A Report of Two Years’ Work at the 
Preston Retreat. 
RY ' 
Richard C. Norjus, A. M., M. D., 
Physician in charge, Preston Retreat, Philadel- 
phia, etc. 
REPRINTED FROM THE 
American Gynaecological and Obstetrical Journal 
for February, 1896. [Reprinted from the American Gynecological and Obstetrical Journal 
for February, 1896.] 
A REPORT OF TWO YEARS’ WORK AT THE PRESTON 
RETREAT* 
By Richard C. Norris, A. M., M. D., 
Physician in charge, Preston Retreat, Philadelphia, etc. 
The report herewith presented includes five hundred consecutive 
deliveries at the Preston Retreat since January i, 1894—a series of 
cases of which nineteen were delivered during the last month of my 
predecessor’s incumbency. 
There has been one death from chronic Bright’s disease, which 
makes the mortality for this period one fifth of one per cent. The 
last death that occurred in the Retreat under Dr. Goodell’s incum- 
bency was a death from eclampsia, on March 21, 1885 (Case No. 2,166). 
Two deaths occurred during Dr. Price’s term : one on the third day 
after labor from eclampsia and apoplexy in a chronic kidney case, 
March 31, 1889 (Case No. 2,745), and one from mania and convul- 
sions on the fourth day after labor (September 15, 1893, Case No. 
3,480). These, with the death during my term of service up to the 
present time, give a total of 1,865 consecutive cases with three deaths, 
or a mortality of one sixth of one per cent. 
After briefly outlining the routine management of the patients 
awaiting delivery and of those delivered at the Retreat, I de- 
sire to present the histories of my cases that seem worth re- 
cording. 
The urine of each patient admitted is regularly examined, and the 
examination is repeated once a week. The presentation and position 
of the foetus are determined by abdominal palpation. The pelvis is 
* Read before the Philadelphia Obstetrical Society, January 2, 1896. Carefully 
prepared statistical tables are appended. 
Copyright, 1896, by J. D. Emmet, M. D. Richard C. Norris, M. D. 
carefully measured externally, and when the patient’s history or her 
external measurements indicate pelvic deformity, careful internal 
measurements are taken. The facts learned from these examinations 
are recorded on the following chart: 
No. 
Name, 
Presentation and position, 
Age, 
Date, 
Gravida, 
Last menses appd., 
Miscarriages, 
Pelvic Measurements. 
Inter-spinous, 
Inter-cristal, 
External conjugate, 
Internal conjugate diagonal, 
True conjugate, estimated, 
Right diagonal, 
Left diagonal, 
I nter-trochanteric, 
Circumference, 
Child. 
Length, 
Malformations, 
Weight, 
Head Measurements. 
Bitemp., 
Bipariet., 
Occip. frontal, 
Occip. mental, 
Trachelo-bregmatic, 
Circum. occip. front., 
Urinalysis. 
Date. 
Quantity 
Color 
Reaction 
Specific gravity.. 
Albumin 
Urea 
Casts 
The total quantity of solids excreted by the kidneys is routinely 
estimated by Haines’ modification of Haeser’s method—viz. : Multiply 
the last two figures of the specific gravity of the urine by the number 
of ounces voided in twenty-four hours, and the product by one and 
one tenth. A woman weighing one hundred and fifty pounds should 
show normally a total of urinary solids of 1,150 grains in twenty-four 
hours. When this examination reveals a marked diminution of the 
urinary solids, then the urine is examined chemically to accurately 
determine the quantity of urea. Very little reliance is placed upon 
the presence or absence of albumin unless it is present in large 
quantity. Albumin was found in twenty-nine cases, and in nine cases 
there was kidney insufficiency which required active treatment. Five 
cases of pelvic deformity were noted that required operative treat- 
ment. A Report of Two Years' Work at the Preston Retreat. 
3 
The technique followed at the Retreat to prevent puerperal sepsis 
does not materially differ from that followed in other similar institu- 
tions, and is briefly as follows : The women awaiting delivery never 
come in contact with the lying-in patients. Two baths a week, daily 
purgation, and a wholesome diet are the rules of the house. At the 
approach of labor the patient is given a full bath, with a generous use 
of soap and brush, and she receives a i-to-2,000 sublimated vaginal 
douche, and thorough douching of the vulva, lower abdomen, and the 
inner surface of the thighs. 
Vaginal examinations are as few as the case will permit, but ma- 
nipulation to favor the mechanism of labor—for example, assistance 
to favor rotation in posterior positions or to correct faulty position—is 
not neglected. In ordinary cases one examination suffices. Diagno- 
sis by abdominal palpation is highly valued and constantly practiced. 
Personal disinfection is rigid. Nail-cleaning : nailbrush and abun- 
dance of soap and hot water repeatedly changed, a i-to-i,ooo bichlo- 
ride solution and in addition, for operative cases, alcohol and a steril- 
ized nailbrush are employed. A lubricant is not used. A large freshly 
laundered gown covers the attendant’s clothing. Prompt delivery of the 
placenta after a single dose of ergot; a post-partum sublimate douche 
(1 to 2,000) and antiseptic occlusive pads are employed in every case. 
Vaginal and perineal lacerations are always immediately repaired 
with silkworm-gut sutures and needles and needle-holder sterilized 
by boiling. Throughout the first ten days of the puerperium the an- 
tiseptic occlusive dressings are worn and are very frequently and ex- 
travagantly changed, the external genitalia being carefully cleansed 
with the bichloride solution when each pad is renewed. Vaginal 
douches in the puerperium are given on alternate days only when 
lacerations have required extensive repair. A two-per-cent, solution 
of creolin is used for intra-uterine or vaginal douches in the very 
rare cases that require douches in the puerperium. The nurses have 
cleanliness and antisepsis forced upon them at every point. The 
building is well ventilated and the wards are used in rotation. Each 
lying-in ward is thoroughly cleansed after ten days’ or two weeks’ oc- 
cupancy, and for the same period the ward is vacated, the windows 
being widely opened in winter and in summer throughout this period. 
There are two delivery rooms which also are used in rotation. The 
hospital furniture in the delivery rooms and in the wards is made of 
iron and of glass and readily can be kept clean. A glass percolator 
and a glass nozzle are used for the douche. All instruments are 
sterilized by boiling in water. 4 
Richard C. Norris, M. D. 
There have been comparatively few complications of pregnancy 
in the women awaiting delivery at the Retreat. Among these 
complications, the following are worth recording : One case of un- 
cotitrollable hiccough whose history is as follows : Mrs. A. (Case No. 
3,626), aged nineteen, primigravida ; has had numerous attacks of un- 
controllable hiccough since the second month of her pregnancy; the 
attacks are always accompanied by vomiting and usually last about 
four hours, but have sometimes persisted for six days. During the 
attacks which I had the opportunity of studying, the diaphragm rhyth- 
mically contracted with a to-and-fro motion that could be felt by the 
hand depressed under the margin of the ribs ; the pulse and tempera- 
ture were not influenced. Each of the attacks occurring in the hos- 
pital followed a hearty supper, and the patient gave the history of 
their usual occurrence after overindulgence in food The patient 
stated that innumerable hypodermics of morphine had been given 
without any beneficial effect, and that on several occasions her physi- 
cian was compelled to administer chloroform. I was able to relax 
the spasm for short periods by the administration of pearls of nitrite 
of amyl containing three drops of this drug. The momentary uncon- 
sciousness thereby produced was soon followed by recurrence of the 
hiccough. Three or four doses were given at intervals, with only 
transient relief; large doses of belladonna and of bromides, together 
with restricted diet, relieved the patient very much, lengthened the 
intervals between the attacks to two weeks, and diminished markedly 
the violence of the spasms. The patient’s urine was normal in every 
respect. After delivery the hiccough did not return. 
