 
vessels, then, causes the color. We do not know where the epithelial 
cells come from any more than we know the real cause of the dropsy of 
the villi. 
" What are thecauses of the differences observed in the various hydatid 
moles? 
" In the first place, the membranous envelop of the mole must be 
the decidua. Each vesicle, like the chorional villus from which it has 
sprung, is in intimate relationship with the internal surface of this mem- 
brane. 
" The dropsy always begins early in embryonal life. If it occurs at the 
very beginning, the villosities which cover the entire surface of the egg 
will undergo hydatidiform degeneration. The embryo and its membranes 
will be dissolved, and we will have the mole en masse of Desormeaux asd 
Dubois. 
" If it occur later, the amniotic cavity will persist, though the foetus 
will be dissolved, and we will have the mole hollow. 
"As to the third form, the embryonal mole, the dropsy also dates from 
the first period of embryonal life, but a portion only of the villi are in- 
volved, being those which were nearest to the inter-utero-placental de- DISEASES OF THE OVUM. 
249 
cidua. The allantoic vessels in the other villi sufficed to maintain the life 
of the embryo; when they became involved, death of the foetus ensued." 
Though the arrangement in clusters of Caylais evident in quite a num- 
ber of cases, it cannot always be demonstrated, on account of the fre- 
quently intricate interlacement of the villi, even in the normal state. 
Cruveilhier, therefore, has given a somewhat different description of the 
mole. He claims that the vesicles are not bunched, and are not united 
by a common pedicle, but that they are joined to one another by num- 
bers of delicate filaments. 
Ancelet has observed the same thing, and describes two forms of ad- 
herence for the vesicles, one by a pedicle, and the other by filaments. 
The pedicle, whose diameter is greater the less the vesicle is developed, 
represents a simple circular contraction, and is formed by the more or less 
intimate fusion of the internal membrane of two adjacent vesicles. 
The adhesion diminishes as the vesicles develop, and they assume a 
pyriform shape; then, as they tend to detach themselves, their fibro-cellular 
pedicle finally breaks. 
Do the vesicles communicate with each other? Vallisnieri and Cayla, 
and especially Shrokius, who insufflated them, say they do; Madame Boi- 
vin is doubtful; Ancelet could not prove it. As to their structure, Cru- 
veilhier says that the cyst membrane is composed of a single layer of 
transparent reticulated tissue; Pelvet has always found it formed of mole- 
cular granules; while Luys claims that it is fibroid and non-vascular. 
From these various opinions Ancelet concludes: that the vesicles are 
pendant in the uterine cavity, and are attached to a membrane that lines 
either the uterine parietes or the coverings of the egg, the decidua vera 
or reflexa. We may admit that, secreted by the glands of the uterine 
mucous membrane, they push its most superficial layer before them, and 
this most superficial layer, being less elastic, gives way, and is torn into 
filaments. This view is justified by the microscopic observations of 
Sirelius de Helsingfords, upon the modifications of the elements of the 
uterine mucous membrane during pregnancy. 
Ancelet concludes, with reservations, as follows: " The hydatid mole 
is a peculiar alteration of one of the surfaces of the deciduous membrane, 
arising under the influence of impregnation, and consists of the produc- 
tion by successive budding and exogenous multiplication of independent 
vesicles, adhering to one another, covered by a common membrane, and 
tending to become isolated as they develop." 
Ancelet thus returns to the ideas of those authors who consider the 
hydatid mole a disease of the decidua and not of the chorion; an evident 
error, since its seat is in the chorional villi. 
But there are still other opinions, which, while admitting the seat of 
the affection to be in the villosities, differ as to its nature. 
Virchow does not believe in any dropsy proper of the chorional villi, 250 
A TREATISE ON OBSTETRICS. 
but regards the affection as a hypertrophy of pre-existing mucoid tissue. 
This exists in the umbilical cord abundantly, and is called the gelatine of 
Wharton, and also in other portions of the foetus. We may denominate 
it imperfect fatty tissue, since in most cases it developes into that tissue 
later. 
It is a distinctly individual tissue, and the most typical tumors formed 
of it are found in the foetus during its early development, and in the 
membranes of the egg. These are the growths which have been described 
as hydatid, vesicular, or cystic mole, and which Virchow calls myxoma of 
the chorional villi. 
This condition is found, he says, almost without exception in the 
human egg after abortion, while it is rarely seen in labor at term. Usually 
a large mass of mixed blood and vesicles is expelled. On removing the 
former, the vesicles are seen to be united in clusters, so that each vesicle 
has a pedicle, and the larger vesicles give insertion upon their surface to 
smaller ones, which in their turn support others. 
Heinrich Muller, on the other hand, places the affection in the exter- 
nal membrane covering the villi, in the so-called exo-chorion; while 
Mettenheimer, whose opinion is shared by Pajot, claims that there occurs 
a cystic transformation of the cells contained in the interior of the villi. 
These contradictions are due, according to Virchow, to an incomplete 
knowledge of the structure of the chorional villi. Virchow was the first 
to show that the hypertrophied villi of the hydatid mole, as well as the 
normal villosities, consist of prolongations of the same mucoid tissue that 
forms the gelatine of the umbilical cord; that the villi are formed of two 
elements only: an epithelial covering (exo-chorion) and a substratum of 
mucoid tissue (endo-chorion), which only later becomes vascularized. 
The epithelial proliferation of Heinrich Muller is simply a stage in the 
normal development of that tissue. It is in the body of the papilla alone, 
and not in the epithelium, that the peculiar transformation occurs that 
leads to the production of a mole. 
In fact, these growths have been found on other parts of the envelopes 
of the egg, both Ruysch and Virchow having seen them upon the umbili- 
cal cord 
Normally, only those villi that correspond to the placenta develop pro- 
gressively; but if a pathological condition supervenes very early in preg- 
nancy, they all proliferate and become hyperplastic. Abortion usually 
follows; but it may happen that the placenta developes normally, only a 
certain group of villi becoming hydatid. Usually, however, the affection 
is situated just at the placental site, though only a portion of the cotyle- 
dons may be affected. 
In any case the affection begins as a multiplication of nuclei and cells. 
Whether simple hyperplasia or a hydatid state results, it is very com- 
mon to find the isolated vesiculated cells which Virchow has designated DISEASES OF THE OVUM. 
251 
physaliphores. They are found in the epithelium as well as in the par- 
enchyma of the villi, but they have no relation to the development of the 
vesicular mole. The morbid process corresponds to that described as the 
mucoid degeneration of cells. Virchow does not deny that some cells 
may disappear, or may undergo a fatty change; but they often persist in 
great number, and the principal accumulation of mucus occurs in the in- 
tercellular tissue. Where this accumulation is relatively large, 'the tissue 
becomes cystic in appearance. Where the fibrinous portions are in ex- 
cess, a simple hyperplasia results. 
Thus these tumors are formed. A villus, whose normal diameter may 
be hardly half a line, may be dilated to half an inch or more. The 
larger they get the more characteristic they become of mucoid tissue. 
They become clear, transparent, and gelatiniform; they contain a ropy 
liquid which gives the reactions of mucin. 
The vesicular appearance depends upon the delicacy of the liquid-filled 
tissue. 
This development has nothing to do with the vessels; but if it occurs 
late in pregnancy, the vesicles may become the seat of an extremely rich 
capillary plexus. But vessels are usually absent, at least in eggs coming 
from the first months; and dropsy of the amnion and atrophy and death 
of the fcetus occur in consequence of the disease, which cuts off the cir- 
culation. 
Hence, the different descriptions given by authors, and the three kinds 
of hydatid mole; they are only degrees of one and the same lesion, vary- 
ing from a simple faulty conformation to complete destruction of the 
fcetus and the cord. 
Most authors regard the disease of the membranes as the primary, and 
that„of the foetus as the secondary and consecutive affection. 
Hewitt has returned to the first theory, and it is the true one; for no 
one has yet shown that the placenta continues to grow when retained 
after the death of the foetus. The villosities remain intact; and besides 
this, the condition in question is found in carnified and sanguineous moles 
as well as in those of the hydatid variety; but it is very likely that the sec- 
ondary condition is not then due to a myxoma, but to the hemorrhage 
which produces the so-called carnified mole. 
Finally, and it is a most important argument, partial myxomata of the 
placenta occur in children which are well developed, and which have 
died during the last months of pregnancy. 
The lesion of the membranes is then the original one. Does it begin 
as an irritation of one of the uterine surfaces, or does it* come by the 
blood of the mother ? The fact that women sometimes have hydatid moles 
several times, and that in them the decidua plainly shows traces of inflam- 
matory thickening, and even, according to Virchow, little polypoid excres- 
cences, is favorable to the former view. A more or less extensive endo- 252 
A TREATISE ON OBSTETRICS. 
metritis will cause such hypertrophy of the villi, that each one will form 
a true, independent tumor, and will not only deprive the embryo of the 
nutritive materials which they should supply to it, but, when that embryo 
is destroyed, can continue to live and furnish a perfect example of a true 
parasitic tumor, heterologous even to the mother's body, and yet proceed- 
ing from it. 
The theories concerning the vesicular mole may be summed up, as 
Duchamp says, in the following propositions: 1st. The vesicular mole is 
entirely independent of pregnancy; 2d. The vesicular mole increases 
under the influence of pregnancy, but is not due to disease of the egg; 
3d. The vesicular mole is due to a change in the product of conception, 
from-a. Alteration of the vascular walls (Cruveilhier); b. Alteration 
of the lymphatic vessels; c. Dropsy of the chorional villi (Robin. 
Cayla); d. Myxomatous degeneration (Virchow and the Germans, Erco- 
lani, Damaschino, Cornil, Ranvier, Ilirtzmann, 1874, Josephson, 1879). 
The vascular and lymphatic theories are untenable, and if true hydatids 
have been expelled from the uteri even of virgins, they bore no likeness 
to the clusters of the vesicular mole. 
Ancelet's idea, that it is a disease of the decidua, is wrong, since the 
degenerated villi might contract adhesions to the decidua without that 
membrane being affected; besides which the villosities have been seen to 
be continuous, by their pedicles, with the chorion. 
Ruysch and Cruveilhier's vascular theory is disproved by the fact that 
the vessels are not dilated, but obliterated; and the theory of the lym- 
phatics is in complete opposition to the structure of the villi. 
There remain the two theories of Robin and of Virchow. Both place 
the morbid change in the villi, but Robin claims that the vesicle contains 
nothing but a fluid, in which a few cells float freely, while Virchow holds 
that what fluid there is, is simply the intercellular fluid of a tissue. The 
following reasons favor the latter opinion: 1st. The normal villus con- 
tains mucoid tissue; it is not astonishing that it should hypertrophy; 2d. 
The vesicular fluid contains mucin; the following is Gscheidlen's analysis: 
Chloride of sodium, . . . . . . 3.34 
Phosphoric acid, . . . . . . . 0.74 
Albumin, . . . . . . . . 6.12 
Mucin, . . . . . . . . 2.94 
Salts, 6.25 
3d. Virchow, Cornil, Ranvier, Malassez and de Sinety, have demon- 
strated the identity of the vesicular mole with myxomata of other regions. 
Causes.-rI*he vesicular mole is rare, and is found oftenest in multiparas 
of twenty-five to forty years. A molar pregnancy is apparently, to a cer- 
tain extent, a predisposing cause. As to its etiology, Ruysch, Scanzoni 
and Graily Hewitt, find it in the death of the foetus; but moles have 
been found with living children. Virchow attributes it to endometritis, DISEASES OF THE OVUM. 
253 
and this is the generally received opinion in Germany to-day. It is prob- 
able that the myxomatous lesion begins in the abundant mucoid tissue of 
the villosities, and that this tissue becomes infiltrated with fluid. 
Symptoms.-According to Depaul three symptoms are generally found; 
but they may be wanting, in part at least: 1st. Rapid and exaggerated 
development of the abdomen not in accordance with the period of preg- 
nancy (Boivin, Depaul); 2d. Small and frequent hemorrhages of a 
peculiar character. According to Percy, there is an alternation of small 
hemorrhagic and watery flows, commencing in most women at the second 
month, and continuing at longer or shorter intervals until parturition. 
Gardien observes that 'the expulsion of hydatids is usually accompanied 
by hemorrhages and syncopes, and Depaul has observed the same pecu- 
liarity; 3d. The expulsion of clusters of vesicles, or of isolated ones. 
This pathognomonic sign is unfortunately rare, and when it does occur, 
it is usually shortly before the expulsion of the entire mass. 
Diagnosis.-The diagnosis is based upon these symptoms, and is diffi- 
cult to make. The first symptom occurs in false pregnancies, and with 
ovarian cysts. The second would lead one to think of cancer of the cer- 
vix, and of a vicious insertion. The third is rare, and appears too late. 
To make the diagnosis, therefore, both the first signs must be present 
during the first months of pregnancy, when uterine development is more 
easily appreciated, and a faulty placental insertion is not likely to be ac- 
companied by frequent hemorrhages. 
The older authors did not consider the mole as always due to preg- 
nancy, and claimed that the mammae did not develop. That is not the 
case, for Cartereau has demonstrated the abundant presence of milk. 
They said the mother did not feel life; but there are moles where the child 
is born living, and at term. Finally, the uterus shows the ordinary ine- 
qualities, and all the signs of pregnancy, nausea, vomiting, etc., may be 
present. 
Prognosis.-1st. For the Mother-Is grave. In many cases the mother 
succumbs, not from the development of the mole, but from hemorrhage. 
The only instance where death could be attributed directly to the mole 
is that of rupture of the uterus mentioned by Madame Boivin. The 
hemorrhages are usually moderate at first, and usually only become seri- 
ous towards the end of pregnancy, and at the moment of expulsion. 
There are several instances on record of women who have had several 
vesicular moles (Depaul cites one in which it occurred three times); but 
as a rule, it happens only once, and does not predispose to a recurrence. 
2d. For the Child.-It is always serious. In the two first varieties, the 
child is liquified or dead; in the third it is almost always injured and ail- 
ing, and ill-prepared for life. 
Treatment.-We can only treat the hemorrhage as an accident of the 
pregnancy. General measures and expectant treatment, if it is slight; 254 
A TREATISE ON OBSTETRICS. 
tamponing, if it is severe. The expulsion of a few vesicles during the 
pregnancy does not affect the treatment. If labor has commenced, and 
the hemorrhage is serious, tampon again if it is thought that the hydatid 
product cannot be extracted. If, however, that can be done either manu- 
ally or with forceps, it should be at once resorted to. 
Finally, Breslau, Eberth, and Spiegelberg, have described another form 
which they call diffuse myxoma of the membranes. It consists of a mucoid 
infiltration of the chorion by a homogeneous mucoid substance with thick 
fibres, with round or star-shaped cells, partly physaliphores. The amnion 
is thickened, and the intermediate layer but little developed, being com- 
pletely absent in places. The superior chorional surface shows numer- 
ous flattened, slightly fluctuating processes, from pea to cherry sized. A 
partial myxoma of this kind has been demonstrated by Rokitansky and 
Winogradow. The latter found a goose-egg sized mucoid mass, soft, 
trembling like jelly, and absolutely analogous to Wharton's gelatine, 
some three inches distant from the placenta. 
Diseases oe the Amnion. 
Like the decidua and the chorion, the amnion is subject to various 
lesions ; but there is one of more importance than all the others from its 
influence upon the mother and the foetus. We refer to what is known 
as dropsy of the amnion or hydramnion. 
Dropsy of the Amnion. 
Dropsy of the amnion, or hydramnion, consists of an exaggerated collec- 
tion of fluid in the amniotic cavity. As Guillemet remarks, it is difficult 
to fix the limit at which the amount of the liquor amnii becomes morbid, 
since it varies considerably in a state of health. It is, therefore, from 
the phenomena that result therefrom that, in the absence of any precise 
point of departure, we decide what is dropsy of the amnion. But these 
phenomena themselves vary with the individual, and with the rapidity 
with which the secretion accumulates; so that an arbitrary limit has been 
fixed upon, and all authors agree that when the quantity of the fluid ex- 
ceeds 32 to 48 ounces there is dropsy of the amnion. 
Frequency.-If we followed the statistics we should hold that hydram- 
nion is rare, occurring hardly once in 100 to 150 confinements; but it is 
really far commoner. Typical cases, with enormous accumulation of 
liquor amnii are rare, it is true, but a relative abundance is often seen, 
the ordinary cases passing unnoticed; for the accidents that occur from 
it depend more upon the rapidity of accumulation than upon the amount 
of the fluid. This accumulation is usually slow and progressive, and is 
well borne; but sometimes the effusion is more rapid, and the womb, forced 
to distend itself suddenly and excessively, rebels, and gives rise to certain 
peculiar symptoms. Jacquemier and Oulmont only have carefully studied DISEASES OF THE OVUM. 
255 
these cases. We ourselves have seen two, which are described, together 
with those which we have been able to collect, in our memoir on hydram- 
nion, 1880. 
Etiology.-We must now return to the theories as to the origin of the 
liquor amnii. The theories concerning it may be reduced to three: 1st. 
It is of foetal origin; 2d. It is of maternal origin; 3d. It is of foetal and 
maternal origin. 
1st. The liquor amnii is of foetal origin.-We may dismiss the ridicu- 
lous theories of Bohn, who derives it from the mammary glands; of Lis- 
ter, who drawsit from the salivary glands; of Warthon, who believed that 
it was a product of the gelatinous matter of the cord, and even of the 
lachrymal glands. The following hypotheses are possible: a. The liquor 
amnii is due to secretion from the skin; b. It is due to secretion from 
the kidneys; c. It is due to a transudation of the liquid parts of the 
foetal blood, through the amniotic membrane; d. It is a peculiar secretion 
of the amnion. 
a. The liquor amnii is secreted by the skin. 
This theory originated with Galen. Scherer says that since the vernix 
caseosa has the same composition; since Schwann found pyine in the 
foetal skin, and Eicholz mucous matter in the new-born at term; since the 
umbilical cord produces a larger quantity of water than its return vessels 
can carry away; that, therefore, the foetal skin excretes a watery fluid. 
Nevertheless, the liquor amnii is not exclusively produced by the skin, and 
the presence of the various materials in the amniotic fluid is due to a 
simple mixture. 
Schatz attributes a considerable influence to the skin upon the forma- 
tion of the liquor amnii during the latter half of pregnancy. The high 
temperature to which the foetus is subjected causes excessive secretion of 
the sweat, and the liquor amnii contains the constituents of that secre- 
tion. During early intra-uterine life, before the sudoriporous glands are 
formed, the liquid parts of the foetal blood transude through the integu- 
ment. Bar denies this, since he never found ferrocyanide of potassium, 
injected into the veins of a pregnant rabbit, in the liquor amnii. 
b. The amniotic fluid is due to the urinary secretion and to the excretion 
of the urine by the fcetus into the amniotic cavity. 
Gusserow claims, that since there must be in the foetus an exchange of 
nutritive materials and activity of function, after the obliteration of the 
allantois at the second month, the urine must flow into the liquor amnii; 
and urea and ammonia, absent at first, increase in quantity in the liquor 
amnii as pregnancy progresses. The amniotic fluid is thus a foetal secre- 
tion. 
That the foetus does secrete urine is incontestible, and, as Bar has re- 
marked, may be demonstrated in three ways: 1st. By anatomical observa- 
tion, showing that the kidneys functionate normally during uterine life, 256 
A TREATISE ON OBSTETRICS. 
since urine is almost always found in the bladder at birth; 2d. By patho- 
logical observation, which teaches us that, when there is obliteration of 
the urinary passages, hydronephrosis of greater or less extent occurs. The 
kidneys are normal, save where modified by the pathological process, 
and the liquid contained in the urinary passages has the chemical com- 
position of urine. If, in these cases, the amount of liquor amnii is not 
diminished, it is simply because the excretion of urine is not the only 
source of the liquor amnii. Finally, uric acid infarctions have been found 
in the kidneys of infante. 3d. By experiment, Fehling, Gusserow and 
others have shown that certain medicines either absorbed by the mother, 
and thus passing through the placenta, or injected directly under the 
foetal skin, could be refound in the urine of the foetus; 4th. By the 
chemical composition of the liquor amnii. 
Prochownick has studied the chemistry of the fluid, and has proved 
the presence of urea, and concludes that the liquor amnii is an exclusive- 
ly foetal product, and is derived from the nutritive materials of the foetus. 
The quantity of urea should therefore be proportionate to the energy of 
nutritive interchange. In point of fact it increases largely as pregnancy 
advances, and the kidneys begin to functionate. lie therefore concludes: 
1st. The liquor amnii always, after the sixth week of pregnancy, contains 
urea; 2d. It is produced by the skin and kidneys of the foetus; 3d. The 
quantity of urea during the last third of pregnancy is proportionate to 
the length and weight of the foetus. 
In a second chapter he proves that the liquor amnii contains chloride 
of sodium, and from a quantitative analysis of the liquor amnii, he con- 
cludes: 1st. The liquor amnii is exclusively a foetal product, and is the 
product of the interchange of foetal nutritive materials; 2d. It is secreted 
by the skin and the kidneys; 3d. The secretion by the skin begins early 
in pregnancy; that by the kidneys commences only at its middle; 4th. 
The amnion is a serous membrane, and can absorb; 5th. This absorption 
becomes more and more easy as pregnancy advances; 6th. The concentra- 
tion of the amniotic fluid increases during the first half of pregnancy, 
decreases rapidly at its middle, and thus remains about the same until 
its termination; 7th. The amount of the fluid at various times will be 
noted later. 
Fehling holds that the albumin in the liquor amnii precludes the pos- 
sibility of its being a purely urinary secretion, since there is none in the 
urine of living children, and that there is no more urea in the fluid of the 
amnion than in other serous fluids. 
c. The liquor amnii. is due to a transudation of the fluid portions of the 
blood through the amniotic membrane. 
Both Monro and Lobstein have seen fluid percolate through the inter- 
nal surface of the amnion after injecting hot water into the umbilical 
arteries; and Jungbluth has found a minute capillary net-work, which he DISEASES OF THE OVUM. 
257 
calls the vasa propria, in the superficial placental layer nearest to the am- 
nion, which is almost always obliterated in the later months of preg- 
nancy. This he considers as the source of the liquor amnii, and hence 
it is that that fluid is nearly identical with blood serum in composition. 
An excess of pressure in the foetal circulation will cause a transudation in- 
to the amniotic cavity from this capillary plexus, although of course, 
when we consider the length of the cord and the multiplicity of its spirals, 
the arterial pressure can be but feeble. 
Gassner considers Jungbluth's explanation as only partially sufficient, 
since the liquor amnii increases during the second half of pregnancy, 
when this capillary plexus has been obliterated. The foetal urinary se- 
cretion explains its continued increase, and explains the cause of Gassner's 
law, that the quantity of the fluid is proportional to the weight of the 
foetus. Thus the relative quantity of albumin decreases in the urine- 
diluted fluid, and therefore, in cases of occlusion of the foetal urinary 
passages in the later months of pregnancy, the liquor amnii is absent or 
nearly so. But while Jungbluth's theory will explain certain cases of 
dropsy of the amnion, there are others that it will not explain. 
Lebedjew seeks to answer the following two propositions: 1st. Does 
there exist, in the limiting chorional layer of children at term, in cases 
of dropsy of the amnion, the capillary net-work described by Jungbluth? 
2d. What circumstances determine this persistence of vascular permea- 
bility which is absent under normal conditions? 
Lebedjew has proved microscopically the existence of this plexus in a 
case of hydramnion with a dead child; but there existed aortic stenosis, 
hypertrophy of the right ventricle, and consequently stasis in the inferior 
vena cava. This obstruction to the flow would be transmitted to the 
placenta through the portal and umbilical veins. This probably interfered 
with the obliteration of the plexus in question, and determined the in- 
creased transudation. Lebedjew claims that dropsy of the amnion is due 
primarily to a foetal anomaly, and hence arises the large mortality in 
these cases 
Sallinger holds that the amniotic fluid is derived exclusively from the 
foetal circulation; coming at the commencement of pregnancy from the 
foetal skin, later from the cord and the vessels of the foetal placenta, and 
only towards the end, in greater or smaller quantity, from the kidneys. 
Only a small amount of fluid is derived, during the early months of preg- 
nancy, from the skin, which soon becomes covered with epidermis, and 
secretes less freely; the greater part of it is due to the resistance that the 
foetal circulation encounters in the placenta, and in the cord. Excess of 
resistance will cause dropsy of the amnion; and clinical observation shows 
that obstruction of the veins that bring blood to the foetus, either in the 
placenta or the cord, or at the umbilical ring or in the liver, is the 
cause of the affection. 
Vol. 11-17 258 
A TREATISE OX OBSTETRICS. 
Sullinger thus holds that hydramnion is due to mechanical disturb- 
ances of the foetal circulation, or to variations in the entire mass of the 
foetal blood, and not, as Jungbluth says, to special anatomical conditions 
of the placenta. Ue performed a series of experiments, which tended to 
prove that the liquor amnii, whether in normal or abnormal quantity, is 
a direct product of transudation from the umbilical vein and from its 
ramifications in the placenta. Taking healthy and untorn placentae, and 
introducing a canula into the umbilical vein, he injected under a con- 
stant pressure pure water and defibrinated bullock's blood. The injected 
liquids transuded through the amnion with great rapidity; thus: 
1st. With a pressure of 36 inches upon the single vein of a small cord, 
there passed in one hour 25.43 grains. 
2d. With the same pressure and a thick cord, 28.91 grains. 
lie once employed the double placenta of twins, and obtained: 
3d. With a pressure of 36 inches on both veins together, 56.31 grains. 
4th. With a pressure of 74 inches on the vein of the thick cord, and of 
36 inches on the vein of the thin one, in half an hour, 60.94 grains. 
5th. With a pressure of 50 inches upon the thin cord, and of 36 inches 
upon the thick one, in half an hour 75.61 grains. 
6th. With an equal pressure of 50 inches on both, in the same time, 
50.68 grains. 
Bar has repeated these experiments of Sallinger, and concludes with 
him: 
1st. Under a certain pressure the fluids contained in the umbilical 
vein may transude into the amniotic cavity. 
2d. Under an equal pressure fluids will not transude through the walls 
of the umbilical arteries. 
These two theories each have their partisans and their adversaries. 
Thus, Winckler has never been able to prove the existence of Jungbluth's 
capillary plexus, but believes that there is a lymphatic plexus in the cel- 
lular layer of the chorion, which opens freely into the cavity of the egg 
through the amniotic epithelium, exactly as occurs in the diaphragm. 
These canaliculi are the source of the fluid in dropsy of the amnion. A 
-considerable dilatation of these lymphatic vessels has been found by 
Winckler in a case of hydramnion complicated with foetal rachitis. 
Levison and Gusserow support Jungbluth's theory. The former, by 
means of injections into the vessels of the umbilical cord, found the capil- 
laries well developed in the membranous lamina of the placenta of pre- 
maturely born infants, while in those born at term, there was none; but 
in cases of hydramnion, either at term or before it, he found it very 
abundantly developed. 
Ue admits the presence of the lymphatic vessels which, with Winckler, 
play the part of the vasa propria of Jungbluth. May not, he asks, dis- 
turbances of pressure in the foetal circulation prolong the permeability of DISEASES OF THE OVUM. 
259 
the vasa propria of the placenta, and thus increase the amount of liquid 
that passes through them. 
Weil and Waldeyer also admit the existence of Jungbluth's vasa pro- 
pria. Bar contests their existence, claiming that Jungbluth never de- 
scribed them as being in the amnion, but only as being in contact with 
its lower surface, being situated below it. He denies the correctness of 
the designation vasa propria, especially as in the amnions of some of the 
lower animals there exist true proper vessels. The branches of the um- 
bilical vein that ramify over the foetal surface of the placenta, give off a 
capillary plexus that ramifies and anastomoses with itself, and then pene- 
trates the placental tissue. Injected with a colored fluid, the plexus be- 
comes visible to the naked eye. 
We, ourselves, have found a venous net-work applied to the deep face of 
the placenta; but never a capillary one. Nor have we ever been able to 
inject it with prussian blue. Nevertheless, we do not absolutely deny its 
existence. We have, ourselves, seen in cases of dropsy of the amnion a 
considerable turgescence of the branches of the umbilical vein; we have 
even in one case seen the chorionic vessels more largely open than in the 
normal state; but Jungbluth's description certainly does not apply to all 
cases of dropsy of the amnion, and permeability of the vasa propria, to 
the end of pregnancy, cannot be the sole cause of the affection. For: 
1st. If the vessels are obliterated at the middle of pregnancy, how can the 
quantity of the liquor amnii increase continuously until the time of preg- 
nancy ? 2d. We have been unable to demonstrate the capillary plexus in 
some cases of dropsy of the amnion. 
As to Winckler's theory of a sub-amniotic capillary plexus, Bar rejects 
it also. 
d. The fluid is a peculiar secretion of the amnion. 
The amnion, according to Hotz, is often covered with a layer of cylin- 
drical cells, and Kblliker records a case in which there were many am- 
niotic caruncles. Buttheir function is still entirely unknown. 
2d. The amniotic fluid is a product of the maternal organism.-Ahlfeld 
claims that in consequence of the eccentric hypertrophy of the uterus,.the 
pressure upon its contents is less than the abdominal pressure; and since 
it is a closed cavity, the maternal blood must necessarily flow into it. 
This negative pressure diminishes progressively up to the third month, 
when it ceases, the contents thenceforward developing equally with the 
organ itself. The serosity, in passing from the vessels to the egg, traverses 
the pores of the chorion and of the amnion, and the author has been able 
to prove the existence of blood-coloring matter in these pores, which had 
traversed the chorion and had penetrated to the epithelium of the amnion. 
Leopold agrees with Ahlfeld so far as the first months of pregnancy are 
concerned; and Zuntz, whose experiments have proved that substances 
injected into the maternal vessels may pass into the liquor amnii without 260 
A TREATISE ON OBSTETRICS. 
going through the body of the foetus, believes that, at least in part, the 
liquor amnii is derived from the maternal blood. Wiener and Bar have 
repeated Zuntz's experiments, and have arrived at the same conclusions. 
3d. The fluid is derived both from the mother and from the child.- 
This is Virchow's opinion; he holds that the foetal portion is composed 
of the vernix caseosa and renal secretion, the rest being essentially a ma- 
ternal transudation. 
As we see, theories are not wanting; but the real cause of dropsy of the 
amnion remains to be found. Whether we admit that the liquor amnii 
comes from the mother, or whether we believe, as is the more probable 
supposition, that it is produced by the foetus and the membranes, it in 
no way explains the occurrence of dropsy of the amnion. The following 
facts are to-day incontestible, and have been proved by various observa- 
tions. 
1st. Dropsy of the amnion coincides very frequently with twin preg- 
nancy. 
2d. Children born with the complication of dropsy of the amnion are 
often the subjects of malformations and monstrosities. 
3d. A certain number of women who have dropsy of the amnion are 
syphilitic, and their children, born dead or living, show unmistakable 
signs of the disease. Finally hydramnion is very rare in primiparse, and 
seems to be especially liable to occur after a certain number of preg- 
nancies. 
Mac Clintock, in 33 cases, found primiparse 5; second pregnancies 8; 
third to twelfth pregnancies 20. 
As to twin pregnancies, the following figures will suffice: 
Oulmont, in 14 cases, had 7 twin births. 
Guillemet " 28 " " 15 " " 
Sallinger in 81 cases, had: 
Primipara?, 19; Multipart, 49; Unknown, 13. 
Primiparae, 19, 
1 single child, ..... 10 
2 children, ...... 9 
1 single child, 31 
Twins, . . . . . . 16 
Triplets, 1 
Quadruplets, 1 
Multipart, 49, 
1 single child, 10 
Twins, 3 
Unknown, 13 
81 
Thus, in 81 cases there were : 
Simple pregnancies, 51 
Multiple " 30 
81 DISEASES OF THE OVUM. 
261 
In the 114 children, 1 of which was a case of extra-uterine pregnancy, 
there were: girls, 23; boys, 38; unknown, 53. 
Can we explain the coincidence of dropsy of the amnion with twin 
pregnancy? Is it exaggerated uterine development, or the stretching of 
the membranes, or compression of one foetus by the other, or is there 
anything peculiar about the circulation or the blood pressure, or in the 
arrangement of the placenta and membranes that accounts for it? It is 
impossible to say. We know that there may be one of four conditions 
present in these twin births: 
1st. A single placenta, chorion, and amnion, with a communication 
between the two foetal circulations. 
2d. A single placenta, chorion and amnion, with an almost constant 
communication between the two circulations; or one chopion and two 
amnions, with a rarer communication. 
3d. Two isolated placentae, united by a membranous bridge; rarely 
communication between the two circulations; often two chorions and two 
amnions. 
4th. Two entirely distinct placentae, two chorions and two amnions; no 
communication between the two circulations. 
Frankenhauser only seems disposed to admit hydramnion as possible in 
cases where there exists a communication between the two foetal circula- 
tions. In consequence, he claims that the cardiac activity of the stronger 
foetus causes cardiac stasis in the weaker one, and hence increased trans- 
udation on that side. Schatz agrees with this opinion, and says: " The 
child that has the more powerful heart will have the greater arterial pres- 
sure, will secrete more urine, and have more liquor amnii." To this Sal- 
linger rightly objects that in that case we should have hydramnion in 
twin pregnancy with an acardiac foetus; whereas this has not been found. 
Every variety of malformation has been found with dropsy of the am- 
nion, from hydrocephalus and spina bifida, to anencephalus, harelip, 
clubbed feet and hands, double monstrosities, etc. Internal deformities, 
malformations of the heart, imperforate genital organs, etc., have also 
been noted. 
And if some of these malformations, such as an imperforate urethra, 
will explain hydramnion, the others will not do so, and we must return 
to the opinion of Burns, who said: " Dropsy of the amnion is a disease of 
the egg, and not of the mother; the foetus is often deformed, and the 
affection must be considered as a species of monstrous conception." As 
to syphilis, Burns, in 1839, had already proved that hydramnion might 
occur with syphilis of the father or the mother. Fournier has recently 
again called attention to this relationship, as have Bourgarel, Preel, De- 
paul, Gucniot, Charpentier, Sallinger, etc. 
In some cases of hydramnion with syphilis, the foetus shows indubitable 
marks of the disease; but in others neither foetus, placenta, nor mem- 262 
A TREATISE ON OBSTETRICS. 
branes showed the least sign, and we are compelled to admit the effi- 
ciency of the maternal influence. To these three main facts-twin preg- 
nancies, foetal malformations, and syphilis-we must add lesions of the 
ovum and membranes of various kinds. 
In the four cases of syphilis we observed in two years of clinical ser- 
vice, there was but a single case of dropsy of the amnion. The woman 
had dropsy of the amnion in 1875, has since had two healthy children 
while under specific treatment, and is at the present moment enceinte 
for the fourth time, and shows a small amount of amniotic dropsy. 
The anomalies of the cord may cause a stasis in the venous circulation 
of the placenta. 
Hildebrandt has noticed the connection between these anomalies and 
the hydatid mole; indeed the hydatid mole is often accompanied by a large 
amount of liquor amnii. 
Among these anomalies of the cord, Sallinger notices: Extreme thin- 
ness; exaggerated torsion; cystic degeneration; stenosis of the umbilical 
vein; rings of the cord. 
There may be also cartilaginous and hepatic degeneration of the placen- 
tal tissue, fibro-myxoma of the placenta; atrophy of the placenta; hyper- 
trophy of the placenta ; abnormality of the hepatic circulation. On the 
side of the mother there may be hydrsemia, tumors, especially fibroids, and 
carcinoma uteri. 
As to the membranes themselves, they may be the seat of a multitude 
of inflammatory and other lesions, concerning which we have recorded a 
number of observations in our Memoire. 
Finally, Gervis decided that the liquor amnii came from the amnion, 
and its excessive accumulation was due to serous extravasation. In most 
cases we can detect either: 1st. Inflammation of the amnion; 2d. A hy- 
pertrophic and morbid decidua, the amnion remaining healthy; the foetus 
is compromised, and abortion is imminent; 3d. Dyscrasias of the mater- 
nal blood, such as cause serous transudations in other parts of the body. 
Symptoms.-By dropsy of the amnion, we mean a disease in which the 
amniotic cavity contains an abnormally large amount of fluid. It may 
exist alone, or be accompanied by other dropsies, as ascites (Scarpa); and 
it shows itself in two forms, sufficiently distinct, though not very sharply 
divided from one another. One is the slower, classical form; the other, 
more acute, has been described by Oulmont and Jacquemier. The 
symptoms are different enough to justify expectant treatment in the one 
case, and to call for active interference in the other. Let us first de- 
scribe the symptoms of the ordinary classical dropsy of the amnion. 
Gassner has found that there is, on the average, 
At 7 months, 32 ounces, 
" 8 " 43 " 
" 9 " 54 " 
" term, 60 " 
of liquor amnii. DISEASES OF THE OVUM. 
263 
This quantity is doubled in twin pregnancies. The figures, of course, 
are not by any means exact. Gassner also found that, in general, the 
amount of liquor amnii increased proportionately with the weight of 
foetus and placenta. The amount of fluid present with hydramnion is 
very variable. Sallinger has collected the following cases: Schneider, 60 
pounds, 24 pints; 0. Reilly, 48 pounds, with 20 pounds of ascitic fluid; 
Hansen, over two buckets full; G. de Gorregues Griffith, 40 pounds; 
Battson, 32 pints; Haerlin, 30 pounds; Klink, more than a bucket 
full; Pelletan, 2£ pounds; Werner, 15 pounds; Rouger, 15 pounds; 
Martin, 14 pounds; Ridder, 14 pounds; Ramsbotham, 15 pounds, with 
25 to 30 pounds of ascitic fluid; Valenta, 5 pounds; Fabrice de Hilden, 
27 pounds; Sallinger, 30 pounds. 
it thus takes five pounds to cause trouble during pregnancy and child- 
birth ; but as a rule the amount varies between 10 and 60 pounds. 
Qsually the disease does not commence before the fifth or sixth month 
of pregnancy, although it occasionally appears earlier. Thus the case 
of Fabrice de Hilden dated from the beginning of pregnancy; those of 
Scarpa, Schneider, Hahn, Depaul, and Menschler, from the end of the 
second month; those of Martin, Pelletan, and Gueniot, from the third 
month; that of Rausch, Werner and Rouger from the fourth month, and 
that of Seulen from the fifth month. 
The first symptom is the appearance of persistent vomiting, followed by 
general enfeeblement, and marked emaciation. But these symptoms are 
not constant, and much more characteristic are the pains, which are seated 
sometimes in the belly, sometimes in the hypogastrium, or even in the 
sacral, inguinal, or lumbar regions; they are usually continuous, though 
they may be intermittent and take on the character of uterine contrac- 
tions. They do not appear, usually, until pregnancy has advanced to a 
certain point. 
Then comes a rapid and exaggerated development of the abdomen, ac- 
companied by thinning of the uterine parietes, and by fluctuation. This 
sensation of fluctuation is never seen in normal pregnancies, and has been 
found so pronounced as to have been mistaken for ascitic fluctuation. 
More often, however, there is a sensation of false fluctuation, exactly like 
that experienced in cases of ovarian cysts. We will return to this subject 
when we come to speak of diagnosis. 
The abdominal development usually begins early in pregnancy, but 
does not become very marked until after the fourth or fifth month. Al- 
though it advances rapidly, and out of all proportion to the supposed 
stage of the pregnancy, it progresses evenly, and may reach an enormous 
development. Hence the morbid symptoms are not very intense, and it 
is only after the disease has existed for some time, that the women begin 
to suffer much. The uterus, in fact, does not react very energetically 
against the progressive liquid accumulation. Hence the relative tolerance 
to and benignity of the affection. 264 
A TREATISE ON OBSTETRICS. 
In consequence of the abdominal distension and increased intra-abdomi- 
nal pressure, oedema appears. It may be limited to the lower limbs, or 
appear on different parts, such as the genitals or the abdominal wall. 
But its consequence may be more serious, and ascites appear. (Edema 
is not a constant symptom, and is absent in many well-pronounced cases. 
In consequence of the great abdominal distension, other symptoms ap- 
pear indicative of compression of the lungs: dyspnoea, oppression, engorge- 
ments of the base of the lung, oedema pulmonum, with syncopes and as- 
phyxias, and in some cases even real hemorrhages. 
Cardiac palpitation naturally ensues, and the pulse becomes small and 
frequent. 
The urine is diminished in quantity; it is thick, reddish, and more or 
less highly charged with albumin. A dysuria more or less pronounced 
appears at the same time; and in rare cases there may be some icterus. 
Constipation is the rule. Then nervous troubles appear, vague neural- 
gic pains, especially marked in the lower limbs. 
Insomnia, with agitation and depression of spirits, may now appear; 
and in some rare cases psychic troubles, delirium, trismus, and even 
eclampsic attacks may follow. 
It is a curious fact noticed by Sallinger, that in most cases there is no 
fever. 
The extreme distension of the abdomen causes thinning of the uterus, 
the vagina is shortened, the cervix effaced, and often partly open. The 
presenting part is very mobile, and ballottement is very marked. 
The foetal heart-sounds are usually feeble; they change their place, and 
sometimes become inaudible towards the close of pregnancy; in some cases 
they may never have been perceived. 
The hyper-distended membranes are often ruptured too early, and pre- 
mature labor occurs. 
Finally, metrorrhagia is common during pregnancy, and occurs during 
labor, and especially after delivery from uterine inertia. Such are the 
principal symptoms of dropsy of the amnion; but we must consider some 
of them more in detail, especially the abdominal tumor, and the sensa- 
tions obtained by palpation. 
The shape of the abdomen is peculiar. In the place of a distinct pro- 
tuberance surmounted by a depression, the belly is evenly swollen, es- 
pecially in front, while the lateral portions appear to be depressed. 
In some cases Guillemet has noticed peculiar deformities. Thus he 
has seen the uterine volume so considerable, that the upper part of the 
abdomen projected in front of the sternum, and the sides of the abdomen 
swollen out with a deep cleft in the middle, so that it resembled the heart 
in a pack of cards. We may notice in addition a supra-pubic oedema, often 
considerable, and finally, that this form of belly remains the same, what- 
ever be the position taken by the woman. DISEASES OF THE OVUM. 
265 
There is a large area of dull percussion, sometimes occupying almost 
the whole abdomen, and tympanitic intestinal percussion can only be 
found at the sides, where a sonorous and fixed percussion note will be 
found when the distension is large. 
Palpation gives different results according to the intensity of the dis- 
ease and the time at which it is practised. 
At the beginning, the uterus is readily appreciable to the hand through 
the soft abdominal walls. Later, they not only become harder, but the 
distended uterus is so intimately applied in some cases to the abdominal 
walls, that it is only to be distinguished from it by its faint contractions. 
The abdominal walls are sometimes very cedematous, sometimes thinned 
out and very white and pale; or the skin may be covered with reddish or 
bluish blotches, and appear ready to break. In the first case the sense 
of fluctuation, and the perception of the foetal part, will be nearly or 
quite imperceptible to the touch; in the other case, fluctuation may be 
so distinctly perceived that the fluid appears to be contained in the peri- 
toneal cavity. 
Fluctuation may be absent entirely. (Chereau.) It is the same pre- 
cisely with the recognition of foetal parts. Sometimes ballottement is 
very easy, and sometimes it is very difficult to obtain. Besides the diffi- 
culties created by the distension of the abdominal wall, the distension 
of the uterus itself is of great importance; and when the dilatation of the 
organ is great, and the foetus is small, it is often difficult to feel it, and 
to appreciate its presence. Twin pregnancies, and death, which alters 
the density and firmness of the foetus, increase these difficulties. The 
same things apply to the vaginal touch. It is true that, in most cases, 
vaginal ballottement is very easily obtained; but in some cases it cannot 
be gotten at all. The finger feels a soft mass filling the vagina, or an 
elastic and hyper-distended pouch, but no presenting part is appreciable. 
Finally, the exaggerated sensibility of the abdominal walls, which are 
sometimes so tender that patients can hardly bear the weight of their 
clothes, is an obstacle to palpation; and the oedema and tenderness of the 
genitals make a vaginal examination so painful, and the sensations are 
so incomplete, that the perception of the foetal parts, if not impossible, is 
extremely difficult. The other symptoms we will find more marked in 
the acute form of dropsy of the amnion. 
Besides this, which we may call the classical form of the malady, and 
which is relatively common, there is another, which is much rarer, and 
of which we have only been able to collect twenty-one cases, two of which 
we ourselves have seen. 
Nevertheless, we believe that we can justify our division of the rapid 
oases from those that we call the classical ones. One prime fact confronts 
us; and that is that, while in the ordinary form the dropsy takes several 
months to attain its maximum, in the other it takes only from a few days 266 
A TREATISE ON OBSTETRICS. 
to three weeks at the utmost for the belly to be enormously swollen, and 
for symptoms so grave to appear that the life of the woman, as well as 
that of the product of conception, may be compromised. For while, in 
the first instance, the uterus has time to accustom itself to the distension, 
in the second case it is suddenly invaded by the enormous liquid accumu- 
lation, and reacts against it. 
And here we meet a second difference. While in the classical hydramnion 
fever is so exceptional that Sallinger only found it recorded in two out of 
the eighty-one cases he collected, it is the invariable rule in the second 
class, and gives the disease an inflammatory appearance. Acceleration 
of the pulse, and increase of the temperature, have never been absent in 
a case of acute dropsy of the amnion. (See observations of Charpentier, 
Cerne, Sentex, etc.) 
Authors have, therefore, sought to attribute acute hydramnion to in- 
flammation of the membranes. 
Besides these distinctive points there is a third; in acute dropsy the 
symptom of vomiting assumes an exceptional intensity and gravity. In 
the two cases that we have seen, it was so severe that the patients could 
eat nothing at all. The vomit is at first composed of food, then of mucus 
and bile; very great abdominal pains, with a feeling of heat and burning, 
accompany it, and reduce the patient to a condition of most alarming 
debility. 
Alimentation becomes almost impossible; milk, bouillon, alcohol, noth- 
ing can be retained; the woman loses flesh with extreme rapidity, and 
the contrast between the volume of the stomach and that of other parts 
of the body is very striking. The shrivelled face, the hollow eyes, bril- 
liant with fever, and the pinched and tightly drawn lips, sufficiently in- 
dicate the serious condition of the sick woman. 
At the same time, the pains are characteristic in their extreme inten- 
sity; occupying the entire abdomen, they shoot down into the loins and 
thighs. They cease neither day nor night, depriving the patient of all 
sleep, and are exacerbated by movement on her part. The dorsal position 
does not ease her, and she can neither stand nor sit; she lies crouched in 
bed, in the most curious positions, writhing occasionally under exacer- 
bations of the pain. She weeps and sighs, piteously demands relief, and 
cries out inarticulately. Treatment is useless; neither quinine nor opium, 
nor chloroform, nor chloral, nor morphine injections are of avail. The 
pains keep the patient in a perpetual state of agitation; the fever and the 
pain increase continuously as the belly is distended. Deprived of sleep, 
and with a constant fever, with frequent vomitings and exacerbations 
of pain, the woman soon sinks into a state of profound exhaustion, and 
cries loudly for the relief which it seems impossible to give her. 
The abdominal distension increases continuously. Although it attains 
an enormous size in a few days, it grows steadily though more slowly after 267 
DISEASES OF THE OVUM. 
the first outburst, until it reaches proportions that are frightful. Espe- 
cially is this the case in twin pregnancies. (Edema of the abdominal 
walls, especially marked above the pubis, where the skin forms a kind of 
sac, adds to the distress, and, causing swelling of the labia majora and 
minora, interferes with micturition. The urine itself is scanty, dark in 
color, and turbid, and contains a variable quantity of albumin. 
Usually, after a certain time, the patient feels other abdominal pains, 
which, from their intermittent character, are readily recognized by mul- 
tipane as uterine contractions. Although not a constant phenomena, 
this is, as we shall see, of great value in diagnosis. 
The abdomen has now assumed the form that we have described in the 
more ordinary variety of hydramnion; but palpation is almost impractica- 
ble from the pain it causes the woman. Where it can be employed, it 
does not give us the same results as regards ballottement and fluctuation 
as it does in the other cases. 
If the abdomen is very cedematous, palpation is useless. If it is not 
cedematous, we feel the uterus as a thin-walled mass, which gives to the 
finger an elastic sensation, but no feeling of fluctuation, exactly as an ex- 
tremely distended ovarian cyst would do. It is in vain that we search the 
mass for foetal parts. Percussion and auscultation give only negative re- 
sults, and, if we have not studied the disease from the beginning of preg- 
nancy, we are liable to make grave errors in diagnosis. As to volume, 
the abdomen may take on enormous dimensions. In our second case, at 
54 months, the abdomen measured 52.8 inches. 
In some cases, as in this one, the abdomen permits a special sensation 
to be perceived, which enables us to establish the diagnosis, though seve- 
ral examinations are necessary for the purpose. Thus, at our first visit, 
the uniformly distended abdomen allowed us only to feel, in the right iliac 
region, a hard and specially painful point, which gave the sensation of a 
thick-walled multilocular ovarian cyst. A t the second examination, made 
two days later, on gently palpating the abdomen, which had in the mean- 
time increased | of an inch in circumference, we first found again the 
same sensation. But on palpating in the right iliac region, we found the 
sensation of hardness to increase under the pressure, diminishing markedly 
as it was relaxed. At the same time, this hard point seemed to increase 
in extent, and, prolonging itself towards the upper part of the abdomen, 
gained the epigastric depression by a curved track; and on placing the left 
hand on the epigastrium, it was plainly felt to become harder. Then the 
abdomen appeared to change a little in shape; it gradually became more 
prominent in front, the lateral portions becoming depressed. This sensa- 
tion of a contracting organ could be given by nothing but the uterus, and 
decided the diagnosis. It is easy to understand the importance of this 
sign, which of course will be more difficult to appreciate where dropsy of 
the amnion is complicated with ascites. 268 
A TREATISE ON OBSTETRICS. 
The intestine shares in the general derangement. Usually there is a 
more or less obstinate constipation, sometimes interrupted by a diarrhoea 
which may persist for several days. 
The vaginal touch, which apparently should give us definite informa- 
tion, and does so in certain cases, is insufficient in others. 
The marked oedema of the external genitals interferes with the intro- 
duction of the finger, and limits the field of exploration. The changes 
in the cervix are sometimes difficult to appreciate at three months. At 
the fundus vaginae, we feel only a more or less elastic mass, which might 
as well belong to an ovarian cyst as to a uterus distended by one or seve- 
ral foetuses. The foetus cannot be reached, nor can the change from the 
neck to the inferior portion of the uterus be appreciated by the finger. 
The only thing that we can be sure of is that the uterus is fixed and the 
cervix but little developed. Rectal touch did not, in our second case, 
give us any more exact information. The vital importance of a precise 
diagnosis for the woman, is, however, easily appreciable. Happily, in 
most cases, the diagnosis of pregnancy has been made beforehand, and 
the field of error is thus limited. 
Thus acute dropsy of the amnion differs in its symptoms and its course 
from the slower form, and it is liable to cause errors of diagnosis, which 
may have most serious consequences for the patient. For energetic 
treatment will not only relieve them, but will remove the threatening 
dangers; while they will surely succumb if the disease be left to its own 
course. 
Happily, nature herself sometimes effects a cure by means of premature 
labor; but in only too many cases the contractile power of the uterus is 
much impaired by the distension; and then the obstetrician must inter- 
fere, and, by perforating the membranes, bring on the labor. 
Diagnosis.-The diagnosis of dropsy of the amnion presents several 
points for examination: 1st. The recognition of pregnancy; 2d. The de- 
termination whether it is single or twin; 3d. The recognition of dropsy 
of the amnion, and its differentiation from hydrorrhoea, ascites, the vesi- 
cular mole, and ovarian cysts; 4th. The determination of the cause and 
the nature of the dropsy. 
1st. The Recognition of Pregnancy.-This is sometimes difficult in 
normal cases, and it is not astonishing that it should be more so in cases 
complicatejl with hydramnion. In ordinary pregnancies we have, besides 
the probable signs, only active foetal movement, the foetal heart-beat, and 
ballottement as positive evidences of pregnancy. The first of these, 
active foetal motion may easily, in dropsy of the amnion, escape the 
notice both of the mother and of the accoucheur. Lost, so to speak, in 
the liquor amnii, the movements of the child are not transmitted to the 
abdominal walls. Then, the foetus being so moveable, its heart-beat, as 
we have seen, is not constant at any one point even when alive; and 
when it is dead, both this and the preceding sign fail entirely. DISEASES OF THE OVUM. 
269 
Luckily, it is not the same with ballottement, which, in cases of hydram- 
nion, assumes a capital importance. It is in fact more readily per- 
ceived than usual, whether practised by the abdominal or by the vaginal 
method. But even ballottement may sometimes be absent, and then it 
is only by a careful consideration of the ensemble of the symptoms that a 
conclusion can be reached. Usually, however, ballottement is easily 
appreciated, and by that sign, with fluctuation, the diagnosis must be 
established. 
2d. The Determination between twin Pregnancy and Dropsy of the 
Amnion.-Both cases give us exaggerated abdominal enlargement; but in 
twin pregnancy there is hyper-enlargement from the beginning of preg- 
nancy, while i n hydramnion the first months of pregnancy pass normally, 
and the rapid and excessive distension comes only later. 
In twin pregnancy, also, the peculiar shape of the abdomen, with its 
increased transverse diameter, and the presence of similar foetal parts on 
opposite sides of the abdomen, are peculiar. In some cases the belly ap- 
pears to be divided into two lobes by a vertical furrow, especially on top, 
and the shape is characteristic. 
In dropsy of the amnion, on the contrary, the shape of the abdomen is 
globular and more regular. The uterus is uniformly distended, and its 
vertical diameter is almost always greater than is its transverse measure- 
ment. 
Of course, twin pregnancies are frequent in dropsy of the amnion, and 
it must be recollected that these signs are by no means absolute. 
In twin pregnancies, foetal mobility is always more or less interfered 
with; the parts that are appreciable by palpation are difficult to displace, 
whereas all authors agree that the size of abdominal ballottement is ob- 
tained with great ease in hydramnion. The same holds true for vaginal 
ballottement. Baudelocque and Levret had already called attention to 
the fact that, while in twin pregnancy, ballottement is incomplete or ab- 
sent, both it and the choc en retour are obtained in dropsy of the am- 
nion with great facility. Depaul mentions another sign, which he has 
been the first and only one to recognize: 11 On examining by the touch 
the membranes that project from the os, he has twice encountered a de- 
pression or furrow upon them, which divides the amniotic cyst into two 
parts; he was thus enabled to recognize the two eggs placed side by side." 
The supra-pubic oedema, regarded by some as of value in the diagnosis of 
twin pregnancy, may exist in cases of single pregnancy complicated with 
dropsy of the amnion; nevertheless, it should be regarded with attention, 
for a number of cases of hydramnion in which it occurred were also cases 
of twins. One extremely important sign for the diagnosis of dropsy of 
the amnion is fluctuation, since it is never met with in simple twin preg- 
nancies. It is an absolute sign, but unfortunately it is not always pres- 
ent, and when it is, it may be due to a dropsy othei' than that of the am- 
nion, such as ascites. 270 
A TREATISE ON OBSTETRICS. 
Auscultation usually enables us to establish the diagnosis of twin preg- 
nancy, while the foetal heart-beats are obscure, fugacious, mobile, or even 
undetectable in cases of hydramnion. 
Auscultation enables us in twin pregnancies to determine the existence 
at two different points on the abdomen of two hearts of different rhythms, 
and between which a point can be found where the two hearts are heard 
with a minimum of intensity, ■which increases as you proceed in either 
direction towards the points of maximum intensity, before ascertained. 
The diagnosis is far more difficult when the foetus is dead; for we are 
forced to rely upon palpation alone, and the modifications of the uterus 
are such that the very existence of pregnancy may be a matter of doubt. 
When dropsy of the amnion has complicated twin pregnancy, as has 
been often the case, the latter diagnosis has usually not been made. The 
dropsy has been diagnosticated early, but the presence of a second foetus 
has only been known after the expulsion of the first. 
We think that, in these cases, very great importance is to be attached 
to the supra-pubic oedema; it does indeed exist in almost every case of twin 
pregnancy, and its presence should always awaken a suspicion of it when 
-dropsy of the amnion is present. 
In our case, where there was both twin pregnancy and acute hydram- 
nion, this oedema was very marked; but it was accompanied by a general 
oedema of the abdominal wall, and of the genital organs. We must con- 
fess that we recognized the complication without thinking of the existence 
of twin pregnancy, which was noticed by Dr. Savornin, whom we had 
called in to see the patient. 
There remains for us to consider the differential diagnosis between 
hydramnion and the diseases which may be mistaken for it, hydrorrhoeas, 
ascites, ovarian cysts, and vesicular moles. 
It would seemingly be difficult to confound hydrorrhoea with hydram- 
nion. Hydrorrhoea is characterized by a flow of watery fluid, occurring 
during pregnancy, and usually first coming on during the night. There 
is generally, after the first outburst of fluid, a slower and continuous loss. 
The material that escapes is clear, has a spermatic odor, and stains the 
linen. The flow may be intermittent, or contixuous, or come drop by 
drop. As a rule, there is no pain, though Naegelc, Belfinger, and Ches- 
ton have recorded cases in which there was. Rare before the fourth, it 
is usually at the end of the fifth or sixth month that hydrorrhoea occurs. 
Recurring generally three or four times during the pregnancy, hydror- 
rhoea may persist after delivery, and replace the lochia (Mauriceau, Nae- 
gele, Dubois). The os remains closed, and if there are uterine contrac- 
tions, they are regular and general. If nature be allowed to take its 
course, whatever pain may be present generally ceases, and the pregnancy 
advances normally. The flow of false water doesnot diminish the amount 
of normal liquor amnii present at birth, nor does it ever contain particles DISEASES OF THE OVUM. 
271 
of sebaceous matter. The diagnosis from ascites may be more difficult, 
especially if the ascites complicates pregnancy. 
In simple ascites, besides what can be ascertained by palpation, auscul- 
tation, and the vaginal touch, and besides the absence of positive signs of 
pregnancy, the abdomen is peculiarly flattened and widened laterally, and 
fluctuation is very readily perceived. There is absolute flatness over the 
lateral portions of the tumor, with an intestinal tympanitic percussion 
note over the superior, anterior, and median portions. 
This flatness varies of course with the position of the patient, the in- 
testines being always uppermost. There is no ballottement, nor can foetal 
parts be felt. (Edema of the lower portion of the abdomen is often 
present, and finally we find in the heart, liver, or kidneys, evidences of 
the lesion that has caused the ascites. 
If the ascites complicate pregnancy, the diagnosis is more difficult. 
The fluctuation is more readily perceived in the upper than in the lower 
part of the abdomen, and the fluid is displaced according to the woman's 
position. 
But when ascites exists with hydramnion, the diagnosis may be very 
difficult; and this explains the errors that have occurred. 
Robert Lee says: " The diagnosis of hydramnion with ascites is very 
difficult. Fluctuation is distinct, but it does not tell us whether the 
fluid is in the peritoneal cavity, or in the amniotic cavity, or in both places. 
The presence of fluctuation, therefore, is not a certain evidence of the 
existence of the affection, and the only way to arrive at a precise diagno- 
sis is by means of the vaginal touch. This enables us to determine whether 
the uterus has undergone changes consecutive to impregnation, and also 
whether there is an excessive amount of liquid within the membranes of 
the ovum. This will be shown by the almost entire effacement of the 
cervix, by the development of the body of the uterus, and by the sensation 
of vaginal fluctuation upon abdominal percussion." In ascites complicated 
with pregnancy, Scarpa has observed that the symptoms are different from 
those of hydramnion. li The large collection of fluid interferes with our 
recognition of the regular form of the fundus and bodv of the gravid 
uterus. The urine is diminished and lactescent, thirst is constant. There 
is obscure fluctuation in the hypogastric region, more distinctly percepti- 
ble in the hypochondrium, between the edge of the rectus muscle, and 
the false ribs." 
Scarpa thereupon maintains that puncture of the pregnant uterus is 
not as serious an operation as has been maintained by Chambon, and cites 
the observations of Bohn (pregnancy mistaken for ascites), of Camper, 
Langius, and especially Nesse: (Dropsy of the amnion at the fifth month. 
Paracentesis at the linea alba, midway between umbilicus and pubes. 
Twins born, that died soon after. A metrorrhagia, not followed by serious 
results, was all that ensued.) 272 
A TREATISE ON" OBSTETRICS. 
Ovarian Cysts.-Though usually easy to distinguish from dropsy of 
the amnion, it is not always so, as the cases of Boddy, Iliod, Hunt, and 
Kidd would show. 
The recognition of the certain signs of pregnancy only can prevent 
error. The menses may be absent in both cases, and there are on record 
cases of inflammation of ovarian cysts in which the accumulation of liquid 
has taken place, almost as quickly as in dropsy of the amnion. In both 
cases great pain accompanies the abdominal enlargement. But the pro- 
gressive growth of hydramnion is replaced in the case of the cyst by sud- 
den enlargements at the menstrual epochs, with slower and more contm- 
uous progress between them. Besides this the tumor in ovarian cyst 
begins on one side, and the uterus is displaced in the opposite direction. 
Finally, we may detect the modifications in the neck and lower part of 
the uterus, and the three certain signs of pregnancy, ballottement, the 
foetal heart and foetal motion. 
Sometimes, as in one of our cases, these signs fail us, and we must 
have recourse to other means of diagnosis. Fluctuation is said to be more 
manifest in hydramnion than in ovarian cyst; but in certain cases it may 
be wanting. But there is one sign which is pathognomonic, and which 
was present in our second case. 
In this case all the certain signs of pregnancy were absent, and rectal 
and vaginal touch gave us no aid. Palpation was difficult from the ex- 
treme sensibility, and the oedema of the abdominal walls permitted only 
the perception of a false fluctuation. Only the suppression of the menses, 
and the results of an anterior examination made by a physician, caused 
us to suspect pregnancy. But at the second examination I could feel in 
the abdomen intermittent contractions, and the uterus is the only organ 
which could give rise to any such sensation. 
G. II. Kidd, discussing the diagnosis between dropsy of the amnion 
and ovarian cysts, says: " The encysted liquid may be a distended blad- 
der, a dropsy of the amnion, an ovarian cyst, or a pregnancy complicated 
by an ovarian cyst. The absence of urine on catheterism, disposes of the 
first; the state of the nipples, and the presence of a floating body in the 
abdomen, shows the presence of a foetus; while with ovarian cysts, the 
uterus can always be felt in the true pelvis." Both Boddy and Iliod punc- 
tured, in cases of hydramnion, believing them to be ovarian cysts, and 
Kill did the same, and delivered the woman of twins, in a case of hydram- 
nion, which he took to be pregnancy complicated with ovarian cyst. De- 
paul, in connection with his case of extra-uterine peritoneal pregnancy 
with hydramnion, says: " This is a rare, if not unique example, of dropsy 
of the amnion, complicating an extra-uterine pregnancy. The size of 
the abdomen prevented palpation of the foetal parts, and there was a 
tense, rounded, and fluctuating pouch instead of the ordinary lumpy 
tumor. The cervix was in its usual place, which is rare in extra-uterine 273 
DISEASES OF THE OVUM. 
pregnancy. The patent orifice permitted me to reach the fundus uteri 
with my finger; but, instead of enlightening me, it simply made me sus- 
pect an obliteration of the internal os." 
There remains to be considered the diagnosis from the hydatid mole. 
It seems impossible to mistake hydramnion for it. The only symptom 
sometimes found in the vesicular mole, that is analogous to any sign of 
dropsy of the amnion, is the rapid development of the abdomen, and its 
want of proportion to the stage of pregnancy. But the constant presence 
of alternating losses of reddish and watery fluid, the hemorrhage which 
always accompanies, precedes, or follows the termination of the disease, 
and the occasional passage of vesicles, should suffice to remove all doubts. 
Pathological Anatomy.-Most authors regard hydramnion as a disease 
of the foetus or its membranes, and it is there that we should look for the 
cause of the affection. But in some cases the examination of these has 
been neglected; and in as many more it has been made without finding 
anything. In a third set of cases, lesions have been found, but they 
were not characteristic. Three varieties of lesion seem, however, to be 
specially constant: 1st. Those of a supposedly inflammatory nature. 2d. 
Foetal malformations. 3d. Lesions of the uterus, or tumors of various 
kinds. 
1st. Lesions of an inflammatory Nature.-These have usually con- 
sisted in thickening of the membranes, with more or less marked capillary 
injection, a varying red color, and false membranes, either on the sur- 
face of the amnion, or on the foetal surface, and in the thickness of the 
placenta. 
Thus Dubois and Desormeaux: thickening and hypertrophy of both 
placentae, which were united. 
Godefroy: membranous plaques upon the internal surface of the pla- 
centa and the membranes. 
Oulmont: infiltration of edges of the placenta, and oedema of the cord. 
Prevost: one placenta and two amniotic cavities for three foetuses, 
the two amnii being enclosed in a common covering. One cord was oede- 
matous. 
Ollivier (d'Angers): thickening of the membranes, which were white and 
opaque, like parchment. Injected vessels. 
Mercier: the same changes, with a species of false membrane. Sen- 
tex: same, placenta livid. 
Robert Lee: placenta soft in parts, and dark in color, looking like the 
lung in cases of pulmonary apoplexy. 
Toogood: adhesions of placenta. Atthill: same. 
D'Outrepont: cartilaginous and hepatic degeneration of the placental 
tissue. 
Hildebrandt: fibro-myxoma of placenta. 
Hunter: hypertrophy of placenta. 
Vol. II.-18. 274 
A TREATISE ON OBSTETRICS. 
Valenta: maternal and foetal syphilis. 
Sedillot: emphysema of foetus. 
Lee, Obs. I.: Foetal ascites, malformations of lungs. Obs. VI.: Foetal 
ascites. 
Bourgarel: Foetal ascites. Pemphigus. Onyxia, congested placenta. 
Liegener, Obs. XII.: Cord soft and short. Obs. XIV.: Cord very 
oedematous; pemphigus; liver much developed. 
2d. Monstrosities.-Pietro Lusana: anencephalus. 
Siebold: hydrocephalus. Cystic degeneration of kidneys. 
Battson: hydrocephalus. Infiltration of skin and subcutaneous cellu- 
lar tissue. Anchylosis of articulations of hands and feet. Cystic degen- 
eration of the cord. 
Thomas: exaggerated development of the head. 
Jungmann: premature ossification of the head. 
Lumpe: umbilical hernia into cord. Hypertrophy of the skin of the 
head. Club-foot. 
Zacharias, Lawrence, and West: encephalocele. 
Griffith: tumor covered with the normal scalp, filled with liquid and 
cerebral debris. 
Werner: thin cord with bands. Double hair-lip. Absence of left lung. 
Biihelen: hydrothorax. 
Loschner: double monstrosity. One child normal, the other atrophied. 
Adhesions of both lungs. 
Frankenhauser: obliteration of the urethra; oedema of cord and foetus. 
Hildebrandt: hydatid mole. 
Rausch, Werner, Parien: faults in the cord. Placental atrophy. 
Lee: hydrocephalus. 
Dill: anencephalus. 
Liegener: double hare-lip. 
Gueniot (Guillemet): anencephalus. 
Polaillon (Guillemet): clubbed hands, -mperforate anus. 
Pinard: two cases of anencephalus. 
3d. Tumors.-Keating: uterine fibroid. Gueniot: same. 
Neuschler: uterine tumor. 
Pfannkuch: carcinoma uteri. 
These are the chief changes; and we shall see tnat it is especially in 
the acute cases of hy dramnion that the lesions considered inflammatory 
have been noticed. 
The liquor amnii itself is generally normal; a few authors have found 
it fetid, and reddish or greenish in color. 
We, therefore, conclude that pathological anatomy gives us no certain 
data; for all the above lesions have often been found in cases in which 
there was not the least trace of dropsy of the amnion. 
Prognosis.-Most authorities consider dropsy of the amnion a serious DISEASES OF THE OVUM. 
275 
complication for the foetus, while it rarely compromises the health or life 
of the mother. This, however, is only true up to a certain point. In 
the slowly progressive form, but little discomfort is experienced by the 
woman; but in acute hydramnion the distress is very great indeed, and 
the prognosis for the mother much more grave. We may, in this respect, 
divide dropsy of the amnion into three degrees. 
In the first degree, the excess of fluid accumulates very slowly, and the 
woman only suffers from discomfort and an increase of the usual malaise 
of pregnancy. As a rule no diagnosis is made, and it is only at the mo- 
ment of delivery that the excessive amount of liquor amnii strikes the ac- 
coucheur. Every obstetrician must have met such cases. 
In the second degree, there is more fluid, and the uterus reacts more 
strongly. Besides the ordinary accidents of dropsy of the amnion, uterine 
contractions causing premature rupture of the membranes, and expulsion 
of the foetus, are liable to occur. 
In the third degree, the same premature contractions exist, but they are 
not sufficient to determine labor, at all events for a certain time. The 
patients are very sick, and are exposed to the various accidents that we 
have noticed, so that active interference is sometimes required. It is 
especially in cases where hydramnion occurs with phenomena that have 
caused errors of diagnosis (ascites, ovarian cysts, etc.), that active meas- 
ures have been taken. 
This is by no means the case in the fourth set of cases, which we have 
called acute hydramnion. In these cases, the diagnosis is made. The 
rapidity of its evolution, and the serious nature of the accidents that may 
occur, can in a short time compromise the life of the woman, and neces- 
sitate immediate intervention. 
Here the enormous distension of the uterus, out of all proportion to the 
presumed stage of the pregnancy, the excessive pain, the vomiting, the 
emaciation, the intense fever, the circulatory and respiratory troubles, 
the asphyxias, oedemas, eclampsias, and even abortions, give us a very 
different form of the disease. 
In regard to delivery itself, let us note the frequency of faulty presen- 
tation, and the occurrence of procidentia and uterine inertia, either dur- 
ing labor or at delivery, and the hemorrhages. The following table of 
observations, deduced from 80 cases collected from literature, show the 
result and the presentations: 
Child dead without sign, ..... 1 
Abortion, 1 
Head, with prolapse of hand, .... 1 
Vertex, ......... 46 
Buttocks and feet, 9 
Shoulders, ........ 20 
Face, ......... 2 276 
A TREATISE ON OBSTETRICS. 
MacClintock, out of 31 cases: presentation of the vertex, 20; breech, 
9; foot, 2. 
We understand to what extent hydramnios complicates confinement, 
by the fact of the abnormal presentations, and these figures only include 
single pregnancies. As for the hemorrhages which accompany or follow 
delivery, and which are due to uterine inertia, all the authors have noticed 
them in the cases of exaggerated distension of the uterus, either by a 
very large foetus, or in cases of twin pregnancy. It is not extraordinary 
to see them produced in cases of hydramnios, or this exaggerated disten- 
sion of the uterus produced in an extreme degree. We confine ourselves, 
with Sallinger, to citing the cases of Senlen, Valenta, Schmatz, Lumpe, 
Gueniot, Martin, Hansen, Klink, Harlin, Parieu, Rigler, Quadrat, Huber, 
Keating. 
As regards the child, the prognosis is still more grave, and though in 
the observations of Liegener, out of 40, there were 31 infants living, we 
do not hesitate to say that hydramnios is one of the diseases which most 
compromise the existence of the foetus. In many cases, indeed, it is ex- 
pelled dead from the uterus (we may ask if the death of the foetus had 
not been the determining cause of the malady); in others, more frequent- 
ly, it dies shortly after birth. We have seen that often delivery occurs 
before term. 
In addition, the frequency of multiple pregnancy, and of dangerous pres- 
entations complicating the confinement, put the infant in unfavorable 
conditions and render the prognosis more grave. 
Finally, we recall the frequency of monstrosities in cases of hydramnios, 
and the connection between syphilis and hydramnios. 
MacClintock considered hydramnios as one of the morbid conditions 
very common in abortion, and he regards it as a frequent cause of the 
premature death and expulsion of the embryo. Out of 33 cases of hy- 
dramnios noted by him, one terminated by abortion at five months, 
one at six months, ten resulted in premature delivery. In 21 cases the child 
appeared to have attained the normal term, and he says " there is good 
reason to think that some cases of the disease in question are a disease of 
the ovum and not of the uterus. The abnormal excess of the amniotic 
fluid, or perhaps the morbid action of which it is the result, appears 
very unfavorable to the foetus. Thus, 9 of the children were still-born, 
of which 5 were putrid, and 10 born alive died some hours after birth. 
This was oftener the case among the girls than the boys (25 girls to 8 
boys). 
Treatment.-In many cases hydramnios passes almost unnoticed. The 
indications are confined to combating the ordinary diseases of pregnancy, 
without the necessity of special treatment. At other times, on the con- 
trary, the conditions are exceptionally serious, and then intervention is 
necessary, which is either medical or obstetrical. DISEASES OF THE OVUM. 
277 
Medical treatment is in general of little use. All forms designed to 
combat the "dropsy," diuretics, purgatives, sulphate of quinine and 
opium, have been employed. All seem to have failed. Phlebotomy has, 
at times, seemed to succeed. 
Modern works on the composition of the blood in pregnant women 
have, however, rejected bleeding in the treatment of pregnancy. We 
believe that the writers have gone too far in this regard. Of course we 
do not believe in the ancient method, in which bleeding was practised to 
an incredible extent, as in the observation of Mauriceau, where a woman 
had been bled 72 times during her pregnancy; but we believe in certain 
cases bleeding has its advantages; and, without speaking here of bleeding 
employed as preventive of eclampsia, we have seen (as interne at the 
Charite) Beau, who certainly was not partial to bleeding, practise it in a 
number of pregnant women, and never have there been other than good 
results. Our teachers did not rej'ect it utterly, and P. Dubois, Cazeaux 
and Jacquemier, advised it in certain cases, where women considered as 
plethoric were threatened with abortion; and they have cited cases where, 
thanks to a rapid and moderate depletion of the vascular system, the preg- 
nancy has continued its course. 
Surgical Treatment.-On account of the serious condition, and the 
threatened life of the mother, it is necessary to interfere. Nature, indeed, 
seems to indicate the means, in provoking premature contractions, which 
induce rupture of the membranes and interruption of the pregnancy. 
Whatever Guillemet may say, all obstetricians agree that it is by the cer- 
vix that the foetal sac must be penetrated, and if there are some instances 
where puncture of the uterus has been done, it was due to an error of di- 
agnosis, and, though Scarpa, Camper, Noel Desmarais, etc., have cited 
cases where a puncture has not been followed by accident, and certainly 
by the woman's recovery, it should be rejected. Consequently rupture 
of the membranes should be adhered to. But here, still, different ques- 
tions are presented: 1st. The point of perforation. 2. The moment for 
intervention. 
1st. Point to rupture the Membrane.-It is seen at once that there 
is no time for hesitation. The cervix being generally partly open 
from the premature contraction, the membranes rush into the inter- 
nal os. Nothing is simpler than to perforate them with a stylet, sound 
or trocar. But this rupture is not always without difficulties. At the 
moment of the rupture, the liquid, by reason of its great quantity, rushes 
out in torrents, tends to enlarge the opening in the membranes, and so 
to sweep along the foetal membrane, cord and foetus. On the other hand, 
the uterus, in consequence of the rapid evacuation of the liquid, tends to 
contract with a rapidity dependent on the quantity of liquid evacuated. 
Further, there is the possibility of detaching the placenta, at one or many 
points, and of hemorrhages. Finally, this rapid evacuation induces 278 
A TREATISE OX OBSTETRICS. 
symptoms analogous to those seen when the pleural or abdominal cavities 
are emptied too rapidly, in pleurisy, hydrothorax or ascites, namely syn- 
cope. Different methods have been advised for this end. The first, 
which is an absolute rule when one has to puncture the membranes for 
hydramnios, or for narrowing of the pelvis-that is, when the foetus is move- 
able beyond the superior strait, or in the excavation-is never to rupture 
the membranes except in an interval of contraction, the woman lying with 
the buttocks raised, so as to increase the inclination of the pelvis back- 
ward. The use of the stylet or trocar, to make only a little opening, has 
been advised, but the liquid increases the size of the opening. 
Tarnier, according to Guillemet, operates as follows: he places the in- 
dex finger on the bulging membrane; at the same time the other fingers, 
closed in the palm of the hand, are applied as exactly as possible over the 
vulvar orifice at the movement of contraction. The membranes are rup- 
tured by the nail of the index finger. At this moment, instead of with- 
drawing the hand, it is pushed against the vulvar orifice. In this man- 
ner a nearly perfect prevention of the issue of fluid is obtained. This 
procedure does not seem to us to be likely to be followed by the hoped- 
for success; for if it prevents the escape of fluid from the vagina, it 
does not prevent the rent enlarging itself. The liquid, it is true, can 
not flow away externally, but it can flow into the vagina, and it will do 
so the more according as we have chosen the period of uterine contrac- 
tion to rupture the membrane. 
We prefer then to choose the interval of uterine contractions. It will 
be a little more difficult to rupture the membranes, but the liquid will 
escape more slowly, there will be less chance of the prolapse of the mem- 
bers, and of premature detachment of the placenta. Impressed by 
these inconveniences, Meissner has invented a curved trocar, with which 
he advises the induction of premature labor, to perforate the membranes 
at the middle part, or above the ovum, to preserve also a certain quantity 
of fluid, and to place the foetus in more favorable conditions. This may 
be resorted to in cases of hydramnios, though the results hoped for by 
Meissner do not seem to have been obtained. 
2d. Moment of Intervention.-Here we are unable to lay down precise 
rules, and from the gravity of the symptoms only can we determine the 
moment of intervention. In slight cases, wait. The uneasiness felt by 
the woman is not sufficient to endanger her life, and consequently the 
obstetrician should act expectantly. On the contrary, in the more serious 
cases, it is necessary to interfere, but here still the indications vary with 
the case. Indeed, ordinarily, hydramnios comes on in an advanced state 
of pregnancy, its course is slowly progressive, and it is only at certain 
times, that it produces serious symptoms. The obstetrician should follow 
the development of the disease; he will gain thus the greatest amount of 
time, and it is rare that he will have to interfere before the seventh or DISEASES OF THE OVUM. 
279 
eighth month. It is, therefore, a premature delivery that he causes. While 
wholly protecting the interests of the mother, he regards the viability 
of the child, and so he should retard the moment of intervention as long as 
possible, to allow the pregnancy to reach as nearly as possible normal term. 
In acting thus, we give to the foetus more chance of surviving, without 
compromising the life of the mother. If the symptoms supervene earlier, 
if the phenomena experienced by the mother are of a nature to endanger 
her life, the obstetrician need not hesitate, and he should interfere prompt- 
ly and rapidly in her interest-we will say, also, in the interest of the foetus. 
In so acting, Guillemet says, rightly, we avoid for the mother excessive 
pain and serious conditions, which have sometimes induced death, as in 
the observations of Lee; and, on the other hand, we eliminate the causes 
of death for the infant, for, in nearly all observations, the signs of life 
in the infant have only disappeared when the symptoms were protracted 
a long time. 
In cases of acute hydramnios, the procedure should be different. The 
rapidity with which the symptoms develop, their intensity, the serious 
phenomena which they cause in the mother, require an early intervention, 
and necessitate, not only premature labor, but, indeed, the induction of 
abortion. The uterus tends itself to expel the product of conception, and 
it is in these cases especially that premature contractions occur. But 
these contractions are most often insufficient to determine labor, and they 
only augment the suffering. It is necessary, therefore, to interfere, and 
induce abortion without hesitation. Of course the responsibility of the 
obstetrician is great, and interruption of pregnancy at a time when the 
foetus is not viable is always an operation not to be undertaken unless 
it is absolutely necessary; but we believe that in these cases to hesitate is 
not allowable, and that on account of the chance of the mother's death, 
the obstetrician should practise abortion conscientiously, which, if it end 
fatally to the infant, allows the mother almost every chance of recovery. 
It is seen by our observation that we did not hesitate. The cure of the 
mother justifies our intervention, and, should we again be thrown with 
such a case, we should have recourse to abortion. By it, indeed, the foetus 
is surely sacrificed, but the mother is almost certainly saved, and we believe 
that between the saving of a woman who has other children, and the saving, 
more or less problematical, of a foetus subject to all the unfavorable circum- 
stances in which it is placed by the hydramnios alone, not only is abortion 
authorized, but indicated; and that the obstetrician who hesitates thus to 
intervene in this case fails professionally, and to his own sense of duty. 