One case of chorea has been observed : Mrs. P. (Case No. 3,975), 
aged twenty-six, II-para. 
When fourteen years of age she had chorea, which disappeared in 
about six months. During her first pregnancy there were no choreic 
movements. She was delivered prematurely at seven months, July, 
1894. The following November she became pregnant for the second 
time. A few weeks before the last pregnancy she had an attack of la 
grippe, which very much prostrated her. Shortly after becoming preg- 
nant her husband noticed the choreic movements, which have per- 
sisted throughout this pregnancy without very marked aggravation. 
During labor the movements were very active until full dilatation of 
the os occurred, after which time they were less violent. The second 
day after delivery, the patient in the adjacent bed being attacked with 
Pregnancy. A Report of Tivo Years' Work at the Preston Retreat. 
5 
eclampsia, the choreic movements were very much increased. Fowler’s 
solution was administered in ascending doses, which drug, and a quiet 
puerperium, brought about very great improvement 
There has been observed one case of very troublesome asthma 
gravidarum. In all of her three pregnancies the patient suffered 
from the same affection, and she was entirely free from such attacks 
when not pregnant. Constipation and a moderate degree of renal in- 
sufficiency explained her condition as one of mild toxaemia. 
One case of aphasia was observed : Mrs. C. (Case No. 3,687), aged 
twenty-five, Ill-para; twin pregnancy. Since the occurrence of 
quickening, the patient lost her power of speech at intervals of a few 
days, but at no time did she lose consciousness. An attack always 
was preceded by pin-and-needle sensations, usually of the entire body, 
sometimes of the right side, and suddenly disappeared, leaving be- 
hind a severe headache. Vision was never impaired. The patient 
had been very constipated ; similar attacks occurred in her two prior 
pregnancies, but they were much worse during the present twin preg- 
nancy. In the intervals between pregnancies she was entirely free 
from the attacks. A careful study of this case convinced me that the 
origin of the loss of speech was hysteria ; her difficulty was more an 
inability to produce a sound than a failure to use words properly—in 
other words, the case was one of aphonia. 
Two cases of aggravated gingivitis and ptyalism were observed. 
Atropine pushed to the physiological limit gave some relief to this 
most distressing affection. A four-grain solution of silver nitrate 
penciled over the gums also seemed beneficial. 
Convulsions occurred among the pregnant women six times. In 
two cases the convulsions were due to hysteria, in one to epilepsy, and 
in three to eclampsia. One case of dysentery in a woman pregnant at 
term was brought to the Retreat in an ambulance; she was isolated 
and passed through her confinement and puerperium without diffi- 
culty. One case of double pneumonia was given shelter overnight, 
and died within twelve hours. The latter patient was not positively 
known to be pregnant. 
Eclampsia.—There have been three cases of eclampsia in the group 
of cases reported this evening. All the patients recovered : 
Case I (No. 3,613).—Mrs. McK., aged twenty-five, I-gravida. This 
woman was a waiting patient at the Retreat when I assumed charge 
of the institution. Her urine had not been examined. The eclamptic 
seizure occurred a few days after I assumed charge of the Retreat, and 
before I instituted routine examinations of the urine of all the patients 6 
Richard C. Norris, M. D. 
awaiting delivery. At one o’clock in the morning several convulsions 
occurred while the patient was in bed ; she was carried unconscious 
to the delivery room ; her vulva was oedematous, and there was con- 
siderable swelling of the legs. She was catheterized, and the urine be- 
came solid after boiling it wdth a few drops of acid. The patient 
was delivered two hours after reaching the delivery room. During 
this time seven convulsions occurred. The treatment was as follows: 
Chloroform at the approach of a convulsion ; chloral, one drachm, by 
enema ; croton oil, gtt. v; hot wet pack, and as soon as the os was 
sufficiently dilated delivery was effected with forceps under chloro- 
form anaesthesia. After delivery the patient remained comatose for 
twelve hours. The lungs were oedematous; the body was swollen ; 
the eyelids were so puffy that the eyes could not be opened after the 
coma disappeared ; the skin was very dry. Sixteen dry cups were 
applied to the chest anteriorly and posteriorly. Two drachms of a 
saturated solution of Rochelle salts were given every fifteen minutes 
until free catharsis followed. Thirty-two large watery stools occurred 
in twelve hours. After the patient was delivered she was kept con- 
tinuously in a hot alcohol-vapor bath. The temperature at no time 
during the attacks was above 103° F. The irregularity, extreme 
rapidity, and weakness of the pulse seemed to contraindicate the em- 
ployment of venesection or of veratrum viride. The child was still- 
born. Throughout the first week of convalescence the patient was 
given, morning and evening, citrate of caffeine in doses of three grains, 
which, apart from the physiological polyuria of the puerperium, had a 
marked influence in increasing the flow of urine. Basham’s mixture 
was thereafter substituted. The diet was confined to milk. The 
urine steadily increased in amount; the albumin decreased, and the 
total quantity of solids excreted increased daily. When the patient 
left the hospital four weeks after delivery, only a trace of albumin was 
present, and the total amount of solids excreted in the urine in 
twenty-four hours was normal. 
Case II (No. 3,659).—Mrs. K., aged nineteen, I-gravida. Two 
days after admission the urine was examined and was found to be 
normal, with the exception of a slight diminution in the amount of 
solids excreted. There was no evidence of toxaemia, and there was 
no oedema. Her labor began June 13, 1894, six days after admission. 
While she was asleep several convulsions occurred at intervals, the 
violence of which threw her out of bed and broke two of her front 
teeth. The urine drawn by catheter now showed a trace of albumin, 
and numerous narrow hyaline casts. The notes of the case for the A Report of Two Years’ Work at the Preston Retreat. 
7 
first twelve hours, including the treatment, are as follows : 10.30 a. m., 
convulsion, chloroform inhalation ; n A. m., two convulsions at short 
intervals, chloral one drachm (enema), croton oil gtt. iv, and veratrum 
viride gtt. x (hypodermatically) ; ir.15 a. m., forceps ; 12 m., delivery. 