Various Alterations of the Amniotic Fluid. 
In dropsy of the amnion, the amniotic fluid is altered in its quantity, 
and in its quality as well, and these alterations are of quite different kinds. 
Some are compatible with the life of the foetus; the others conduce to A TREATISE ON OBSTETRICS. 
280 
its death. At the beginning of pregnancy, limpid, transparent, colorless, 
of a density less than water, the amniotic fluid later should become unctu- 
ous, a little thick, and especially remarkable for the presence of little 
whitish caseous lumps, which are similar to the sebaceous matter cover- 
ing the body of the foetus. Most of the foreign substances absorbed by 
the mother are there met with. We cite, among others, the case of 
Levret, who has seen the amniotic fluid whiten copper in a woman who 
was undergoing mercurial treatment. A case has been cited where the 
odor of camphor, absorbed by the mother, was noticeable. Everyone 
knows the case of Stoltz, who has seen a child, born living, where 
the amniotic fluid gave an offensive odor of putrefying tobacco; the 
mother worked in tobacco. The amniotic fluid may acquire irritating 
properties, as in the case of Naegele, where there was found a kind of mac- 
eration of the foetal epidermis. The child, though born feeble, recovered 
perfectly, and was in perfect condition at the end of the fifth day, after 
shedding its epidermis. 
There is one form of alteration which is much more frequent-that 
which is due to the presence of meconium in the liquor amnii. Nor- 
mally, in cases of breech presentation, the meconium gives to the fluid a 
green tinge, more or less pronounced according to the quantity that has 
been mixed. In some cases the fluid is thin; in others it is much thick- 
ened and sticky; and if one does not consider the escape of the greenish 
fluid as evidence of the death of the foetus, as the older obstetricians 
thought, it indicates at least an action on this little being, by compression 
of the cord or otherwise, prolonged labor, etc. However, this sign is not 
certain, and it is not rare to see the child born alive after abundant escape 
of very dark liquor amnii. One can say, in a general way, that the de- 
gree of intensity of these changes, and the greater or lesser fluidity, are 
proportional with the perfect health of the foetus, though the foetus may 
be born alive with very thick and fetid liquor amnii. Auscultation only 
can decide as to the beating of the heart; its perfect regularity and nor- 
mal force has completely reassured us in a case where at first one might 
have some fear. 
Concerning the alterations which are consecutive to the death of the 
foetus, Lempereur describes three degrees. In the first, there is a solu- 
tion of the foetus; in the second, a mummification; in the third, macera- 
tion; the other alterations are only produced after the escape of the fluid, 
and after the entrance of air into the sac. To these three periods, differ- 
ent states of the amniotic fluid correspond. 
In the first (solution), the fluid is no longer clear, transparent, limpid 
and pale yellow, but sometimes simply dirty and thickened, sometimes 
milky, like an emulsion, according to the quantity of organic elements 
dissolved. This fact is mentioned by the older obstetricians, as Mauri- 
ceau, Puzos, Bischoff. Martin, and others. 281 
DISEASES OF THE OVUM. 
In the second (mummification), the liquid is diminished, still thicker, 
granular, purulent, or rather, as if mixed with a clayey earth. At a 
more advanced degree it disappears, leaving on the embryo a grayish 
oily sediment analogous to the deposit of overflowed water. 
In the third (maceration), the liquid is altered according to the state 
of the foetus. This period is characterized by the cedematous infiltration 
of the foetal tissue with a bloody serum, complete inhibition of the soft 
parts with their softening and shrinking, and raising of the epidermis in 
phlyctenulae, in vast blisters. It is this escaped liquid which gives to the 
liquor amnii its special characteristics. It is thin, red and bloody, more 
or less thick. With this condition of the fluid the foetus is dead. This is 
verified by clinical observation. These changes, however, are not always 
found in cases of foetal death. 
Lempereur has noted many cases, where on rupture of the membranes, 
a clear and quite transparent liquid escaped. This is due to the fact 
that, at the moment of rupture, the bullae are intact, and it proves that 
the liquid which they contain alters the amniotic fluid after their rupture. 
Amniotic Cords. 
These amniotic bands are not as rare as might be supposed, for Klotz 
was able, in 1869, to collect 34 cases. Montgomery, who had already ob- 
served them, considered them as organized lymph; Simpson, as the result 
of local inflammation of the skin of the foetus; Simonart, as due to ulcer- 
ation of the skin of the foetus, and to inflammation of the amnion; Gurlt, 
as prolongations, not detached, from the skin of the foetus; Scanzoni, as 
exudations from the internal surface of the uterus, and penetrating across 
the amnion; G. Braun considers them as the folds of the amnion. Very 
probably they are not inflammatory products, but adhesions, partly meta- 
morphosed, of the amnion to the foetus. Spiegelberg proclaims that they 
should be considered as due, sometimes, to a very early inflammation of 
the amnion having induced an adhesion to the skin of the foetus; some- 
times, more rarely, as an arrest of development, an abnormal fold of the 
amnion, but he rightly remarks that, up to the present time, no one has 
discovered vessels in the amnion, hence its inflammation is more than 
problematical, and he supposes, with Braun, that they are due to abnormal 
folds of the amnion, or to an incomplete or too late separation from the 
foetus, produced by an unknown cause, perhaps by insufficient or tardy 
secretion of the liquor amnii. As a consequence, arrest of development, 
sometimes fissures in the foetus, the liquor amnii developing and distend- 
ing the amniotic sac. These adhering points are lengthened in bands, 
which, by the constriction they exercise on the foetus, cause malforma- 
tions and spontaneous amputations. One sometimes finds the foetus thus 
malformed, and at points corresponding to the constriction, free ends, 282 
A TREATISE ON OBSTETRICS. 
detached bands, or sometimes only cicatrices. Finally the bands may 
suspended free in the amniotic sac. According to Braun, when the a 
niotic fluid is produced tardily, the amnion is torn, while the chorion i 
mains intact. Under the influence of the foetal movements the amni 
becomes rolled around the cord, and induces thus, by compression, t 
death of the foetus. (Fig.23.) Finally, these amniotic folds may be pi 
duced after the death of the foetus by diminution of the liquor amnii. 
According to Crede, these bands are necessarily found in the third 
fourth weeks of foetal development, or before the closure of the vent 
cavity; for, in admitting inflammation, it is only possible to affect th< 
parts still projecting. Ordinarily, however, it is in the deep part, or 
their neighborhood, that the amnion is adherent. And, moreover, o 
Fig. 23.-Amniotic Bands. (After Braun.) a, Cutaneous-bridge, b, Liver, c, Osseous stump 
of l§ft lower limb, d, Left foot, e, Right foot. /, Vulva. g, Anus, hh, Amniotic bands. 
never sees those ulcerations, capable of traversing the abdominal integu- 
ment, and even of the bone, in cases of tuberculosis, scrofula, rachitis, 
syphilis, etc. It is later, in the eighth week, that these lesions are pro- 
duced. In the second month the foetus is separated from the amnion by 
a notable quantity of liquid, and the amnion adheres to the chorion. It 
is, therefore, before this that they are produced, that is, towards the time 
of formation of the amnion, the third week. Another proof is the differ- 
ence that exists between the amnion and the skin of the foetus. From 
the eighth week the foetus has its epidermic covering, and this cannot fur- 
ther proliferate. In the third, on the contrary, the amnion is developed, 
and tends to blend towards the middle of the back of the foetus, and its 
folds, before they unite, form an acute angle; and he believes that the ex- 
aggeration of the amniotic fold becomes the origin of the premature DISEASES OF THE OVUM. 
283 
formation of cells and nuclei, which, manifesting .themselves on each 
side, induce premature fusion of the two amniotic folds. If, on the 
other hand, one remembers that Reichert and Remak consider the amnion 
as composed of two layers, one epidermic, in connection with the skin of 
the embryo, the other in immediate continuation with the cutaneous layer, 
one understands that the folds are able by their traction to cause the 
flexion of the foetus and help to give it its form. Braun finds the cause 
of this adhesion in the too little quantity of fluid, or the too tardy sepa- 
ration of the amnion, and in concussion of the foetus, which forces it to 
lengthen, instead of remaining bent. (Stadhagen.) Crede depending 
on the researches of Panum, of Dareste, believes in the influence of the 
variations of temperature and variations of pressure in the uterine con- 
tractions, and the sudden vaso-motor disorders, produced in the uterus 
by the emotions and physical influences. 
What is the relation between monstrosities and these amniotic bands? 
Crede, out of 109 cases of monstrosities, has found 69 of them with 
amniotic bands, and 21 with hernias cerebri, eventrations, spontaneous 
amputations, and atrophies of the bones. The opinion of Braun, who 
thinks that the spontaneous amputations are produced more frequently 
in the upper than the lower extremity, because the upper are more 
prominent, is not sustained by Crede's cases. On the other hand, amni- 
otic adhesions are more common in the upper extremity. Out of 11 
cases, 7 were of the upper extremity. All agree that the spontaneous 
amputations are due to the amniotic bands. CHAPTER IV. 
DISEASES OF THE FCETUS. 
rpiIE diseases of the foetus and the embryo are as yet little known, not- 
withstanding the progress in this direction made during recent years. 
Of those appertaining directly to teratology we say a few words only; 
others, more directly interesting to the obstetrician, not only because 
they compromise the life of the foetus, but because they occasion serious 
difficulties at labor, we refer to under Dystocia. 
The first, the true foetal diseases, we will pass in review. 
Fevers. 
The eruptive fevers, the intermittent fevers, and typhoid fever, have 
been studied with reference to then' influence on pregnancy and the foetus, 
in detail. (See Diseases of Pregnant Women.) The same is true of 
icterus. 
Cerebral Diseases. 
Scanzoni distinguishes: 1. Hypertrophy of the brain, which sometimes 
occurs to such a degree that it impedes the development of the cranial 
vault, sometimes partially, sometimes totally. In the first case, the head, 
notwithstanding its exaggerated volume, is soft and compressible, the 
bones are thin and compressible, and their compressibility is still further 
increased by the size of the fontanelles and sutures. In the second case, 
the hypertrophy may lead to hemicephalus. 
2. Hemorrhages.-They may occur in the brain, but ordinarily they 
are vascular or intra-meningeal apoplexies. In two cases, the cord has 
been found around the neck; once with a true twist of the cord, and 
twice with numerous apoplectic nuclei in the placental parenchyma. Usu- 
ally the cause escaped notice. 3. Hydrocephalus, with atrophy, more or 
less extensive, of the brain. We will study it in detail under Dystocia. 
Diseases of the Respiratory Organs. 
Depaul, Jacquemier, Dubois and Desormeaux, have noticed true croup- 
ous, and even purulent pneumonia, in the lungs of the foetus and before 
the air had penetrated the pulmonary vesicles. Scanzoni and Rokitansky 
have never found them, but they admit them more willingly since the 
pleural inflammations have been observed and described by Jacquemier, DISEASES of THE F(ETUS. 
285 
. Veron, Tarnier; and their existence is absolutely incontestable. The 
existence of tubercles and emphysema in the lungs, have been also noted. 
(Depaul, Hecker.) Veron, Depaul, Dubois, have noted alterations of the 
thymus, which have been demonstrated to be syphilitic. (See syphilis.) 
Diseases of the Digestive Tract. 
Billiard, Scanzoni, Rokitansky, Desormeaux and Drouadaine, have 
noted different changes in the alimentary canal. In the case of Billiard, 
there was injection and redness of the pharynx, larynx and oesophagus. 
The stomach presented a certain number of little ulcerations; besides a 
general discoloration, without softening of the mucous membrane, the 
intestine, at the caecum, presented a series of whitish follicles enclosed in 
• a red circle, but not ulcerated. Desormeaux has noted a case of enteritis 
very distinct, old and very intense. To Scanzoni and Carteaux, the in- 
testinal mucous membrane presented every degree of hyperaemia. It 
occurred rapidly and violently, it gave place to bloody extravasations 
with an accompanying hemorrhagic peritonitis. If it were less intense and 
progressed more slowly, it was confined to the more or less pronounced 
inflammation of the intestinal follicles. Rokitansky has seen, in some 
rare cases, these inflammations produce false membranes. Cases of in- 
testinal perforation are still more rare. (Scanzoni.) The entozoa (asca- 
rides lumbricoides and taenia) have been noticed. 
Diseases of the Liver and of the Spleen. 
In the liver, hepatitis with persistent softening, fatty degeneration, 
hypertrophy, induration, etc., have been noted. The lesions are now 
recognized as syphilitic. Ruptures of the liver, due to traumatism sus- 
tained by the mother, may occur. In the spleen the same lesions, also 
syphilitic, may be present. 
Fcetal Peritonitis. 
The most common lesion is peritonitis, which has been studied particu- 
larly, by Simpson and Lorain. Out of 106 still-born infants, Lorain has 
found it 10 times, and out of 193 infants, born alive, but dying in a few 
hours or a few days after birth, peritonitis, sometimes simple, sometimes 
complicated with meningitis, multiple abscesses, or erysipelas, has been 
found 40 times. (Lorain.) As we shall see, the existence of peritonitis 
in the foetus and the newborn is due to the same cause which causes it 
in the mother after delivery, namely, puerperal fever, which attacks the 
foetus first, and the mother afterwards. 
Simpson, previous to Lorain, had collected 23 cases, 2 of them per- 
sonal, some borrowed from Allan, 4 cases, from Billiard, 3 cases, from 
Banks, Fisher, Fairbain, Cruveilhier, Scott, Veron, Brachet, Chaussier, 
Duges and Carns, each one case, a total of 10. Finally, 4 cases of chronic 286 
TREATISE ON OBSTETRICS. 
peritonitis, 2 from Billiard, and 2 from Andral and Morgagni. Since 
then, such cases have multiplied, and there is no obstetrician at the head 
of a large hospital who does not each year observe a great many of these 
cases. 
Pathological Anatomy.-The nature of the effused fluid varies consid- 
erably. Sometimes it is purulent, mixed with more or less plastic lymph. 
Sometimes the lymph exists alone, or mixed with a large quantity of serum. 
Sometimes there are non-adherent flakes and membranous deposits of va^ 
rious sizes, floating or adherent; sometimes, soft and pulpy, forming 
more or less solid adhesions, or even true false-membrane, gluing together, 
in one unique mass, the abdominal organs. Concomitant lesions are 
thickening of the intestines, softened liver, persistent infiltration, inflam- 
matory nuclei in the lungs, bloody clots in the abdominal cavity, pro- 
ceeding from a rent in the liver, enormous development of the spleen, 
peritoneal adhesions, mesenteric glands enormously swollen, little hemor- 
rhagic effusions in the different organs. Generally the whole peritoneum 
is affected; at other times only partially. The peritoneum may be 
hypertrophied and indurated. 
Causes.-Simpson cites, successively, hard work on the part of the 
mother, fatigue, cold, dampness, a physical lesion during gestation, peri- 
tonitis in the mother during pregnancy, syphilis-especially, anomalies of 
abdominal viscera, and accidental effusion of irritating liquids, on the 
peritoneal surface itself-urine, and rents of the liver. Lorain does not 
believe in the very great influence of syphilis. He thinks the peritonitis 
due to tfie puerperal fever which is manifested as in the mother, by the 
peritonitis, and is reproduced after birth. 
Symptoms.-The symptoms are more than obscure, the mother 
generally.having experienced only the cessation of movements, accompa- 
nied sometimes by false pains, followed by the signs of the death of the 
foetus. 
Duration.-Nothing is definitely known. 
Periods of Foetal Life when Peritonitis occurs.-Velpeau, without speci- 
fying, said that he had seen incontestable pathological alterations in the 
lungs, liver, peritoneum, and other parts of the body from three months. 
According to Simpson, it may develop at all ages, even at term, the in- 
fants being born alive, succumbing from a few hours to one or two days 
after birth. Finally, Lorain has observed in the new-born, hydrocele 
of the tunica-vaginalis, erysipelas, phlegmon, phlebitis and arteritis of the 
umbilical vessels. 
Diseases of the Circulatory Organs. 
Inflammations of the endocardium, described by Cruveilhier, those of 
the pericardium and the consecutive lesion of the heart, valvular lesions, 287 
DISEASES OF THE F(ETUS. 
dilatation, pericardiac adhesions, are either spontaneous and isolated or 
dependent on inflammation of other organs. In the foetus, the right 
heart is especially affected. 
Diseases of the Skin and Cellular Tissue. 
Besides the eruptive fevers, Moreau has found different colorings of 
the skin in the dead infant; Naegele, Edis and Ollivier d'Angers, mace- 
ration and changes in the epidermis of a living child; Dohrn, inflam- 
mation of the skin; Houel, a case of hypertrophy with icthyosis: Char- 
pentier, an identical case, 1877; Simpson, icthyosis; W. Smellie, 
icthyosis. Finally, pemphigus has been noted, which, according to 
Reeser, 1876, is always syphilitic. Still, cases of non-syphilitic pemphigus 
have been seen by Krauss, Hervieux, Hassan-Mahmoud, Faloy and Des- 
ruelles. One of the most interesting is that of Lorain and Prevost. 
There existed in a syphilitic infant pemphigus, and also changes in the 
lungs. Finally, Ammon has cited a case of melanosis of the eyes, and 
Lobstein a case of cirrhosis. Simpson has described certain tumors of 
the cervical region, and spina bifida. Meckel and Otto, a cystic tumor 
of the cellular tissue, situated at the posterior part of the neck, divided 
into two lateral and symmetrical lobes, by the ligamentum nuchse. 
Berndt, Caesar Hawkins, Beatty, Muller and Henke, cystic congenital 
tumors of the neck. Simpson, cystic tumors, whose mass consisted of 
the union of little cells, filled with a thick glairy liquid, at the upper part 
of the neck, and projecting more or less into the mouth. Wallmann has 
described a similar case. These are true ranulae, consisting of hyper- 
trophied salivary glands. Simpson, tumors in the cervical region, formed 
by vascular erectile tissue, deeply situated and disappearing on pressure, 
- on the contrary, increased by crying or efforts. One of these was 
operated on later; there was profuse hemorrhage. Under the name of 
bronchocele, has been described congenital hypertrophy of the thyroid 
gland; this may disappear after some years; Simpson has seen 5 cases of 
it. Ollivier has seen in front and to the right of the neck, a tumor, the 
size of a hazel-nut, of a whitish-yellow color, soft and fluctuating, which 
yielded pus. Planteau, in 1876, collected a number of cases of cervical 
tumors. Riveau Landreau has noted a case of purulent ophthalmia, 
supervening during uterine life. 
Taylor records abscesses in the foetus; Finnell, intra-abdominal 
tumors; Legendre, hydrocele of the cord; Friedreich, cancer. The intra- 
uterine foetal pathology is, however, as yet hardly outlined. 
. Scrofulous Affections. 
Temporary swellings of the thyroid gland have been especially noted 
in face presentations, and are easily explained, but there exists another 288 
A TREATISE ON OBSTETRICS. 
rare affection, which Spiegelberg has called " struma intra-uterina con- 
genita." It is one of the most rare diseases of the foetus, and consists 
of a simple parenchymatous hyperplasia, and is persistent. It comes on 
endemically, apart from the general hereditary condition. Congenital 
goitre may cause brow or face presentation, in causing bending of the 
head. Hecker, Simpson, Ldhlein, have each cited a case of it. It may, 
after birth, be the cause of respiratory trouble, and even. of death, by 
compressing the trachea. Both Spiegelberg and Hecker, the first in two 
cases, the second in one case, have observed this asthma due to hyper- 
plasia of the thyroid. 
Affectioxs of the Boxes. 
Fractures. 
The fractures which are seen in the foetus may be produced in utero, 
or may result from traumatisms occurring during delivery. We shall 
only consider the first variety. Intra-uterine fractures are due to a de- 
fect of ossification, to the non-union of the osseous masses, developed from 
the different centres (occurring particularly in bones of the head), to the 
separation of epiphyses, this separation depending on an inflammatory 
process, or a non-union of the diaphyses with the epiphysis, or to congeni- 
tal rachitis. They may be caused by some traumatism sustained by the 
mother, which may leave no trace on her body. These fractures will be, 
of course, more readily produced where there exists already a primary de- 
fect of ossification, or where there is less amniotic fluid. Almost always 
the extremities are the parts involved, and the thigh frequently, since its 
situation exposes it unfavorably; whereas the head, from its form, its 
situation or its engagement in the superior strait, usually escapes. The 
actual displacement, which is almost always seen in these cases, is the 
result of muscular traction, which, however, has not prevented union. 
Can these lesions be produced in the uterus in healthy bone, without 
external injury ? This seems at least doubtful to Spiegelberg, who 
admits, however, that in these cases, there may have been a protruding 
promontory and prolonged compression of the head or of other parts 
against it. Some cases of fracture of the cranial bones have been seen 
after natural labor in women who had pelvic deformity. 
The prognosis is generally not grave. These fractures heal rapidly, 
unless from the influence of complications, gangrene occur. In some 
cases, however, they are caused by lesions of which traces are found at 
birth, in the form of pareses, atrophy of limbs, which show that there 
have been lesions of the nervous trunks, or inflammation,, terminating 
by atrophy or sclerosis. 
Cranial fractures, accompanied by hemorrhages, by concussion or by 
cerebral contusions, are most often fatal. If these last injuries are es- DISEASES OF THE F(ETUS. 
289 
caped, the infants may recover from the fractures. Concerning the tor- 
sions, the forced flexions, the general compression of the foetus, they may 
be caused, considering the little space the foetus occupies, by either an 
internal pressure exercised on the foetus by uterine or peri-uterine tumors, 
by deformity of the pelvis, by insufficient liquor amnii. Hohl and Con- 
rad have collected a certain number of examples. 
Luxations. 
Concerning luxations, the etiology is obscure. They may be ascribed 
to an anomaly of development of the articular cavity, which, in conse- 
quence of causes to-day still unknown, manifested itself first, not at the 
normal point, but at some other point of the iliac bone. It is curious that 
the greatest number of these observations have been in female foetuses. 
Fehling believes that these depend on the fact that the flattened portion 
of the iliac bones was extended. In this connection it is necessary to 
cite the coxalgia observed by Bird, Broca, Morel Lavalie, Padieu, and 
the curious cases of ankylosis, by Bird, Richaud, Joulin; of ankylosis 
with hydrocephalus, by Becourt; and of gibbosity with or without .hy- 
drocephalus by Joulin, Mantoux, Nivert. 
Spontaneous Amputations. 
Under the name of intra-uterine amputations, spontaneous amputations 
or congenital amputations, are designated certain defects of conforma- 
tion, characterized by total or partial absence of one or more extremities. 
Duplay, holding rightly that among these defects some are due to failure 
of the normal evolution of the limbs, an arrest of their development, 
others due to the action of some mutilating agent, which cuts them off 
as with the surgeon's knife, designates them as congenital amputations. 
The first, considered under teratology, group of ectromeliens (Geoffroy 
Saint-Hilaire), we shall not consider here. The second directly con- 
cern the obstetrician. 
Causes.-While Haller attributes them to malformations and not to 
separation of formed parts, Chaussier, the first to find in the uterus the 
separated part, attributes them to gangrene, but Watkinson shows that, 
although the stump was largely cicatrized, the foot, found in the uterus, 
showed no trace of putrefaction, and appeared to be in a state of perfect 
preservation, and therefore excluded the idea of gangrene. Montgomery, 
Levert, Simonart, have shown that these amputations result from constric- 
tions of the extremities, sometimes by the umbilical cord, most often by 
bands of false membrane, which, looped about the extremities, completely 
cut them off; the bands are developed in the interior of the amniotic cav- 
ity. Whether these bands are due, as Montgomery thinks, to an inflam- 
mation of the foetal membranes, accompanied by an effusion of plastic 
lymph, or as Simonart, Moreau, and German authors think, to the am- 
Vol. II.-19 290 
A TREATISE ON OBSTETRICS. 
niotic bands, the instances have multiplied, and, by those of Zagorski and 
of Montgomery, we are able to follow the lesion from its beginning, a 
simple cutaneous depression, up to a complete amputation. These bands, 
indeed, fixed by both extremities to the internal surface of the membranes, 
form rings or loops in which any part of the foetus may be entangled. 
But authors are not all agreed as to the action of these bands. Mont- 
gomery thinks that the ligature, in compressing the vessels more and 
more, obliterates those of the bones themselves, whose vitality ends by the 
obliteration; and these bones, now soft and friable, are entirely separated 
by the foetal movements. He has observed that the skin and soft parts 
are not divided but depressed inwards to the bone, so that when the sec- 
tion is complete, the skin covering the surface of the section, the stump 
appears cicatrized. Martin Jena does not believe that the simple liga- 
turing is able to act on the bone, unless it is in a cartilaginous state, 
lie thinks it should limit its action to the soft parts, and the cause of 
these amputations, therefore, must be exterior. This opinion, given 
already by Simpson, is not absolutely tenable. It is perhaps true in cer- 
tain cases, that of Martin proves it, but besides that the ligature acts 
frequently on the cartilaginous parts, these ligatures have often produced 
incomplete sections only including the soft parts; and the morbid influ- 
ences which cause these bands, and in particular, the inflammation, pro- 
duce functional difficulties and organic malformations, incompatible with 
the life of the foetus, which succumbs often before the separation is com- 
plete. Finally, the instances of Hecker, Fitsch and Watkinson prove that 
the mother has not received any accident. 
Contrary to the opinion of Braun, who thinks that the spontaneous 
amputations are produced generally on the upper extremities, it is in the 
lower extremities that Crede and Duplay have most often found them, and 
generally on the left side. The direction of the cord to this side, ex- 
plains to a certain extent this predilection. 
Sometimes, and it is the rule, the stump is cicatrized; sometimes there 
is a wound, generally little extended, at the centre of the stump. In 
this case, the bone or the bones of the member are prominent on the 
surface of the wound, as in a circular amputation, in which the stump 
would be conical. 
In the cases where these amputations are due to a veritable malforma- 
tion, the extremity of the stump has one or more appendages. (Figs. 24 
and 25). Sometimes fingers more or less complete with phalanges and 
nails, sometimes simple cutaneous tubercles; and in these cases, Debout 
has noted extreme sensibility of the deformed members, due to the enor- 
mous development of the nerve trunks, which does not exist in cases of 
congenital amputations. Simpson, who has observed five or six of these 
last cases, believes in a tendency in the human species to a reproduction 
of a missing extremity, and having seen in a case of Withe, the thumb DISEASES OF THE FCETUS. 
291 
amputated, first by Withe and a second time by Bromfield, grow again, 
he supposes that, where the amputation is produced in the early part of 
foetal life, at a time when the physiological activity is similar to that of 
an order less elevated, the lost portion is perhaps at least liable to a par- 
tial and rudimentary restoration. It is only in exceptional cases that 
these bands become a cause of dystocia. The only case known is that of 
Bleeck, but Fitsch has observed one, in which the amputated part had 
been expelled fifteen days before the birth of the child, following spon- 
taneous and premature rupture of the membranes. Most frequently the 
children are still-born. Gay and Martin have each observed a case of 
spontanous amputation with birth of living children, and which have 
survived. On the contrary, in cases where the amputations were simply 
an arrest of development, the children are often born living. We have 
Figs. 24 and 25.-Congenital Spontaneous Amputation. 
seen an example of this: the lesion was double; there was a slender stump 
of the left leg, with complete absence of the foot, and a rudimentary right 
foot attached to a very atrophied leg; the child is now two years old. As 
in the cases of Bleeck and Guy, the child presented by the breech. 
Beauregard has noted in the negroes and Hindoos, an affection which 
he calls dactylolysis, and which, always produced in the little toe, at its 
base, consists in a circular strangulation, which transforms it into a thin 
•pedicle, which breaks off if not cut off. At the same time, the little toe, 
deviating from its direction, deformed, triple in size, is converted into a 
compact spheroidal mass, like a little ovoid. Beauregard, who has com- 
pared this to spontaneous amputations, describes three varieties of ectro- 
dactylia: first, complete arrest of development, true abortion; second 
brachydactilia, arrest of phalangeal development; third, spontaneous am- 
putation. We are dealing here, then, with a defect of conformation and 
not spontaneous amputation. 292 
A TREATISE ON OBSTETRICS. 
Intra-uterine Rachitis. 
The description given by Depaul is so complete, that we can do no bet- 
ter than borrow from him. 
' "Recent State.-The size of the head strikes one at once, and contrasts 
sharply with the slight development of the trunk and extremities; but 
this disposition is rather relative than real, and the cavities and organs 
which it contains are in the normal state. The vertebral column does 
not present an unusual curve. It only seems that the cervical region is 
a little short; the head appears as if placed on the upner part of the tho- 
Fig. 26.-Intra-Uterine Rachitis. 
rax. The chest has a very pronounced conical form, at the top narrow, 
at the bottom very wide. The lower border of the cartilages and the 
xyphoid appendix are as if turned outwards, and show themselves under 
the skin. The thorax is flattened from before backwards. The four ex- 
tremities are remarkable for their little length and their volume. The 
upper are held in a nearly vertical situation. In contrast, the clavicles 
are very long. The lower limbs appear made up of two kinds of enlarge- 
ments, separated by a furrow, which is found above the knee. The 
upper one is considerably enlarged, and presents a rounded surface which 
is directed forward and a little outward. Movements of the articulations 
are easy, and palpation proves the tissues sufficiently firm. Beneath DISEASES OF THE FCETUS. 
293 
the skin, which is normal, exists a bed of fatty cellular tissue of the usual 
thickness. The muscles, normal, are relaxed; the aponeuroses are per- 
fectly adapted to the conformation of the limbs, and do not hamper them 
in any direction. There is no anomaly in the nerves, nor in the vessels. 
"Lesions of the Skeleton.-Cranium.-The fontanelles are wide, but not 
of the usual shape; sometimes normal, as also the sutures. Ossification of 
the bone is regular and complete. 
"Face.-In proportion to the cranium, is normal. Maxillary bones well 
developed and regular, containing the teeth-germs. Forehead, normally 
prominent. 
" Thorax.-The capacity is not considerable, very wide at the base, when 
the sides and the cartilages are strongly thrown outwards. The ribs are 
regularly curved; sufficiently slender at their vertebral extremities, they 
commence to increase toward the anterior part, and terminate by a consid- 
erable enlargement. This is not marked except in the first three and last 
two. At the centre of each of these extremities, which is hollowed out, 
starts the cartilage, which is slender and filamentous. Certain of the 
intercostal spaces are wanting. Besides, the ends of certain ribs are 
sharply and abnormally curved upwards. 
"Upper Extremities.-The clavicles are very long, considering the di- 
mensions of the thorax. Their curves are not exaggerated. The result 
is that the scapula) are thrown backwards, and tend to overlap at the 
spinal border. The volume is not abnormal either in the shafts or the 
extremities. The scapula) are but little altered in form, and present a 
curve backwards, which increases the depth of the intra-spinous fossae to 
such an extent that it effaces the subscapular fossae, which are replaced by 
a convexity. The ossification is normal. 
"Humerus.-Represents, on each side, the arc of a circle, strongly 
curved on its anterior plane; the convexity is backward, on its posterior 
plane. The osseous surface, which belongs to the concavity, is flat and 
almost excavated; that of the projecting part is rounded in its whole ex- 
tent. Besides this general curve, another is seen toward the lower third, 
the concavity directed outwards, the convexity inwards. The two ends 
are noticeably enlarged. The upper end has a rounded form, the lower 
is more extended transversely than from before backward; the epiphyses, 
entirely cartilaginous, are reduced by dessication to a very small size. 
"Radius and Ulna.-Of equal length, but whereas the radius exceeds 
the ulna below, this exceeds the other above, and in the same proportion. 
The intra-osseous space is narrow and elliptical, the extremities are of 
considerable volume. A double inflection exists, the first has the concav- 
ity anteriorly, and the convexity posteriorly; the second, the concavity 
internal to the radius and external to the' ulna. ♦ 
"Hand.-No point of ossification in the bones of the carpus; those of 294 
A TREATISE ON OBSTETRICS. 
the metacarpus and phalanges are regular as to form and direction. The 
size is above the normal. 
"Pelvis.-Sufficiently regular at first, but the upper rim of the pubes is 
slightly elevated, hence there is considerable obliquity of the superior 
strait. Considerable increase in the transverse diameter, compared to 
the an tero-posterior; pubes and ischio pubic rami cartilaginous, the other 
parts regularly ossified. 
"Femora.-Curve is very marked, directed backward and inward. A 
second curve, with internal concavity and external convexity less pro- 
nounced; extremities largely increased in size. 
Fig. 27.-Intra-Uterine Rachitis. 
"Tibia.-Large and very short, very obliquely cut away at the upper 
part, from above downward and behind forward. Curve gentle, concavity 
backward and outward, convexity forward and inward. The lower ex- 
tremity presents an analogous curve. 
"Fibula.-Placed more posteriorly than normal; slight curve, concavity 
anterior and internal; convexity, posterior and external; separated from 
the tibiae by a large elliptical space. Normally large; much enlarged at 
the ends. 
"Feet.-Tarsus completely cartilaginous, metatarsus and toes abnormally 
ossified and formed; feet incline outwards in relation to the leg. 
" Vertebral Column.-Nothing unusual, spinous and transverse processes 
cartilaginous, with ordinary points of ossification. 
"Periosteum.-Thin, regular, normally adherent." DISEASES OF THE F(ETUS. 
295 
This description, which relates to a foetus of seven and a half months, 
born alive, but respiration failed to be established, is typical and charac- 
teristic. But in other cases different alterations are observed. In a case 
seen by Gueniot, and in another seen by myself (and whose skeleton is 
found in the museum of the Clinic), the changes were identical. Besides 
the curves and the enlargements of the epiphyses, noted by Depaul, we 
found on the cranium an ossification more than incomplete, characterized 
by some disseminated osseous plates, but all the long bones and the lower 
jaw presented an infinite number of fractures or solutions of continuity. 
Each bone seemed to consist of little osseous masses, mobile, bound to- 
gether by the periosteum, which rendered the dissection very difficult. 
But, contrary to the observations of Gueniot, in our case all the bones 
of the skeleton, vertebral column, pelvis, hands and feet, participated in 
the changes. Spiegelberg has found these same changes, and has seen 
the curves of the bone, the enlargement of the epiphyses, and the frac- 
tures, with remarkable integrity of the clavicle. He noted: the flatten- 
ing of the pelvis, the extension of the sacrum, the deviation of the prom- 
ontory forward and downward, transverse flattening of the sacral vertebrae 
and the iliac crests, increase of the pubic arch, the characteristic superior 
strait, and ossification, sometimes incomplete, sometimes almost exag- 
gerated, of the cranium. 
Depaul does not believe that these cases are true instances of intra- 
uterine rachitis, and holds that in each of the observations there has been 
omitted mention of the sign which characterizes the second period of 
rachitis, namely, softening of the bony tissue; but, while e^ra-uterine 
rachitis rarely invades the whole skeleton, and has a predilection for the 
long bones, in so-called zWm-uterine rachitis the whole of the skeleton 
is invaded. Only the points of ossification which are in the spine appear 
as exceptions. The deformity is produced with a certain symmetry on 
the corresponding bones. Contrary to Spiegelberg's opinion, the curves 
are generally in relation with the muscular action, sometimes more mani- 
fested inversely. Finally, there is no arrest of development. 
In all probability, the affection began at a slightly advanced period of 
foetal life where as yet, only a little, if any, calcareous material had been 
deposited in the tissue. As a result, it is necessary to reject the idea of 
a deformity succeeding a perfectly regular state, and to recognize the in- 
fluence of a single cause, namely, an unequal distribution of the material 
which gives to the bones their form and their solidity. In short, in the 
true rachitis, the entire organism appears affected, while in the case of 
intra-uterine rachitis, the lesion appears exclusively confined to the bony 
system. 
Concerning the solutions of continuity which are described under the 
name of fractures, Depaul believes them to be of two kinds: the one, the 
true, due to external violence, to exaggerated muscular contractions, or 296 
A TREATISE ON OBSTETRICS. 
to an essential weakening of the tissue, which lies at the seat of the 
trouble; and the other, the false, those which coincide with the supposed 
intra-uterine rachitis. 
Even as the curvature may be explained by an unequal development 
of the different parts of the same bone, so may the solutions of continu- 
ity result from the fact that calcareous deposits are not made in one or 
more points of the shaft; hence it is not a fracture which occurs, but an 
absence of ossification. It is of no account that there has been noted in 
many observations, in that of Chaussier in particular, the existence in 
the course of some of the long bones of certain enlargements, which have 
been cited as proof of fractures which have united, for there is nothing to 
show that there is true callus. A limited prominence of bony tissue is all 
that exists, and it is not harder to understand this superabundance of 
the calcareous material than the diminution, the absence or irregular- 
ity of its deposit; and, according to Depaul, all these alterations of the 
bony tissue are of the same nature, and due to the anomalies of ossifica- 
tion. The health of the mother has nothing to do with their development. 
In no case has scrofula, rachitis or syphilis been found. In many in- 
stances, the disease has occurred in twin pregnancies, which fact is prob- 
ably connected with the development of the rickets. 
As opposed to these ideas Spiegelberg says that histological examina- 
tion proved that the process is identical in intra-uterine and extra-uterine 
rachitis. 
Winckler makes two subdivisions: rachitis micromelica and annular 
rachitis. The first is eminently intra-uterine; the second, beginning, 
possibly, in the last months of pregnancy, passes into the intra-uterine 
phases of rickets. Muller has described a special alteration in the bones, 
characterized by disease of the primitive cartilages. Of all the diseases of 
the bones, that affecting the inner surface of the skull is the rarest. 
Spiegelberg once found a gumma. Wegner detected lesions of the bony 
canaliculi. In general, the changes in the bones are most marked in the 
end of the femur, then in the lower extremity of the tibia, and in the 
radius and ulna; later in the upper extremity of the humerus and of the 
radius, and lastly in the lower extremity of the humerus. This alteration 
is usually due to syphilis of* the father. In addition to osteo-chondritis, 
Wegner has noticed alterations in the marrow of the canaliculi, sometimes 
diffuse, and sometimes in isolated patches. The medullary tissue is red- 
dish, and under the microscope is found to be in a state of fatty degener- 
ation, especially of the medullary cells and the walls of the vessels. 
Congenital Syphilis. 
In studying maternal syphilis we have shown the conditions in which 
the disease is transmitted to the foetus. In connection with diseases of 
the placenta, membranes and cord, we have noted the lesions which are DISEASES OF THE FOETUS. 
297 
regarded as characteristic of syphilis; it now remains to study them in 
the different systems and organs of the foetus. 
In recent years hereditary syphilis has been studied authoritatively by 
Parrot, from whom the following description is borrowed: 
Two different groups of lesions are produced: one, peripheral or super- 
ficial, located on the skin or mucous membranes; the other, profound, 
which affects the different viscera and the bones. 
The cutaneous lesions are bullae, maculae or papules, as shown by the 
following table. 
1. Bullae (pemphigus). 
2. Maculae. 
3 Plaaues J true' 
n ' I lenticular. 
4. Vesico-papulae (very rare). 
Syphilides, 
Ulcerous syphilides are only the ordinary syphilides which have become 
ulcerated by the action of external bodies or under the influence of a 
generally bad condition. The more intense the diathesis, the sooner the 
syphilides appear. The first manifested is the bullous syphilides (the 
pemphigus). It is a precocious manifestation of extreme gravity, which 
often coincides with visceral lesions, and which frequently and rapidly 
reaches a fatal termination. On the contrary, the lenticular syphilides is 
manifested later; it ordinarily appears isolated. The vesico-papular 
syphilides are extremely rare, are the expression of a vanishing diathesis, 
and of little gravity, and, as intermediate to these different cutaneous 
lesions, we find the macular syphilides, rarely isolated and united some- 
times to the bullous syphilide, sometimes to the " plaque " syphilide (syphi- 
litic roseola of authors). The mucous patch, the most frequent, is char- 
acterized by permanent, tenacious, indurated elevations in patches. 
The patches are circular, red at the centre, violet or salmon-red at the 
periphery. They are found about the anus, on the lower limbs, thighs, 
scrotum, labia majora. (The child at the same time has coryza). They 
ulcerate easily. On the face they often become crusted; finally they 
occur on the scalp. The eruption is produced in eight, ten or twelve 
days, and increases. They last a long time. The lenticular syphilides 
occur on the buttocks, the upper and back part of the thighs and the leg, 
the labia majora and the scrotum; these are the true lenticular patches. 
Then, the buccal ulcerations appear. But while all or nearly all the buccal 
ulcerations, due to marasmus, are symmetrical and lying on the median 
line or at symmetrical points, the syphilitic ulcerations are never found 
in the median line, and it is impossible to give them a particular topogra- 
phy. They have an irregular contour and a hemorrhagic tendency; they 
occur particularly on the tongue, on the internal surface of the cheeks, 
on the alveolar border of the maxillae, and quite frequently on the velum 298 
A TREATISE ON OBSTETRICS. 
palati. They are found also in the mouth, as red, prominent patches, 
similar to ordinary mucous patches. On the lips are found fissures, the 
true rhagades, erosions and projecting mucous patches. When the chil- 
dren die of syphilis, we find profound lesions of the bones and viscera. 
All the organs may present the lesions; indeed they have been found in 
the brain, where occurred a softening of a bluish-red color, and little 
purulent nuclei, located near the longitudinal fissure and to the left side 
of the cerebellum. But these four organs, the thymus, the lungs, the 
liver and the spleen are always affected. In the thymus, Dubois has noted 
the presence of pus diffused or collected in foci in the parenchyma, with- 
out changing the color, form or size of the organ. The observations of 
Braun, Spaeth, Depaul, Wild, Virchow, Weber and Hecker, have con- 
firmed those of Dubois; but Spiegelberg, who also found these changes, 
thinks that, in a good many cases,there is an increase in the size of the gland. 
In the lungs, Depaul, in 1851, stated: sometimes true collections of pus, 
or more or less thickened cavities enclosing a liquid of the same nature, 
are found. "I have many times," said he,"found another disposition which 
should be considered as the first degree, and which consists in a grayish 
induration, without as yet recognizable pus, with a considerable deposit 
of fibro-plastic tissue. Sometimes the lesion was disseminated and limited 
to circumscribed points; sometimes, on the contrary, it was general and 
had invaded one or more lobes. But always the pulmonary tissue was 
impermeable to the air, as proved by mucous insufflations. It is not rare 
to find these different degrees in the same organ." The lesions are con- 
nected with other conditions characteristic of syphilis. 
Lebert contests the presence of pus. The tissue has a particularly 
yellow color, it is resistant and elastic. At the middle of the mesh, formed 
by the pulmonary network of fibro-plastic elements, is found a soft sub- 
stance, pulpy, diffused, and in which are many little cells, which are 
neither cancerous, nor tuberculous elements, but resemble in every way 
the cells of syphilitic gummata. 
Liver.-There is described, sometimes simple hypertrophy, sometimes 
general or partial congestion. Gubler has described the organic lesion 
which is peculiar to the liver. This lesion may be general or partial. 
1st. General.-When the alteration is of high degree, the gland shows 
a yellow color, very different from the normal condition, and which is 
best compared to the hue of flint. The appearance of the two substances 
has completely vanished, only on the yellow base we find, on close atten- 
tion, a more or less clear space of little white opaque grains, looking like 
grains of millet, and free arborizations appertaining to the exsanguin- 
ated vessels. The liver is sensibly hypertrophied, globular, tinged, hard 
and difficult to grasp with the fingers; it tears without allowing an im- 
pression on the surface. Its elasticity is such that if pressed forcibly be- 
tween the fingers, so as to crush a wedge-shaped piece from its sharp edge, DISEASES OF THE F(ETUS. 
299 
the piece escapes like a cherry-stone from the compressing fingers. In- 
cised it creaks under the scalpel. The incisions which are made into the 
liver should be very clean, homogeneous, and the great consistence allows 
us to obtain very thin sections, semi-transparent, which to a certain de- 
gree are found in the naturally thinned portions of the organ (as the bor- 
ders and especially in the tongue which terminates the left lobe.) 
2d. Partial.- This form is more common than the general. The liver 
is less enlarged and shows an undecided coloring, shaded yellow and red- 
dish-brown. No part of the parenchyma appears entirely sound. At the 
same time the liver has a certain semi-transparency, which allows one to 
distinguish, at a little depth, millet-like, the grains with which its sub- 
stance appears strewn. These opaque points are here more numerous and 
compact. In fact these opaque grains, plunged lightly into the transpar- 
ent substance, reproduce to a certain point the aspect of the two sub- 
stances which constitute the hepatic tissue, but, beyond that, the grains 
are separated by very great intervals, the surface substance does not re- 
semble particularly the net-work, essentially vascular, of the areolar spaces 
of the healthy state. 
Under the microscope we find, in the altered tissue, a considerable, 
sometimes enormous, quantity of fibro-plastic elements in all stages of 
evolution, in the centre of which the ecchymosed cells are dispersed. The 
relation of these fibro-plastic elements', by their connection with the 
proper tissue of the organ, is more or less strong as the alteration is more 
or less advanced. There is very little in the parts, still brownish, of the 
second form, or it is lost in the midst of the proper cells. They are, on 
the contrary, very predominant in the yellow and very hard livers, as 
well as in the strongly indurated portions of the livers which only present 
a partial alteration, -while they exist very slightly in parts whose aspect is 
only slightly modified, and not at all in normally appearing tissue. The 
fusiform bodies strike us at first; of which some are short, shaped like a 
spindle, the others very long, enlarged in the centre, and terminating by 
tapering extremities. Nearly all have an oval or ellipsoid nucleus enclos- 
ing a granular substance, in the midst of which are noticed one, two, or 
three larger granules, of a more fiery brilliancy. There are also many 
rounded or oval cells, sufficiently like the smaller cells of the parenchyma, 
but enclosing nuclei, like the fibres. In some cases, especially in the 
general form, there is found in the tissue indurated nuclei, of which some 
are soft and filled with a purulent material, true suppurating gummata. 
Under pressure the liver yields a yellowish liquid, a little ropy, partly 
coagulable by heat. The heart is soft and flabby, containing a currant- 
jelly like liquid, characterized by a notable diminution of tlie globules, 
which are dissolved in albumin.- The pericardium and the cardiac mus- 
cular tissue are filled with milky patches. 
Peritoneum.-We have noted the hemorrhagic peritonitis of Simpson. 300 
A TREATISE ON OBSTETRICS. 
The spleen is hypertrophied, softened, indented, permeated with indu- 
rated nuclei, as the disorganization is more or less advanced. 
The pancreas presents analogous alterations to those of the liver. Pro- 
liferation of the fibro-plastic tissue, induration, hypertrophy; on section 
it is whitish, brilliant. The structure of the acini has disappeared to the 
naked eye. The proliferation is extended, not only to the intermediate 
tissue of the glandular groups, but also to the intermediate tissue of the 
acini; it compresses them, destroys their epithelium, thickens the walls 
of the vessels and destroys the capillaries. 
The kidneys are hypertrophied, the Malpighian pyramids contain little 
yellow nuclei, indurated, with commencing suppuration. 
On the intestines one finds blackish, indurated patches occupying the 
entire wall of the intestine, and constituted by net-work of fibres, holding 
entangled at their centre fatty and purulent globules, and their cells hav- 
ing prismatic angles, rounded, strongly tinged with brown. 
Finally we find the osseous lesions which, noted vaguely by Waldeyer, 
Wagner, Korner, Taylor, have been studied in detail by Parrot and Huge. 
Parrot finds that in every foetus bearing on the skin, the mucous mem- 
brane or in the viscera, the marks of hereditary syphilis, the bony sys- 
tem is altered. These lesions may exist alone. Parrot has observed 
them in a very clear case. The long bones of the extremities, excepting 
those of the hands and feet, are with the scapulae, the iliac and cranial 
bones, most frequently attacked; then the ribs, the clavicles, the metacar- 
pal and metatarsal bones, and lastly the vertebrae. But these last are 
only affected when the disease is of long standing. The symmetry of the 
lesions is constant. 
Parrot thinks that there are four varieties, or better, four degrees of 
the lesion. 
" 1. Seen in foetuses, and in infants dead a few days after delivery. 
The bones are heavier than normal. Under the periosteum, are found 
osteophytes. Around the diaphysis the same osteophytes are found, per- 
pendicular to the diaphysal axis. The medullary substance is very much 
diminished, and the medullary canal almost obliterated. The scapula and 
the iliac bone are also covered with osteophytes. 
" 2. The bones are less heavy, the new-formation layers less dense, and 
more porous. The changes affect in particular the inferior part of the 
diaphysis of the humerus, the upper part of the ulna, the anterior surface 
of the femur, and the internal of the tibia. A peculiar characteristic of 
this degree is the gelatinous atrophy of the bones. The spongy tissue is, 
in particular, affected. To this atrophy, is added the pseudo-syphilitic 
paralysis of the new-born. Fracture occurs at the cartilage. Pus forms; 
osseous fragments become detached; abscesses occur, which may spread 
to the joints and break outwardly. 
" 3. This is characterized by medullarization, which appears in cases of DISEASES OF THE F(ETUS. 
301 
longer duration. The osteophytes are still present, often, as also, the 
gelatinous atrophy. But the changes are most apparent in the medullary 
substance, which spreads, invading gradually, in particular, the inferior 
region of the humerus near the nutrient foramen. It is here, indeed, 
that we find the distinctive mark of the disease. There occurs enlarge- 
ment of this extremity, especially from before backwards. A section per- 
pendicularly through the diaphysis, reveals the lesion best. The diaphy- 
sis is enlarged, the antero-posterior diameter may be doubled. This is due 
to one oi- two layers of osteophytes. The chondro-calcareous layer is not 
so hard as in the normal. 
"4. This degree is characterized by the formation of a spongy tissue at 
the periphery and end of the diaphysis, where it tends to replace the 
chondro-calcareous layer. The characteristic deformity of the humerus 
diagnosticates the lesion. This degree is found in children beyond six 
months. The older the infant, the more it approaches rickets in appear- 
ance. 
"Syphilitic bones of the first degree,with their compact osteophytes, and 
their gelatiniform atrophy, are the very reverse of rachitic bones. The 
two other degrees resemble one another, but the characteristic shape of 
certain bones, in particular the humerus, and the greater density of the 
spongy tissue, and, further, the less development of the cartilaginous 
layer, are certain signs of syphilis." (Parrot.) 
Death of the Fcetus. 
The causes of foetal death are numerous. It may depend on the father, 
through alteration in the semen; on the mother, through general disease, 
irritability or excitability of the uterus, lesions of this organ, etc.; on the 
foetus itself, from faulty development or monstrosities; on the annexes 
of the foetus, membranes, placenta, cord. Finally, on external influ- 
ences, such as traumatism. 
Many of these causes we have already studied at sufficient length. We 
will refer here only to certain facts which result from modern physio- 
logical researches. 
Influence of high Maternal Temperature on the Vitality of the Fcetus. 
Without referring here to the transmission of disease, variola, intermit- 
tent fever, etc., to the foetus from the mother, the researches of Hecker, 
Fielder, Buhl and Winckel, prove that acceleration of the maternal pulse 
from disease, may cause foetal death. The foetus sympathizes with the 
mother, both in evening exacerbations and in morning remissions of the 
pulse. 
Further, Hohl, in 1830, Kaminsky, in 1866, Winckel, in 1869, and es- 
pecially, Runge, in 1877, have proved the noxious influence of elevation 
of the maternal temperature on the foetus. 302 
A TREATISE ON OBSTETRICS. 
Runge, whose experiments were elaborate, concludes: 1. The tempera- 
ture is always a few tenths higher than that of the mother. 2. The foetus 
is killed by the elevation of the temperature alone, even before the 
mother dies. 3. A maternal temperature of 107°, even though it lasts 
but a few minutes, will inevitably kill the foetus. 
Action of the Maternal Blood on the Vitality of the Fcetus. 
We have seen, in the article on the respiration of the foetus, that there 
is an exchange of materials between the foetus and the mother through 
the placental villosities. As Zweifel, Gusserow, Runge and Porak, have 
shown, certain soluble salts (salicylic acid, iodide of potassium, benzoic 
acid), certain poisonous substances (chloroform, ether, alcohol) may pass 
directly and naturally from the mother to the child; certain forms of 
virus, certain miasms (variola, syphilis, malaria), may be transmitted by 
the same, from the mother to the foetus. Finally, the gaseous inter- 
changes are particularly apt to be produced, the foetal blood-glo- 
bule taking oxygen from the maternal blood-globule. But, on the other 
hand, it appears from the experiments of Zweifel, of Zunz and of Andreas 
Hogyes, that when the maternal blood, from any cause, cannot renew its 
oxygen from the external air, if the maternal blood corpuscle is intact, 
and preserves its absorbing power, it in its turn borrows oxygen from the 
richer foetal blood and thus endangers the life of the foetus. If the ma- 
ternal blood corpuscle is altered, or if it has lost its absorbing power, it 
does not take up the foetal oxygen, and the foetus, consuming little, con- 
tinues to live more or less time after the death of the mother. It appears 
then that whatever interferes with the exchange of gases and nutritive 
materials between the foetus and the mother, is fatal to the former. 
Then the utero-placental circulation may be obstructed either in the 
uterine vessels, in the placental villosities or in the cord. It is thus that 
uterine tumors, peri-uterine tumors, diseases of the placenta, bloody effu- 
sions, changes in the villosities, degenerations, may act, as also maternal 
diseases, pyretic or apyretic, gravido-cardiac accidents; certain toxic sub- 
stances, phosphorus, lead, arsenic; violent deaths, asphyxia, syncope, 
finally all the causes which determine the premature contractions of the 
uterus or obstruct its development; also lesions of the cord. 
But in a certain number of cases the foetus succumbs without any cause 
being found, and this at several consecutive pregnancies (13 times in a 
case known personally to us; it was only in the 18th pregnancy that she 
had a living infant, and indeed it was born at 8 months). In these cases, 
the young, strong and healthy women were married to strong and vigor- 
ous men. Nevertheless, most frequently the cause of death of the foetus 
may be found, but authors are not agreed on this point. 
Ruge, in an interesting article, " uber den foetus sanguinolentus," states 
that most authorities believe syphilis to be the usual cause of foetal death, DISEASES OF THE FCETUS. 
303 
while Simpson believes that it is only a secondary cause, the primary 
being the existing peritonitis. 
According to Huge, the foetus sanguinolentus, or the macerated foetus, 
is almost always the outcome of syphilis. 
Leopold believes that the habitual death of the foetus is due: 1. To 
syphilis; 2. To anemia; 3. Chronic diseases of the mother; 4. Heredi- 
tary tendencies. [In 1883, in an article on "Habitual Miscarriage" we 
tabulated the causes of foetal death, as follows: 1. Syphilis; 2. Maternal 
anemia; 3. Uterine disease, and disease of the uterine appendages; 4. 
Uterine displacements; 5. Chronic cellulitis and peritonitis; 6. Laceration 
of the cervix; 7. Intermittent fever; 8. Chorea; 9. Bright's disease; 10. 
Tumors of the uterus, and in its neighborhood; 11. Poisoning from me- 
tallic substances, lead, arsenic, etc., seen particularly in workers in the 
arts where these metals are used; 12. Reflex conditions. These latter, 
we stated, may have their outcome either from the nervous system, in 
general, or from the uterus and its appendages, in particular. There 
are some women so delicately nurtured, so highly impressionable, as to 
react to the slightest nerve stimulus. Like hot-house plants they must 
be watched and tended, lest the slightest influence, outside of their accus- 
tomed habitat, affect them unfavorably. Gestation with them is often 
toxic. The uterus repels the impregnated ovum as it would a foreign 
body. 
Of the above causes, it is apparent that certain ones are more likely to 
act than others in causing foetal death. In any given case of repeated 
miscarriage, the greatest care is necessary to determine the possible cause. 
In certain cases it may be advisable to absolutely forbid sexual inter- 
course during gestation, the foetal death being apparently the result of 
the congestion which accompanies copulation. 
As a still further cause, and likely enough not a very infrequent one, 
we would mention the uterus septus. This is all the more likely to be 
overlooked, because of the difficulty in determining the malformation, 
except on very careful examination. The cause of death, in this case, is 
the development of the foetus in a space too contracted to allow of its due 
expansion. Munde recently reported a case of this nature, before the 
New York Obstetrical Society.-Ed.] 
If the majority of the causes of foetal death are absolutely beyond the 
accoucheur's control, it is not so in a certain number of other cases, and 
particularly for syphilis, all authors, excepting Despres perhaps, arguing 
that a careful treatment, begun during the pregnancy, can, and only can, 
save the child. Hence the precept of Depaul, to always follow an anti- 
syphilitic treatment in women who abort repeatedly, without known cause, 
even when they do not present, nor does the father, traces of syphilis. 
A large number of cases have justified this treatment. We have our- 
selves plainly observed a case; four abortions without known cause, 304 
A TREATISE ON OBSTETRICS. 
syphilis absent in the father and mother, at least in appearance, and ab- 
solutely denied by both. Anti-syphilitic treatment of both. Since, two 
healthy infants* the elder is two years old, the younger just 9 months; 
neither has ever presented any symptoms. The mother has been able to 
nourish both. 
But, when the anti-syphilitic treatment fails, have we the right to 
resort to premature delivery? To us, it does not appear even doubtful; 
and, without hesitation, we should induce labor in the weeks which pre- 
cede the usual death of the foetus, not forgetting, however, that, in a 
good many cases, the death seems to come on more and more tardily, 
according as the pregnancy is renewed. Such women, who have begun 
by abortion, have come gradually to premature delivery, and we believe 
that it is in these cases especially that there is the chance of success. 
[In case of habitual miscarriage not dependent on any special appre- 
ciable cause, absolute rest in bed for weeks before the usual period of 
miscarriage, and for some weeks afterwards, associated with the constant 
administration of the chlorate of potass, and the tincture of the chloride 
of iron, will sometimes succeed in enabling the woman to go to term, and to 
give birth to a living infant. Cases of the kind have been recorded by 
Barker, Munde, etc., and we are familiar with two instances.-Ed.] 
Duration of Retention. 
The dead foetus may remain a variable time in the uterine cavity before 
being expelled. There is no absolute limit. Where death occurs in the 
course of an acute disease, or as the result of traumatic influence, expul- 
sion is ordinarily rapid. 
If, on the contrary, it follow a chronic affection, syphilis for example, 
or causes which only act slowly on the foetus, it may be retained longer 
in the uterine cavity, and this without danger to the mother. Sheltered 
from contact from the air, it does not undergo putrefaction, but a pecu- 
liar alteration, which constitutes maceration, to which we shall return, 
and the health of the mother is, in general, but little influenced. At 
the best, some trifling pains in the abdomen; sometimes, slight general 
malaise, without fever, and slight hemorrhage, at first sero-sanguinolent, 
of negative odor and more or less acid; and then delivery occurs a little 
more slowly, often in the normal way. 
However, generally the foetus is expelled rapidly enough after death, 
but may be retained many months in the uterus. 
Such are the cases of:- 
Young, 2 months and ten days. 
Pridie, 
Newmann & Harley, . 
3 months. 
Graily Hewitt, . . . . 
Markoe, 
5 months. 305 
DISEASES OF THE F(ETUS. 
Jacobi, . . . . . . 5months. 
Peaslee, . . . . . .7 months. 
Cedersjbld, ...... 8 months. 
Fairbank (entire ovum), . . .3 months. 
Noggerath, Chamberlain and 
Peaslee (foetus only), . 
3 months. 
Schacher (foetus unchanged at the end of) 5 months. 
Stephen, . . ... . .4 months. 
Warner (ovum entire, unchanged), . 6 months. 
MacClintock, . ' . . . 4^ months. 
Holst (foetus unchanged), . . .5 months. 
In addition to these extraordinary cases, we mnst mention what have 
been called prolonged gestations, where the foetus has remained in the 
uterine cavity beyond the normal term of gestation, and then been ex- 
pelled more or less altered. 
Such are: 
Manget, . foetus of 5 months, retained 12 months 
Johns, . " " 6 " " 5 to 6 months. 
Olshausen, . " " 3 " " 8^- " 
Madge, . " " 4 " " 11 " 
McMahon, . " " 4 " " 18 
Voigtel, . 9 years. 
Uhlrich, . 2 " 
MacClintock, 1 " 
Simpson, . pregnancy of 12 months. 
Keiller, . " " 12 " 
Halley & Davis, " "6 years. 
Menzies, . " " 17 months. 
Prael, . " (l 32 years. 
Hecker, . " " 14^ " 
Muhlbeck, . " 11 14^ li 
(See in this connection, Prolonged Pregnancies.") 
At what period do the infants habitually succumb, and how long before 
delivery ? These are the two questions which Ruge has endeavored to 
solve in his memoir on infants born dead and macerated; and, basing his 
assertions on the comparative weights of the foetuses, and on the mater- 
nal recollections, he has arrived at the following conclusions, which, he is 
careful to say, are only approximate, and which we tabulate: 
Syphilitic Children : 67. 
Weight over . . . 6f pounds over 38 weeks, 3. 
" . . . 5^ " " 34| " 6. 
" " 4| " " 32 <f 12. 
" ... 3^ " " 37 " 19. 
" " 2^ " " 15. 
" ... 1T1(T " 9. 
" less than . . 1^ " 3. 
Vol. II.-20 306 
A TREATISE ON OBSTETRICS. 
Non-Syphilitic : 12. 
Weight over . . 6| pounds. 
" " . . 5t3q " from 26th to 31st week 2. 
" . . 4| " " " " " 1. 
" . . 3^5 " " " " " 5. 
" . . 2f " " " " " 2. 
" less than. . 2| " " " 11 " 2. 
It results, then, that dead and macerated children are usually met with 
from 6^ months to 10^ months, remembering that the Germans count 
pregnancy by lunar months. 
But, how long can the foetus remain in the uterine cavity ? In case of 
abortion, it is not rare to see the foetus expelled and the placenta retained 
to vegetate for a longer or shorter time. We have seen three cases our- 
selves: once, with symptoms of putrid infection of the mother (138 days), 
the mother recovered; once, three months, the mother having no other 
symptoms than little trifling floodings from time to time; the placenta 
was expelled during our absence, and the associate who assisted could 
not give us any information, except that it was without odor and shriv- 
elled up. There was a slight hemorrhage. In a third, in the service of 
Dr. Guyot, the placenta was only expelled at the end of five months. 
In case of stillborn and macerated foetuses, it is generally 14 or 16 
days after the cessation of the foetal movements that expulsion should take 
place, according to Ruge. We have seen two cases, in which one followed 
this rule, 14 days; the other was prolonged until 18 days. It is not rare 
to see the expulsion rather sooner; but it may also come off more tardily 
still, and Muller reports a certain number of cases where the foetus re- 
mained in the uterus many months, and even up to term. There are a 
certain number of cases of multiple pregnancies where this has occurred; 
we have seen an example. One of the twins dies, and the other lives, 
and both are expelled at the same time. But, can the dead foetus be 
retained in the uterus beyond term or indefinitely? We have developed 
this point in the article on prolonged gestation, and have seen that these 
extremely rare cases should only be admitted with reserve. (Menzies, 
Ilerrgott.) 
Symptoms: 1st. Signs perceived by the Mother.-These are absence of 
active foetal movements, signs only having value as they have been per- 
ceived quite clearly at first, but especially when she noticed that they 
gradually weakened, presented irregularities, and ceased sometimes sud- 
denly. Sometimes, the cessation has been preceded by an unusual exag- 
geration of the movements which seem to be convulsive. Some women 
complain of a sensation of coldness in the abdomen, and these sensations, 
contested by most authors, have been found once by Hourlier. Schling 
has established, by the aid of thermometric observation, that there is con- 
siderable elevation of the uterine temperature, compared to that of the DISEASES OF THE FCETUS. 
307 
vagina,when the foetus retains life. The abdomen sinks, the uterus-losing 
its tonicity, and not finding resistance in the foetal parts-collapses on its 
lower segment, spreads out, and its centre tends to be depressed. The 
mother feels the child move about in the abdomen, take next differ- 
ent positions, and fall to the side to which she inclines. Often, in the 
two or three days which follow the death of the foetus, there occurs at 
the breasts a kind of congestive manifestation, a kind of lacteal showing, 
which is more or less as the woman is advanced in pregnancy, and to 
which succeeds shrinking of the breasts, and sometimes flowing of lacte- 
scent liquid. Then all the sympathetic symptoms of pregnancy disap- 
pear, the vomiting particularly. The abdomen ceases to enlarge, and at 
the same time in some women there is a vague feeling of malaise, charac- 
terized by loss of appetite, a feeling of lumbago, of fatigue, of general 
lassitude; sometimes in very delicate women, a slight febrile reaction, 
especially towards evening. 
2d. Signs perceived by the Obstetrician.-Absence of the heart-sounds, 
established by different trials, is the absolutely certain sign, especially if 
the obstetrician has clearly perceived them previously. We think this is 
almost the only sign, for those of palpation seem to us more hypothetical 
than real, more theoretical than truly practical. 
If the accoucheur has previously examined the patient during foetal 
life, it may be easy to reach a diagnosis of its death, but the conditions 
are very different when he sees the woman only after the death of the 
foetus. Then, vaginal touch and palpation give us no information. 
Stoltz has noted a sign, a sound isochronous with the mother's pulse, a 
species of crackling, which he attributes to the decomposition of the liquor 
amnii. This sign is, however, not invariably present. 
[In one case under our observation, where the woman carried a dead 
five months foetus for a period of four months, this crackling was very 
apparent, but we can hardly say that it was isochronous with the mother's 
pulse. In other instances, however,we have failed to hear the sign. To 
us, the most characteristic physical sign of foetal death is a flabbiness of 
the uterus, instead of resiliency and compressibility, on the bi-manual pal- 
pation, associated, of course, with the decrease in abdominal distension, 
and collapsing of the mammae.-Ed.] 
What now may be the appearance of the foetus after its retention in the 
uterus ? 
Lempereur, Sentex and Huge, have described the changes well, and we 
copy their classification: 
"According to the stage of foetal life at which it has succumbed, we find: 
1. Dissolution; 2. Mummification; 13. Maceration; 4. Putrefaction; 5. 
Peculiar alterations, and of doubtful nature. 
" Dissolution is apt to occur during the first two months of foetal life. 
The liquor amnii then appears more or less milky, in a state of emulsion. 308 
A TREATISE ON OBSTETRICS. 
so to speak. The placenta may continue to develop, and finally be con- 
verted into one or another form of mole." 
Mummification.-Dessication.-"At the second period of intra-uterine 
life is a particular change, entirely distinct in form from those which 
precede or which follow. The embryo, endowed with a greater force of 
resistance, provided with an osseous frame, frail and incomplete, it is true, 
but nevertheless solid, composed of newly organized elements, which 
already have a fixed texture, does not liquefy; it preserves its first 
form, except its volume, which suffers a proportional reduction. This is 
mummification, withering, emaciation, contraction, drying up of the 
authors. The tissues, yet soft, are condensed under the influence of this 
prolonged maceration in a saline fluid; they diminish in volume, reduced 
to a thinner layer, in a word, shrivelled up. The color also changes very 
rapidly; it becomes dull, gray, yellowish, tarnished, and as if cachectic, 
contrasting clearly with the normal color, a brilliant dark rose." Sentex 
adds to this description that the quantity of sanguinolent serum exuded 
in the different serous cavities is very small, very dark, and the rose color 
of the eye-humors hardly marked. The liquor amnii in the first degrees 
of change exists still, but it ends by disappearing, leaving on the embryo 
a dull grayish sediment, analogous to the deposit of overflowed water. 
The actual drying up may be retarded, in proportion as the fluid medium 
remains. The embryo undergoes, at the same time with emaciation, a 
sort of shortening; besides, it is already very small at the time of its 
death. 
To this change, in cases of multiple pregnancy, is added another, 
namely, flattening. One of tfie foetuses dying at this time, and the other 
continuing to develop, the dead foetus, beaten down, is flattened like a 
ginger-bread image. It is found at delivery joined to the placenta of the 
sound twin, and contained in a little isolated pouch, as we have had occa- 
sion to observe in a clinical case. This is the foetus compressa of the 
Germans. 
3d. Maceration.-This is by far the most frequent of the alterations, and 
the most varied in its forms. It differs essentially from putrefaction, in 
that the decomposition proceeds slowly, without production of gas, with- 
out odor, without green cadaveric tinge, and never involves the mother in 
those formidable consequences to which true putrefaction exposes her. 
Ruge and Sentex have described the changes in these foetuses, to whom 
Martin has given the name of "foetus sanguinolentus" from its peculiar 
red-brown appearance, in which respect German authors follow him. In 
France, such foetuses are called simply macerated (foetus maceres.) 
The shape of the cadaver is peculiar, being flattened out, as it were, in 
the thorax, while the abdomen projects like that of a frog. The bones 
have all softened to such an extent that the foetus collapses, so to speak. 
The epidermis is readily detachable, and is covered with bullae. The cel- DISEASES OF THE FOETUS. 
309 
lular tissue is edematous and colored reddish. The foetus is so supple 
that it is often expelled doubled in two. The internal organs are simi- 
larly changed. The serous cavities are full of bloody fluid. The uterus 
and the lungs are, of all organs, the least altered. There is no odor to 
the foetus of a nauseating nature. It is simply stale and disagreeable. 
According to both Lempereur and Sentex, the alterations are divisible 
into periods, the changes being the greater the more delayed the reten- 
tion. Sentex has followed these changes day by day, as it were. 
[Readers especially interested are referred to the original articles of 
Sentex and Lempereur, where the details, as regards gross and histological 
appearances, are strikingly minute.-Ed.] 
Lempereur, who admits the prolongation of pregnancy beyond term, 
says that, in such cases, the foetus may present the following alterations: 
1. Maceration, general breaking up of the foetus, and expulsion of all 
the debris either at a menstrual period, or during a subsequent preg- 
nancy, or delivery. 2. Putrefaction, if air gains access to the uterus. 3. 
Dessication. 4. Ossification, petrification. 5. Saponification. 
As for the foetal adnexa, fibrinous masses are found in the vessels of 
the cord, or else simply liquid blood or recent coagula. The cord is 
swollen, of a color like that of the foetus. The placenta presents, on the 
maternal surface, a number of smooth-walled cavities, containing yellow 
purulent masses. Its color, and that of the membranes may be of an 
earthy-brown. 
There is nothing unusual about the expulsion of the foetus. Out of 77 
macerated syphilitic foetuses observed by Ruge, 35 presented by the ver- 
tex, 24 by the pelvis; there were 8 transverse presentations, 6 of which 
turned spontaneously. Two points we have noticed particularly. One 
being that the membranes ruptured slowly, or required to be ruptured; 
they seemeol to have spread considerably. The entire ovum is expelled 
more frequently than when the foetus is living. On the other hand, the 
labor proceeds more slowly, the uterine contractions are feeble. 
Are these alterations due to syphilis, or is maceration simply a post-mor- 
tem change present as well in non-syphilitic infants ? Ruge's researches 
are absolutely conclusive. According to him, 78 out of 94 dead macerated 
foetuses are syphilitic, but it is not this disease which causes the macera- 
tion, and induces the alterations, and the proof of this assertion rests on 
the fact that foetuses absolutely not syphilitic are born macerated, and 
presenting identically similar changes; and further, in that syphilis is char- 
acterized rather by the presence of peritonitis, and hypertrophy of the 
liver, spleen, lungs, and, above all, the bones, and these changes we do 
not find in macerated foetuses. Maceration, therefore, is caused by post- 
mortem changes. 
Putrefaction.-This is the decomposition established spontaneously, 
under certain conditions, in organs deprived of life. It causes pro- 310 
A TREATISE ON OBSTETRICS. 
duction of new substances, especially vapors and very fetid gases. This 
decomposition only occurs when air has penetrated after the rupture of 
the membranes. The decomposition goes on very rapidly, the three con- 
ditions essential to fermentation being present in the uterus, that is, 
air, heat, humidity. 
The changes affect the whole foetus at once, and are, as it were, instan- 
taneous. At the outset, there is infiltration of all the superficial cellular 
tissue with gas, whence more^or less generalized emphysema, and marked 
crepitation on palpation. At times the gases accumulate in the uterus, 
and are expelled with a loud report. These gases are poisonous to the 
mother. She is seized with fever, chills, hiccough, vomiting, and may 
shortly die if we do not extract the foetus. The odor is awful, but the 
foetal epidermis is never covered with bullae, as in maceration. 
Cadaveric Rigidity.-Does this exist in the foetus at the time of birth? 
Casper says that he has never observed it in the foetus before term, al- 
though it has been noted in maternity hospitals; and that, in those born 
at term, it is of very short duration. Taylor has seen one case; Tourdes 
saw it, at Strasburg, in twins of five months; he affirms that it may 
occur in the uterus itself, and he says that in those cases where it was not 
noted, this was because the duration was slight. 
In England, cadaveric rigidity is admitted by Grigg, Young, Parkin- 
son, but denied by Thompson. Bailly grants it, and has always found it. 
Dagincourt,'who, to the other observations, adds two cases of Budin's, 
and one personal, says that muscular rigidity is due to coagulation of the 
myosin, under the influence of the post-mortem acid reaction of the 
muscles. The foetal muscle does not differ in composition from that of 
the adult, and, therefore, may be presumed to act similarly under similar 
conditions. 
The question cannot as yet be answered. The two hypotheses, cadaveric 
rigidity, and cadaveric spasms, have each weighty arguments in their 
favor. Are the cases of Thompson and of Bailly analogous to those to 
which Taylor has given the name of spasm? We believe, with Pinard 
and Dagincourt, in a true cadaveric rigidity, for, as Pinard justly says, in 
case of convulsions, we do not observe flexion, but extension of the limbs, 
and in all the cases cited of cadaveric rigidity, the foetus has been in a 
state of flexion. CHAPTER V. 
MISCARRIAGE. 
milE term miscarriage is applied to the expulsion of the product of con- 
ception before it is viable. It is seen at once that this differs from 
premature labor, which means the expulsion of the product of conception 
before term, but where the foetus is viable. In this respect accoucheurs 
differ from the rulings of the law. The latter states that the foetus is 
viable after the sixth month, while the former- contend that it is not so till 
the seventh. It is oui- belief, then, that miscarriage consists in the expul- 
sion of the foetus during the six first months of pregnancy. This foetus 
may be born dead or alive, but its development will not admit of life-it 
is not viable. In certain exceptional cases, foetuses of less than seven 
months may live, but these cases are of such rarity that we are justified 
in the division which we have made. Before seven months, therefore, 
miscarriage; after seven months, premature labor. To the exceptional 
cases which have been recorded, we can add another. A woman last 
menstruated the tenth of March; was delivered the twenty-eighth of 
September, that is to say, twelve days before the seventh lunar month. 
The child survived. 
Although we make this division, it should be understood that miscar- 
riage from the third to the fourth month is a very different affair from 
miscarriage at the fifth or sixth month. While during the early months, 
the first three in particular, the phenomena of miscarriage are special and 
peculiar, from the fourth month on, these phenomena approach more 
and more in character labor at full term. Struck by these peculiarities, 
the older writers, and certain modern, (we would instance, in particular 
Guillemot), made three divisions of miscarriage: 1. Ovular miscarriage. 
2. Embryonic. 3. Foetal. Why this division? It is because each cor- 
responds to a certain stage of development of the ovum, and such distinc- 
tion, while subtile, has, practically, certain advantages. 
Ovular miscarriage includes the first three to four weeks of the life of 
the ovum. 
Embryonic miscarriage extends from the end of the first month to the 
end of the third. 
Foetal miscarriage frotn the fourth to the seventh month 
Coincidently, indeed, with the development of the ovum, it undergoes 
modifications in structure, which necessitate infinite differences in its 312 
A TREATISE OX OBSTETRICS. 
expulsion; and even as we were able to say of labor at term, that not one 
resembled the other, the same may be said of miscarriage. When we 
study the phenomena of miscarriage, we must remember that we are 
dealing with a number of factors. Kunecke, in Germany, makes four: 
1st. Mechanical modifications. 2d. Organic. 3d. Dynamic. 4th. Plas- 
tic. We make of these, two: The modifications which concern: 1st. the 
ovum, 2d. the uterus. 
On the side of the ovum these modifications are enormous, from the 
day when it arrives, as a new organism, in the womb, up to the end of 
the third month; so great, indeed, that it is impossible to compare the 
ovum of the first, second, and third month together. 
During the first month, the ovum, engrafted on the uterine mucous 
membrane, which swells around it, so as to constitute what is termed the 
decidua refiexa, is surrounded entirely by the villi of the chorion, which 
develop over its surface. It is composed already of its two membranes, 
the amnion and the chorion, and the uterine mucous membrane may be 
decomposed into three portions, parietal decidua, decidua refiexa, and 
mucous membrane between placenta and uterus, or, better still, between 
uterus and ovum. There is still no cavity in the ovum. It is being 
formed. When removed from the decidua, the ovum looks like a small 
body roughened by the projection of a number of appendages, one longer 
than the others, at the centre of which is found the amnion, containing 
the microscopic embryo, so to speak. This little ovum is surrrounded by 
a second membrane, thicker, and more voluminous, in which it is almost 
lost, and which is no other than the uterine mucous membrane, in two 
portions, the one applied directly to the ovum, the decidua refiexa, the 
other larger, and separated from the former by a space filled with gelatin- 
ous matter, more or less liquid, and this is the parietal mucous mem- 
brane. This gelatinous matter, which disappears later, is the hydroperion. 
The whole is surrounded by clots, more or less dense. 
From the fifth week, the ovum is composed of three distinct layers. 
An internal, the amnion, which, growing away from the embryo, forms 
a cavity which fills up, more and more, with the amniotic fluid. An 
external, the chorion, furnished with ramifying villi, which cover the 
whole of the ovum, and penetrate into the mucous membrane of the 
uterus. A middle, the allantois, which, thinning out more and more as 
it tends to disappear, becomes a vesicle, a cellular layer, which brings the 
umbilical vessels to the finest radicles of the chorionic villi. The whole 
is surrounded by the uterine decidua. From this time forth, the vital 
conditions of the ovum change. While up to now, it is the umbilical 
vesicle which has furnished nourishment to the ovum and the embryo, 
from the moment when, through the allantois, the umbilical vessels 
reach the mucous membrane of the uterus, it is these which supply 
nourishment to the foetus, and we are going to witness the formation of a .MISCARRIAGE. 
313 
new organ, the placenta, which becomes the centre of foetal nutrition. 
The umbilical vesicle atrophies and collapses, and it is to be found, be- 
tween the amnion and the chorion, as a little vesicle adhering to the 
embryo by a long obliterated pedicle, the omphalo-mesenteric cord, in 
which are seen traces of the primitive vessels of the embryo. Before, 
however, the placenta is formed, the ovum undergoes many other changes, 
which concern in particular the amnion and the chorion. 
At first adhering to the embryo, from which it is an offshoot, except at 
the level of the ventral opening, the amnion recedes more and more 
towards the dorsal and ventral portion, forming thus a complete sac in 
which the embryo is plunged, a sac, which, at its ventral surface, is going 
to form an addition to the organs which issue from the abdominal cavity 
of the foetus to form the umbilical cord. It thus gradually meets the 
chorion, and is separated from it only by the cellular layer, which is the 
remnant of the allantois. The amnion and chorion then grow simulta- 
neously, and, the amniotic fluid increasing, the decidua reflexa is, in turn, 
pushed towards the parietal decidua, and, towards the fourth month, 
this decidua joins the parietal and merges into it. 
During this period, what becomes of the villosities which we have seen 
covered the entire ovum ? While those which cover the side of the ovum, 
towards the parietal decidua develop further to form the placenta, those 
which correspond to the decidua, reflexa, pushed aside by the growth of 
the ovum, are flattened out, and their vessels obliterated. These villi 
atrophy, and, when the decidua reflexa and parietal meet, these villi 
exist no longer, so to speak, and the ovum remains in communication 
with the mother only by the placental villi, which, bathing in the uterine 
sinuses, become the medium of exchange in nutritive substances which 
go towards the development of the foetus. As the ovum developes, these 
utero-placental adhesions become the stronger, so strong in certain in- 
stances that we are obliged to detach the placenta even at term. The 
nearer we approach term the feebler, normally, become these adhesions, 
and consequently, the greater the ease with which the ovum detaches 
itself from the uterus. 