Child was asphyxiated but revived ; mother’s pulse, 96 ; 2.30 p. m., 
pulse 60 ; saturated Epsom-salts solution, two drachms, every fifteen 
minutes ; hot-air bath during alternate hours; 6 p. m., convulsion fol- 
lowed by free evacuation of the bowels and by a uterine haemorrhage, 
with the loss of about one pint of blood ; pulse 122, temperature ioi° 
F. ; chloral, one drachm (enema); 8.30 p. m., pulse 84 ; 9 p. m., pulse 
108, strong and bounding ; fluid extract of veratrum viride gtt. v 
(hypodermatically); elaterium one eighth grain; 10 p. m., pulse 65 ; 
elaterium one eighth grain; 10.30 p. m., free catharsis occurred ; pa- 
tient’s mental condition improved. In thirty hours thirty-four 
drops of the fluid extract of veratrum viride were given in five- or 
eight-drop doses, when the frequency and the volume of the pulse, 
the rise of temperature and the excessive restlessness of the patient 
threatened the occurrence of a convulsion. Two drachms of chloral 
by the bowel and fifteen grains by the mouth were given within six- 
teen hours after delivery. Twelve ounces of Epsom salts were ad- 
ministered within thirteen hours in saturated solution in doses of two 
drachms, and during this time two doses of elaterium, each one eighth 
of a grain, were administered ; free catharsis began at 7.30 p. m., 
seven and a half hours after delivery. The patient was kept in a con- 
tinuous hot-vapor bath, the vapor being secured from alcohol poured 
upon heated blocks of soapstone placed under the bedclothes, and a 
current of hot air was supplied by means of an alcohol lamp and an 
elbow of stovepipe. This means of securing diaphoresis was kept up 
continuously for three days and thereafter, for one hour, three times 
daily for four days. Free action of the skin was thus secured. The 
patient was given all the water she could drink. The quantity of 
urine secreted by this patient after her delivery is of interest and 
shows the great value of caffeine as a diuretic. During the first ten 
hours after delivery the bladder contained no urine. Throughout the 
next twenty-four hours, Tune 15th, the quantity was § xij ; June 16th, 
1 xxiij ; June 17th, § xxiv ; caffeine (grs. iij) was now given every 
four hours ; June 18th, | lxiij ; June 19th, 4.25 pints; JuneT 20th, 4 
pints ; caffeine was now replaced by Basham’s mixture, which the pa- 
tient continued to take throughout her convalescence. 
The value of free catharsis and of diaphoresis was unmistakable in 
this case ; also the use of veratrum viride to diminish the force and 8 
Richard C. Norris, M. D. 
frequency of the pulse. This drug was given whenever the pulse rose 
above ioo and when the increasing volume of the pulse indicated the 
probability of a recurrence of a convulsion. The haemorrhage from 
relaxation of the uterus also contributed to depress the force of the 
heart’s action. The patient’s recovery was uninterrupted. 
Case III (No. 3,962).—Mrs. J., aged eighteen, I-gravida. In 
the fifth month of her pregnancy she was attacked with severe 
headache and partially lost her vision. At this time the symptoms of 
threatened miscarriage disappeared under rest in bed. During the 
past three months oedema of the ankles has been present and the pa- 
tient has not been able to wear her shoes with comfort. Throughout 
the same period headache was almost continuous and at times her 
vision was blurred. July 10th, the patient was admitted to the Re- 
treat. The next day a morning specimen of the urine was examined 
with the following results: No albumin; specific gravity 1017; 
acid reaction ; tube casts were not found. She was freely purged 
with Rochelle salts, after which the head symptoms were less severe. 
July 20th, urine examination showed no albumin ; faintly acid ; spe- 
cific gravity 1024. July 22d, quantity of urine in twenty-four hours 
was forty-eight ounces; specific gravity 1017 ; no albumin ; acid re- 
action. The quantity of urea was estimated and was found only 
slightly below normal. July 30th, specific gravity 1015, faintly acid. 
Labor began August 2d, n p. m., and delivery occurred August 3d, 
7.30 a. m. The presentation was left occipito-anterior and the birth 
natural. At 3 p. m., August 3d, the woman suddenly lost her vision, 
vomited, had intense headache and was very sleepy. Her tongue was 
heavily coated. A powder of potassium bromide (grs. xxx) and caffeine 
(grs. iij) was administered. At 7 p. m. vision had returned in the left 
eye, but the right eye had not recovered. The patient was very drowsy 
and slept heavily. Pulse 100. At 11.30 p. m. a convulsion occurred 
which lasted about five minutes. A second convulsion occurred an 
hour later. I discovered that the nurse had neglected to catheterize 
the patient and that the bladder was distended, pushing the uterus far 
upward and to the right. Twenty-three ounces of urine were drawn 
with a catheter. The pulse during the second convulsion was 130. 
Ten drops of fluid extract of veratrum viride were administered hypo- 
dermatically. A drachm of chloral was given by enema, most of 
which was not retained. When the coma following the first convul- 
sion had largely disappeared, four drops of croton oil and, later, 
twenty grains of chloral were administered by the mouth. The bowels 
moved at 4 a. m., and shortly thereafter the patient slowly regained A Report of Two Years Work at the Preston Retreat. 
9 
consciousness. By means of an alcohol lamp and a shoulder of 
stovepipe, profuse perspiration was secured. The following day 
further action of the bowels was maintained by the administration of 
Rochelle salts, one drachm every hour, twenty doses being taken, which 
secured thirteen bowel movements. August 14th, the total quantity 
of urine in twenty-four hours was fifty-eight ounces, specific gravity 
1020; no albumin ; quantity of total solids excreted was above the 
normal. The patient had no recurrence of headache or disturbed 
vision, and four weeks after labor she was discharged perfectly well. 
The urine at this time was normal. 
Six other women have been admitted to the Retreat in whom 
there were marked evidences of kidney insufficiency. Labor was in- 
duced in three of these cases, under which heading their histories will 
appear. The histories of the remaining three are as follows : 
Mrs. C. (No. 3,960), aged eighteen, I-gravida. During the last 
three months of pregnancy oedema of the ankles, the legs, the 
vulva, and the face was very marked, during which time the patient 
complained of intense headache. There had been no dimness of 
vision. The bowels, under the action of purgatives, had been mov- 
ing. Upon admission to the hospital, a few days before term, the ex- 
amination of the urine showed albumin three fourths by bulk and 
numerous hyaline casts. The total quantity of urine in twenty-four 
hours was thirty-one ounces and the specific gravity 1017. In the 
absence of systemic symptoms and with a restricted diet and the in- 
gestion of large amounts of water I decided to permit the patient’s 
pregnancy to continue for a time with careful supervision of her ex- 
cretions. Three days later she fell into labor, during which there 
were marked nervousness and jactitation. As soon as the os was 
sufficiently dilated Tarnier’s axis-traction forceps was applied and a 
living female infant was delivered; weight, nine pounds. Within a 
few days after delivery, under the influence of caffeine, the kidneys 
secreted from forty to seventy ounces in twenty-four hours, the quan- 
tity of albumin steadily diminished, and the total quantity of solids 
excreted increased. Convalescence was normal. 
Mrs. C. (Case No. 3,955), aged thirty-five, I-gravida. Some 
swelling of the ankles had been noticed in the early months of preg- 
nancy, but during the last month the oedema was very marked. Dur- 
ing the last week oedema of the vulva was present. There is also 
considerable puffiness of the face and eyelids. The patient recently 
complained of gastric distress on three occasions. During the night 
had nausea and vomiting. Has not had headache and vision has al- Richard C. Norris, M. D. 
10 
ways been normal. During the past month has had very frequent 
micturition. Admitted to the hospital Sunday, July 7th. Calculat- 
ing from the menstrual history, confinement is due July 20th. Ex- 
amination of the urine, July 8th, shows a very large proportion of 
albumin, one half by bulk and numerous casts. The total amount of 
solids excreted was two thirds the normal amount. The patient was 
kept in bed, and the activity of the skin, of the kidneys, and of the 
bowel was promoted by means of sweating and the administration of 
milk, caffeine, and Epsom salts. Labor began July nth, 3 a. m ,and 
was completed spontaneously in twelve hours. During the second 
stage there was much nervousness ; the pupils were unequal ; there 
was incessant rolling of the head from side to side. 
Fibrillary contraction in the muscles of the right side of the face 
and irregular twitchings of the right arm were noted; the right pupil 
was slightly dilated; the pulse 120. A drachm of chloral was admin- 
istered by the bowel, and while the forceps was being prepared for 
an instrumental delivery the infant was spontaneously born, weighing 
four pounds twelve ounces. The nervousness and muscular twitching 
persisted for some hours after delivery. During the night, by the ap- 
plication of heat, the patient perspired moderately and four ounces of 
Rochelle salts were administered, followed by one bowel movement. 