After three months and a half to four months, miscarriage becomes a 
labor in miniature. The placenta is fully formed, the ovum has definite 
structure. The uterine mucous membrane has sent solid epithelial pro- 
longations between the villi, so as to intimately attach the ovum to the 
uterus, and protect it against destruction. While prior to this, the ovum 
lived, so to speak, by its entire periphery, under the influence of the de- 
velopment of the amnion, and of its greater distension by the liquor amnii, 
the distended chorion loses its villi, and thins out, and, at the same time, 
displaces before it the decidua reflexa, which becomes similarly thinned 
out. At the end of the fourth month, the parietal decidua and the re- 
flexa unite, and the ovum exists as it remains till the end of pregnancy. 314 
A TREATISE ON OBSTETRICS. 
Attached to the uterus by the placenta, the ovum is composed of the 
amnion and the chorion, thin membranes, of great tenuity, and it is 
covered by the decidua. In the liquor amnii swims the foetus, attached 
to the cord, which gains in size and in length. It is especially important 
to remember that the placenta is relatively larger than the foetus, and, 
above all, more solid and resisting. 
The second factor consists in the modifications of the uterus. 
These, we have seen, concern both the cervix and the body, and 
are characterized by increase in size, in capacity, in weight, by 
change in form, in situation, in consistency, in thickness, and above 
all by modifications in the serous, muscular, and mucous layers. 
These changes, and modifications, we have already sufficiently noted. 
Let us recall only the transformation of the inter-utero placental 
mucous membrane into a species of spongy tissue, the whole of the in- 
terstices of which are filled with blood in which the villi of the placenta 
are plunged, and are united to this tissue by epithelial bands from the 
mucous membrane; and further, let us recall the progressive develop- 
ment of the muscular tissue, which, through the exercise of its funda- 
mental property, contractility, becomes the active, essential agent, which 
expels the foetus. Let us add, finally, the shedding of the uterine mucous 
membrane, a process which to-day, it is admitted, concerns not alone the 
parietal decidua, but also the superficial part of the inter-utero-placental 
mucous membrane. 
It is apparent, now, why it is that miscarriage may be different, ac- 
cording to the period of gestation at which it occurs, and the conditions 
which determine it. 
Having stated the above general views, we begin at once the study of 
miscarriage. 
Frequency.-Is miscarriage a frequent accident? According to hospi- 
tal statistics, it is rare, but nevertheless it is of very common occurrence. 
The reason for this discrepancy is that miscarriage during the early weeks 
is generally not noticed. Many women believe that the menses are sim- 
ply retarded, and although they may suspect a miscarriage from the pas- 
sage of clots, or crampy pains greater than they usually suffer when men- 
struating, they do not consult a physician, and even if they did there 
would still be doubt, seeing that the ovum is not likely to be found in 
the clots which have been passed. Even if the woman knows she is mis- 
carrying, she does not go to the hospital, but household remedies are usu- 
ally administered. It is only in his private practice, therefore, that the 
physician can really be certain, and even then only in part, of the mis- 
carriage. The same uncertainty exists in regard to the frequency at 
different periods of pregnancy. While many authors believe that miscar- 
riage occurs oftener from the third to the fourth month, Jacquemier, De- 
paul, Cazeaux, state that this is true only in the first two or three months. MISCARRIAGE. 
315 
Depaul is even more precise, and places the period of greatest frequency 
at two and a half to three and a half months, from thence diminishing in 
frequency up to term. Opposed to this opinion is Jacquemier, who, with- 
out agreeing fully with Madame Lachapelle, in whose experience the sixth 
month was the time of election, rather than earlier in pregnancy, declares 
that at this month it is settled that miscarriage occurs with certainly as 
great frequency as in the earlier months. This view, while true of pre- 
mature labor, appears to us exaggerated as applied to miscarriage, and 
we believe with Depaul that the latter is of greatest frequency from two 
months to three and a half. Still we are speaking now purely of certified 
miscarriages, and it still holds true that many an ovum is shed unnoticed 
during the first four to six weeks; this is not astonishing when we remem- 
ber that it is only at three months, to three and a half, that the placenta 
is developed, and that up to this time the feebleness of the adhesions 
which bind the ovum to the uterus, and the ease with which extravasa- 
tions may take place between the chorion and the decidua reflexa, render 
it an easy matter for the ovum to be disturbed. 
Is miscarriage more frequent in case of female than of male foetuses ? 
Morgagni and Desormeaux have so held, but their opinion is based on 
absolutely no statistical data. Jacquemier is in doubt on this point; Ca- 
zeaux is inclined to agree with Desormeaux, because at term the propor- 
tion of boys to girls is as 16 to 15, and therefore it is possible the miscar- 
riage of females may be more frequent. 
Causes.-These may depend on: 1st. The father; 2d. The mother; 3d. 
The ovum; 4th. Criminal attempts or external violence. 
1st. The father may be the cause of miscarriage through constitutional 
or acquired means. Men too young or too old; those whose constitution 
is weakened by debauchery, or excesses, or disease, these are likely to be- 
get a foetus not fit for development. Further, the influence of syphilis 
in the father is, to-day, admitted universally, and the lesions presented 
by the foetus are so distinctive in such cases that they point at once to 
syphilis of the father. 
2d. In women who are very young, with body incompletely developed, 
and menstruation not normally established, with tissues delicate and fee- 
ble; in women who are old, with tissues dense, and brittle-in these 
miscarriage is frequent. Depaul absolutely denies this, but Jacquemier 
affirms that it is not unusual to see women miscarry with the greatest 
ease the nearer they are to the age when aptitude for conception usually 
ceases. We have, ourselves, seen three children, of thirteen, thirteen and 
a half, and fourteen years, respectively, confined at term, but these chil- 
dren in their physical development were in advance of their age. 
As for the temperament of the mother, it has been claimed that the 
nervous, the bilious, the sanguine, were, in turn, causes. This seems to 
be true, in particular of the latter. Many women, indeed, who are of 316 
A TREATISE ON OBSTETRICS. 
full habit, and lose profusely at their periods, miscarry readily, and this 
usually at a time which coincides with the menstrual epoch. As for the 
form of temperament, nothing has been proved; indeed the nervous is 
often dependent on functional uterine disease, and to this, therefore, 
must we look for explanation of the miscarriage. 
On high temperature as a cause Depaul attaches much importance. 
In warm climates, uterine hemorrhages are of common occurrence, and 
these in turn may provoke miscarriage. We refer here only to climatic 
temperature, and not to elevation in the mother, the result of disease. 
In mountainous countries, further, miscarriage is frequent, and we are 
told by Saucerotte and Jourdanet that the women of such regions are 
accustomed to resort to the valleys in order to avoid miscarriage. 
Madame Boivin and Madame Lachapelle admit, as a further cause, epi- 
demic influence, but, although such is the case with animals, it cannot 
be considered so in the human female. It is especially during famines 
and sieges that this cause has been supposed to hold, but, evidently, here 
there are other factors at work. 
Finally, there are a number of women in whom there exists a habit of 
aborting, either because the genital system functionates badly, or because 
the menses are irregular, often scanty or painful, or else, because the geni- 
tal system seems to lack vigor. These women, pale, feeble, and subject 
to lencorrhoea, possess, frequently, this trait in common with those of the 
sanguine temperament, that they suffer from menorrhagia; but they are 
always irregular in menstruation. Stolz has further pointed out that 
stout women are often sterile, and that, when they do conceive, they are 
predisposed to miscarriage, doubtless because local nutrition is at fault, 
and the fluids intended to nourish the foetus are insufficient for its de- 
velopment. 
Every acute or even chronic disease of the mother may become a cause 
of miscarriage, when such diseases affect profoundly the respiration, the 
circulation, or the temperature. Of these diseases, there are certain 
which act more powerfully than others. (See Pathology of Pregnancy.) 
Diseases of the uterus: metritis, endometritis, interstitial, and sub- 
mucous fibroids, versions, flexions, organic disease of the cervix, espe- 
cially of the body. Still further: adhesions of the broad and round liga- 
ments, of the tubes and ovaries, since they may interfere with the 
development of the uterus. Again, inflammations of the bladder, of the 
rectum; neighboring tumors, pelvic deformities, which prevent the regu- 
lar development of the uterus or retrovert it. 
Finally, there are certain women who, without special cause, miscarry 
over and over again, and it would seem as though in them there existed 
special irritability of the uterine fibre. The sphincter of the uterus seems 
to be weakened, and, when pregnancy ensues, the least effort overcomes 
it. This has been called laxity of the fibres of the cervix. This irrita- MISCARRIAGE. 
317 
bility of the uterus determines the premature appearance of contractions, 
the cervix yields, the membranes rupture, and miscarriage occurs, without 
other cause than this excessive irritability of the uterine fibres. 
Jacquemier has studied, in particular, uterine congestion as a frequent 
cause of miscarriage, and we reproduce his views: " Active or passive 
congestions of the uterus are the most frequent causes of miscarriage. 
They excite the uterus to contract abnormally, and determine often ex- 
travasations between the uterus and the placenta. These extravasations 
are the result of rupture of the vessels which go from the uterus to the 
placenta. Indeed, in many miscarriages, the determining factor is the 
existence of hemorrhage, or its manifestation internally or externally. 
"All stout women are not equally predisposed to uterine congestion. 
Those who are plethoric, and have hemorrhages apart from pregnancy, 
are equally more inclined to puerperal hemorrhage than others. The 
very existence of pregnancy inclines to further congestion. This organ 
is then much more vascular than before. New blood-vessels are sent 
ramifying through the placenta and the decidua, and these vessels are 
soft in texture, and easily torn. The moderate and regular contraction 
of the uterine muscular fibre for the moment empties the uterus of the 
excess of blood which distends these vessels; but let this contraction be 
over strong, spasmodic, or local, and the connection between the ovum 
and the uterus may be changed, and hemorrhage occur between it and 
the uterus. Further, it should be remembered that at the dates corre- 
sponding to the suppressed menstrual periods, the uterus is still further 
temporarily congested, and every accoucheur has noted the frequency of 
miscarriage at dates coinciding with the menstrual cycle.'-' 
It remains to note as causes of miscarriage: tight clothing, which in- 
terferes with the abdominal circulation, moral emotions, mechanical shak- 
ing, such as results from carriage or horseback riding; external trauma- 
tism, which acts either directly on the uterus, or indirectly by determin- 
ing congestion of the organ; violent muscular efforts; operations on 
the genital organs; efforts at criminal abortion; drugs which have an oxy- 
tocic influence. Many of these causes, as Jacquemier truly says, only 
suffice when they act with great intensity, or in women who are predis- 
posed to miscarry. 
Causes residing in the Ovum.-Here are included all the diseases of 
the placenta, of the membranes, of the cord, of the foetus itself. Let us 
only recall the alterations in the placenta, the hemorrhages and their 
results, the alterations in the villi, the premature rupture of the mem- 
branes, shortness of the cord, anomalies, knots, stenosis or phlebitis of 
the vessels of the same; in a word all the diseases which may cause the 
death of the foetus. 
Symptoms.-One great fact dominates the symptomatology of miscar- 
riage, and this is uterine hemorrhage, profuse or moderate. At times, 318 
A TREATISE ON OBSTETRICS. 
says Jacquemier, it is the provoking cause of miscarriage; again, it is not 
caused by the contractions of the uterus, but the separation and the ex- 
pulsion of the ovum are accompanied, from the start, by a slight flow 
which frequently assumes, in character, the proportions of a hemorrhage. 
The causes of miscarriage produce the following three results: 1st. 
Either the ovum is abruptly severed from its attachments, and the mis- 
carriage is an immediate phenomenon. This is rare; 2d. Or uterine con- 
tractions, premature, are determined, and there results immediate sepa- 
ration of the ovum; 3. Or, finally, there results uterine congestion, which 
entails rupture of blood-vessels, and separation of the placenta. Then 
there follow uterine contractions, and these are secondary, consecutive. 
This is the most frequent form, and it is here that are observed the pro- 
dromic phenomena of miscarriage. 
Signs of impending Miscarriage.-If, in certain instances, miscarriage 
results suddenly, without the women being aware of it, except through 
the appearance of the ovum, this is not always the case, and there are 
usually prodromic signs, more or less marked, and which vary with the 
etiological factor at work. O^ten these symptoms are simply an exagger- 
ation of those common to the menstrual period, a feeling of malaise, of 
general weakness, accompanied by pain in the loins, radiating to the rec- 
tum and to the bladder. At the same time, the touch reveals certain 
changes in the cervix, accompanied by flaccidity of the vagina and in- 
creased secretion. Three circumstances, above all, influence these symp- 
toms, which vary accordingly: 1st. Imminence of hemorrhage; 2d. Causes 
acting directly or indirectly on uterine contractility; 3d. The death of 
the foetus. 
Where hemorrhage is imminent, plainly it is congestive phenomena 
which are in the foreground; phenomena not limited exclusively to the 
abdominal organs, but affecting the whole body, as evidenced by the ac- 
celerated circulation, by the force and fullness of the pulse beat, by con- 
gestion of the face, or again, by irregular chills, by pain and tension in 
the loins and the abdomen, increased by the least fatigue. Rarely, true 
uterine contractions exist; usually the woman is conscious of these, with- 
out being able to exactly locate them. Often a slight show appears, ceases 
under rest or appropriate treatment, and the pregnancy goes on to term. 
Again these symptoms may recur, and, at length, after two or three simi- 
lar recurrences, the ovum is expelled. These congestive symptoms al- 
most always coincide with a menstrual epoch, and similarly the miscar- 
riage occurs. 
In other instances, instead of congestive phenomena, the signs are char- 
acteristic of uterine irritability, merging, on the slightest provocation, 
into contraction. The least fatigue, the least effort, results at once in 
pain in the loins and abdomen, with sensation of weight in the rectum 
and bladder, and, finally, true uterine contractions, appreciable often to MISCARRIAGE. 
319 
the hand where the woman is thin, or the uterus has risen above the 
brim, set in. In such cases, the cervix is less changed, remaining firm, 
and resisting, and it is only when the miscarrage is well under way, that 
blood appears. 
When the foetus is dead, the phenomena are far different. When the 
foetus has developed sufficiently to allow us to feel its movements, and to 
hear the pulsations of its heart, we may, so to speak, be present at its 
death, by following the slow disappearance of these signs of foetal life; and 
then it is that the women experience all those sensations which we have 
referred to when speaking of the death of the foetus. But, when the ovum 
has not reached such a developmental stage as to allow us to appreciate 
the signs of life, the diagnosis becomes difficult, and the precursory phe- 
nomena are obscure, and not easy to differentiate. It is exceptional, in 
such instances, for miscarriage to follow at once on the death of the foetus. 
Usually it is only at the end of six to ten days, and often longer, that 
the foetus is expelled. Where the foetal death results from acute feb- 
rile disease of the mother, miscarriage, on the other hand, follows soon, 
and the precursory signs are masked under the symptom the outcome of 
the maternal disease. When, however, the foetus succumbs to a slow in- 
toxication, or from accidental cause, then the precursory signs are sharply 
accentuated. To the positive signs of foetal death, are joined symptoms 
from the side of the mother; paleness, feebleness, lassitude, a sensation of 
something abnormal. At times a gentle evening rise of temperature, a 
feeling of weight in the pelvis, the cessation of the sympathetic signs of 
pregnancy, swelling of the breasts, exudation of a milky fluid from the 
nipples, followed by decrease in size of these organs; relaxation of the 
cervix, patency of the external os; above all, the appearance of a red dis- 
charge, which may increase markedly, and become sero-sanguinolent of 
stale and disagreeable odor. Again, this discharge is intermittent, ceas- 
ing for a few hours, or days, and reappearing with greater intensity. 
From time to time, appear true uterine contractions, at first gentle, and 
then intense, and followed by greater discharge. Then these contractions 
cease, and all is quiet and normal, until, at last, labor frankly sets in. 
Symptoms.-Two phenomena always accompany miscarriage: hemor- 
rhage, and uterine contraction. These symptoms are variable, according 
to the stage of pregnancy, and according to the life or death of the foetus. 
When the miscarriage occurs during the early weeks of pregnancy, 
whether the foetus be dead or alive, makes no difference. The uterine 
tissue is denser than the normal, but the muscular fibres have only be- 
gun to develop. It is not the contractions of the uterus which are going 
to cause the shedding of the ovum, but it is uterine congestion and the 
resultant hemorrhage which produce this phenomenon, and dilatation 
of the cervix occurs but imperfectly. As at the time of menstruation, the 
cervical canal opens, and becomes patulous, but without true dilatation, 320 
A TREATISE OX OBSTETRICS. 
and clots and ovum are so soft that they readily pass through this canal. 
The resistance offered is lessened by the softening of the uterine tissue, 
and it is not the ovum which gives rise to trouble, but the clots which 
surround it. The ovum is lost within these clots, and the miscarriage 
is, usually, soon accomplished. The hemorrhage, often no more than is 
lost at the menstrual periods, is accompanied, or at once followed, by a 
few colic-like pains, or uterine contractions, and these suffice to expel the 
ovum. If the process lasts over long, occasionally, it is because the uter- 
ine mucous membrane is detached with difficulty, often in shreds, as is 
seen in pseudo-membranous dysmenorrhoea, which has often been mis- 
taken for miscarriage. At times, shreds are passed for a few days, ac- 
companied each time by hemorrhage and contraction; then the discharge 
becomes sero-sanguinolent and serous, and the miscarriage is ended. The 
cervix remains patulous for a few days, but it retains its length, and the 
uterus quickly regains its form, consistency, and normal dimensions. In 
such cases, the ovum is passed entire, and, if it seem torn, this is because 
the scarcely formed cavity, between the decidua reflexa and parietalis, is 
mistaken for the cavity of the ovum. The shreds, which are seen, do 
not belong to the ovum, but to the decidua which the uterus furnishes to 
the ovum as an outer covering. 
Miscarriage from the first to the second month, differs notably from 
that of the early weeks. The uterus, indeed, has developed with the 
ovum, has become proportionately hypertrophied, especially in its mus- 
cular tissue, since the mucous coat is intended to be shed with the ovum, 
and replaced by another. Miscarriage here, then, consists in: 1st. Sep- 
aration of the ovum. 2d. Separation of the mucous membrane. 3d. 
Expulsion of the ovum. 
At this period still, spontaneous miscarriage frequently occurs, because 
the bands which unite the ovum to the uterus are very fragile, and it is, 
in particular, at the menstrual epoch that the accident occurs. The mis- 
carriage, may occur entire-that is to say, the ovum maybe expelled en 
masse, intact, or with ruptured membranes. If the catamenial or other 
congestive factor be strong, hemorrhage results, and the blood, escaping 
into the uterine cavity, tears these fragile bands, often even tears the 
chorion, penetrates this membrane, reaches the amnion, ruptures it, and 
gains the interior of the ovum, as is proved by the cases of Breschet, 
Dance, Blot, Dohrn, Hegar, Henning, etc. The ovum, therefore, is ex- 
pelled with ruptured membranes, and not entire. If the hemorrhage be 
less abundant the ovum is simply detached, and this, being a foreign 
body, is expelled by the uterus,. either entire, or with ruptured mem- 
branes, but ruptured here from another cause. We insist on this point, 
because we are opposed to the opinion of Gallard and of Leblond, who 
state that the expelled ovum is, in the early months, always entire, -with 
membranes intact, and who believe that when the membranes are rup- MISCARRIAGE. 
321 
tured, it is a sign of criminal abortion. Miscarriage, it is undoubted, has 
greater chances of resulting in an intact ovum, the younger this is. But, 
even as early as the fifth week, the ovum may be expelled with torn mem- 
branes, and to call such rupture proof of criminal attempts is in opposi- 
tion alike to the experience of scientific and practical observation. 
That which characterizes, in particular, miscarriage at this period, is 
the initial hemorrhage, contractions of the uterus only supervening sec- 
ondarily. At the outset there exists congestion, then hemorrhage, and 
it is only when the ovum is entirely detached, or nearly so, that contrac- 
tions appear to expel it. Now, it is precisely because of this tardy ap- 
pearance of contractions that we often obtain an intact ovum. Since the 
hemorrhage affects almost complete separation of the ovum, only a few 
uterine contractions are necessary to complete the detachment, and the 
ovum falls on the cervix. Then it only has to overcome the resistance of 
this portion of the uterus. That which delays the completion of the 
miscarriage is not the ovum, but the decidua. As for the ovum, it slowly 
insinuates itself in the cervix, which dilates enough for its passage, but 
surrounded as it is by clots, it passes without rupture. 
In other rare instances, the contractions of the uterus are the initial 
phenomenon. At first faint, irregular, these contractions approach nearer 
one another, and become intense enough to detach the ovum. Here, 
the hemorrhage is secondary. 
The ovum detaches itself slowly, progressively, little by little, each act 
being preceded by contraction, and accompanied by hemorrhage, which 
has not the same characters as at first. It is now intermittent, coincid- 
ing with the contractions, and the more intense these latter, the more 
abundant. This hemorrhage only ceases with the expulsion of the deci- 
dua. In this instance the ovum is living, and resists destruction as far 
as in it lies. It is no longer a foreign body, of which the uterus tries to 
rid itself as soon as possible; it is a living being, which, engrafted on the 
maternal organism, requires, for its separation, heroic and persistent 
efforts. Whence the longer duration of the miscarriage, whence the alter- 
nation of rest and pain, the intermittent character of the contractions 
which is typical of uterine action, in particular during miscarriage. It is 
apparent, therefore, that for us the vitality of the foetus plays an impor- 
tant part in the symptoms of miscarriage, and it is this vitality which en- 
tails on miscarriage a portion of its gravity. 
In case the ovum is dead, a number of days may pass without the 
woman suffering at all to speak of, and then appears a gentle flow of dark- 
ish blood, which may last six or eight days, in the absence of uterine con- 
tractions. At length these supervene, a digital examination is made, the 
cervix is found more or less dilated, the internal os open, and the finger 
may pass in and touch the ovum. Finally, the ovum engages in the cer- 
vix, which opens still further, and it falls into the vagina, where it may 
Vol. 11-21. 322 
A TREATISE ON OBSTETRICS. 
remain some time before expulsion. The amount of hemorrhage accom- 
panying the process may be slight, there may be none at all. The ovum, 
indeed, having died some time before, the uterine and utero-placental 
circulation have become deeply modified through the cessation of preg- 
nancy. Uterine congestion is, thence, relatively slight, and therefore 
the amount of blood lost is also slight. 
If the death of the ovum be recent, and the result of accident or trau- 
matism, if miscarriage follow soon on the death, the hemorrhage precedes 
by but a few hours the onset of contractions; frequently even they ap- 
pear together, and the hemorrhage, if the act of miscarriage be a trifle 
prolonged, may be excessive and dangerous. 
If, finally, the ovum has been dead a long time, it rests quietly in the 
uterus for a considerable interval, and then, of a sudden, the woman loses 
blood, violent contractions supervene, and in a few hours, at times almost 
at once, the uterus expels this foreign body, with scarcely any premoni- 
tory symptoms. This variety of miscarriage is of unusual occurrence 
where the foetus is dead, and still more so where it is alive, and it is only 
as the result of violent traumatism, and during the first five to six weeks 
of pregnancy that we see it. It has occurred twice in our experience. 
When the ovum is living, and the process of miscarriage is prolonged, 
it may be expelled in two different ways: either entire, as is claimed by 
Gallard and Leblond, or else in two pieces, so to speak, as ordinarily hap- 
pens at the second and the third month. Then the ovum is not a for- 
eign body with nothing binding it to the uterus. It is no longer hemor- 
rhage which causes it to separate, but it is the contraction of the uterus, 
and the ovum, still partially attached to the uterus, is incompletely pushed 
towards the cervix by these contractions. Pushed by the uterus at the 
time of contraction, it tends, during relaxation, to resume its normal 
place; but the contraction augments, the cervical canal opens, the ovum 
engages within it; the contraction now ceases, and the ovum lies between 
two forces, the cervix, on the one hand, which tends to retain it, the body 
of the uterus, on the other, which tends to pull it back on the cessation 
of contraction. Whence traction, which, if the adhesions resist, tends to 
inevitably rupture the ovum, a rupture all the more likely the greater the 
vitality of the ovum, and the stronger its adhesions. The miscarriage will, 
therefore, occur at divided periods; the foetus will issue first, the remain- 
der of the ovum later, and this remainder will sometimes be expelled only 
after the lapse of a number of days. It is in these instances that hemor- 
rhage may be profuse and serious. For apart from its intensity, the 
woman is exposed to a renewal as long as the placenta remains in the 
uterus. The uterine contractions are irregular, intermittent, appearing 
for a while, and then disappearing, and this very prolongation of labor is 
of grave import for the welfare of the woman. We will see further on MISCARRIAGE. 
323 
that there is another danger, depending on retention of the placenta, and 
on the alterations it may suffer. 
The prolongation of labor, in these cases, depends, on the one hand, 
on the weakness of the uterine contractions, and, on the other, on the 
resistance of the cervix and the adhesions of the decidua. 
Weakness of contraction is to be expected at this period. The uterus 
has by no means attained the muscular development it will later; the 
muscular layer is only in process of formation, and contractility, hence, 
can be present only incompletely. Again, the cervix, at two months, has 
changed simply through a little softening at the tip. It has still its nor- 
mal length. At labor at term, the cervix, which has been softening 
throughout pregnancy, first disappears, then dilates, being represented 
simply by a ring, the result of the disappearance of the external os, and the 
opening of the internal. In case of miscarriage, however, the cervix 
neither softens, nor dilates, but only opens sufficiently to allow of the pas- 
sage of the ovum. It retains its entire length; the two orifices remain at 
the same distance, one from another; the ovum is obliged to pass through 
a canal, the more rigid the less advanced the pregnancy. Whence, there- 
fore, an additional resisting force it has to overcome, and whence, also, 
the likelihood of rupture, the greater the more intense the uterine con- 
tractions, the rigidity of the cervix, and the length of the labor. Miscar- 
riage may last for days, and even for weeks. The process is started by 
the uterine contractions, the ovum tends to become detached, but un- 
equally; pushed against the cervix, it engages in the canal, and it tears. 
What happens then ? The foetus, which is so small and weak, passes 
out first, and easily. The cord, scarcely formed, breaks, and the ovum 
may be lost in the discharges. The true miscarriage, however, has not 
occurred; the membranes and the placenta must still detach themselves, 
and it is only at the end of a few days that these are shed, and the mis- 
carriage is ended. These, then, are the two stages at this period of ges- 
tation. The cervix closes after the escape of the foetus. A second labor 
is needed for the expulsion of the remainder of the ovum. 
From two and a half to three and a half months the conditions are still 
more different. The placenta has been definitively formed, it is relatively 
larger than the foetus, it is attached more firmly to the uterus. In case 
of accident or of hemorrhage, the ovum will no longer separate entire, 
but only by portions from the uterus. Therefore miscarriage in two 
stages becomes the rule, and in one the exception. The uterus is far from 
having acquired its definitive structure, the muscular fibres are still in a 
rudimentary condition, and hence, the uterine contractions are too feeble 
to detach the placenta. Whence the infinite duration of the process, at 
times. Furthermore, there is marked disproportion between the dilata- 
tion of the cervical canal and the body which has to pass through it. The 
cervix, indeed, still neither dilates nor retracts; whence, again, the likeli- 324 
A TREATISE ON OBSTETRICS. 
hood of rupture of the membranes. Under the influence of contractions, 
the internal os opens, the ovum enters the canal, and remains there for a 
number of days. Then, at a given time, as a result of a contraction, or 
of some effort on the part of the woman, the ovum ruptures, and the em- 
bryo is expelled through the cervix, and often breaks the cord; if not, 
the embryo remains attached to the cord until traction, or effort of the 
woman, breaks it. The placenta stays in the uterus, and, whether sepa- 
rated or not, a new labor is necessary for its expulsion. The cervix closes, 
and new contractions are needed to re-open it for the passage of the pla- 
centa. If this organ has entirely separated, hemorrhage is ordinarily not 
abundant, except at the time of expulsion; if separation be incomplete, 
the hemorrhage lasts until detachment has occurred. In any case, no 
effort should be made to remove it, before its engagement in the cervix, 
otherwise, there is risk of tearing it, and of leaving portions in the uterus, 
and still another labor will be necessary for the expulsion of the remnants; 
and if this new labor should not supervene, the placental shreds may 
putrefy, and, as we will see, entail grave complications. 
The above is not all. There is another element which we must remem- 
ber, and this is the decidual membrane. In labor at term this membrane 
is really decidual, because it has lost its vitality; but in miscarriage, it is 
still living, and adheres strongly to the uterus; and instances are not 
rare where miscarriage is divisible into three stages, one for the foetus, 
one for the placenta, one for the uterine mucous membrane. 
Very infrequently, in our opinion, the ovum is expelled entire at this 
period of gestation, and then the foetus is dead. 
From three and a half to the seventh month, miscarriage approaches, 
progressively, nearer in character to labor at term. Two stages are the 
rule. The muscular fibre of the uterus is more developed, the uterine 
mucous membrane is detached the more readily, and while considerable 
time elapses between the expulsion of the foetus and that of the placenta, 
this interval is relatively less. It is exceptional to see the expulsion of the 
placenta delayed beyond twelve to twenty-four hours. The nearer to the 
seventh month the less profuse the hemorrhage; but even up to the fifth 
month, it may be very considerable. 
Such are, in outline, the phenomena of miscarriage at various stages 
of gestation. We now consider, in detail, each of these phenomena, the 
hemorrhage, the uterine contractions, the modifications of the cervix. 
Uterine Hemorrhage.-This is intimately connected with miscarriage, 
and if every hemorrhage does not determine the process, we may, never- 
theless, say that there can occur no miscarriage without hemorrhage. 
The very structure of the ovum, even during the first months, necessi- 
tates this. Immediately at conception, the qvum becomes surrounded by 
vascular villi, its detachment is, therefore, necessarily accompanied by 
hemorrhage. Again in case of premature detachment of the ovum, the MISCARRIAGE. 
325 
separation occurs but slowly, and here is another source of bleeding. 
The appearance of hemorrhage, therefore, in the early months of preg- 
nancy, should always awaken the anxiety of the accoucheur. In the vast 
majority of cases, it is an indication of impending miscarriage. 
[It is well to recall further causes of hemorrhage, slight in amount usu- 
ally, during the early months of pregnancy. Up to the sixth or eighth 
week it is still allowable to think of a return of the menses. At a later 
period, although there are a few undoubted instances on record, men- 
struation can hardly occur without imperilling the ovum. Frequent 
causes of hemorrhage are, slight separation of the ovum, the result, not 
infrequently of violent or often repeated coitus, erosions of the external 
os, cervical polypi or tumors, carcinoma of the cervix, lacerations of this 
organ. The point we desire to insist upon is that in every instance where 
a gravid woman complains of hemorrhage, both a digital and specular 
examination should be made to determine if one or another of the above 
causes be not at the bottom of it, instead of impending miscarriage.-Ed.] 
This hemorrhage is sometimes preceded by signs of uterine congestion, 
sometimes is sudden in appearance. It may be internal, external, or 
mixed. " When the hemorrhage is internal, it may be limited to the 
membranes, to certain portions of the placenta, constituting what has 
been called placental apoplexy. It may then, if slight, not determine 
quickly either labor, or the expulsion of the foetus, or its death. One or 
another of these result only after the repetition of such hemorrhage. In 
other instances, it may be profuse, and may spread throughout the entire 
placenta, the whole ovum separating without the appearance of the least 
blood externally." (Jacquemier.) 
The precursory signs of miscarriage, it is understood, are more or less 
intense, according to the amount of separation of the ovum, which fol- 
lows on the hemorrhage. The uterus, distended by blood and clots, be- 
gins to contract, and this contraction becoming more frequent, the cervix 
opens, and the clots, with a little fluid blood, pass out. The hemor- 
rhage has become external. 
When the hemorrhage is external, it may begin by a simple trickling 
of a reddish fluid, only becoming later hemorrhagic in character, or else 
announce itself at once by the appearance of clots and blood. Some- 
times the blood is black, followed only later by red. The duration of the 
flow is variable. It may begin with the miscarriage and persist continu- 
ously to the end; again it may appear only with the contractions. At 
times it ceases not to recur until the expulsory act, and then profusely. 
The amount lost is very variable, from a few drops on. It comes, we 
believe, from both the arteries and the veins, and as a result of the rup- 
ture of the mucous membrane and detachments of the placenta, which 
leave open the uterine sinuses. The blood, hence, is rathei' venous than 
arterial. 326 
A TREATISE ON OBSTETRICS. 
Uterine Contractions.-Like those which occur at term, these are pain- 
ful, although less intense, and they differ in regularity and in rhythm. 
Instead of pains progressively increasing in duration and in intensity, 
and which are separated by intervals less and less long, the contractions 
of miscarriage recur frequently at very long intervals only, during seve- 
ral days, until they finally become established, and expel the foetus. 
Changes in the Cervix.-These are not at all comparable to those which 
have occurred at term. Jacquemier thus describes these changes: under 
the influence of the uterine contractions, there occur alterations in the 
cervix, which are the first indices of effective labor. These contractions 
are, for some time, obscure, irregular, as though continuous, with mo- 
mentary exacerbations. The cervix is shortening and softening, the ora 
are opening, first the external, and then the internal, the vagina is re- 
laxing, and is covered by a thick, abundant mucus. The body of the 
uterus sinks into the pelvis. Only after the above changes have occurred, 
do the contractions become regular, and truly intermittent. This period 
of labor may last a number of days. Once the cervix softened and re- 
laxed, dilatation supervenes quickly enough, if the contractions are good. 
This dilatation is accomplished as follows. As the cervix softens it 
shortens-[Does it not rather seem to shorten, from the very fact of the 
softening? This matter is in dispute.-Ed.]-and the external and inter- 
nal os approach one another. The internal os insensibly opens more and 
more, and the contractions act on the external os, the border of which 
becomes thin, and cutting, as dilatation progresses. The ovum presents 
at this orifice, and is projected out by a pain. These expulsory pains not 
only dilate the cervix, and drive out the ovum, but they cause rupture of 
its adhesions to the uterus. Whence the premature hemorrhages which 
ordinarily accompany miscarriage, and which, in labor at term, or in ad- 
vanced stages of pregnancy, are only seen after the expulsion of the foetus. 
As soon as the entire ovum has been expelled into the vagina, the pains 
and the hemorrhage cease. 
The phenomena which follow the regular expulsion of the ovum are 
very similar to those of labor at term, but less accentuated the earlier the 
period of gestation. 
The Lochial Discharge.-This is scarcely noticeable after very early mis- 
carriage, and more and more marked thereafter, especially when the de- 
cidual mucous membrane separates but slowly. The sero-sanguineous 
discharge then lasts a long time, and in the uterine and vaginal excretions 
are found blackish debris, often very fetid. Truly, as Garimond has well 
said, we are dealing not with the lochia, but with a discharge caused by 
the fact that the miscarriage is incomplete. It ceases with the expulsion 
of the last shred. 
The Lacteal Secretion.-1This is present, as we have already stated, before 
miscarriage, in cases where the foetus dies, but it ordinarily recurs after MISCARRIAGE. 
327 
the expulsion of the ovum. Usually this is the case in multipara?, and 
after the third month. Joulin has related a case where milk was secreted 
six weeks after impregnation. 
Finally, involution takes place more rapidly than after labor at term, at 
least as regards the cervix, which closes much more quickly, and also re- 
gains its length and consistency sooner. The same does not apply to the 
body, and it is not unusual, after miscarriage, to find the body of the 
uterus remain larger than the normal; and in case of frequently repeated 
miscarriages, this incomplete involution merges into hyperplasia, the 
more so, indeed, because the precautions taken after miscarriage, parti- 
cularly in the early months, are far less than after term. 
After-pains do not follow miscarriages in the first months; usually they 
are not present till after the fifth in multiparse. When they do exist, it 
is usually proof that the miscarriage was incomplete, and that shreds of 
the decidua are still in the uterus. 
Diagnosis.-In the diagnosis of miscarriage there are included a num- 
ber of questions: 1. Is the woman pregnant ? 2. Pregnancy assured, are 
the symptoms those of pure uterine congestion or of beginning miscar- 
riage? 3. Is miscarriage inevitable ? 4. Is the miscarriage complete, or 
are there still in the uterus shreds of membrane, of placenta, or of deci- 
dua ? 
Is the woman pregnant ? If the diagnosis of pregnancy is easy, after 
the fourth month, when the foetal heart, and the active movements, of 
the foetus are appreciable, it is far from being so in the earlier months 
when all we possess are the probable signs. There is nevertheless one 
sign which may be of the highest importance, and this is the suppression 
of the menses. If the woman was regular up to the time of suppression, 
if this latter has occurred without morbid cause, if the rational signs of 
pregnancy are present, if, in case of a nullipara, the mammary areola, and 
Montgomery's follicles are present, then the chances are great that we are 
dealing with pregnancy. If, under such circumstances, persistent lumbo- 
hypogastric pains appear, with momentary exacerbations; if, at the same 
time, there appear an abundant bloody discharge, persisting, and mixed 
with clots; if at the same time, the cervix is softened, and the external 
os is open, we are nearly certain that we are in the presence of a miscar- 
riage. One point only is in doubt, if we have not been present from the 
start, and have not seen the discharge and clots,-this is if the miscar- 
riage is complete or not. 
When, on the other hand, the woman is naturally irregular, the diag- 
nosis is far more difficult. The suppression of the menses loses its value 
in diagnosis. It is not exceptional, indeed, to meet women who men- 
struate only every two to three months, in whom the breasts swell, the 
abdomen enlarges, and who present the signs of pregnancy in its begin- 
ning, and yet are not so. 328 
A TREATISE ON OBSTETRICS. 
According to Madame Lachapelle, the hemorrhage precedes and accom- 
panies the pains, and increases with the intensity of the pains, and is al- 
ways attended by clots, in case of miscarriage. In case of dysmenorrhoea, 
on the other hand, uterine contractions always precede the hemorrhage, 
and diminish as the hemorrhage increases. Further, clots are always less 
abundant than in case of miscarriage. In miscarriage the os is open, and 
the cervix modified in consistency, while it remains closed and is not 
softened in dysmenorrhoea. Clots coming from the empty uterus are tri- 
angular, while in miscarriage they have no special shape. All these signs 
are more than hypothetical, and hence are of little value. 
Still further, there are certain women who, during the first three months 
of pregnancy, suffer from slight hemorrhages which do not seem to have 
a tendency to provoke miscarriage. Such women may not know that 
they are pregnant, believing themselves to be menstruating. These slight 
hemorrhages differ, however, from the menses, in that they do not cor- 
respond to the menstrual epoch, either in time, quantity, or duration. 
We see, then, that there are many sources of error, and it is only by 
obtaining all possible information, and by examining the discharges and 
the clots that we can reach a nearly certain diagnosis. 
[The decision as to whether the woman is pregnant or not, it seems to 
us, may almost infallibly be reached by a sign not mentioned by the 
author, and this is Hegar's sign of early pregnancy, which we have de- 
scribed in the first volume, under the Diagnosis of Pregnancy.-Ed.] 
The woman is pregnant, then, but are the symptoms purely those of 
simple uterine congestion, or is miscarriage imminent? 
In the majority of instances, as Cazeaux justly says, "We cannot tell 
whether, even when pains have ceased, if the congestion has been relieved 
before vascular rupture, and hemorrhage between the placenta and the 
uterus have killed the foetus. Even though the foetus be still alive, we 
know nothing about the extent of placental separation. Often, indeed, 
the foetus, deprived of a greater part of its respiratory means, is placed 
in the same condition as an adult in whom a greater part of the lungs 
has been destroyed; there remains only insufficient respiration and 
nutrition, it dies little by little, and it is only after the lapse of eight to 
fifteen days, often at the next menstrual epoch, that it finally succumbs." 
Jacquemier, further, has insisted that the first placental apoplexy pre- 
disposes toothers, since it interferes with the development of the placenta. 
Miscarriage has Commenced.-Is it inevitable, or can it be caused to 
cease ? Generally it may be said that as long as the fostus is not dead, 
miscarriage may be prevented. But, if at the fourth month, we possess 
certain signs of the life or.the death of the fo?tus, the same does not hold 
true before this period, and, as we have seen, it is during the first three 
months that miscarriage most frequently occurs. The fuetus once dead, 
the miscarriage will necessarily occur sooner or later. One sign alone, may MISCARRIAGE. 
329 
be of value, and this is the cessation of all the rational signs of pregnancy; 
but there are many women in whom these signs are so little marked as 
not to be noticed. 
However intense the pains, however in character like uterine contrac- 
tions, however much the profuseness of the hemorrhage, or however 
marked the changes in the cervix, we are yet not justified in considering 
the miscarriage inevitable if the ovum be intact, and the membranes not 
ruptured. In certain exceptional cases all these signs have disappeared, 
and the pregnancy has continued. 
There are other instances again where the diagnosis is still more diffi- 
cult. For instance: The woman had been certainly pregnant, she has 
passed through, apparently, a miscarriage, having lost much blood, and 
suffered greatly from the contractions of the uterus. Clots have been 
passed and with them a body, which a midwife or a physician has ex- 
amined, and pronounced an ovum, and furthermore it is stated that the 
miscarriage is complete. This body has been thrown away, and the ac- 
coucheur, hence, cannot examine it. The bloody discharge continues, 
the woman does not regain her strength. Now has she really miscar- 
ried, and did the body really constitute the ovum ? Is the miscarriage, 
if one has occurred, complete or incomplete ? Here the diagnosis is diffi- 
cult, and often cannot at once be made. If the ovum has really been 
expelled, the hemorrhage will shortly cease, the cervix and the body of 
the uterus will return to the normal. If the miscarriage be incomplete, 
at the end of a certain interval the hemorrhage and the uterine contrac- 
tions will recur, and the remnant be expelled, or else some pathological 
factor will supervene pointing to the retention of ovulai' remnants in the 
cavity of the uterus. Not infrequently a portion of the placenta remains 
behind, the woman will bleed irregularly, and have occasional contrac- 
tions until it has been shed. Sometimes this placental remnant under- 
goes complete changes in the uterus, and these are two in number: either 
this remnant becomes converted into a fibrinous polyp, (Fig. 28), as has 
been noted by Kiwisch, Virchow, Scanzoni, Sallinger, Frankel, Dun- 
can, etc.; or else, more frequently, the remnant empties itself of the blood 
which it contained, becomes hard, takes the shape of the uterine cavity, 
and is transformed into what has been called placental polyp. (Braun, 
Schroeder, Valenta, Frankenhauser, Martin, etc.) 
In other instances the diagnosis is still more difficult; where a placen- 
tal tuft, or remnant of membrane or of decidua, remains in the uterus, 
and undergoes change. Here, instead of abruptly ceasing, the discharge 
persists, being black in color, and composed of detritus, and further-a 
very characteristic phenomenon-is intensely fetid. At the same time 
the woman's health is compromised. She suffers from chilly sensations, 
and has fever, effects which we will study when we speak of puerperal 
complications. 330 
A TREATISE ON OBSTETRICS. 
Prognosis.-For the foetus, of course, it means death, since it is ex- 
pelled before it is suitable for extra-uterine life. For the mother, it is 
grave, for, even if life is rarely compromised, health very frequently is; 
everything depends, however, on the progress of the miscarriage, and on 
the period of gestation at which it occurs. The prognosis is the graver, 
of course, where pregnancy is advanced, and the foetus and the foetal an- 
nexes are shed separately, because to the dangers of miscarriage are added 
those of retained placenta, and its consecutive alterations. Generally, 
in a word, the prognosis is most unfavorable in cases where the miscar- 
riage is the result of criminal manipulations or of disease of the mother. 
If we compare the process of miscarriage with confinement at term, aside 
from puerperal fever which is more common after the latter, the former 
Fig. 28.-Fibrinous Placental Polypi.-a, Fibrinous polyp, b, Placental site, c, Uterine cavity. 
predisposes to metritis, to displacements. The complications of miscar- 
riage, above all of note, are: profnse hemorrhages and retention of a 
portion of the ovum. Garimond insists on a third, faulty position of the 
foetus. In our opinion this does not constitute a serious complication, 
for up to the fourth month the foetus is too small to give rise to trouble, 
and at five and six months, the foetus is so soft and compressible that it 
readily passes whatever the presentation. What really constitutes the 
gravity in these cases is the hemorrhage which accompanies the prolon- 
gation of labor, and which may be so profuse as to become very disquieting. 
Although vertex presentations are the rule in labor before term, it is 
still true that the frequency of pelvic and of transverse presentations m- MISCARRIAGE. 
331 
creases considerably the further from term the pregnancy is interrupted. 
If we conjoin the statistics of Veit and of Hugenberger, we find that of 
1517 children born at the seventh, eighth and ninth month, 76.1 per 
cent, were cephalic presentations; 19.9 per cent, pelvic; 3.7 per cent, 
transverse; while of 355 children born at the fifth to sixth month, only 
54.6 per cent, were cephalic presentations; 40.2 per cent, pelvic, and 5 
per cent, transverse. In these figures, however, are included macerated 
foetuses, where the presentation alters from change in the centre of grav- 
ity. But even if these cases be left out, the law remains an exact one. 
For, according to Veit, of 379 children (eighth to ninth month), there 
were 84.7 per cent, cephalic, 13.7 per cent, pelvic, and 1.6 per cent, 
transverse presentations; of 43 children (fifth to sixth month), 62.8 per 
cent, were cephalic, 27.9 per cent, pelvic, and 9.3 per cent, transverse. 
Complications. 
I. Hemorrhage.-This always accompanies miscarriage in the early 
months. Generally intermittent, it is usually well borne by the woman; 
at times, however, it may be because of difficulty in the separation of the 
decidua, it may be because of special hemorrhagic tendency, or of a natu- 
ral atony of the genital system; it becomes very profuse, and is accom- 
panied by syncope, small pulse, cold extremities, in a word, by all the 
symptoms indicative of great loss of blood. It is particularly at from two 
months to three and a half that such hemorrhages are noted, and when- 
ever miscarriage occurs in two stages. The reason is that, in such cases, 
the ovum separates but slowly, and that the cervix closing up after the 
expulsion of the embryo, a second labor is necessary for the shedding of 
the remainder of the ovum. Now, we have seen, that this second labor 
may last a number of days or weeks, and all this time the woman loses 
blood, often profusely. The hemorrhage, therefore, is grave, not only 
from its profuseness, but from its duration. If it does not compromise 
the life of the woman, it does her health, leaving her in a state of anemia, 
from which she may recover but slowly. 
II. Retention of the Ovum, and of the Placenta.-li From the study of 
the means of union of the placenta to the uterus, Meyer states that this 
union, very intimate in the early months of pregnancy, becomes less so 
as pregnancy advances, through the retrograde processes which occur in 
the decidua serotina and in the utero-placental vessels; and that retention 
of the placenta depends, on the one hand, on the feebleness and irregu- 
larity of the uterine contractions, and, on the other, on the firm adhesions 
of the placenta to the uterine wall in case of miscarriage, whether these 
adhesions are normal or due to a pathological process. In the early stages 
of pregnancy, the placenta is divisible into two portions, the maternal 
and the foetal. The bond of union between these is feeble, and the foetal 
villi are easily separable from the maternal portion of the placenta. Still, 332 
A TREATISE ON OBSTETRICS. 
the uterine mucous membrane, and, in particular, that between the uterus 
and placenta, adheres firmly to the uterine wall, whence one of the rea- 
sons why it is often retained in the uterus after miscarriage. Up to the 
end of the third month, this mucous membrane separates slowly and with 
difficulty. Afterwards, the changes which it'undergoes renders its shed- 
ding easier, and, consequently, its retention unusual. Up to the third 
month, hence, we observe either the retention of the entire placenta, or, 
oftener, of the serotina and the adjoining parts of the foetal placenta. 
This retention is due to: 1. The firm adhesion of the maternal placenta 
to the uterine wall. 2. The ease with which the foetal portion separates 
from the maternal. 3. The feeble development of the muscular tissue of 
the body of the uterus. 4. The slight dilatation of the cervix. 5. The 
pathological processes which are often the cause of miscarriage, and which 
may exist in the uterus, in the foetal annexes, in the organs neighboring 
on the uterus. 
When the miscarriage is not determined by premature involution of the 
decidua, or by pathological processes which necessitate the complete sep- 
aration of the decidua, the expulsion of the product of conception is 
usually incomplete. Either the entire placenta, or shreds of the decidua, 
or of the serotina, remain in the uterus. Now the expulsion of these 
remnants may require an interval of many weeks, and even months." 
The placenta retained in the uterus may undergo cystic degeneration, 
as has been pointed out by Meckel, Scanzoni, Muller, Virchow, and 
others. 
We would further mention as causes of placental retention, the diseases 
of this placenta, and endometritis. 
These placentas, thus retained for a longer or shorter time in the 
uterus, may: a. Be expelled not altered, not putrid, b. Altered and 
putrid, c. With symptoms of septic fever, d. Without such symptoms. 
e. Be absorbed, f. Remain indefinitely in the uterus. 
a. Retarded Expulsion without Alteration.-When the placental adhe- 
sions are not firm, and the probable cause of retention is functional trouble 
of the uterus, or slight mechanical obstacles, then the efforts of nature 
may suffice for its elimination, and this occurs shortly through uterine 
contractions alone. It is about the tenth to the fifteenth day that the 
placenta begins to separate, and that hemorrhage reappears; but the in- 
terval may be months, and the only sign accompanying the shedding is 
sub-involution, and one of its consequences, hemorrhage. The placenta 
may be slightly degenerated, but this is not always so; it is especially the 
case when we are dealing with shreds of the ovum. Baudelocque has 
noted such retention for many months. Cazeaux says: " When we examine 
these placentas they are not altered, and have no odor, and they may be 
as fresh, even after weeks, as though extracted immediately after miscar- 
riage. The integrity of the vascular connections has given them lease of MISCARRIAGE. 
333 
life, and explains the innocuousness of this prolonged retention. Scheller 
has noted retention for eleven weeks; Metz for two and a half months; 
Prost, 103 days; Plasse, 15 weeks, and Reichmann, 13 weeks. 
Unfortunately, the above is not always the case, and hemorrhage may 
be so profuse as to compromise life. Hecking cites a case where the pla- 
cental remnant was passed only at the end of four and a half months. 
During this entire period the woman had profuse hemorrhages. 
During retention, the uterus retains its increased size. Sometimes 
the vaginal portion of the cervix is shortened, the external os open, 
the lips softened and swollen, the internal os patent. The lower 
segment of the uterus is full and distended, the boundary between 
cervix and body is not marked. Again, the cervix is closed, and has 
resumed its shape; and again, the internal os alone is closed. The 
functional troubles of the uterus are manifested by pains, occurring, 
usually, when the placenta partially detaches itself. From time to time, 
the women have pains in the back, in the abdomen, frequent desire 
to urinate. The lochial discharge, instead of being almost nil as after 
completed miscarriages, persists, remains reddish, sometimes is fetid: 
but what predominates is hemorrhage, which may be profuse, even 
though the placental remnant be small. Finally, the woman may have 
slight rise of temperature. 
(b.) Expulsion of the Placenta Altered and Putrid.-1st. Without 
symptoms of septic infection.-In these cases the marked phenomena are 
localized in the uterus and its neighborhood. The lochia become 
fetid, and this persists, until the placenta has been expelled, either 
spontaneously, or by instrumental means. Inflammatory symptoms from 
the uterus, or the adjacent organs, not rarely supervene, but these are 
accompanied only by slight fever, and hemorrhage. Even as the lochia 
may be putrid without the presence of micro-organisms, even so the 
placenta may become putrid in the absence of such organisms. The 
alterations are purely chemical in nature, and consist in the production 
of alkaloids of very penetrating odor; fermentative microbes are not 
present, and, therefore, there is no danger of serious intoxication. 2d. 
With septic infection.-Degeneration of the placenta may occur before 
the expulsion of the foetus. Kauffmann has reported a case of miscarriage 
at the fourth month, where, before the expulsion of the foetus, the 
woman had chills, hemorrhages, high temperature, with escape of putrid 
clots. Two-thirds of the placenta remained in the uterus after the 
expulsion of the foetus, and the woman died in four days, of septic fever. 
When the retained placenta putrefies, and septic fever supervenes, it 
may be acute, or sub-acute, from the start. The woman may die quickly 
after the expulsion of the foetus. At other times, the progress is 
less rapid; it may last from weeks to months, and end in cure or in 
death. In these instances, to the signs we have already noted as 334 
A TREATISE ON OBSTETRICS. 
following on retention of the placenta, are joined those which are 
characteristic of placental putrefaction. The lochia become sero- 
sanguinolent, blackish, and contain remnants of placenta or membrane, 
intolerably fetid. When injections are administered, this odor is 
diminished, but it quickly reappears. At the same time there are 
symptoms of metritis, metro-peritonitis, and all those of septic infection 
-chills, fever, diarrhoea, change in the appearance. 
(c.) Absorption of the Placenta.-May this occur? The fact is admit- 
ted by Velpeau, Lagemard, Maslieurat, and denied by Madame Boivin, 
and others. Hegar has lately studied the question, and he thus tabu- 
lates the reported cases: 1st. Cases in which no discharge, either bloody 
or serous, purulent or putrid, has been observed, in which the placenta 
might have passed away. Such are the cases cited by Nagele, Gabillot, 
d'Outrepont, Villeneuve, .Porcher, Charleston, Maslieurat, Lagemard; 
2. Cases in which there has occurred more or less abundant discharge of 
putrid sero-sanguinolent fluid. Such are those of Salomon, Schmidtmul- 
ler, Burger, Steinberger, Kyll, Ovalide, Velpeau, Dubois, Planque, Ingle- 
by, Glover, Morlane, Deubel, Villeneuve, Delpierre, Godefroy. Hegar 
first establishes the fact that cases in the second category can not be of 
placental absorption, and that they must be considered as instances of 
retention of the placenta with degeneration. But is this also true of 
the cases in the first category? By resorption of the placenta authorities 
understand not absorption of putrefied and loose placentae, but of 
those still adherent to the uterus, neither liquefied nor putrefied. And 
in the seven observations noted, the existence of an adherent placenta 
had been assured. No uterine or vaginal discharge, containing remnants, 
had been present; on the contrary the lochia are said to have been 
diminished, without odor. Both cord and membranes had been 
expelled. With the exception of slight fever, and a few after pains, 
nothing in particular was noted. In five cases menstruation reappeared 
from the seventh to the thirteenth week, and in those there speedily 
occurred another pregnancy, and normal confinement. 
Certainly, at first sight, absorption seems incontrovertible. Hegar 
proposes three hypotheses: 1. Either the accoucheur was in error in 
observation, or there was deception on the part of the patient ; 2. Or 
there occurred retention of the placenta, and consecutive alteration; 
3. Or true absorption took place. In conclusion, without absolutely 
denying the possibility of absorption he does not consider as credible the 
cases heretofore recorded. It is most likely that the retained portions 
were liquefied, and broken up, thus passing away in the vaginal excre- 
tions. 
(d.) Indefinite Sojourn of the Placenta in the Uterus.-It is granted 
by Hegar that the placenta, and even the entire ovum, may remain in 
the uterus even up to the death of the woman. They undergo retro- 335 
MISCARRIAGE. 
grade metamorphosis, and this is the explanation of those curious cases 
where, after death, foreign bodies, containing foetal debris more or less 
altered, have been found in the uterus of women of the age of 75, 80, 
and 90. Such are recorded by Kilian, Bohmer, Sandifort, Vallisnieri, 
Morgagni, Van Swieten, Camerarius, Dedek, Niemann. 
The Treatment of Miscarriage. 
Whatever the causes of miscarriage, we have seen that they induce one 
or another of the three following phenomena: 1. Either they deter- 
mine the death of the foetus, and thus necessitate miscarriage; 2. Or 
else they induce congestions, hemorrhages, -which, by causing the prem- 
ature detachment of the ovum, thus compromise, either directly or 
indirectly, the existence of the product of conception; 3. Or, finally, 
they excite premature contractions of the uterus, and then follow 
expulsion of the ovum and of the foetus. To combat these causes, such 
is the indication which the prophylactic treatment of miscarriage, as it 
has been called, must fulfil. When this prophylactic treatment has 
failed, or has not been instituted, and the miscarriage seems inevitable, 
then, by means of the curative treatment of miscarriage, we still seek 
to stop it, and thus allow pregnancy to continue, or else, if we cannot, 
to avoid complications, and to successfully overcome them. 
Prophylactic Treatment.-"The death of the product of conception 
-within the uterus, whenever it is not accidental, or caused by independent 
disease of the foetus, or of its appendages, is the result of one of the 
pathological causes, usually hereditary or acquired, which we have men- 
tioned." This sentence, which we have quoted from Jacquemier, 
resumes in a word the greater portion of the indications for prophylactic 
treatment. We say the greater part, because it only applies to those 
cases where the product of conception is dead, before the symptoms of 
miscarriage are evident; and in a large proportion of cases the ovum is 
expelled living, and long before term, under the influence of some local 
morbid state of the mother, without one being able to lay its death to 
any special diathetic cause. When this diathesis exists, and causes the 
death of the foetus, we must determine it, and fight it by appropriate 
treatment, before we allow a second pregnancy. If the woman is of 
a lymphatic, chloro-anemic constitution, we must have recourse to tonic 
and strengthening means; the preparations of iron, or arsenic, sea baths, 
hydrotherapy, mineral waters containing sulphur or iron, used as baths 
or douches, quinine, these are indicated; but, be it understood, such 
treatment must be continued for a long time, in order to give good results, 
and a second pregnancy, supervening too rapidly, not only would not go 
to term, but the woman would lose the little benefit which had resulted 
from the treatment. 
Among.these diatheses, there is one which leads all the others, and 336 
A TREATISE ON OBSTETRICS. 
this is the syphilitic, and we have seen already how frequent it is, and 
also how deadly to the product of conception. We have seen also that, 
in habitual miscarriage, syphilis, possibly latent, either of the father 
or of the mother, is the cause. Anti-syphilitic treatment, therefore, as 
well for the father as for the mother, especially the latter, should be 
rigorously enforced. 
In regard to syphilis, we would make the following statements: 1. 
Syphilis may be latent both in the father and in the mother, and yet 
neither possess any symptom, and it may be only the recurrence of mis- 
ckrriages without known cause which awakens the suspicion of syphilis. 
2. Both father and mother may be syphilitic, either recent or old, and 
both may know it. 3. Very often the father alone is syphilitic, and 
the mother is ignorant of the symptoms she has had or still has. 4. In 
rare instances it is the mother who is contaminated, and the husband 
has escaped contagion. 
In any instance anti-syphilitic treatment must be resorted to. The 
following is our practice in this respect: 1. Syphilis is latent, and there 
are habitual miscarriages. We give a teaspoonful of Van Swieten's liquor 
every morning during four to five months, interrupting the treatment 
for a few days in case of colic and gastralgia; then the treatment is 
interrupted during two or three months, and resumed for four weeks. 
At the end of a few months we allow a second pregnancy. 2. Syphilis 
exists in both the father and the mother. Here it is necessary to subject 
both to treatment. 3. Syphilis exists in but one of the couple. The 
suspicions of the other must not be awakened, but the treatment must 
be as persistent. 
[The preparation of mercury used will depend on the preference of the 
individual physician. The most efficient means of bringing the system 
rapidly under the influence of the drug is by inunction with the oleate 
of mercury, and, further, thus there is less risk of interfering with the 
digestive organs. In this country the biniodide of mercury is usually 
preferred to Van Swieten's liquor, which is entirely too irritating to the 
digestive tract. The necessity of tonic treatment in conjunction with 
the mercurial, should never be forgotten.-Ed.] 
1 Under diathetic affections, we would class ulcerations of the cervix, 
and chronic endometritis. Especially is it of importance in these cases 
to subject the woman to local treatment, in order to cure these affections 
before allowing a second conception. 
[There is one cause of miscarriage, the importance of which is not 
recognized by the author, and this is laceration of the cervix. Although 
in certain instances, laceration of the cervix would seem to favor concep- 
tion, because the cervical canal being widely open, the spermatozoa have 
readier access to the uterine cavity, still, remembering that this laceration 
is a direct irritant to the uterus, keeps it in a state of congestion, and MISCARRIAGE, 
337 
is at the bottom of a chronic cervical catarrh, we must believe that this 
is a frequent cause of habitual miscarriage. Many cases have been 
recorded of late years where this habit has been broken up through the 
repair of the lacerated cervix. In any case, therefore, where this lesion 
exists, and the woman habitually miscarries, the operation is indicated 
as a prophylactic measure. 
In cases of habitual miscarriage, where the causal factor is apparently 
impoverishment of the mother's blood, the tincture of the chloride of 
iron, together with the chlorate of potash, administered daily throughout 
pregnancy, will frequently enable the woman to go to term.-Ed.] 
Aside from diathetic and uterine affections, there are a number of 
causes which call for prophylactic treatment. Pregnancy itself, we 
have seen, through the influence which it exerts over every organ in the 
body, predisposes to miscarriage, especially by causing abnormal irritability 
of the uterus; and again, in certain women, the uterus is in such a 
condition of atony, that it becomes congested with the greatest ease. It 
is in such cases that rest in bed is absolutely indicated. But we must 
be careful not to en* to the other side, for too much rest may cause loss 
of appetite and weaken our patients. Ordinarily, we only require our 
patients to stay in bed at the time corresponding to the menses, for two 
days before, during this time, and for forty-eight hours afterward. 
Usually, at the fourth month it is no longer necessary to follow this rule. 
In this manner we have often been able to carry to term, women who 
had before miscarried a number of times. If the irritability do not yield 
to rest alone, and if, above all, the pain in the back persists, accom- 
panied by slight uterine contractions, then opiates should be associated 
with rest. Opium should be administered in enemata fifteen to twenty 
drops morning and evening for a few days, taking the precaution to 
avoid constipation. In women who object to enemata, suppositories of 
belladonna and the chlor-hydrate of morphia will be of service. It is 
remarkable the amount of opium which the gravida can take. We have 
often administered from forty to one hundred drops of the tincture of 
opium in twenty-four hours, without causing narcotism. 
Phlebotomy is often of great assistance, and this too in women who 
are not plethoric. General bleeding from the arm is, in our opinion, 
far preferable to local. It should be practiced with the woman in the 
recumbent position, in order to avoid syncope. Depaul, Devilliers, 
Triaire, agree with us in thinking that general venesection is preferable 
to local. 
In a certain number of instances the means indicated above do not 
suffice. The symptoms of miscarriage, hemorrhage, uterine contrac- 
tions, appear. What are the means at our disposal? 
Curative Treatment.-Miscarriage, as we have seen, is absolutely in- 
evitable only if the foetus is dead, or the ovum is not intact. Up to the 
Vol. II.-22 338 
A TREATISE ON OBSTETRICS. 
fourth month, signs of foetal death are absent, and yet we ought to act, 
always, as though we were certain of the vitality of the foetus, that is to say, 
turn all our endeavors toward preventing the miscarriage. In the presence 
of hemorrhage and of uterine contractions, especially if neither is 
marked, we must act quickly. 
The first thing to do is to put the woman to bed, keep her absolutely 
quiet, and administer opium enemata. At the outset we give twenty- 
five drops of the tincture with a syringe, in order to be certain that she 
receives the entire dose. At the end of six, or of twelve hours, accord- 
ing to the urgency of the case, this is renewed, and so on for twenty- 
four to seventy-two hours, if necessary. When opium is thus admin- 
istered continously for a number of days, each morning the woman should 
receive a large enema of glycerine and water, in order to avoid constipa- 
tion. 
Venesection, on the appearance of hemorrhage, we cannot quite 
counsel, although, if the woman is plethoric, and has a full pulse, with 
signs of congestion, we do not hesitate to withdraw a slight amount of 
blood from the arm. 
Hohl has advised the use of the sulphate of quinine. Plantard, on 
the other hand, absolutely rejects it. The Italians have advised tannic 
acid. Richardson, and Barnes, the nitrite of amyll. We prefer, above 
everything, laudanum, and if this fails, but little can be expected from 
other means. 
[The viburnum prunifolium in drachm doses, repeated every few 
hours, is often of value in attempted miscarriage. Chloral hydrate may 
also be tried, particularly where the main symptom is uterine contraction. 
Quinine should not be used, for whilst it has not the property of evoking 
uterine contractions, it certainly may intensify them when present.-Ed.] 
Unfortunately, in many cases, all treatment fails, either because the 
foetus is dead or the ovum has partially separated, or because the 
membranes have ruptured. Then miscarriage is inevitable, and the 
proper treatment is all-important. 
Miscarriage, as we have seen, necessitates hemorrhage, and, whilst 
usually this is moderate in amount, it may be profuse, and compromise 
not only the health, but the life as well, of the woman. Whilst, further, 
in the early weeks, the ovum may be expelled entire, it may also be 
shed in two portions, and the remaining membranes, placenta, or 
decidua, may undergo degeneration, and entail puerperal accidents of 
grave import to the health, and the life, of the woman. When we bear 
in mind the concise description, already given, of the manner in which 
the ovum is expelled, and how the phenomena differ according as the 
ovum is shed entire or not, according as the foetus is alive or not, it 
is at once apparent that our efforts lie in two directions: 1. To fight 
against hemorrhage. 2. To end the miscarriage as sopn as possible, and MISCARRIAGE. 
339 
to avoid retention of any portion of the ovum, and the deplorable 
consequences. These precise indications are met very differently by 
different accoucheurs. Certain ones limit their endeavors to the control 
of the hemorrhage, assisting, as far as may be, uterine contractions, and 
thus accelerating the separation, and the expulsion of the ovum, never 
resorting to instrumental or manual intervention, except where placental 
retention entails serious accidents. Others, on the other hand, insist on 
the necessity of speedy interference, in order to stop at once the 
hemorrhage, and to render impossible the retention of the afterbirth, 
and the accidents this entails. These two methods of action are 
championed and opposed with zeal. It is in particular in connection 
with retention of the afterbirth that opinion varies most markedly, the 
practice in regard to hemorrhage being nearly uniform. 
Methods of Controlling Hemorrhage.-When it is not profuse, and stays 
within moderate limits, it is usually sufficient to insist on absolute rest, 
to administer cold drinks, and to apply cold cloths over the abdomen, 
and over the thighs. But, if it be serious, if it be profuse, more 
energetic action is requisite, and three methods are at our disposal: 
1. Administration of ergot. 2. The tamponnade. 3. Ergot and the 
tamponnade associated. We prefer this method. 
(a). The Administration of Ergot.-This drug, it is claimed by those 
who advocate it, has a double action. On the one hand by exciting, and 
increasing uterine contractility, it quickens the separation of the ovum, 
and the dilatation of the cervix; on the other hand, by causing con- 
traction of the blood vessels, it stops hemorrhage. These two actions 
call for brief consideration. In order that ergot may act forcibly on 
the uterine muscle, this must have acquired its full development, and 
contraction be already present. And these two conditions are rarely 
present in case of miscarriage. The uterine muscular fibre is but little 
developed during the early months of pregnancy, and, on the other 
hand, hemorrhage is often profuse, before contraction sets in. Again, 
the contractility evoked by ergot differs notably from that which is 
peculiar to the uterus; it is a species of tetanic retraction, which, when 
it affects the cervix, not only does not cause dilatation, but causes 
rigidity. Ergot then may act directly opposite to the desired end, and, 
by interfering with dilatation of the cervix, shut up the ovum, or its 
remnants, in the uterine cavity. On the other hand, it has been proved 
by the researches of Parola, of Beatty, of Laborde, and, above all, of Lee, 
and his pupils, that ergot acts on the blood vessels, causing considerable, 
although transitory, diminution in the force of the circulation; that it 
further acts on the heart, making its pulsations more feeble, and slower; 
and that it also acts on the capillary network, determining its contrac- 
tion, and diminishing the amount of blood it contains in a notable 
manner. Finally it produces a contraction of the vessels of the spinal 340 
A TREATISE ON OBSTETRICS. 
cord, and of its membranes, decreasing the amount of blood there 
circulating. 
Ergot, therefore, is a powerful hemostatic, and should not, hence, be 
rejected in the treatment of miscarriage. 
(b.) The Tamponnade.-Well applied-see in this conhection the 
section on obstetrical operations-it certainly will stop the hemorrhage, 
and, if it fail, it is because it is imperfectly applied. The tampon 
opposes the external appearance of blood, and thus favors coagulation in 
the uterine cavity, and the pressure which it exerts on the cervix, 
bladder, and rectum, tends to increase uterine contractions, and thus 
accelerates dilatation, the separation of the ovum, and its expulsion. 
The sole objection to it is the pain caused by pressure, and the inter- 
ference with the functions of the rectum and the bladder. The danger 
of converting external into internal hemorrhage is slight, owing to the 
small size of the uterine cavity at four months; and if, at a later period 
of gestation, we ought to watch the tampon more readily on this 
account, we still believe that it is to it we should resort under conditions 
of which we will speak later. (See Placenta previa. Vol. III.) We 
believe, however, that there is a better method than the use of either 
ergot or the tampon alone, and this is the combination of the two. 
(c.) Tampon and Ergot Associated.-The tampon is first applied, and 
left in situ, not a few hours, as is the custom of Barnes and the Ger- 
mans, but for 24 to 36 hours according to the case, and we administer 
to our patients thirty grains of ergot, in eight divided doses, at first 
every ten minutes, and then, after an interval, every hour. We prefer 
ergot in powder form, to the subcutaneous injection of ergot, and we 
only resort to the latter when the former disagrees. 
[With us a reliable fluid extract of ergot, administered in drachm 
doses every three hours, will be preferred to the powdered drug. Better 
still, than either, is the aqueous extract of ergot by suppository, for thus 
no risk is run of causing digestive troubles. An excellent combination 
is the aqueous extract of ergot (gr. v.) and the alcoholic extract of 
Cannabis Indica gr.), repeated every four hours. Cannabis Indica, 
when pure, has marked hemostatic powers, but its administration should 
be carefully watched, since certain patients are peculiarly susceptible to 
it.-Ed.] 
We thus obtain together the effects of both ergot and the tampon. 
Frequently, in removing the tampon, the ovum is found more or less 
engaged in the cervix. If then the hemorrhage be slight, and the con- 
tractions energetic, the tampon need not be reinserted, but the case may 
be left to nature. If, however, the contractions are feeble, if the hem- 
orrhage is again intense, a new tampon should be inserted, and ergot 
again administered. In certain cases, where the ovum is engaged, we 
may simply give the ergot, since retraction of the cervix is no longer MISCARRIAGE. 
341 
to be feared, for the ovum in its canal acts partially as a tampon, and 
partially from its irritating effect on the cervix determines uterine con- 
tractility. But, and this is a point of prime importance, we must be 
careful not to interfere with this engaged ovum: it must be allowed it- 
self to escape from the external os, and it must never be extracted until 
it is in the vagina. Otherwise only a portion would be removed, which 
would mean recontraction of the cervix, and retention of a portion of 
the ovum, and its consequences. 
Unfortunately, however, matters do not always progress after the 
above fashion, and in many instances to the hemorrhage are joined the 
complications entailed by the prolonged retention of the placenta, rem- 
nants of the membranes, and of the decidua, in the uterine cavity. If, 
at times, the retention of the placenta means only more profuse hem- 
orrhages, the cases are far more frequent where the placenta putrefies, and 
determines in the woman phenomena which may prove fatal. And 
therefore it is why every writer has taken great interest in this subject 
of retention of the afterbirth. 
At the outset, one capital point should be remembered: In many 
cases the prolonged retention of the placenta is admirably supported by 
the woman. It continues to live in the uterine cavity, without altera- 
tion, and, at the end of a longer or a shorter time, it is expelled perfectly 
fresh, without other accident than more or less hemorrhage. Nothing is 
more variable than the time during which this retention may obtain, 
and to endeavor, as Gueniot has done, to fix the limit of what he calls 
normal retention, seems to us rather the result of visionary theory than 
of clinical experience. We protest, therefore, against this view. Our col- 
league forgets that miscarriage is constituted not by the expulsion of 
the embryo, but by that of the placenta. Miscarriage is simply delivery, 
and to endeavor to set precise limits, is to contradict a fact of experi- 
ence. Nothing is more irregular than miscarriage, and the time requisite 
for its full completion may vary from hours to days, and this without 
further accident to the woman than hemorrhage, which we can control 
by ergot and the tampon. 
[In addition to the combined use of the tampon and of ergot, there is 
a further agent which we can strongly recommend, from the fact that 
it has been of marked service to us, in cases of uterine inertia, by invok- 
ing contractions, by intensifying them, and thus hastening delivery, 
and checking hemorrhage. This agent is the Faradic current. A mild 
current is all that is requisite; the main point in its application being the 
intermittency of its application. The patient should hold one electrode, 
it is an indifferent matter which, and the other should be passed to and 
fro over the abdomen. A strong current is to be avoided, in order not 
to produce spasm of the uterine muscular fibre. A further useful point 342 
A TREATISE ON OBSTETRICS. 
about this method, is the fact that the patient's suffering is markedly 
diminished, although the pains are rendered more effective. 
A word about the tampon will here not be out of place. As the au- 
thor says with truth, the tampon, in order to be effective, must be ap- 
plied well. The only way to efficiently tampon the vagina is, with the 
patient lying in the left lateral position, to insert them through the 
Sims speculum. The posterior cul-de-sac should first be thoroughly 
packed, then the anterior, and finally the vagina underneath. The 
tampons further should be carbolized, in case it is likely they will re- 
main in place for a longer interval than a few hours.-Ed.] 
We may have to face one of two conditions: 1. The placenta, although 
in the uterine cavity, is in part engaged in the cervix. 2. The placenta 
is entirely in the cavity above the cervix. 
In the first instance we advise ergot, with or without the tampon, 
according to the amount of hemorrhage; and, if the ovum has passed 
completely, or nearly so, through the external os, digital extraction- 
but only when we are perfectly sure it is not at all adherent to the ute- 
rus. 
In the second instance, we make, with Gu6niot, five subdivisions: 1. 
Miscarriage has occurred, but the afterbirth is incomplete, and there is 
no complication calling for immediate action. 2. The same exists, but 
with complications. 3. Miscarriage has occurred, but there is uncer- 
tainty as to whether it is complete or not. 4. Miscarriage is certainly 
complete, but there are complications calling for interference. 5. Mis- 
carriage is in progress, inevitable, and more or less advanced. 
At the outset, it is apparent that, where all is normal, there is no call 
for interference. All authorities agree that here expectation is the 
proper conduct. The difficulty is to draw the line where justifiable in- 
terference begins. But when delivery is prolonged, ought we still to 
abstain, ought we to wait, or ought we to interfere actively in order to 
forestall the complications which almost infallibly will result, and in- 
terfere, further, at a time when it is far easier than later, when we may 
be forced to action? Such is the problem, the answer to which divides 
obstetricians into two opposing forces. The one insists on active in- 
tervention, in order to terminate the process as soon as possible, and 
thus prevent complications. The other, having deep faith in the powers 
of nature, only allows interference in case of serious complication. 
The following propositions may be laid down as acceptable to all au- 
thorities: 1. It is necessary to interfere in case of complication, opin- 
ions only varying" as to the manner of interference. 2. In miscarriage 
during the first two months, since hemorrhage may be completely con- 
trolled by the tampon, and since the placenta is small, pliable, and may 
become disintegrated and discharged in the lochia, septic complica- 
tions are not apt to be pronounced or serious, and are easily mastered by 343 
MISCARRIAGE. 
antiseptic injections and tonic treatment, aided by alcohol, and the 
sniphate of quinine. 3. At a more advanced period of pregnancy, 
mechanical means of delivery, other than manual, are very difficult of 
application, and expose the woman to the danger of metritis, and peri- 
tonitis. 
In the first two months, therefore, retention of a portion of the ovum, 
no matter for how long, calls for no active interference, unless serious 
accidents supervene, and then we must extract these remnants ;ib soon as 
possible. It is, then, after two months, that opinions vary. 
Views of those in favor of active interference.-To speak simply of 
our contemporaries, we mention, in England, Tyler Smith, Murray, Hall 
Davis, Priestley, Leishmann, Simpson-in Germany, Spbndly, Botters, 
Veit and Fehling-in America Munde [and many others.-Ed.]-in 
France Gueniot. The reasons given by Spondly, in favor of active in- 
terference, are similar to those advanced by the others. The frequency 
of retention of the afterbirth; the dangers which may supervene in pro- 
longed delivery; the almost constant possibility of manual extraction. 
Veit is possibly, with Simpson, the most active partisan of interference. 
If the cervix is dilated, or patent, he acts at once; if it is not dilated, he 
dilates at once with prepared sponge, removing this at the end of sixteen 
hours. The woman is then anaesthetized, the uterus depressed as much as 
possible by the external hand, and with the index finger of the other he 
removes the placenta and the membranes. If he cannot sufficiently 
depress the uterus with the hand, he does not hesitate to forcibly drag 
it down by a double tenaculum fixed in the cervix, as is also done by 
Simpson, and Hegar and Kaltenbach. It is evident that he does not 
always succeed, for he speaks of the possible persistence of hemorrhage 
after this method. In order to stop this he washes out the cavity with a 
solution of carbolic, and then applies to the endometrium, the sub-sul- 
phate of iron, or pure phenic acid. 
Botters and Munde go further still, and not only resort to Veit's 
method, but proceed to curette the cavity of the uterus with Simons' 
scoop, or the metal curette of Thomas. They then similarly cauterize 
the endometrium. 
[The author is here in error, certainly as regards Munde's practice. 
It is not his custom, nor indeed of any of us in this country who 
practise interference because thereby the woman's safety is at once 
assured and she herself not at all endangered, to use Simons' scoop, 
or any variety of sharp curette, for the removal of the retained placenta, 
or shreds of the ovum. The former, indeed, has devised the special 
instruments which we figure below, for the purpose of loosening the 
adherent placenta, and for its removal from the uterus. His curettes 
have no cutting edge, and are applicable to cases where there is a large 
mass to remove, and where, in consequence, nearly always the cervical 344 
A TREATISE ON OBSTETRICS. 
canal is wide open, and will hence admit them. Where we are dealing 
with small shreds, and the os is less patent, the dull curette of 
Thomas answers every purpose. As to whether the patient will be 
injured by such instrumental measures, or not, depends purely on the 
manner, and on the gentleness with which they are resorted to. The 
position of the woman should always be the left lateral, and the removal 
should always be through Sims speculum. Then the cavity should be 
carefully dried by a cotton applicator, and tamponed' by means of 
the slide applicator, the cotton on which has been saturated in the 
Figs. 29 and 30.-Mundi's Placental Curette. (2 sizes.) 
compound tincture of iodine. These manipulations are painless, and 
if performed gently, even as every intrauterine manipulation should be, 
can do the patient absolutely no harm. On the contrary, she is spared 
the danger from profuse hemorrhage, which might occur in the absence 
of the physician, and notwithstanding the ergot, she is spared the risk 
of septic infection, general or local, she is spared the mental anxiety to 
which otherwise she is subjected. Active intervention does not mean 
unnecessary interference. Nature is ever to be given a chance. But 
when we see that her efforts are futile, certainly it is but rational to assist 
her after a method which, rightly performed, bodes no harm to the 
patient, but is full of good. Those of our readers who have carefully 
studied the graphic pen pictures wherein Charpentier delineates the 
possible dangers which may, at any moment, follow on prolonged waiting, 
will at once agree that the procedure advocated in this country, particu- 
larly by Munde, is far preferable, if it be only free from risk, and this 
we are amply satisfied is the case. Miscarriage is fraught with more MISCARRIAGE. 
345 
danger to the woman than labor at term, because, as Goodell aptly puts 
it, the process is like plucking immature fruit. We believe, however, 
that timely, active intervention, 
resorted to with care, will rob 
miscarriage of its dangers, and 
not at all substitute new ones. 
American women, and German 
too, can stand the practice we 
advocate, not because they differ 
at all from the French, but 
because French accoucheurs, 
with scarcely any exception, have 
yet to learn the manner how to 
assist their patients rationally in 
case of prolonged miscarriage. 
-Ed.] 