During the first twenty-four hours subsequent to delivery ten ounces 
of urine were passed. Convalescence was rapid and complete, the 
functional activity of the kidneys speedily improving after the admin- 
istration of diuretics and a milk diet. 
Mrs. G. (Case No. 3,702), aged nineteen, I-gravida ; admitted to 
the Retreat three weeks before term. She was very anaemic; suf- 
fered from headache and there was oedema of the lower extremities. 
An examination of the urine showed the total amount in twenty-four 
hours to be twenty-six ounces; specific gravity 1016; an abundant 
amount of albumin and diminution in the quantity of urea. The pa- 
tient was very nervous and apprehensive of her coming confinement. 
Rest in bed; activity of the skin, obtained by means of hot-air baths ; 
a milk diet; administration of caffeine and, later, of Basham’s mix- 
ture carried her to term with improvement in her condition. After 
her labor the quality and quantity of her urine slowly improved. 
Meanwhile she was exceedingly nervous and became melancholic. She 
suffered from galactorrhoea, which seemed to be an expression of her 
nerve prostration. It was necessary to discontinue lactation. She 
finally recovered entirely from her nervousness and left the hospital 
with her blood and kidney conditions much improved. A Report of Two Years' Work at the Preston Retreat. 
11 
Coinplications of Pregnancy. 
No. of Cases. 
Albuminuria 29 
Aphasia 1 
Asthma gravidarum 1 
Chorea 1 
Chronic Bright’s disease 2 
Dysentery 1 
Eclampsia (threatened) 3 
Epilepsy 1 
Gingivitis 2 
Hysterical convulsions 2 
Influenza 3 
Kidney insufficiency (grave) 9 
Pleurisy 1 
Syphilis 10 
Uncontrollable hiccough 1 
Labor. 
Presentation 
and Position. 
L.O. A. 
R.O.P. 
R.O.A. 
L. O. P. 
Breech. 
Trans- 
verse. 
Com- 
pound. 
Total. 
Infants. 
Primigravidse 
121 
25 
7 
I 
4 
I 
157 
Male, 264 
Multipart... 
256 
70 
6 
2 
11 
2 
343 
Female, 242 
Total... 
377 
95 
13 
3 
15 
2 
I 
500 
Total, 506 
Six twin pregnancies—two primigravidse, four multipart. The presentation in 
four was vertex, in two vertex-breech. 
Complications of Labor.—There has been one case of placenta prce- 
via: Mrs. McG. (Case No. 3,669), Xl-gravida, aged forty-three ; 
last menses, September 7, 1894. On December 10th, June 6th, March 
8th, and April 14th had uterine haemorrhages, and on the last date the 
flow was quite free and lasted six days. June 7th, membranes rup- 
tured. On June 12th, while working at the table, she was suddenly 
attacked with alarming bleeding which was not accompanied by pain ; 
she was hurriedly taken to the delivery room, and upon examination 
the os was found undilated and only partially dilatable. A margin of 
the placenta extended to the external os on the right side ; presenta- 
tion and position left occipito-anterior ; head not engaged. The 
largest sized Barnes bag was introduced but would not remain in 
place; the cervix was therefore dilated manually after the method 12 
Richard C. Norris, M. D. 
of Dr. P. H. Harris, and the head was brought into the pelvic inlet 
by axis-traction forceps which was then removed. 
The haemorrhage ceased and a living child with double harelip 
and cleft palate was born spontaneously, six hours later. Puerperal 
convalescence was without incident. 
There has been one case (No. 3,892) of alarming epistaxis during 
labor. Careful examination of the patient could discover no disease 
of the kidneys or blood-vessels. The patient’s face and eyes were 
markedly suffused and puffy during her labor. Four hours after the 
beginning of labor, profuse bleeding occurred from the left nasal pas- 
sage. Applications of ice checked the haemorrhage temporarily. One 
hour later a second outpouring of blood occurred, perceptibly weak- 
ening the pulse and requiring a plug of gauze smeared with cosmoline 
and dusted with tannic acid. The plug was removed immediately 
after the delivery of the placenta and there was no recurrence of 
bleeding. 
There was one case of premature detachment of a normally situated 
placenta that was accompanied by a haemorrhage not dangerous to the 
mother but fatal to the child : 
Mrs. C. (Case No. 4,020), I-gravida, left occipito-posterior posi- 
tion.—There was delay in anterior rotation of the occiput due to 
obstruction by a very prominent ischiatic spine. During the second 
stage cf labor a free discharge of bloody liquor amnii and blood oc- 
curred that decidedly weakened the patient’s pulse, and caused a 
cessation of the foetal heart. Immediate extraction with the forceps 
delivered a child in the second degree of asphyxia which proved 
fatal. A retroplacental clot the size of a cocoanut was found, and 
the placenta showed areas of fatty and fibroid degeneration. Autopsy 
upon the infant was made by Dr. C. W. Burr. All the organs were 
normal. The infant’s death was due to intra-uterine asphyxia. 
Uterine Fibroids.—Labor has been complicated three times by 
uterine fibroids. 
Case I (No. 3,620).—Mrs. T., II-gravida. A submucous fibroid 
about the size of a newborn infant’s head caused free bleeding imme- 
diately after labor by interfering with uterine retraction. Haemor- 
rhage was controlled by a hot intra-uterine douche. Patient’s puer- 
peral convalescence was normal, and on the twelfth day the tumor 
had been reduced to a very small size. 
Case II (No. 3,619).—Mrs. C., I-gravida. Several subperitoheal 
tumors, each about the size of an orange, were felt on the anterior 
uterine wall. When labor began two nodules were distinctly felt be- A Report of Two Years' Work at the Preston Retreat. 
13 
hind the bladder, but at the time of delivery the tumors had been 
drawn above the bladder by the longitudinal fibers of the uterus. 
Convalescence was afebrile. 
Case III (No. 3,781).—Mrs. K., aged thirty-seven, I-gravida. 
Six subperitoneal fibroids were detected by abdominal palpation. 
Vaginal examination discovered a fibroid low down on tlje left side 
fixed below the pelvic brim and offering serious obstruction to the 
birth of the child. Preparations were made for a Caesarean section, 
should the uterus fail to lift the tumor out of the pelvis, during the 
progress of labor. After two hours of active uterine contractions the 
tumor had been lifted sufficiently high to permit spontaneous birth. 
During convalescence I watched with considerable interest the pro- 
gressive diminution in the size of the tumors, and when the patient 
left the hospital they had been reduced from the size of an infant’s 
head to that of an English walnut. While it is true that uterine 
fibroids complicating labor should be closely watched and serious 
obstruction should be anticipated, I believe cases of uterine fibroids 
so situated as to be drawn up by the longitudinal fibers of the lower 
uterine segment should be given a fair chance before resorting to the 
Caesarean operation. 