Truly, indeed, as Pajot says, 
the German womb is very slug- 
gish to be able to resist such 
treatment, which, further, it 
seems to us, is directly contrary 
to the aim of those who resort to 
it. [His objections are purely 
the result of the fact that the 
method of active intervention is 
not understood. That the sharp 
curette will wound the endome- 
trium, we grant, but then the 
sharp curette is not advocated, 
certainly in this country; that 
deep cauterization of the endo- 
metrium may in turn produce 
trouble, we grant, but then we 
do not argue for such cauter- 
ization. The compound tinc- 
ture of iodine is used as a gen- 
tle styptic and disinfectant, 
and produces no slough, on the separation of which new hemor- 
rhage will occur. We make these criticisms because our author, 
being opposed to active intervention, is not always just to the 
method.-Ed.] 
Fig. 31.-A.-Sims' Slide 
Applicator. 
B. - The same, with 
Cotton Tampon Attach- 
ed. 346 
A TREATISE ON OBSTETRICS. 
Views of those Opposed to Active Intervention.-The authorities who 
counsel waiting foi' the appearance of some complication before interfer- 
ing, are just as many. We mention: Viardel, Leboursiei' du Coudray, 
Lachapelle, Capuron. In England, Ramsbotham, Davis, Lee, Dewees, 
Ingleby, Burns, Blundell Fleetwood Churchill, Grailly Hewitt. In 
Germany, Honing, who advises resort to Kristeller's method of uterine 
expression, Martin, Kehrer, Hegar, Schroeder, Scan zoni, Spiegelberg. 
In France, all accoucheurs, except Gueniot, are in accord, and Cordes 
has stated the prevalent belief exactly, when he says: "Miscarriage only 
ceases to be a physiological process, when the organism refuses to 
tolerate longer the placenta, and ceases to expel it, even as it will any 
foreign body. In other words, when uterine contractions supervene, 
when the patient loses blood, when the hemorrhage, or sero-sanguinolent 
discharge, is fetid-then, and then only, ought we to aid the failing 
forces of nature." 
To resume, then, the practice we would recommend in case of mis- 
carriage: A woman is miscarrying, the process is inevitable: tampon 
and administer ergot, against the hemorrhage. Remove the tampon at 
the end of twenty-four hours to thirty-six, if the contractions are feeble, 
at the end of eight to twelve hours if they are energetic. Then examine 
the cervix, being careful not to injure the ovum. If the ovum is 
engaged in the cervical canal, or if it be in the vagina, and if it is 
entirely detached from the uterus, this is a sine qua non, remove it at 
once; if the cervix is not sufficiently dilated, if the ovum has not 
engaged, if it is still adherent, in case of persisting hemorrhage reapply 
the tampon, and wait. 
If the woman miscarries in two stages, if the foetus has been expelled, 
and the placenta remains, what is to be done? Usually nothing: nature 
can do the work, the placenta may remain seven to fifteen days, before 
being expelled: whilst there is no complication, wait, at least till the 
placenta is engaged in the cervix and detached from the uterus, and 
then extract quickly. 
If the placenta is not engaged, and the cervix is closed: wait, and, in 
case of hemorrhage, tampon and give ergot, never the latter alone. 
If the placenta, still adherent, is in part engaged in the cervix: give 
ergot, for the cervix can no longer retract, since its canal is filled by the 
placenta. If the placenta is at the fundus, and adherent: wait still in 
case there exists no complication; interfere rapidly, in case of accident. 
If it be hemorrhage-the tampon and ergot. If it be putrefaction of 
the placenta-recognize this, and extract at once. 
How are we to recognize putrefaction of the retained placenta or 
membranes? Ordinarily this is an easy matter. The first symptom 
is fetor of the lochial discharge, fetor which, at times is such as to per- 
meate, and extend beyond, the lying-in room. The discharge, further, MISCARRIAGE. 
347 
loses its normal character, and diminishes in quantity, becoming black in 
color, or deep brown. It is no longer bloody, or sero-sanguinolent, but 
is composed of reddish-black detritus, the debris of the retained mass. 
Involution ceases, and the uterus becomes sensitive to pressure. At 
times, slight tympanites supervenes, with or without diarrhoea, and this 
too may be fetid. The woman has chills. Sometimes the chill is vio- 
lent and single, sometimes many, separated by intervals of one or two 
days; there exists fever, with elevations even to 104°-105° F. The pulse 
ranges to 120 and above. The temperature shows marked remissions, 
often, but the pulse remains high, and thus it may be day after day, 
until the woman dies. At times again, these remissions are not marked, 
the fever being continuous. The general condition alters for the worse, 
the eyes are sunken, anorexia, vomiting, and diarrhoea exist; the woman 
grows weaker, and, if we cannot suppress these symptoms, the woman 
dies of septic poisoning. 
[A truly classical picture of sepsis 1 Has the physician any business to 
allow the woman to enter into such a state ? Is he doing his full duty by 
her, when he sits, with folded hands, awaiting the onset of sepsis before 
acting? His condition is one of armed expectancy. He knows what he 
will do in case of the onset of sepsis, but action then, however prompt, 
may be of no avail-the woman may still die of septicemia. Seeing then, 
that in no given case of retained placenta or secundine can it be predicted 
whether sepsis will develop, or not, which is the wise course, we had almost 
said the non-criminal course, to do at the outset what may eventually be 
forced upon us, or to do it when it may be too late for good, and when cer- 
tainly action is far more difficult ? Again, we repeat, the immediate re- 
moval of the secundines is safe, and easy, and guarantees the woman 
forthwith against sepsis.-Ed.] 
When the first symptoms of sepsis appear, we must not hesitate, but 
we must immediately extract the placenta, or the secundines, and this, 
it is understood, is all the more difficult the more completely the cervix 
has closed. If the cervix is permeable to the fingei' or to instruments, 
the operation is easy. If closed, then we must dilate at once with 
sponge, or laminaria, with a branched steel dilator, or with Barnes' bags. 
We prefer the latter in urgent cases. Dilatation once accomplished we 
must proceed to extraction, and this must be done by the finger, or by 
instruments, according to the case. We reject absolutely both traction 
on the cord, and intra-uterine injections. The former will simply end 
in rupture, the latter will disinfect, but will not detach the secundines 
or the placenta. We further reject, cold applications, electricity, expres- 
sion, ergot-all these are too slow. 
When the cervix has been dilated, the woman is chloroformed, and, 
lying on the back, the hand on the abdomen depresses the uterus as 
much as possible. The index finger of the right hand is then introduced 348 
A TREATISE ON OBSTETRICS. 
into the uterine cavity as deeply as possible, and the adherent remnants 
are detached, and brought out by the finger, which is bent like a crook. 
This procedure is repeated until the uterus is empty. If the finger do 
not suffice, because the placenta is too friable, or firmly adherent, in- 
struments-like Prof. Pajot's curette-take the place of the finger. The 
cavity should then be washed out, through a double-current catheter, 
with plenic acid solution, and these injections practiced every day, as long 
as the catheter can be inserted. Vaginal injections are still to be con- 
tinued by the nurse. Intra-uterine injections must always be given by 
the physician. At the same time, both quinine and alcohol should be 
administered. Certainly 15 grains of the former should be given daily- 
the object being to keep the patient under the continuous action of the 
drug. 
Fig. 32.-Articulated Curette of Pajot. 
[Since the introduction of antipyrin into our therapeutic list, it 
has obtained a deservedly high rank amongst antipyretic measures, and 
in all cases of high temperature in the puerpera, exclusive of course of 
malarial influences, in particular when the rise is of septic origin, this 
drug should take the place of quinine. It should be given boldly, prefer- 
ably by rectum, at first, and then repeated in smaller doses pro re nata. 
Forty grains by rectum, and twenty by the mouth is a fair average dose 
to begin with. The drug should always be guarded by alcohol, and the 
pulse carefully watched, in order that digitalis may also be administered 
in case of evidence of cardiac failure. The occasional appearance of 
sub-normal temperature, of urticaria-like eruptions, and of even slight 
syncope, should be borne in mind, when giving the agent. These occur- 
rences are, however, exceptional, and need not alarm.-Ed.] 
Alcohol may be given in any form. Aconite we have little confidence 
in, although, in certain cases, it has seemed of value. Nourishing diet 
is, of course, indicated. 
We cannot insist too strongly on the use of antiseptic injections-in- 
tra-uterine as long as odor exists. The utility of these injections is in- 
contestible. 
[In case the extracted placenta or secundines were intensely fetid, 
we would advise, after the uterine cavity has been thoroughly emptied 
and cleansed, the insertion of a suppository containing ten to twenty 
grains of iodoform. This may modify, markedly, further absorption of 
septic products. For the intra-uterine injections we know of nothing MISCARRIAGE. 
349 
better than the Chamberlain glass tube, without the terminal opening. 
A small size, suitable to miscarriage cases, may be obtained.-Ed.] 
Between four and five months, there is another complication, at times, 
and this is where the foetus presents by the breech, and the head, through 
forcible traction on the breech, is torn off, and left in the uterus. Ex- 
traction may be very difficult. 
The woman who has miscarried, should be subjected to the same rules 
as those applicable to the puerpera at term. Prolonged rest is needed, 
and this is hard to obtain, for women are apt to look upon miscarriage 
as a slight affair. And after miscarriage, metritis, peritonitis, flexions 
and versions of the uterus are very frequent, and they may entail sterility, 
or impress the habit of miscarrying. 
[All the more liable is the woman to such affections, when the treat- 
ment advocated by the author in case of incomplete miscarriage is the 
rule. If the woman recovers from the immediate complications of 
the miscarriage, she infallibly possesses a sub-involuted uterus, an endo- 
metritis, and, if not at once, very likely later, a retroversion. These 
are further reasons, therefore, why the ultra-expectant treatment deserves 
condemnation.-Ed.] CHAPTER VI. 
EXTRA-UTERINE PREGNANCY. 
TT^CTOPIC gestation, doubted by the ancients, who, with their primitive 
J ideas in regard to fecundation, could not understand the possibility, 
only assumed rank in medical literature when the ovum was discovered, 
and its presence in the ovary attested. The earlier instances of this 
anomaly from normal gestation were considered as curiosities, unex- 
plainable, and they were simply noted without further comment. Certain 
accoucheurs, Mauriceau amongst them, denied absolutely the possibility. 
Nevertheless, Ambroise Pare, Amand, Roderer, Smellie, and Astruc, 
have reported incontestable instances. 
Levret first subdivided pregnancy into false, into true, and into vicious, 
when the foetus is situated elsewhere than in the uterus. At the same 
time, Andreas Lindemann, distinguished tubal, ovarian, and ventral 
pregnancy. Lauverjat, Dionis, and others, cite examples of the kind. 
It was only later, however, that these apparently supernatural events 
received an explanation, at the period when the ovum was detected in 
the ovary, and from this time forth, extra-uterine pregnancy was ad- 
mitted as a distinct morbid phenomenon, and was carefully investigated. 
Baudelocque, Joseph Jacobi Plenk, Stein, Denman, Gardien, Capuron, 
Velpeau, and others, have left us detailed monographs. It was only, 
however, on the appearance of the works of Negrier, Raciborsky, and of 
Coste, that, the phenomena of menstruation and of fecundation having 
been well established, we possessed a rational account of ectopic gesta- 
tion; and, if now, we have cause for wonder, it is not as to the existence 
of ectopic gestation, but at its comparative rarity, dependent, as says 
Schroder, not so much on the small number of fecundated ova which 
reach the abdominal cavity, as on the fact that these ova do not often 
find there conditions favorable for their development, and hence perish 
and undergo absorption. 
. The existence of ectopic gestation once established, opinions have 
differed widely in regard to classification; and since the days of Baude- 
locque, what innumerable varieties! Whilst one or another form has 
been admitted without protest, still another has been rejected. To 
speak only of ovarian pregnancy, it required the labors of Coste, Max 
Mayer, Kiwisch, Virchow, Dezeimeris, to prove its possibility. 
To-day, the numerous reported cases of ectopic gestation prove, not 
only that the fecundated ovum may develop on any of the genital EXTRA-UTERINE PREGNANCY. 
351 
organs, even the cervix (Chavanne), but also that it may engraft itself 
on any one of the abdominal organs, and undergo all its developmental 
phases. Whence the fact of the numerous sub-divisions, according to 
the anatomical site of the ovum; Dezeimeris made ten sub-divisions, 
and Hubert de Louvain twelve; Triadou, in his work, makes four sub- 
Fig. 33.-View of the Left Ovary, in Vertical Section.-VW, Veins traversing the lateral, 
median and superior borders of cyst. Pla, Portion of left broad ligament. Pip, Portion of broad 
ligament extending over the foetal sac. T, Portion of the left tube. K, Foetal cyst. 
divisions: ovarian (fig. 34 to 36), abdominal (fig. 43), tubal (fig. 38 to 40), 
and interstitial (fig. 37). Cazeaux admits five varieties: abdominal, 
tubo-abdominal, tubal, tubo-uterine, interstitial. Niigele and Grenser 
accept the four varieties of Triadou, and Schroder agrees with Cazeaux, 
Fig. 34. FG, Graafian follicles.-R, Point of cyst rupture. Zv. Vascular zone of ovary. K, 
Foetal cyst resting on posterior wall. Zv, Remnant of fimbriated extremity of broad ligament. E, 
Remnant of the parovarium. 
but adds a sixth variety, which he calls tubo-ovarian, or tubo- 
abdominal. Depaul, arguing from a practical, rather than from an 352 
A TREATISE ON OBSTETRICS. 
anatomical standpoint, makes only two varieties: tubal and abdominal, 
each one of these admitting sub-division. Thus tubal pregnancy may, 
in a measure, be also interstitial, and abdominal may be either primary 
or secondary. 
In the first variety of abdominal pregnancy, the fecundated ovum, 
instead of entering the fallopian tube attaches itself to the peritoneum, 
and contracts adhesion. In the second, the pregnancy was, at the out- 
set, tubal, and it becomes peritoneal when the tube ruptures in the 
early months, and the ovum lives in its second situation. 
Depaul thus excludes a variety of gestation which was first described 
by Dezeimeris, and where the ovum is found under the peritoneum. 
Fig. 35.-Fcetal Sac Open.-Pp. Peritoneum. Tt, Tube in the wall of the cyst. Lt, Canal of 
the tube. A ch, Amnion and chorion united. Ck, Cavity of the foetal cyst. Pl, Placenta. A, Foetal 
cyst. Fu, Cord. X, Foetus. 
The cases cited, however, by him, and by Loschge, Helie, Baudelocque, 
Decord and Pelvet, Saviard, Bernard Calvo, Leven, Noel, Von Horn, 
Lobstein, Gallard, Fleuriot, Nonat, Hecker, and others, prove its possi- 
bility. In these instances the ovum develops between the layers of the 
broad ligament independently of the ovum and tube. According to 
Cauwenberge, the ovum can only find its way here under two conditions: 
either a Graafian follicle ruptures at the lower border of the ovary, 
which is not covered by peritoneum, and. since this does not tear, the 
very situation of the ovum renders impregnation impossible; or else, 
it engages between the proper covering of the ovary and its peritoneal 
envelope, on the thin and irregular border of a torn follicle, and the 
nature of the obstacles in the way of fecundation of an ovum in this 353 
EXTRA-UTERINE PREGNANCY. 
situation, authorizes us in considering very rare, if not in absolutely 
rejecting, cases of this nature. We would add, further, that recent views 
in regard to the structure of the ovary, proving as they do the absence 
of the membrana propria of the ovary, must modify considerably the 
opinions which have been held in regard to ovarian pregnancy. The 
fecundated ovum must needs develop in the interior of the Graafian 
follicle, and the walls of the cysts must be made up by the thinned-out 
walls of the vesicle, and, more or less, also, of the peritoneal covering. 
Whatever the case, we may well limit ourselves to Depaul's classifica- 
tion-the tubal and the intraperitoneal, for they are, in truth, the 
only ones where diagnosis can be positive. We would add, further, that 
tubal pregnancy, through early rupture, often kills the woman, and the 
diagnosis is only made post-mortem. Nevertheless, we will see that in 
Fig. 36.-Pregnancy in a Left Rudimentary Cornu. (After Heyfelder and Kussmaul.)-A 
Right half of uterus, b, Left half, c, Vagina, e, Right tube, f, Left ovary, h, Rudimentary cornu. 
k, Left round ligament. Mm, Limits of the peritoneum, n, Left tube, o, Right ovary, q, Placen- 
ta. g, Membranes, r, Foetus, k' Right round ligament. 
many instances the diagnosis has been made at the very beginning of the 
pregnancy. 
To the above varieties, Keller adds another form, which he calls extra- 
abdominal. Here the ovum develops in inguinal, and chiefly, crural 
hernias. It is consequently situated not only outside of the uterus, but 
of the true abdominal cavity as well. Here belong the cases of Widerstein, 
Muller, Skrievan, Genth. Finally, we mention the cases of gestation 
in the cornu of a uterus bi-cornus-such as those reported by Stoltz, 
Rokitansky, Kussmaul (fig. 37.) 
Causes of Ectopic Gestation.-Here, also, there is divergency of opinion. 
Of the incontestable causes we note: Everything which may interfere 
Vol. 11-23 354 
A TREATISE ON OBSTETRICS. 
with the migration of the ovum into the tube-such as imperforate, or 
congenitally imperfect tube; its obliteration by old pelvic inflammatory 
remnants, by mucus, by polypi; tumors of the uterus (cases of Stoltz, 
of Bohmer); pelvic tumors compressing the tube; pelvic adhesions, 
occluding the orifice, or preventing free movement; organic affections of 
the uterus (cancer), traumatism, causing the rupture of the uterine wall, 
and allowing the escape of the ovum into the abdominal cavity (cases of 
Tuefferd, Braxton Hicks, etc.) More singular causes still: that of 
Lecluyse, where pregnancy was consecutive to an antecedent Cesarean 
section, the uterine wound not having healed and the ovum escaping; 
that of Koeberl6, where the body of the uterus had been amputated, 
and through a fistulous opening in the cervix the spermatozoa had 
passed, and fecundated the ovum. This occurred two years after the 
operation. Finally, moral causes-violent fright, great exertion dur- 
ing coition, or immediately after. Velpeau cites such instances. Here, 
however, there is simply a coincidence, for impregnation does not occur 
at the time of coition, but some time, possibly days, thereafter. 
Certain cases might also be explained by what is termed, in Germany, 
the external or internal transmigration of the ovum, that is to say, 
where an ovum expelled by the ovary of one side is caught into the tube 
of the other. The cases of Conrad and of Langhans would seem to prove 
this. That this transmigration occurs in case of uterine pregnancy, is 
proved by the cases of Rokitansky, Oldham, Scanzoni, Kussmaul, 
Spaeth, and others. We mention here, also, those rare cases where 
both uterine and extra-uterine pregnancy have existed simultaneously. 
These have been recorded by Goessmann, Cook, Landon, Clark, Behm 
Tuffnel [Browne of Baltimore-Ed.], and others. 
Pathological Anatomy.-All authorities are agreed as to the ovum, 
but when it comes to the site of implantation, what differences! The 
difficulties are, indeed, often very great, and interpretations vary accord- 
ing to the skill and the patience of the observer. When it is necessary 
to recognize the ovary or the tube in the midst of exudation, in the 
presence of the lesions produced on neighboring organs by the foetal sac, 
and to determine precisely the point of implantation, the difficulties are 
often not surmountable; and it suffices to recall the instances cited by 
Velpeau, in order to understand, how what one authority calls an ovarian 
gestation, another will consider tubal, or tubo-ovarian. Nevertheless, 
certain varieties of ectopic gestation., formerly considered inadmissible, 
are to-day accepted without protest-ovarian pregnancy, for example 
(fig. 34-36). 
Now that we know that the ovary is composed of two substances, the 
one, central, spongy, vascular, the bulk of the ovary, made up of muscular 
fibres, vessels, and laminated fibres; the other, superficial, containing 
the Graafian follicles, the ovular layer of Sappey, that is to say, and that EXTRA-UTERINE PREGNANCY. 
355 
we know that the ovary does not possess a tunica albuginea, there can 
be question of but one variety of ovarian pregnancy-where the point of 
insertion of the ovum is in the Graafian follicle itself. But the fecundated 
ovum, in the follicle, may develop in two ways: If the follicle is open, 
the ovum, in the course cf its development, may project outwardly, so 
that the foetal sac lies outside of the ovary, and is extra-peritoneal, whilst 
Fig. 37.-Interstitial Pregnancy.-aa, Body of the uterus, b, Cavity of the uterus, wherein 
lay the decidua, c. Cavity in the uterus, where lay the placenta, ddd, Foetus, with the capillary 
network, c, Vascular portion of the placenta, still united to uterus, ff, Fallopian tubes, g, Ova- 
ries. ii, Cervix, opened anteriorly, kk, Vagina. (Breschet.) 
the point of implantation of the ovum remains in the ovary, and is 
intra-peritoneal; if, on the other hand, the tear in the follicle closes, the 
ovum develops entirely in the ovary. We then witness the same phe- 
nomena as in ovarian cysts, only the growth is far more rapid. The 
ovarian tumor may contract no adhesions, but, furnished with a long 
pedicle it carries with it, in its growth, its peritoneal covering. This 356 
A TREATISE ON OBSTETRICS. 
is not always the case, but, usually, the ovary, containing the foetal sac, 
contracts adhesions to the neighboring organs. The tube of the same 
side, lengthened out, becomes mixed in the sac, in which its terminal 
fibres are lost. We can, therefore, no longer speak of external and in- 
ternal ovarian pregnancy. We deal only with different phases in the 
development of ovarian pregnancy. 
Cauwenberghe has studied the pathological anatomy of ectopic gesta- 
tion carefully, and we will adopt his division. 1. The pathological anat- 
omy in so far as it concerns the maternal organs. 2. That which concerns 
the product of conception. 
1st. Site of Implantation of the Ovum-What are the modifications in 
the maternal organs produced by the implantation of the ovum? When the 
ovum reaches the uterine cavity, it finds the soil prepared for it from 
which it may obtain the elements indispensable to its development. The 
modifications in the uterine mucous membrane produced during menstrua- 
tion, the swelling, the vascularization, are the beginnings of the work 
to be continued by conception, and the ovum, on its arrival in the uterine 
cavity finds the conditions most favorable for its development. Condi- 
tions are very different when the ovum engrafts itself in some other 
portion of the maternal organism. Nature must supply at once the 
elements necessary for development in the unusual site. In a word, the 
ovum must find not only the site, but the conditions necessary for its 
development, conditions which must approach, as far as possible, the 
normal. Therefore, as' soon as the ovum engrafts itself, a more thorough 
vascular system develops at the site. The peritoneum becomes vascular, 
large veins appear in the sub-peritoneal tissue, the arteries, in the neigh- 
borhood, double in size, and thus is formed a species of vascular erectile 
tissue, where the placenta is implanted (Hohl). Whatever the site, the 
ovary, tube, or abdominal cavity, the modifications are the same. All 
observers agree on this point, difference of opinion being only in regard 
to the extent of the changes. 
The genital organs do not watch with indifference the changes occur- 
ring around them, but they, as well, undergo modifications, which are 
evident, even if not clearly explainable. The vaginal walls thicken, and 
soften; the secretion of the vaginal mucous membrane increases, the 
uterus increases little by little in size, rises in the abdominal cavity, its 
walls thicken, its vessels increase in size, and the cervix presents the 
appearances of early pregnancy. Finally, a true decidua is formed, anal- 
ogous to that which is expelled in case of miscarriage. At the same 
time, the breasts alter, and a true secretion of milk takes place. The 
two chief phenomena, however, concern the cervix and the decidua. 
The changes in the cervix deserve special notice, for they may assist 
notably in diagnosis. Although the modifications recall in a measure 
those which exist in case of uterine pregnancy, in the immense majority EXTRA-UTERINE PREGNANCY. 
357 
of cases they are not in harmony with the period of pregnancy. The 
cervix softens, and the external os changes a little, but only in so far as 
usually happens in the first two months of gestation. The lower portion of 
the organ is alone affected. The internal os remains closed, even in multi- 
parae, and the consistency of the cervix is more like that of a non-pregnant 
woman, than of a pregnant. Whilst, further, in normal gestation the 
cervix is usually situated behind, and to the left, owing to the right 
lateral inclination of the uterus, in ectopic gestation the cervix usually 
lies in front and above. This is a point strongly insisted upon by De- 
paul. 
As for the decidua, it is usually found. Where the decidua has not 
been noticed in certain reported cases, this is because it was very thin, 
or else had already then expelled. The modifications which, in normal 
Fig. 38.-Interstitial Pregnancy. (Popp el.}-CO, Cavity of ovum, b, Placenta, v, Chorionic 
villi. LR, Round ligaments. 
gestation, occur in the uterine mucous membrane in order to form the 
decidua, are, according to Cauwenberghe, independent of the ovum. 
These changes begin even before the ovum has reached the organ. Fur- 
ther, this membrane is esssentially transitory. At first voluminous, it 
soon becomes the seat of true atrophy, of active absorption, and this ex- 
plains why at term scarcely any traces often remain. It may be asked, 
then, if, in extra-uterine pregnancy, this useless decidua will not un- 
dergo the same atrophy, this same absorption, which results as soon as 
it is no longer necessary to the development of the ovum, in normal 
cases; and why, further, in similar cases the retrogressive phenomena 358 
A TREATISE ON OBSTETRICS. 
will not occur more rapidly in certain cases than in others, and if we 
may not thus explain the instances where the decidua has been lacking 
-for such instances exist. It is particularly in case of abdominal ges- 
tation that the increase in the size of the body of the uterus has been 
denied, as well as the formation of the decidua; there exist a number 
of authentic observations of this nature on record. (Fleury, Depaul.) 
It is accepted, however, that this decidua exists in extra-uterine preg- 
nancies, but this decidua can only form in the uterus, and those authori- 
ties who have searched in the ovary, and in the tube, and even around 
the ovum for the decidua, could not, of course, find it, for it does not 
exist there. It is through sympathy that the uterus produces the de- 
cidua, and it alone can make it, for it alone possesses a mucous membrane 
from which it can be formed^ And this is so true, that the further from 
Fig. 39.-Tubal Pregnancy.-OD, Right ovary. TD, Right tube. (7. Uterus. H, Hydatid. STr 
Foetal sac. OG. Left ovary. TG, Left tube. CS, Clots. 
the uterus the point of implantation of the ovum, the less is the decidua 
developed; and it is exclusively in case of abdominal gestation that its 
absence has been noted. 
Schroeder, however, claims that, in case of tubal gestation, the mucous 
membrane of the tube swells similarly to that of the uterus, and that a 
normal decidua, frequently also a reflexa, forms there. The appearance 
may be the same, but the structure differs; for the mucous membrane 
of the uterus alone possesses the peculiar glands and special cells which 
play so great a part in the evolution of the decidua, and the mucous 
membrane of the tube, notwithstanding its swelling, can never present 
the histological structure of the uterine decidua. Contrary, therefore, to 
the opinion of Lee, Fleetwood Churchill, Breslau, and others, we cannot 
admit, in tubal pregnancy, the presence of a true decidua in the tube. 359 
EXTRA-UTERINE PREGNANCY. 
and the microscopic appearances, described by Conrad and Langhans, 
seem entirely to prove this. 
2d. Anatomy of the Foetus and its Annexes.-Here there is no difference 
in opinion. The embryo always possesses its two peculiar membranes- 
the chorion and the amnion, at least during its period of development, 
and it can not be otherwise: each is inherent to the very evolution of 
the ovum, each is a direct outgrowth from the ovum; without them the 
ovum can neither exist nor develop. Where difference of opinion begins 
is in regard to the elements which constitute the protecting envelope 
around the product of conception, as it grows in its abnormal site. 
In Ovarian Pregnancy, the ovum develops in the thickness of the 
Graafian follicle. 
In Interstitial Pregnancy, it is the substance of the uterus itself which 
forms the bed of the ovum and its membrane. 
In Tubal Pregnancy, it is the walls of the tube, and the peritoneum. 
Fig. 40.-Pregnancy in Left Tube. (Spiegelberg, after Sommer.) 
In Abdominal Pregnancy, two alternatives offer: the pregnancy is either 
primary or secondary. In the first case, where the ovum escapes from 
the Graafian follicle, instead of entering the tube it falls into the abdom- 
inal cavity, and there engrafts itself at some point, and undergoes de- 
velopment. Dezeimeris is wrong when he denies the existence of a pro- 
tecting cyst. All authorities agree that it exists, and it has been de- 
scribed by Jacquemier, Kiwisch, Gerlach, Hohl and others. This cyst 
may vary according to the variety of pregnancy, and to speak only of 
the sub-peritoneal pelvic variety, which is almost always secondary, the 
cyst is exclusively formed of peritoneum; at times, however, a portion of 
the uterus, deprived of its abdominal serous coat, enters into the formation 
of the sac. 
Usually, the formation of the cyst is, even as the pregnancy, necessarily 
secondary, and the following are the stages: Originally interstitial, or 
tubal, or ovarian, the cyst ruptures, and then either the ovum remains 
in place, the membrane alone projecting through the rupture site, or else 360 
A TREATISE ON OBSTETRICS. 
it falls entire into the abdominal cavity. In both instances rupture is 
accompanied by hemorrhage, which, often fatal, may at times be limit- 
ed, and the woman recover. The exuded blood becomes organized; a 
new membrane is formed which, merging into the true cyst wall, renews 
it. Again, it may be the clot which becomes organized and repairs the 
rent. 
Often finally, during the course of an extra-uterine pregnancy, an 
exudation occurs around the cyst, and this forms a second sac, surround- 
ing the first more or less. The ovum is thus enveloped in two mem- 
branes, and resists the better external influences: the internal cyst may 
alter without danger to the mother, and the foetus, thus protected, de- 
velops the better. 
Finally, in any variety of ectopic gestation, and even uterine, the prod- 
uct of conception may, through change in the gestatory organ, pass 
Fig. 41.-Tubal Pregnancy, with Fibrous Tumors. (After Harley.) 
into the peritoneal cavity, whilst the placenta remains attached to the 
site where the ovum was implanted. Ordinarily the foetus dies, neverthe- 
less there are many recorded instances where it lived. In Walther's case, 
for example, ovarian pregnancy, the foetus developed for four months 
amidst the abdominal viscera, and was found, at the end of gestation, as 
free, and without cyst, as at the time of its escape from the ovary. 
Triadou has recorded a case of Bichet's (ovarian), where microscopic 
examination by Jouon, revealed the following nature of the cyst: Com- 
posed of a cellular layer, with vessels, thicker in the posterior than in the 
anterior wall. Of another layer A of an inch in thickness, composed of 
epithelial cells with very large nuclei. Of a further layer, tV of an inch 
in thickness, composed of connective pigmented tissue. Finally of a 
granular fat layer, in contact with the amnion, and inclosing fat debris, 
and other not recognizable elements. EXTRA-UTERINE PREGNANCY. 
361 
The Placenta.-This differs from that of normal pregnancy, in situa- 
tion, in shape, and in volume. In its situation there is no regularity, 
although, from the researches of Koeberle, it would seem frequently to be 
attached to the anterior wall of the abdominal cavity. In volume and 
in form it differs markedly. Sometimes it is double, and triple the 
size of the ordinary placenta; sometimes it is much thicker; sometimes 
it is spread over a large extent of surface; sometimes it is divided into 
a number of vascular portions, distributed over many of the abdominal 
viscera. The insertion of the cord is usually central, but there is noth- 
ing constant about this. The manner of placental insertion differs 
Fig. 42.-Abdominal Pregnancy. (After Dreesen.)-a, Anus, b, Vagina, c, Bladder, d, Os uteri, 
e, Fundus uteri, f, Broad ligament, g, Left tube, h, Cecum, ii, Intestines, kk, Peritoneal ad- 
hesions. 
scarcely at all from the normal, and the placental villi float in trenches 
filled with blood analogous to the uterine sinuses. In tubal pregnancy, 
according to Kiwisch and Oldham, there exist, at least in the first 
months, ramification of the villi and the maternal blood vessels, very 
much like the disposition of the placental vessels in carnivorae. 
The Foetus.-Up to term, the foetus develops even as in normal preg- 
nancy; but when the foetus has gone beyond term in the abdominal cav- 
ity, it may assume very different appearances. Occasionally it lives 
beyond term, as is attested by the cases of Grossi, Schmidt, Bayle, and 
others, and then it corresponds, in appearance, to the stage of gestation- 362 
A TREATISE ON OBSTETRICS. 
advanced ossification of the skeleton, teeth, etc.; again, it is purely like 
an infant born normally at term. These instances are, however, excep- 
tional. Usually, the foetus dies before term, or at term; and, if the mother 
survives, it undergoes manifold changes. Lempereur has, especially, 
studied these changes. "After having established the fact that, in nor- 
mal pregnancy, the foetus, according to the period at which it dies, un- 
dergoes dissolution, mummification, and maceration, he studies the altera- 
tions which occur in case of prolonged uterine gestation. He admits, 
at the outset, that prolongation of uterine pregnancy is possible, as is 
attested by the observations, in cows, sheep, rabbits, of Sherman, Bout- 
rolle, Huzard, and, in the human species, of Oldham, Cheston, Bompar, 
Penker, Shorland, Harris, Schultz, etc. He shows that, in such cases, 
Fig. 43.-Transformation of Fcetus into a Lithopedion, a. Calcareous capsule. 6, c, A essels 
on the wall of the cyst, d, e,p,g, h, i, Foetal parts. 
Fig. 44-Extra-uterine Pregnancy.-Transformation of the foetal cyst. 
the fcetus may undergo maceration, and putrid decomposition in case there 
is access of air to the uterus, mummification, ossification, and, finally, sap- 
onification. Passing then to ectopic gestation, he shows that the altera- 
tions are similar. Rejecting the dermoid cysts as products of conception, 
he shows that, in the early months, dissolution, mummification, and ma- 
ceration, may take place-in a word, the changes peculiar to intra-uterine 
gestation. The foetus, further, may undergo other changes-such as 
changes into adipocire, or steatose. Through organic adhesions to the 
maternal organs, this foetus lives a parasite at the expense of the mother. 
These adhesions, however, allow only imperfect nutrition, and fatty de- EXTRA-UTERINE PREGNANCY. 
363 
generation sets in." Whence, according to Cauwenberghe, retrograde 
metamorphosis, progressive atrophy, which may result in calcareous de- 
generation or in complete disappearance of the soft parts, and only the 
skeleton remains (fig. 43 and 44). It is understood, then, that the foetus 
may remain for years in the abdominal cavity, without risk to the mother, 
and all.authorities give examples of the lithopedion. The best known is 
that of Leinzell, which was found in 1720 in a woman of 94, who had car- 
ried it for 4G years. In certain exceptional cases, the foetus, although 
dried up, is so wTell preserved that the tissues have their normal structure. 
(Cases of Wagner and of Virchow.) 
It is, especially, in abdominal pregnancy that these transformations 
are noted. 
Symptomatology and Progress.-It is only, as Depaul says, by ac- 
cumulating observations, and carefully studying those cases where 
there has been error in diagnosis, that we can hope to establish the 
differential diagnosis of ectopic gestation, and all authorities agree in 
the statement that, in the early months, this is almost impossible. 
Nevertheless, there are a number of symptoms which are well nigh 
constant. Usually, during the first days following conception, there are 
present the symptoms peculiar to pregnancy-the nausea and vomiting, 
the longings, salivation. Vomiting is slower to appear, and, at times, 
ceases abruptly, without discernible cause. These symptoms are, 
however, insufficient. The menstrual phemonena are of higher value. 
All authorities insist on important modifications in regard to menstrua- 
tion. Suppression, even as in uterine pregnancy, exists, but this sup- 
pression is less constant. Sometimes, the menses persist during the first 
months, and are normal in regard to time and duration, and only 
disappear later; again there is suppression, at the outset, then they 
reappear, only to disappear again. In any event, women at times 
conceive again, and bear to term one or more healthy children, whilst the 
foetus, developed or not, remains in the abdominal cavity. Usually 
bloody, or sero-sanguinolent discharges, mixed with mucus, take the 
place of the menses. Accompanying them are colicky pains, and in the 
discharges it is not uncommon to find pseudo-membranous debris, the 
remnants of the decidua. These discharges reappear when the foetus 
attains term, and when false labor sets in, and Duguet is inclined to 
think that the expulsion of the decidua corresponds to the death of the 
foetus. The case he reports would seem to prove this. But such is not 
always the case, for the decidua may be shed a longer or shorter time 
before labor, and this will explain, in a measure, its absence in those 
cases where it has not been noted. Duguet is further inclined to think 
that these hemorrhages are especially marked in case of tubal pregnancy. 
Another symptom, which certain observers consider pathognomonic, is 
a peculiar pain, very variable, in site, in intensity, in appearance-often 364 
A TREATISE ON OBSTETRICS. 
appearing at the beginning of pregnancy, usually it is only at the end of 
about three months that it is noted. At first dull, a simple sensation of 
weight, of abdominal tension, generalized, it later becomes localized at 
the umbilicus, or in the inguinal or sacral regions, and thence irradiates 
into the thighs and legs. Walther says that, in one of his cases, the 
pain was so intense that the patient only found relief in the knee-chest 
position, and that the least motion caused her to utter awful shrieks. 
Often continuous, except when the abdomen is palpated, when it 
increases in intensity, this pain is subject to exacerbations dependent on 
varying causes. At times the access is accompanied by discharge of 
clots, and decidual debris. The pain is then like that of miscarriage, 
intermittent, irregular, like true uterine colic, which disappears only 
concurrently with profuse hemorrhage. Again, the pain is like that of 
peritonitis, and seems dependent on localized attacks, which are not 
sufficient to cause the death of the woman, but result in the formation 
of .adhesions, and false membranes, which bind the foetal cyst to the 
neighboring organs. Finally, sooner or later, <11686 pains increase in 
intensity, are accompanied by tearing sensations, and symptoms of 
internal hemorrhage: these are the first symptoms of rupture of the foetal 
sac. These last symptoms may appear suddenly, whilst the woman is 
enjoying good health, and, of a sudden, she is at the point of death. 
The pain, further, may diminish, instead of increasing with the 
progress of gestation. Usually it persists until the foetus dies, and then 
ceases; occasionally it is present until the foetus has been expelled or 
extracted. 
When gestation proceeds to term, pains of another character supervene. 
These are those of labor, returning with the intermittency and 
periodicity of true uterine contractions. In appearance a true labor, it 
is in reality a false. It may last two to three days, be followed by 
absolute remittency, and reappear again at variable intervals. Usually 
the death of the foetus coincides with this false labor; but it is not 
always so, and the observed cases, where the foetus has lived several 
months beyond term, justify our assertion. 
Finally, in a number of instances, these pains have lasted even 
longer. In a case recorded by Hohl, they reappeared every four weeks, 
until the return of the menses. In Schmidt's case, they reappeared 
eight times, during the eight years' retention of the foetal sac. Lospikler 
(a six years' case) witnessed their return every year. 
What is the true cause of the pains? Must we, with Dezeimeris. seek 
it in uterine contraction? Does it reside in contractions of the foetal 
cyst? It has been proved that the foetal sac contains numerous muscular 
fibres, and the assertions of Zwanck, of Naegele, of Rapin, of Baudelocque, 
of Hohl, that they have seen the sac contract, cannot be doubted. This 
fact, however, does not exclude the uterus from contracting through EXTRA-UTERINE PREGNANCY. 
365 
sympathy; and although Hohl, by introducing a sound into the uterus, 
during violent pains, found absolutely no contraction of this organ, we 
believe with Cauwenberghe that the increase in size of the uterus, the 
hypertrophy of its muscular tissue, the presence in the cavity of numer- 
ous membranous remnants, and of old and new clots, the expulsion of 
the decidua, the production of even profuse hemorrhage coincidently 
with the pains, which decrease with the emptying of the uterus-that 
these facts prove that the organ plays a part almost equal to that of 
the sac in the production of the pains. 
To the above probable signs, are joined certain which may almost be 
termed absolutely diagnostic. These are furnished by the local exam- 
ination. 
1st. External Examination.-By this means we may determine the 
presence of a tumor in the abdomen, a tumor which, unlike the uterus, 
does not occupy the median line, but lies usually to the right or left, 
and further which, instead of presenting the soft and elastic feel of the 
gravid uterus, is harder, more resisting, and above all painful to pressure. 