A very interesting complication occurred in a woman on whom a 
ventro-fixation (Case No. 3,909) had been done two years prior to her 
delivery. This case has been reported in the A?nerican Journal of 
Obstetrics, December, 1895. The anterior uterine wall throughout its 
entire extent was apparently fixed to the abdominal wall and the 
physiological hypertrophy of the uterine muscle had occurred, but in 
such a manner as to double up the muscle fibers into a mass which 
obstructed the pelvic inlet and which was observed, alternately, to 
relax and contract with each recurring pain. A finger placed above 
the symphysis was at least five inches distant from a finger touching 
the interior surface of this hypertrophied mass of muscle. Almost 
the entire uterine sac was formed by the posterior uterine wall, which 
extended from the upper margin of the hypertrophied muscle in front 
to the sacral promontory. The uterine sac was therefore danger- 
ously thinned; the contraction ring was situated low anteriorly at the 
junction of the cervix and the aforementioned hypertrophied and 
imprisoned muscle ; posteriorly, the contraction ring was situated at 
least three inches above the sacral promontory. The child’s position 
was oblique with the head lying under the spleen in the left upper 
quadrant of the uterus. The face was anterior, and the feet rested in 
the depression above and behind the hypertrophied anterior uterine 14 
Richard C. Norris, M. D. 
wall. The danger of rupturing the uterus by version was promptly 
recognized, and, after failing in efforts to dislodge and bring down the 
feet, cephalic version was performed ; the head was made to rest 
posteriorly upon the promontory and anteriorly upon the obstructing 
mass of muscle. Tarnier’s forceps was applied to the head above the 
pelvic brim ; the cord had prolapsed and could not be replaced ; 
rapid extraction therefore was employed, and the head brought past 
the obstruction into the pelvis. The child was now in a posterior 
position, with the occiput in the hollow of the sacrum. Rapid extrac- 
tion, in order to save the infant, was employed, but without success. 
The cord had been compressed between the child’s head and the 
mass of muscular tissue. The infant could not be resuscitated. 
Pelvic Deformity.—Case I (No. 3,601).—Mrs. D., aged thirty, Ger- 
man, IV-gravida. Her first child was born dead at full term ; at- 
tended by a midwife. Her second child was delivered alive with for- 
ceps ; this child lived five years and carried a deep depression in its 
forehead from the pressure of the forceps. The third child was pre- 
maturely delivered with forceps. The patient was admitted to the 
Retreat in labor March 23, 1894. Her pelvic measurements taken 
during labor were as follows : Interspinous, 25 centimetres ; inter- 
cristal, 26.5 centimetres; external conjugate, 17.25 centimetres; 
internal conjugate diagonal, 9.75 centimetres; true conjugate (esti- 
mated), 8.5 centimetres ; right diagonal, 20 centimetres ; left diag- 
onal, 20 centimetres; intertrochanteric, 31 centimetres; circumfer- 
ence, 86 centimetres ; patient’s height, four feet seven inches. 
Presentation and position : Vertex, occiput to the right. After 
several hours of ineffectual pains the membranes were not ruptured 
and the os was only partially dilated. Podalic version. The posterior 
foot was the first one grasped, the anterior foot not being readily 
reached. An attempt was made during extraction to rotate the child’s 
body so as to bring anterior the occiput of the after-coming head. 
This manoeuvre caused a nuchal displacement of the right arm, 
which was liberated with some difficulty. After its liberation the head 
required powerful dragging and suprapubic pressure to accomplish 
delivery. The infant was deeply asphyxiated, but was finally revived 
after twenty-five minutes of hard work ; it lived three days and then 
died in convulsions. Autopsy showed a widespread intracranial 
haemorrhage. The child at birth weighed nine pounds and a half, 
and had the following measurements : Bitemporal, 9 centimetres ; 
biparietal, 9.75 centimetres ; occipito-mental, 14 centimetres ; trachelo- 
bregmatic, 10.25 centimetres; occipito-frontal circumference, 37 cen- A Report of Two Years' Work at the Preston Retreat. 
timetres. It was a source of regret that symphyseotomy was not 
utilized for this case, since that operation might have saved the child. 
Case II (No. 4,005).—In August, 1895, the same patient was 
brought to the Retreat in labor, one week before term. The pelvic 
measurements were again carefully gone over and verified. Supra- 
pubic palpation of the foetal head and digital examination under ether 
to determine the relative size of the head and the pelvis indicated 
that this time the child was of smaller size than at her labor the pre- 
ceding year. Version was again performed, this time with the birth 
of a living child, whose weight was seven pounds. The biparietal 
diameter was eight centimetres. This case emphasizes the necessity 
of studying the relative size of the head to the pelvis before determin- 
ing upon the operative procedure to be employed in a given case of 
pelvic deformity. 
Case III (No. 3,719)-—Mrs. McL., aged thirty, Ill-gravida. After 
three days of active labor her first child was born dead, with a spoon- 
shaped depression of the parietal bone. The physician who attended 
her at that time told her that she was too small to bear a living child and 
proposed craniotomy, which was refused on account of the patient’s 
religion. In her second pregnancy she miscarried at two months ; 
was sick in bed seven weeks, and was subsequently treated at the dis- 
pensary of the Woman’s Hospital. She came to the Retreat in her 
third pregnancy one week before term. Her measurements were as 
follows: Interspinous, 24 centimetres; intercristal, 26 centimetres; 
external conjugate, 17.25 centimetres; internal conjugate, diagonal, 
9.5 centimetres; true conjugate, 8 to 8.5 centimetres; right diagonal, 
19.5 centimetres; left diagonal, 19.5 centimetres; circumference, 
81 centimetres; intertrochanteric, 29 centimetres; patient’s height, 
four feet five inches; weight, one hundred and thirteen pounds. 
Presentation and position: Vertex, occiput to the left; sagittal 
suture in the transverse diameter of the pelvic inlet. Diastasis of recti 
muscles and pendulous abdomen. Labor began August 7th, one 
week after admission. Suprapubic pressure and digital examination 
under ether showed plainly that the head protruded well beyond the 
symphysis pubis and was not likely to enter the pelvis without undue 
compression. 
The child was apparently of average or large size. After six hours 
of active labor pains the os was partially dilatable, and the head freely 
movable above the pelvic brim. At 2 a. m. symphseotomy was per- 
formed. A median suprapubic incision was made and the pubic 
joint severed with a Galbiatti knife ; free bleeding followed the in- 16 
Richard C. Norris, M. D. 
cision through the joint; the haemorrhage was controlled by iodoform- 
gauze packing. The symphysis immediately after its section sepa- 
rated about half an inch. When axis-traction forceps was applied 
and moderate traction made, the separation increased to an inch and 
a half as the head suddenly slipped through the pelvic inlet; the 
child was then extracted without difficulty, and was moderately 
asphyxiated, but was soon resuscitated. The gauze packing and a 
few blood clots were removed from the abdominal wound, and to se- 
cure drainage three strands of silkworm gut were passed to the bot- 
tom of the wound, avoiding the pubic joint. The silkworm gut was 
removed at the end of forty-eight hours ; it afforded no drainage, and 
I shall not employ it again for this purpose, since it seems to be un- 
necessary and may prove a source of danger. The measurements of 
the child were as follows: Bitemporal, 8 centimetres; biparietal, 9 
centimetres; occipito-frontal, 11.5 centimetres; occipito-mental, 13 
centimetres ; trachelo-bregmatic, 8 centimetres ; circumference, oc- 
cipito-frontal, 34 centimetres; length, 48 centimetres; weight, seven 
pounds four ounces. 
During the patient’s convalescence the urine was blood-tinged 
during two days, after which time it was normal. The patient’s con- 
valescence was afebrile. She was kept in bed five weeks. I examined 
this patient two weeks ago and find there is no difficulty in locomo- 
tion, and there is no appreciable movement of the joint surfaces when 
she walks. , 
Case IV (No. 3,641).—Mrs. U., aged twenty-five, ITgravida. Her 
first delivery occurred at the Woman’s Hospital after a difficult for- 
ceps operation. The patient stated that the baby’s head received a 
serious injury, and the child died six weeks after birth. The patient 
came to the Retreat ten days past term. Her measurements were as 
follows: Interspinous, 25 centimetres; intercristal, 27 centimetres; 
external conjugate, 17.5 centimetres ; internal diagonal conjugate, 9.75 
centimetres ; true conjugate, 8.5 centimetres ; right diagonal, 21 centi- 
metres; left diagonal, 21 centimetres; intertrochanteric, 28 centi- 
metres; circumference, 75 centimetres; weight, 105 pounds. Pres- 
entation was vertex, occiput to the left ; sagittal suture in the 
transverse diameter at the inlet. The urine showed a trace of albu- 
min ; specific gravity, 1027 ; the quantity normal. The head had 
not entered the pelvic inlet. The apparently small size of the 
child’s head, determined by suprapubic pressure and digital examina- 
tion under ether, indicated the probability that the head would en- 
ter the pelvic inlet with cautious use of axis-traction forceps at the A Report of Two Years' Work at the Preston Retreat. 
17 
pelvic brim. It was therefore determined that the treatment should 
be immediate induction of labor followed by application and cautious 
traction with forceps. If engagement of the head could not be se- 
cured without undue force, symphseotomy was to be performed. 
Labor was induced. A bougie was introduced April 25th, and pro- 
voked a few slight pains; second bougie, April 26th. Softening of 
cervix and a few slight pains were the only results of the introduction 
of the bougies. On April 27th the largest size Barnes bag was intro- 
duced, and six hours later the os was well dilated. The patient was 
etherized ; the membranes were ruptured and Hodge forceps was ap- 
plied at the brim, the right blade being applied first and above and 
behind the symphysis ; the left blade followed and was placed above 
and in front of the sacral promontory. After careful but vigorous 
traction the head was drawn into the pelvic inlet and the forceps was 
removed. Spontaneous birth of a living child occurred one hour 
later. The measurements of the child were as follows : Bitemporal, 
7.5 centimetres ; biparietal, 8.5 centimetres ; occipito-frontal, 9.5 cen- 
timetres; occipito-mental, 12 centimetres; trachelo-bregmatic, 8 cen- 
timetres ; occipito-frontal circumference, 32 centimetres ; length, 43 
centimetres ; weight, five pounds twelve ounces. Mother’s convales- 
cence afebrile. 
Case V (No. 3,851).—Mrs. N., Il-gravida. Patient had been de- 
livered with difficulty the preceding year at the Retreat by means of 
high forceps. The pelvic measurements were as follows : Interspi- 
nous, 23 centimetres ; intercristal, 25 centimetres ; external conju- 
gate, 16.5 centimetres; internal conjugate diagonal, 9.75 centimetres; 
true conjugate, 8.5 centimetres ; right diagonal, 19 centimetres ; left 
diagonal, 19 centimetres; intertrochanteric, 27 centimetres; circum- 
ference, 80 centimetres. 
Labor induced two weeks before term : First bougie, at 7 p. m., 
February 3d ; second bougie, at 9.30 a. m., February 4th. Pains be- 
gan at 2 p. m. Membranes ruptured spontaneously at 3.45 p. m. De- 
livered of a living child spontaneously at 5 p. m. The measurements 
of the child were as follows: Bitemporal, 8 centimetres ; biparietal, 
9 centimetres; occipito-frontal, 12 centimetres; occipito mental, 13 
centimetres ; trachelo-bregmatic, 8 centimetres ; circumference, 34 
centimetres ; length, 48 centimetres ; weight, seven pounds two ounces. 
An obliquely contracted pelvis, due to coxalgia, has been observed 
in three patients. The head in each case descended in the larger 
oblique diameter and delivery was spontaneous. 
Induced Labor.—Labor has been induced five times—twice for Richard C. Norris, M. D. 
18 
pelvic deformity in the cases just described, three times for threat- 
ened eclampsia. The histories of the latter cases are as follows : 
Case I (No. 3,621).—Mrs. H., aged twenty-nine years, I-gravida, 
was sent to the Retreat three days before term. Upon examination, 
the face, lower abdomen, and legs were markedly oedematous. She 
complained of nausea, headache, and dimness of vision. The urine 
was diminished in quantity and contained a large amount of albumin 
and narrow hyaline casts; specific gravity, 1015. The quantity in 
twenty-four hours was seventeen ounces, and the total solids was half 
the normal amount. The day after admission on March 18th, at 3 
p. m., a flexible bougie was placed in the uterus, and at 10.30 p. m. a 
larger size. March 19th at 10 p. M. the largest size Barnes bag was 
introduced. At midnight the os was dilatable. The membranes 
were ruptured, after which a living child was delivered with forceps. 
March 22d the quantity of urine in twenty-four hours was ten ounces, 
and after the administration of caffeine the quantity of urine slowly 
increased. Throughout the first two weeks of convalescence the pa- 
tient was freely purged, and her skin was kept active by means of hot 
alcohol-vapor baths administered throughout one hour at intervals of 
four hours. The patient was discharged four weeks after delivery 
and her urine at that time showed only a trace of albumin. There 
were no casts and the quantity of urea was almost normal. 
Case II (No. 3,683).—Mrs. N., aged thirty-four, VUI-gravida, 
referred to the Retreat, June 22d, by Dr. Brous. On examination, 
the patient’s legs, face, and vulva were very oedematous. She had 
been passing a very small quantity of water which she stated stained 
her underclothing red. Immediately after admission she was catheter- 
ized, and only an ounce of urine was obtained which contained four 
fifths albumin by bulk, and a microscopic examination made without 
waiting for settling of the urine showed the presence of a large 
amount of blood; narrow hyaline and blood casts. .There were 
nausea, occipital headache, and loss of vision in the right eye. A 
bougie was introduced at 3 p. m., after which 3 gtt. of croton oil 
were administered, followed in two hours by an eighth of a grain of 
elaterium. At 10 p. m. a glycerin enema was given, which was fol- 
lowed by a slight bowel movement. June 23d, feeble pains had oc- 
curred throughout the night; at 11 a. m. the cervix was softened and 
partially dilated ; head not engaged ; two bougies introduced ; cro- 
ton oil, 3 gtt. ; catheterized, and three ounces of urine were obtained 
having the same character as above described. At 3.30 p. m., free 
bowel movement; active labor pains. Spontaneous birth of living A Report of Two Years' Work at the Preston Retreat. 
child at 4 p. M. ; 6 P. M., patient very restless ; respiration, 60; pulse, 
160, weak and intermittent ; temperature, 104° ; caffeine (gr. j), digi- 
talis (10 gtt.), were administered hypodermically every four hours ; ice 
cap to head ; hot wet pack. At 7 p. m., pulse, 144; respirations, 36 ; 
temperature, ioi° F. 1 hroughout the night caffeine (gr. iij)j whisky 
(three drachms), and milk (two ounces), were administered every four 
hours, and the patient was kept continuously in the hot vapor bath. 