Varying in size from that of a nut to that of an orange, this tumor 
tends ever to increase, and soon palpation determines the presence of 
foetal parts, and of active foetal movements, whilst auscultation reveals 
the foetal heart. 
[Be it ever remembered, however, that the gravid uterus, after the 
third month, when it appears above the pelvic brim, reveals to the 
palpating hand those intermittent uterine contractions, which are 
characteristic of the uterus containing an ovum, which are absent 
always when we are dealing with an ectopic gestative cyst, and which 
phenomenon at once, when appreciated, tells us that we are palpating the 
gravid uterus, and nothing else. Of course there may also exist an 
ectopic gestation, for the two forms may coincide; but, we would 
strongly insist, that the presence of intermittent uterine contractions, 
appreciable to the hand of the accoucheur, means uterine pregnancy, 
and their absence negatives uterine pregnancy. In very obscure cases, 
this sign, by its absence, will give us the courage to prove the uterus 
empty by means of the sound.-Ed.] 
Such is not always the course of events. The tumor may suddenly 
disappear, and acute pain, and the signs of internal hemorrhage, followed 
by sudden death, leave us in doubt, except in case of autopsy, of the 
nature of the tumor. 
As the tumor develops, it changes in shape; its outline is less distinct; 
fluctuation is apparent; and we may obtain true abdominal ballotement. 
The cases where diagnosis is relatively easy, are very rare, and then we 
have to depend on other symptoms, still from the side of the abdomen. 
In case of ectopic gestation, the abdomen is more tense. The tumor is 
irregular, not spherical, and, if we are able to palpate carefully, two 366 
A TREATISE ON OBSTETRICS. 
tumors may be distinguished-the one smaller, resistant, elastic, like 
the gravid uterus at two to three months, the other larger, irregular, 
projecting, in which ballotement, or the foetal parts, are readily apparent. 
Palpation, however, is often impossible except under anesthesia, [and in 
view of the safety of ether, in any case at all doubtful, anesthesia should 
be resorted to.-Ed.] 
By means of percussion we learn scarcely anything. As for ausculta- 
tion, we may affirm, if we hear the foetal heart-beat, that we are deal- 
ing with pregnancy. The uterine souffle is often absent in ectopic 
gestation. [Similarly is it often absent, or not heard, in case of uterine 
gestation. A similar souffle has often been detected over uterine 
fibromata and ovarian cysts. The value in diagnosis, therefore, of ab- 
sence of the souffle, is very slight.-Ed.] 
2d. Internal Examination.-Depaul believes that it is by means of the 
touch we will obtain the most positive information. If the uterus 
increases in size, it is never as in normal pregnancy. Its tissue becomes, 
true enough, softer, more boggy, but never in proportion to the age of 
the supposed gestation. The form is not spherical, but flattened, and 
far from sinking into the pelvic cavity in the early weeks, it tends to 
rise to the right or left, or behind the symphysis. According to Depaul 
the lattei' is the usual position. 
The cervix undergoes changes, but these are never as marked as in 
ordinary gestation, and the changes further do not correspond to the 
period of pregnancy. It deviates with the uterus, to the right or left, 
usually behind the symphysis, so as to be, at times, inaccessible to the 
finger. (Depaul.) When the finger can reach it, -we may observe 
softening and patency of the external os, the more readily in cases 
where the woman has previously borne children; but at the end of a 
certain time these changes disappear, especially when the foetus dies, as 
though the uterus underwent retrogressive changes. 
As the gestation progresses the cervix becomes more and more inac- 
cessible, and we simply feel through the vagina, a larger or smaller 
mass, more or less immovable, through which it is sometimes possible 
to perceive more or less resisting or voluminous parts. This tumor, in 
certain cases, may fill the whole pelvis, lying at times behind the uterus, 
at times between it and the bladder 
, B. Rectal Examination.-This gives more precise information in 
regard to the form, the volume, and the position of the uterus, and 
the dimensions of the tumor. 
Such are the signs ordinarily attainable. There are two. in particular, 
on which Depaul lays great stress. The one, is the fact that the foetal 
parts discernible are more superficial than in ordinary pregnancy, in 
certain cases it seems as though they were just under the skin, so that 
the head may be distinguished from the breech; the second is the 367 
EXTRA-UTERINE PREGNANCY. 
peculiar form of the tumor, its transverse diameter is longer than its 
vertical, and the tumor inclines rather to the left than to the right, 
whilst in uterine pregnancy the reverse is generally the case. 
[These signs are also open uto doubt. In uterine pregnancy, the 
walls of the uterus may be so thinned out as to give to the hand the 
sensation of the foetal parts being immediately underneath, and again in 
abdominal pregnancy, of which it is ordinarily question when gestation 
has advanced far enough to allow palpation to be of value, the walls of 
the sac may be so thickened as to interfere with our feeling the foetal 
parts at all. Further, in case of transverse presentations in uterine preg- 
nancy the transverse diameter is increased over the vertical, and if the 
breech of the foetus lies in the left uterine segment, so will the inclination 
of this organ be the reverse of the customary. Indeed, there are 
certain obscure cases of ectopic gestation, those for instance where expe- 
rienced observers have diagnosticated ovarian cyst and normal pregnancy, 
where apparently nothing short of the uterine sound will make the 
differential diagnosis-even anesthesia fails to help us. It is here, we 
believe, that the absence of intermittent uterine contractions will not 
only give us the courage, but justify us in passing the sound. All 
observers are agreed that this rhythmical action of the uterus is peculiar 
to this organ when gravid, and to nothing else. The distended bladder, 
and sub-peritoneal fibroids, have also been said to contract, the former 
by Pajot and Tarnier, the latter by Pinard, but only the veriest tyro 
would mistake either of these conditions for gravidity. These remarks 
are applicable purely to abdominal gestation. In the interstitial form, 
and the tubal, we will, of course, obtain contractions, although possibly 
not rhythmic.-Ed.] 
When the cyst ruptures, the symptoms will suggest the diagnosis, [but 
then diagnosis may be of no use to save the mother.-Ed.] These 
symptoms are: sudden acute pain, syncope, followed shortly by signs 
of internal hemorrhage, and death may soon close the scene. 
If the hemorrhage is less profuse, these signs become less marked, 
and they are replaced by chills, intense, and frequently repeated, and by 
the symptoms of acute peritonitis. Death may here also follow, but not 
so rapidly. 
Cure may, however, follow. If both the foetus and the mother have 
escaped destruction, gestation may go on to term, and then false labor 
set in. This labor may kill the woman. If she resists, she may live a 
greater or less time, carrying the foetal tumor, which, in its turn, 
undergoes changes, which we will refer to shortly. 
Duration.-This is far from being settled for all the varieties. It is 
readily apparent that when the ovum develops in the tube or ovary, and 
more still in the thickness of the uterine tissue, there is a limit to pos- 
sible distention, and pregnancy thus necessarily is interrupted, or con- 368 
A TREATISE ON OBSTETRICS. 
verted into the abdominal variety. In the latter, however, the ovum is 
contained in a large cavity where it may increase freely. Whence, then, 
great differences in the duration of the various varieties. 
Those of least duration are the interstitial. Rarely do they exceed 
the fourth, usually they end at the third month. According to Hecker, 
of 26 cases: 
Pregnancy lasted 4 weeks, . . 1 case. 
" " about 3 months, 2 cases. 
" "3 months, . 12 " 
" " 4 " .3 " 
" " 5 " .1 case. 
In 7 cases, the duration was not noted. 
Next come the tubal pregnancies. If we consider together the 45 
cases mentioned by Hecker, and the 43 by Cauwenberghe, for these 88 
cases the duration: 
4 to 5 weeks in . . . . 3 cases. 
4 to 6 " . . . 17 " 
6 to 7 " . . . . 9 " 
6 to 8 " . . . 13 " 
For 2 months in . . . 4 " 
3 ... 17 " 
4 " ... 11 " 
5 " 4 " 
6 " 2 " 
7 " 2 " 
9 " 6 " 
Total, ... 88 cases. 
Of the 4 cases which reached term, Cauwenberghe considers authentic 
only the two cases of Lamm and Ssobel Schsiboff. To these we must, 
however, add those of Haussner, of Rosshirt, of Saxtorph. 
These cases are all doubted by Stoltz, who contends that the tube, 
distended by the product of conception, must always rupture in the 
early months of pregnancy. Neither can he grant the so-called second- 
ary gestations, where- the ovum becoming free through rupture of the 
tube, continues to develop in the abdominal cavity and the sub-peritoneal 
cellular tissue. 
Ovarian pregnancies last a little longer. The majority extend beyond 
the third month, but those passing as far as the seventh, eighth, and 
ninth month, are nearly as rare as the tubal beyond the fifth month. 
Thus Cauwenberghe in 39 cases found: 
From 3 to 8 weeks, . 5 From 5 months, . . 3 
2 months, 4 6 " . . 5 
3 " . . 8 7 " . . 3 
4 " . . 7 9 " . . 4 EXTRA-UTERINE PREGNANCY. 
369 
The variety in which duration is the longest is the abdominal. Here, 
however, a distinction must be made. Shall we consider as pregnancy, 
those cases only where the foetus continues to live, or should we include 
those cases where, after death, the foetus has remained years in the 
abdomen of the mother? We contend for the latter, because as long as 
the foetus is in the abdomen, it is liable to changes which may com- 
promise the mother's life, or call for surgical aid. We cite below the 
table which De Smedt has compiled. It concerns 185 cases. 
Duration was 
15 days, . . 1 case. For 20 years . 2 cases. 
3 weeks, 1 " 22 " .1 case. 
1 to 2 months, . 18 cases. 25 " . 1 " 
1^ to 2£ months, . 4 " 26 " .3 cases. 
3 months, . . 5 " 28 " . 3 " 
3 to 5 months, . 22 " 30 " . 6 " 
6 to 8 " .15 " 33 " . 3 " 
9 " .18 " 35 " .1 case. 
10 mos. to 1 year, . 6 " 39 " . 1 ." 
1 to 2 years, . 24 " 40 " .2 cases. 
2 to 3 " .10 " 46 " 4 " 
4 to 10 " . 23 " 47 " .2 " 
For 11 years, . 1 case. 50 " . 2 " 
15 " . 4 cases. 54 'l . lease. 
16 " .2 " 
Indeed the duration of this variety of gestation, once the foetus has 
passed term, and the woman has resisted the effects of the false labor 
■wherein the foetus was killed, is purely subordinate to the changes the 
foetus undergoes, to their nature, their progress, and the ability of the 
female organism to resist them. In this respect nothing is more varia- 
ble, for traumatic causes may at any time join hands with the foetal 
changes, hasten their progress, and thus determine spontaneous expul- 
sion, or call for surgical interference, at any unexpected moment. 
Termination.-Although, in the majority of instances, extra-uterine 
gestation terminates with the death of the foetus or immediately after, 
yet often the woman is able to survive the grave dangers surrounding 
her at this period. She may rally, keeping her babe in the depths of 
her abdominal cavity, and enjoy relative health until her death, which 
may be due to some action of this foreign body, or else to causes aside 
from it. We may, therefore, from the present standpoint, divide ectopic 
gestation into two categories. Where the pregnancy ends during the course 
of gestation, or at the term of complete foetal development, before or 
immediately after its death, instances of what Cauwenberghe has called 
recent pregnancies; and where the pregnancy ends only after a variable 
interval, after a longer or shorter stay of the foetus, which has become 
Vol. n.-24 370 
A TREATISE ON OBSTETRICS. 
a foreign body, in the body of the mother, instances of ancient pregnan- 
cies, according to the same authority. 
De Schmedt prefers the following divisions: 1. The cyst ruptures at 
a variable period of pregnancy, and this rupture entails hemorrhage fatal 
to foetus and mother. 2. The foetus continues to develop and is subject 
to the modifications which we have already considered. 3. The foetus 
determines in the neighboring organs a more or less acute inflammatory 
process, and is eliminated through various channels. This division only 
differs from the former in that it makes a special class of the cases where 
the foetus undergoes retrograde changes. Now it is precisely these 
changes which, according to their nature, determine complications, or 
are not perceived. 
We will follow the first classification. 
1st. Recent Pregnancies.-A. Rupttire of the Cyst.-This rupture, 
which is the rule in certain varieties of ectopic gestation, may not occur 
at all in others; and although extremely grave, it is not always fatal, 
since of 232 cases, Cauwenberghe only found 71 where the women died. 
This rupture is usually sudden, and occurs the earlier in gestation where 
the sac is interstitial, tubal, or ovarian. In abdominal gestation, it rare- 
ly happens before term, at the time of the false labor. The consequences 
are usually fatal to mother and to child, although not always so, as 
witness the case of Schbller, Mayer, Wegscheider, Campbell, Virchow, 
and others. 
Accompanied by hemorrhage, which Bernutz and Goupil say proceeds 
from the dilated ovarian veins, from the tube, from the ovary, from the 
cyst, it determines, at times, such shock that this alone may cause death. 
Usually, however, it is the profuseness of the hemorrhage, and the com- 
plications, which induce the fatal end. Again, the organism is not so 
deeply affected, and the pregnancy continues, the foetus as well having 
escaped destruction. Further still, it causes the death of the foetus, and, 
according as this remains in the sac, or escapes into the peritoneal cav- 
ity, we may witness new complications. The gestation, in either event, 
becomes ancient, through the formation of a new sac, and this we con- 
sider further on. 
B. Without Rupture of the Cyst.-When this does not occur, gestation 
may end in three ways: 
1st. False labor sets in, usually at term, it ceases shortly, and the 
woman, whether the child is alive or not, recovers relative health; 2. 
The organic troubles which accompany this abnormal pregnancy, instead 
of diminishing, increase, and the woman, worn out, dies of marasmus: 
3d. The presence of the cyst amongst the abdominal viscera, sets up 
chronic peritonitis, and the woman dies from inability to withstand 
these repeated and prolonged shocks. 
If we examine the reported instances of each variety separately, we EXTRA-UTERINE PREGNANCY. 
371 
find that, for the interstitial variety, of the 26 cases of Hecker, all ter- 
minated fatally from rupture of the cyst. For the tubal variety, of 46 
cases, 28 died from rupture, 1 from rupture of a vein, 13 passed into the 
category of old pregnancies, 2 ended in cure, 2 through expulsion of 
the foetus through the uterus. 
For the abdominal variety, of 128 cases we find: 
Transferred into ancient pregnancy, .... 85 
Abdominal section, and one case by rectal section, . 11 
Elytrotomy, 1 case through rupture of the vagina, . 6 
Rupture of cyst, ....... 7 
Separation of placenta, fatal hemorrhage, ... 1 
Death at term, ........ 5 
Peritonitis and cyst rupture, ..... 3 
Marasmus, a little before term, ..... 3 
Peritonitis consecutive to rupture, .... 2 
Acute peritonitis, 1 
Chronic " ........ 1 
Metrorrhagia at term, ....... 1 
Osteomalacia, . 1 
Ascites, ......... 1 
Of the ovarian cases: Of 44, 19 died from rupture of the cyst; 17 were 
transformed into the ancient pregnancy category; 2 died of peritonitis 
without cyst rupture; 1 case of rupture of cyst, consecutive abdominal 
pregnancy, fatal chronic peritonitis; 1 case of retention of urine, death; 
1 of fatal metrorrhagia; 1 case transformed into abdominal pregnancy, 
and went to term; 1 case, gastrotomy, success for mother and child ; 1 
case, hanging of the mother during pregnancy. 
Referring back to the abdominal variety, the 85 cases, transformed into 
ancient gestation, are decomposed as follows: 
In 22, mummification, etc., and cure. 
In 3, death, hectic fever, no cyst rupture. 
In 3, ascites, death, foetus dead. 
In 57, elimination by vagina, the abdominal walls, the rectum, the 
the bladder, and 33 recovered. 
Total number of recoveries-55 cases. 
2. Ancient Pregnancies.-These are characterized by the presence of 
a dead foetus in the midst of the abdominal organs, surrounded by a cyst 
more or less isolated from the viscera, or forming adhesions to them. 
Mattei has collected 100 cases, and he thus classifies them according to 
termination: 
By mummification, 12 cases. 
Without external opening, . . . . . 2 " 
Elimination through abdominal walls, . . . 38 " 
" " vagina, ... 7 " 
" " bladder, . . . 8 " 
" " rectum, ... 30 " 372 
A TREATISE ON OBSTETRICS. 
This table accords with that of Cauwenberghe, who, for 180 cases,, 
resumes as follows : 
A. Women dying from cause not depending on the preg- 
nancy, after having carried the foetal debris for a 
number of years. ...... 42 
B. Women dying from complications due to the presence 
of the cyst, without external opening : 
1st. From inflammation, . . . . .9 
2d. " septic fever, . . . . .1 
3d. Opening into peritoneum, .... 2 
4th. Hectic, and marasmus, .... 4 
5th. Ascites, . . . . . . .5 
21 
C. Opening of the cyst through anterior abdominal walls : 
1st. Spontaneous opening, cure, . . . .23 
" " death, .... 1 
2d. Surgical extraction, cure, . . . .14 
" " death, .... 3 
3d. Gastrotomy, cure, ..... 8 
" death ..... 4 
53 
D. Opening of cyst into bladder, extraction of bones: 
Cure, 7 
Death, ...... 3 
10 
E. Foetus eliminated by vagina : 
1st. Spontaneous expulsion, cure, . • . . 1 , 
" " death, . . . 2 
2d. Operative extraction, cure, . . . 3 
6 
F. Opening into intestines, elimination of foetus in whole 
or in part, with and without interference : 
1st. Cure, ...... 18 
2d. Death, 30 
48 
Total, . . 180 cases 
The above table gives, in general, the manner of issue of ectopic 
gestations, but in a number of individual instances, death occurred 
under peculiar circumstances: Richets' case, where a woman on the 
road to recovery, was seized with epidemic puerperal fever; Depaul's 
case, which died of cholera; Depaul's second case, where the uterine 
sound pierced the uterus, and resulted in fatal peritonitis; two other 
cases of Depaul and Boinet, where the women died of hemorrhage 
resulting from separation of the placenta; a case of Guichard d'Angers, 
where the sound caused peritonitis; Spiegelberg's case, where both 
mother and foetus died of eclampsia; Wurm's case, where the woman 
died with symptoms of intestinal obstruction. 
Diagnosis.-The diagnosis is divisible into two categories: 1st. We 
must establish the fact that we are dealing with pregnancy, and that it 
is ectopic. 2d. Establish the variety of ectopic gestation present. 
It would seem as though, from an enumeration of the symptoms, the 
diagnosis ought to be easy, nevertheless ectopic gestation has often been EXTRA-UTERINE PREGNANCY. 
373 
overlooked and only recognized post-mortem. In the absence of the 
foetal heart and the active movements of the foetus, the diagnosis of 
pregnancy itself is frequently difficult, the greater the difficulty when 
the pregnancy is ectopic. We agree with Depaul, however, that we 
will usually reach the diagnosis, by remembering the signs furnished by 
palpation and the touch. But what number of errors committed since 
the case of Huguier (uterine pregnancy mistaken for ectopic), to that of 
Duboue, where first pregnancy in the uterus, then ectopic gestation, then 
the use of the sound, and again uterine pregnancy, were diagnosticated! 
What the result in a case like Depaul's, where hydramion complicated? 
What, where both intra- and extra-uterine pregnancy concomitantly 
exist? What, in case of ovarian cyst, and ectopic gestation (Gueniot)? 
At the sixth month, in the presence of the foetal heart, and the foetal 
movements, felt often just under the surface, in the presence, further 
of the form, volume, and situation of the tumor, the diagnosis may be 
easy, but later the difficulties n|ay increase. If the case is first seen 
after foetal death, the signs of pregnancy are obscure. The uterus has 
retrograded, and the tumor has changed greatly. The absence of history, 
further still, increases the difficulty, and it is only by careful elimination 
that we may form an opinion as to the nature of the tumor. 
[The errors in diagnosis committed by various authorities are here 
cited. They might be increased by a long list taken from the clinical 
records of this country. Sufficient the statement that the following 
amongst other mistakes have been made: uterine pregnancy (and the 
reverse has occurred); retroversion of the gravid uterus; pelvic hemato- 
cele; multilocular cyst of the ovary; anteversion of the uterus; fibro- 
cystic tumor of the uterus, etc.-Ed.] 
As for the differential diagnosis between the varieties of ectopic 
gestation, there is only question during the early months, for later it is 
rare to meet with anything but abdominal pregnancy. 
In Tubal Pregnancy, the pain is deep, dull, fixed; the tumor is mov- 
able, the uterus is to the side opposed to the tumor and adhering to it. 
[On the contrary, in many of the reported cases of tubal pregnancy in 
this country, the tube has been detected behind the uterus, and con- 
sequently not so very movable.-Ed.] According to Heim, it is in this 
variety that the pain is most characteristic. 
In Ovarian Pregnancy, pain is still a factor, but the tumor is further 
from the uterus and consequently more movable. 
In Abdominal Pregnancy, the uterus is less developed, it may be more 
readily isolated from the tumor. The foetal movements are more easily 
felt. At times the foetal parts are felt under the skin, as it were. The 
tumor is larger, and has attained greater development, [intermittent 
rhythmic contractions cannot be evoked.-Ed.] 
Such are the diagnostic signs as stated by the authorities. They are 374 
A TREATISE ON OBSTETRICS. 
very vague, and if it is possible, at times, to diagnosticate ectopic 
gestation in tlie early months, it is usually not possible to state its 
variety. 
[Nevertheless, if, in the early months, a woman has missed one period, 
has had irregular discharges preceded by cramp-like pain in the abdomen, 
if, further, certain of the rational signs (nausea, etc.,) of pregnancy are 
complained of, and on careful examination an oval-shaped tumor is 
found posterior or to one side of the uterus, we may always think with 
a great degree of certainty of tubal pregnancy. Examination by the 
rectum under anesthesia will assist our diagnosis, and it is peculiarly 
necessary to reach a diagnosis of this form of gestation early, for, as we 
point out further on, we possess a certain means of arresting the gesta- 
tion before the mother's life is imperiled by rupture, and this means 
further is of absolutely no danger to her. In this country the weight of 
opinion certainly is that tubal pregnancy may ordinarily be diagnosti- 
cated early, and of late years the number of instances where this has 
been done have greatly increased.-Ed.] 
Prognosis.-This is always ominous, both to the child and the mother, 
either in the present, or in the future. 
Treatment.-Authorities are in agreement as to there being two 
divisions of the cases in regard to treatment: 1st. The woman is in the 
fourth to the fifth month of pregnancy; 2d. she has passed this period, 
she is near term, or has passed it. 
Since, in the early months, it is nearly impossible to say with what 
variety we are dealing, we are authorized, says Keller, to consider it 
tubal, since this is the one which most endangers the mother's life. 
Since now, tubal pregnancy nearly always results in the death of the 
mother, we must stop the gestation, as soon as it is recognized. We must, 
then, determine the easiest and safest method of accomplishing this. 
Van Bitgen has advised the employment of meagre diet, and to weaken 
the mother further by administering daily purgative salines and ergot. 
But such treatment whilst likely to diminish the size of the foetus, will 
not kill it, and therefore does not produce the desired result. As for 
ergot its action is nil. More radical methods were then thought of, 
and Heim, and Osiander, even counseled extirpation by the knife. But 
this means has never been put into practice before rupture. [After 
rupture it has a number of times, by Lawson Tait, in particular, and with 
success. In less than three years he has performed laparotomy in case of 
ruptured tubal gestation, in 21 cases, with success in 20. He advocates, 
also, operating in these cases, even as he would for distention of the 
tube by serum, pus, or blood. He does not trouble himself about 
exact diagnosis, indeed he has lately stated his belief that it was 
impossible to reach an early diagnosis of tubal pregnancy, and herein 
he is unquestionably in error. He would operate because the exami- EXTRA-UTERINE PREGNANCY. 
375 
nation reveals a tumor, probably tubal, and because the symptoms 
complained of can be traced to the tubal enlargement. His principle 
is correct, for it is as easy a matter to remove a tube distended by 
a product of conception, as one distended by pus or blood. But, 
as we will see, his advice is not justifiable, except in the presence 
of rupture, because we possess a less radical, less dangerous, and just as 
effective means of disposing of tubal pregnancy.-Ed.] There are other 
methods which seem less dangerous, although just as effective. For 
instance, puncture of the foetal cyst, as proposed by Scanzoni. Martin 
resorted to it through the abdominal walls (abd. preg. of months), the 
patient died. Braxton-Hicks, and Simpson punctured through the va- 
gina. The patients also died. Greenlagh was more successful in a case 
at two months. Depaul asks, if in these instances it was really ectopic 
gestation, for we have seen how difficult the diagnosis is, if not impossi- 
ble, at such an early stage of pregnancy. 
Joulin proposed to kill the foetus by the injection into the sac, of mor- 
phia, or strychnia, in sufficient quantity to kill the foetus, but not sufficient 
to be toxic to the mother. Friedreich resorted to this method a year 
after with perfect success. Koeberle also obtained a good result. But 
in Fournier's case, as recorded by Depaul, the injection caused inflam- 
matory symptoms in the mother, requiring laparotomy, and ending in 
the maternal death. 
Paul Dubois recommended electricity, and Bachetti thus endeavored 
to kill the foetus, and the mother recovered. Braxton-Hicks failed by 
this method: Duchenne, of Boulogne, rejected it. 
Finally, Dr. Malin proposed compression of the tumor between sand- 
bags, but this has never been tried. 
[The method, above all others, applicable to tubal pregnancy, is elec- 
tricity. This may fairly be called an American method, because, up to 
the present, with but one or two exceptions, it has been practised only 
here, but with such uniformly happy results as to lead us to reject every 
other proposed means of treating tubal pregnancy when diagnosticated 
before rupture. 
Puncture of the sac has been rejected by American authorities because 
of its nearly uniformly fatal results. Braxton-Hicks, Goodell, Simpson, 
E. Martin, Gallard, Depaul, Wetzel, and others, have placed on record 
cases where, in consequence of the method,' the mother died. The 
method, further, if not fatal to the mother, is by no means certain as 
regards death of the child. 
Injection of the sac has been successful in a number of instances, but, 
as proved by Friedreich's second case, the method is tedious, as well as 
dangerous. Lately another case has been recorded by Rennert, making 
the fourth treated by this method, where the mother recovered, the 376 
A TREATISE ON OBSTETRICS. 
foetus, in the fifth month, was killed, and where, notwithstanding most 
careful antiseptic precautions the mother narrowly escaped death. 
Extirpation by the vagina, attempted once successfully by Thomas, has 
been also attempted by the late Albert H. Smith, who opened with the 
cautery, the patient dying of gangrene of the peritoneum; by Battey, of 
Georgia, with the bistoury, the patient dying of exhaustion. This meth- 
od, therefore, may fairly be called dangerous, and be rejected. 
Laparotomy is strongly advocated, as we have stated above, by Lawson 
Tait, but prior to rupture of the tube, no American authority will herein 
agree with him. To mention only one. and him on account of his ex- 
ceptionally large experience with these cases, Thomas, of New York, says, 
"the growing triumphs of abdominal surgery are apt to lead to the con- 
viction that laparotomy should, as a rule, be the procedure of election 
in these cases. From this view I unqualifiedly dissent," for the reason 
that he, in conjunction with Lusk, Mund6, Goodell, Garrigues, Rock- 
well, and a host of other distinguished gentlemen, know of a safer and 
just as effective method, which we how consider as the method par ex- 
cellence in the treatment of tubal pregnancy, prior to the fourth, per- 
haps the fifth month of gestation-electricity. 
Either the galvanic or Faradic current, may be used. The current 
from a twenty-cell galvanic, or from a pocket Gaiffe Faradic, is of 
sufficient strength. One electrode is placed over the abdomen, and 
the other in contact with the tumor per vaginam, or per rectum. In 
case of the galvanic current, it should be rapidly interrupted. This 
current should never be too strong, else, as in the case recorded by 
Munde, shock may result. Electricity should be used every other day 
until the tumor has markedly diminished in size. The death of the 
foetus is known by the cessation of the growth of the tumor, and of 
whatever rational, or physical signs of pregnancy may be present. This 
method, when compared with all the others, is seen to be absolutely free 
from danger: it has proved successful in every case where it has been 
tried. Thomas himself has had over six-eight?-and all the cases 
included amount nearly to forty. Mundo, in the early part of this year, 
gives the figures as about thirty-five. A further advantage of this 
method is that, in case of an error in diagnosis, it can do no possible 
harm. The method is applicable to every form of ectopic gestation 
prior to the middle or end of the fourth month, and prior to rupture of 
the cyst. It has been claimed against the method that it is likely to cause 
rupture of the cyst. Our best answer to this objection is that rupture 
has never been produced. 
It is in place to mention here the fact that in case of interstitial preg- 
nancy, the effect of the electricity may be to convert this form of ectopic 
gestation into uterine, by driving the foetus from its sac into the uter- 
us. Such instances have been reported by Mund6 and others, and Gar- 377 
EXTRA-UTERINE PREGNANC Y. 
rigues lias recently recorded a case where the foetus went to term in the 
uterus, after having been expelled from its interstitial sac. 
Up to the present, the use of electricity in early ectopic gestation 
has been almost entirely limited to the United States. In the old world, 
men's minds are slow to receive methods practiced in this new world. 
It is safe to predict, however, that electricity will yet become the only 
method of treatment of ectopic gestation prior to rupture of the cyst, 
and that through this means the dreadful mortality from gestation of this 
nature will be reduced by fully three-quarters.-Ed.] 
The means which we have outlined are rational, but the difficulties 
in application are great, and the greatest of all is to reach certain diag- 
nosis in the early months. 
This diagnosis, we have seen, is reached often only at rupture of the cyst, 
and when the symptoms of internal hemorrhage are marked. What 
must then be the course of action? Must we, as Depaul counsels, limit 
our efforts to fighti ng the symptoms of hemorrhage, and of supervening 
inflammation? or, as Keller counsels, resort to gastrotomy, and extract 
the sac and foetus? Stoltz admits the justifiability of extirpation only 
when the tumor is movable; when the sac is adherent to the peritoneum, 
to the intestines, the bladder, the uterus, etc., it would be folly to touch it. 
Depaul, in view of the fact that symptoms of internal hemorrhage, 
and of peritonitis, may occur aside from ectopic gestation, and that we 
have no means of knowing the exact cause, is opposed to all surgical 
measures. Keller, on the other hand, backed up by the weight of 
authority of Velpeau, Kiwiscb, Duparcque, and Keoberle, favors opera- 
tion. We must, he says, check the hemorrhage, remove the cause, 
cleanse the peritoneal cavity. 
Cauwenberghe agrees with Depaul, and so do we. Practise, indeed, 
one of the gravest of all operations, at the time when the woman is in 
deep shock' The time required to open the abdomen, to search for the 
source of the hemorrhage, to apply the ligatures, to cleanse the peri- 
toneum, might better be given to compression of the aorta, and the 
dangers to which the woman is exposed during the operation, in fact 
and in consequence, are greater than those for which it is attempted, 
since numerous cases prove that the woman may rally from the symp- 
toms, and the infant continue to live in the new locality where rupture 
places it. 
[Although rupture does not always mean the death of the mother, it 
may, as reported cases prove. The surgery of to-day is tending' to the 
belief that, in the presence of symptoms of internal abdominal hemor- 
rhage, immediate laparotomy is not only justifiable, but the proper duty 
of the attendant as well. It is an emergency, above all others, requiring 
nerve, but it is one from which we may no longer shrink. Over twenty 
years ago, an American, Stephen Rogers, advocated immediate laparot- 378 
A TREATISE ON OBSTETRICS. 
omy in case of tubal rupture; Veit, of Berlin, performed it; Thomas, 
of New York, would have done so, a few years past, had he not been 
overruled; Briddon, of New York, in 1883, performed it, the patient 
rallied for forty-seven hours, and then died of shock-in this case, how- 
ever, laparotomy was not resorted to on the first symptoms of rupture; 
Tait, of Bermingham, has repeatedly operated, with almost uniform 
success. Other instances might be mentioned,* but our point here is 
simply to show that laparotomy is justifiable, and likely to save the 
mother if performed in time. We have no desire to dogmatize; we 
simply aim at pointing out the drift of surgical opinion. The operation 
itself, whether the sac be adherent or not, is only a little more difficult than 
extirpation of the adherent pyosalpinx, or diseased ovaries, on account 
of the hemorrhage, the amount of blood in the abdominal cavity. A 
specimen recently presented by Munde to the New York Obstetrical 
Society proved conclusively that, however easy the removal of the cyst 
and foetus might be, the checking of hemorrhage is another matter. In 
the specimen referred to there existed a rent in the posterior wall of the 
uterus, where the tube had been adherent. This rent was in part the 
source of the hemorrhage, and had an operation been attempted it could 
only have been successfully ended by hysterectomy. It is well to 
remember, therefore, that this latter operation may be called for.-Ed.] 
After the fourth to the fifth month the conditions are no longer the 
same. 
The diagnosis may be assured, and we are dealing, nearly always, with 
the abdominal variety. It has been proved that, m these cases, the 
foetus may go to term, and live. Although the physician ought to 
succor the mother, his duty as well is, as far as possible, to save the 
child. Gastrotomy best subserves these two indications. When should 
it be performed? 
Whilst Zang and Velpeau have proposed to extract the foetus as soon 
as it is viable, in order to avoid the complications which may occur 
between seven and nine months, Depaul favors a little longer waiting, 
in the interests of the child. But he would not wait "till the ninth 
month. Although certain women have gone to term, and passed it, 
before the phenomena due to foetal death have manifested themselves, 
I should fear whilst waiting for nature's danger signal, to lose altogether 
the advantages accruing from hastier action. We need simply to be in 
no doubt as to the infant's viability. This, for ectopic gestation, must 
be placed at the end of the eighth or the beginning of the ninth month, 
for the foetus does not develop as quickly as in uterine gestation. I 
* As these pages are passing through the press, we are able to record the first successful primary 
laparotomy in case of ruptured tubal cyst ever performed in this country. The operator was 
Johnstone of Kentucky, and the case is recorded in the New York Med. Rec. February 26, 1887.-Ed, 379 
EXTRA-UTERINE PREGNANCY. 
would then only interfere at this period, except where labor sets in earlier, 
and at a stage when I might count still on the viability of the infant." 
Keller favors waiting for the pains. Other authorities do not accept 
this opinion; Sabatier, Siebold, Gerdy, amongst others, nearly absolutely 
reject it. 
[In this country, Lusk probably states the prevalent opinion. "If we 
accept Parry's statement as approximately correct-that in 499 cases of 
extra-uterine pregnancy, including 174 of ruptured cyst, the mortality 
was 67.2. per cent.-it is evident that much remains to be done in the 
way of perfecting the primary operation before its admissibility, except 
under desperate conditions, can be recognized. In ten cases reported by 
Litzmann, only four children survived the third day." Thomas says, 
"If there is a living child in the abdomen, remove it at the end of the 
ninth month. The life of the child should be saved at the expense of 
increased risk to the mother."-Ed.] 
The capital point, however, is not to touch the placenta. This must 
be left to be eliminated, when the maternal blood vessels have become 
obliterated. The chief dangers after gastrotomy at term, are septicemia, 
secondary hemorrhage, and peritonitis. 
The following cases we borrow from Keller: 1st. Schreger, 1836, 
pregnancy at term, mother and child saved. 2d. Heim, child saved, 
mother died. 3. Mattfeld, child saved, mother died of hemorrhage 
and peritonitis. 4th. Dr. N., child living, mother died. 5th. Lecluyse, 
mother died of peritonitis, child a little after. 6th. Sale, uterine and 
extra-uterine pregnancy, children living, mother dead. 7th. Muller, 
mother and child living. 8th, Bingen, and 9th, Gardien, mothers and 
children living. 
Kellei' cites other cases where gastrotomy might have been performed 
at term, since the child did not die till after. He concludes from his 
observations: Often, in abdominal gestation, the condition of the 
mother, at term, is very good. 2d. Expectation is far from being always 
favorable to the mother, and often complications ensue soon after 
foetal death. He therefore favors gastrotomy. 
In certain special cases it has been proposed to substitute vaginotomy 
for gastrotomy. Of three cases of the kind, in the first the mother died 
in a few days of acute peritonitis, in the second, a living child, although 
not at term, was extracted, in the third, the success was complete for 
mother and child. 
What should be our course of action, if we only see the woman after 
foetal death? Depaul counsels expectancy. If the pregnancy has reached 
term, or nearly, he would only interfere in case of symptoms showing 
that the foreign body was not being tolerated. In case complications 
pointing to inflammation, or cyst decomposition, occur, he would inter- 
fere at once, since the success of the operation depends on the health, 380 
A TREATISE ON OBSTETRICS. 
and the condition of the woman. When term has been passed, and the 
foetus is dead, we need only think of the mother. Now the formation 
of a lithopedion is rare, and sooner or later, nature attempts the elimina- 
tion of the foreign body. The cyst inflames, and the gravest compli- 
cations may ensue. The cyst may open through the abdominal walls, 
rectum, vagina, bladder, even the perineum, as two cases of Pigeolet 
prove. It is evident, to what dangers the woman is exposed during 
this work of elimination: peritonitis, hemorrhage, sepsis, marasmus. 
Therefore gastrotomy is indicated. Conditions differ according to 
whether adhesions are present, or the cyst is free. Where the latter is 
the case, it has been proposed to cause the formation of adhesions by 
practising gastrotomy by means of caustics instead of the bistoury. 
We append the operations practiced by bistoury and caustic, in so far 
as we have been able to collect them: 
Gastrotomy by the Knife. 
Keller, . 13 recoveries. Keller, . 5 deaths. 
Jessop, . 1 recovery. Depaul, . 2 " 
Ross Jordan, 1 " Tarnier, . 1 death. 
Lawson Tait, 1 " Meadows, . 1 " 
Scott, . 1 " 
Total, 16 recoveries. Haberly, . 1 " 
Tait, . 1 " 
Boinet, . 1 " 
Total, 13 deaths. 
Gastrotomy by Caustics. 
Rousseau, . 1 recovery. Depaul, . 1 death. 
Beauvoisin, . 1 " 
Duboue, . 1 " 
Total, 3 recoveries. 
I 
[Meadows, of London, lias had a successful case. Thomas three suc- 
cessful, where gastrotomy was performed by the knife. 
It is gastrotomy then, and not vaginotomy which should be resorted to, 
except in those rare instances where the foetal sac bulges in the vagina. 
All authorities are agreed on this point. Tait, Freund, and Thomas, 
and others. Further the same point is proved by Parry's, statistics, and 
also by those of Deschamps, which are the most recent we have. The 
following table, compiled by him, is of interest, as showing the issue in 
59 cases which went beyond term, out of 114, reported between 1875 
and 1880. EXTRA-UTERINE pregnancy. 
381 
In 11 cases formation of lithopedion or encystment. 
In 19 " opening into rectum with 8 deaths. 
In 3 " " " vagina " 1 death. 
In 1 case " " uterus " 1 " 
In 5 cases " at umbilicus " 0 " 
In 18 " secondary laparotomy " 4 deaths. 
To quote then a statement made by us, a year ago, when reporting 
a case of abdominal gestation : "When nature establishes an outlet in 
the abdominal wall, the patient is more likely to recover, than when 
she establishes an outlet elsewhere; and thus she endeavors to teach us 
the point at which incision should by preference be made." 
The mortality from secondary laparotomy had, in 1880, been lowered 
to 22.3 per cent. When Parry wrote it was 38.8 percent. We have 
a right to expect better results in the future, especially when we find 
Bandl and Lusk advocating the secondary operation, as soon as the 
maternal blood vessels have had a chance to shrivel, instead of waiting, 
as has been the custom, until the woman is in the grasp of sepsis, or 
of peritonitis. Indeed, with electricity for the early months, and timely 
laparotomy in the later, ectopic gestation bids fair to be robbed of its 
terrors and murderous results.-Ed.] 
Gastrotomy, then, in ectopic gestation, should receive the careful con- 
sideration of observers. The ever-increasing betterment of the results 
after ovariotomy, lead us to hope for the same aftei' gastrotomy. Every 
observer should publish his cases: thus alone may we-be enabled to reach 
an effective method of treatment.