June 24th. pulse, 104 ; temperature, 99.20 ; respirations, 20. Pa- 
tient able to see the print of a newspaper, but was not able to read , 
the left eye now had less vision than the right ; there was intense 
pain in the right supra-orbital region. Salines in saturated solution 
were administered throughout the day until free evacuation of the 
bowels occurred ; 10 p. M., pulse, 102 ; respirations, 30 ; temperature, 
99.8°. In the next forty-eight hours the quantity of urine had rapidly 
increased to forty-eight ounces in the last twenty-four hours. 1 he 
bowels were kept freely moving by means of salines and elaterium ; 
the skin was kept active by hot vapor baths for an hour, administered 
every three hours, and after the quantity of urine began to increase, 
Basham’s mixture was substituted for the caffeine. 
On July 13th two hyaline casts were found on one microscopic 
slide. The patient now complained of intense pain in the right 
sacro-iliac joint and was unable to rest her weight upon her right leg. 
Upon examination, the uterus was found to be displaced backward 
and evidently exerted pressure upon the sacral plexus. 1 he uterus 
was replaced and a pessary was introduced. 1 he pain finally dis- 
appeared after salicylates had been used over a period of three weeks. 
Case III (No. 3,826).—Mrs. M., aged twenty-two ; III-gravida. 
This patient was referred to the Retreat by Dr. C. E. Cadwallader, 
and gave the history of having been treated for dropsy prior to her 
present pregnancy. Admitted December 1 ith. Upon examination, 
the face, arms, legs, abdomen, and vulva showed widespread oedema, 
the woman complained of headache and nausea, and was suffering 
from dyspnoea so extreme that she was compelled to sit on a chair 
in the ambulance which brought her to the hospital. Her pulse 
was 140, her respirations 60. No urine had been voided during 
the last eighteen hours, and by means of the catheter two ounces of 
porter-colored urine were drawn. Specific gravity, 1014, five sixths 
albumin by bulk ; reaction acid. Fourteen broad hyaline and blood 
casts were counted on the first slide examined. I he patient was six and 
a half months pregnant. Dilatation of the cervix attempted by means 
of Barnes’ bags was begun at 12.30. At 5 p. m. dyspnoea was so ex- Richard C. Norris, M. D. 
treme and the patient was apparently failing so rapidly that it was de- 
cided to empty the uterus at once ; the os was sufficiently dilated at 
this time to permit further manual dilatation sufficient to introduce 
axis-traction forceps. A macerated child was delivered at 6.30 
p. m. After free purgation and tapping the pleural cavities, and pro- 
fuse diaphoresis, the patient had somewhat improved. Notwithstand- 
ing ten to twenty stools a day, continuous hot vapor baths, free cup- 
ping over the lungs, administration of cardiac stimulants, and inhala- 
tions of oxygen, all efforts to prolong life and to secure action of the 
kidneys failed. The patient died six days after her delivery, having 
secreted throughout this period ten ounces of bloody urine. There 
were no convulsions. The autopsy was made by Dr. Thomas G. 
Ashton, whose notes are as follows : 
Autopsy—Mrs. Martin. 
Body that of a young woman apparently about twenty-two years 
of age. Eyelids cedematous, oedema of abdominal wall, marked 
oedema of lower extremities ; skin distended and glistening. Slight 
discoloration of dependent portions of body. 
A subcutaneous ecchymosis to the left of the sternum below clav- 
icle, where wet cups had been applied. 
Upon the abdomen, in the left iliac region, there is an abrasion of 
the skin, ante-mortem, due to excessive distention from anasarca. 
The abdomen is very prominent in the umbilical and hypogastric 
regions, due to tympanites. 
The tissues of the thoracic and abdominal walls are oedematous 
upon section. 
The Thorax.—Pleural cavities are filled with fluid, that of the left 
side containing about a litre and a half, that of the right about one litre, 
free from fibrin. An old adhesion, limited, between the lower portion 
of the upper lobe of the left lung and the parietal pleura upon the lat- 
eral aspect. Lungs elsewhere free from adhesions. 
Left lung somewhat cedematous, crepitant throughout, no evi- 
dences of tuberculosis. 
Right lung oedematous, crepitant, except the middle lobe, which 
was consolidated throughout, in the stage of gray hepatization. No 
infarcts. 
Pericardium contained about ten ounces of serous fluid contain- 
ing flakes of fibrin. No adhesions, or roughness of the surface. 
Heart, size about normal. 
Right auricle contained clots. Right ventricle filled with well- A Report of Two Years' Work at the Preston Retreat. 
21 
marked chicken-fat clots, which extended well into the pulmonary 
artery. Tricuspid valves normal, admitting three fingers with ease. 
Pulmonary valves normal. Right ventricle of normal size. 
Left auricle filled with soft red clots, which extended into left 
ventricle. Muscular substance of left ventricle normal. 
Mitral valve somewhat thickened at its edges, and upon its auricu- 
lar surface, a short distance from the edge of the leaflets, there exists 
a complete ring of fresh vegetations, which prevent the approximation 
of the valves, and produce a distinct narrowing of the mitral ring, so 
that the mitral orifice will no more than admit but one finger. These 
vegetations are friable and easily broken down. There are no evi- 
dences of ulceration. 
Abdomen.—The abdominal cavity contained a considerable quan- 
tity of clear fluid, in amount about two litres. Intestines extremely 
pale and greatly distended. No evidences of peritonitis. 
Spleen normal. 
Live, normal. 
Kidneys.—Both kidneys large ; left five inches and a half in length, 
right five inches in length. Very pale and whitish in appearance. 
Capsule stripped easily, leaving a smooth surface. Upon section, the 
cortex was found to be much increased in width, and the difference 
between the cortex and the pyramids very ill-defined, the tissue being 
universally pale and somewhat granular in appearance. 
The bladder was empty. 
The uterus enlarged, coming well out of the pelvis. The ovaries 
and tubes showed nothing macroscopically abnormal; no evidences of 
septic infection. 
Prolapsed Cord.—There have been four cases of prolapse of the 
umbilical cord. In the first case the cord prolapsed before engage- 
ment of the head occurred, and when the amniotic sac burst. The 
patient was placed in the knee-chest posture, and the cord was man- 
ually replaced. The membranes were then ruptured, and the head 
was held in position until a few uterine contractions caused engage- 
ment. A living child was born spontaneously. 
In the second case, after engagement of the head the cord pro- 
lapsed when the amniotic sac ruptured. The knee-chest posture and 
manual and instrumental efforts to replace the cord were all unsuc- 
cessful. The pulsations in the cord ceased, and a rapid forceps de- 
livery hastened by an episiotomy failed to save the infant. The third 
case accompanied a labor obstructed by a flat pelvis : Mrs. S. (Case 
No. 3806). The patient’s first pregnancy terminated in a miscarriage Richard C. Norris, M. D. 
at two months. In her second labor craniotomy was performed by Dr. 
Price at the Retreat. In her third labor she was delivered by version 
of a living child. Her fourth labor was the one in which the cord 
was prolapsed ; the membranes were ruptured, the os dilated, and the 
head was engaged when the patient entered the Retreat. At the first 
examination the pulsations in the prolapsed cord ceased while the 
examination was being made. All efforts to replace the cord having 
failed, forceps was at once applied and the child was delivered within 
five minutes. There were no pulsations of its heart. All efforts to 
revive the infant failed. The length of the cord was thirty-six inches, 
and the weight of the child seven and three quarter pounds. In the 
fourth case the prolapse of the cord occurred in the patient whose 
labor was complicated by a ventrofixation as previously described. 
This infant also perished. 
The malpresentations which have been encountered and which 
required operative treatment have been the following : A shoulder 
presentation with prolapsed arm and a right occipito-posterior posi- 
tion with prolapse of the right arm alongside the head. In the former 
a living infant was delivered successfully by version. Unsuccessful 
efforts were made in the latter case to replace the prolapsed arm. 
The patient was then carefully watched and rotation of the occiput 
was assisted and expected. This plan of treatment was especially 
indicated, since the infant’s viability was in doubt, the patient not 
having felt foetal movements for two days and the heart sounds being 
inaudible. The arm finally interfered with flexion of the head, and 
therefore with descent and rotation of the occiput. For these reasons 
forceps was applied, but with small hope of delivering a living child. 
When the child was born there was no sign of the heart’s action and 
all efforts at resuscitation failed. 
Post-partum Hcemorrhage.—There have been five cases of alarm- 
ing haemorrhage after labor. In two cases the haemorrhage occurred 
before delivery of the placenta. These two cases were twin pregnan- 
cies. In two other cases the haemorrhage occurred at intervals of one 
and one and a half hours respectively, after delivery. In the fifth 
case the haemorrhage occurred two hours after delivery. Immediate 
evacuation of the blood clots accumulated in the uterus, and a hot 
intra-uterine douche of boiled water were sufficient to check the haem- 
orrhage in all the cases except one, which required the introduction 
of iodoform-gauze packing. All the women were multiparae, and one 
was the mother of thirteen children. The puerperal period of all the 
cases was afebrile. A Report of Two Years' Work at the Preston Retreat. 
23 
Obstetric Operations. 
Indications. 
Number of 
cases. 
Infantile 
deaths. 
Forceps. 
After-coming head 
1 
O 
Eclampsia 
2 
I 
Eclampsia threatened (chronic Bright’s 
2 
i (premature 
disease). 
birth). 
Feeble heart sounds 
2 
2 
Flat pelvis 
5 
0 
Inertia uteri 
23 
1 (inspiration 
4 
pneumonia). 
Occipito-posterior presentation 
4 
0 
“ “ (occiput 
in sacral hollow) 
2 
0 
Occipito-posterior presentation (with 
prolapsed arm ; absence of the heart 
sounds) 
1 
1 
Placenta praevia 
1 
0 
Prolapse of umbilical cord 
2 
2 
“ “ “ (after ceph- 
alic version) 
1 
I 
Premature separation of placenta 
1 
1 
Total multiparas. 24 ; primiparae, 23 
47 
10 
Version 
Shoulder presentation with prolapsed 
arm (podalic) 
1 
0 
Flat pelvis (podalic) 
2 
1 
Labor complicated by ventro-fixation 
(cephalic) 
1 
0 
Total 
4 
1 
Induced labors. 
Pelvic deformity 
2 
0 
Threatened eclampsia 
3 
1 (premature 
birth). 
Total 
5 
1 
Symphyseotomy. 
Flat pelvis 
1 
0 
Episiotomy. 
To effect rapid forceps delivery 
1 
0 
Irrigation and 
Elevated temperature : subinvolution ; 
curettage. 
prolongation of bloody lochia 
9 
0 
Offensive lochia 
1 
0 
Total 
10 
0 
Sutured perinei. 
Vaginal and perineal lacerations : mul- 
tiparse, 8 ; primiparae, 36 
44 
0 
Incision of mam- 
Abscess following mastitis (mother).. . 
4 
0 
mary abscess. 
“ “ “ (infant).... 
4 
1 
Fifteen puerperal patients required the use of the catheter. 
In one case the cervix required suturing to control haemorrhage from a laceration Richard C. Norris, M. D. 
24 
Lacerations of the Vagina.—In the five hundred cases perineal and 
vaginal lacerations requiring suture have occurred forty-four times. 
In only two cases has union failed to occur. The suture material has 
invariably been silkworm gut sterilized by boiling just before being 
used. In two cases stitches have been necessary to control bleeding 
in the anterior vaginal wall near the urinary meatus. In one case 
it was necessary to stitch a laceration of the cervix to control free 
haemorrhage. The lacerations extending into the vaginal sulci are 
always repaired in the same manner as in the secondary perinoi- 
rhaphy known as Emmet’s operation on the posterior vaginal wall. 
The Puerperium. 
Fever in the Puerperium.—The analysis of the temperature charts 
of all the cases delivered in the Retreat since January i, 1894, gives 
the following results : In twenty-one per cent, of the cases the tem- 
perature has not risen above 990 F. ; in sixty-six per cent, of the 
cases the temperature has never been above ioo° F. ; in eighteen per 
cent, of the cases the temperature has been above ioo° F. not longer 
than twenty-four hours ; and in sixteen per cent, of the cases the 
temperature has remained above ioo° F. for varying periods longer 
than twenty-four hours. An analysis of the temperatures throughout 
the first eight days of the puerperium—the period embraced by most 
German statistics—shows that the temperature did not rise above 
ioo° F. in ninety-one and eight tenths per cent. In other words, the 
puerperal morbidity for the period named has been eight and two 
tenths per cent. The temperature charts are herewith exhibited to 
the Society, with the exception of fourteen, which are the charts of 
convalescent patients now in the Retreat, and with the exception of 
six charts of patients delivered early in January, 1894, which charts, 
together with the charts of all previous patients, disappeared shortly 
before I assumed charge of the Retreat. An analysis of the charts, 
showing temperatures above ioo° F. for varying periods longer than 
twenty-four hours, gives the following result: 
Temperature above ioo° F. longer than Twenty-four Hours. 
Cause of fever. No. of cases. 
Caked breasts, including also all cases of mastitis in which resolu- 
tion occurred 33 
Constipation i 
Eclampsia 3 
Emotion 5 
Exposure to cold 6 A Report of Two Years' Work at the Preston Retreat. 
25 
Cause of fever. No. of cases. 
Insanity (intercurrent delusions) X 
Malaria 6 
Mammary abscess : 
Interstitial, requiring incision 1 
Parenchymatous—a small amount of pus expressed by massage.. j 
Small abscess of areola 1 
Neuralgia: facial, 1 ; supraorbital, 1 2 
Phlegmasia alba dolens 2 
Phthisis 2 
Sapraemia X! 
In two cases there was a rise of temperature to 104° F. due to 
emotion. In one case the patient suddenly was told that her husband 
had been killed in a railroad accident, and the temperature rose from 
98.8 F. to 104° F. The following day it was normal. In another 
case the temperature rose to 104.20 F. when a patient had for several 
hours the delusion that her infant had been substituted for the infant 
of the patient who occupied the adjacent bed, and who was so alarmed 
that her temperature immediately became elevated. A temporary and 
moderate elevation of temperature (ioo° F. to 102° F.) in three other 
cases was apparently due to emotional excitement. In two cases the 
temperature rose from 990 F. to 104° F. from exposure to cold. Both 
patients left their beds on the eighth day and walked through a cold 
corridor to a closet. In four cases the exposure incident to using the 
commode caused a rise of temperature. In one case a temperature 
of 1020 F. was observed as the result of constipation. 
I here have been two cases of phthisis which complicated labor 
and the puerperal period. The charts of these cases are herewith 
presented. One case (No. 3,902), Mrs. K., entered the hospital with 
fever, cough, and expectoration of moderate severity. The relief to 
the patient’s embarrassed respiration was most marked after her de- 
livery. The temperature slowly declined until it was almost normal, 
ten days after delivery. 
The second case (No. 3,652) was that of an Indian girl sent to the 
Retreat from the Lincoln Institute. I had seen the patient with Dr. 
Cochran McClelland at the Lincoln Institute several months before 
her admission to the Retreat. At this time she was very weak and 
emaciated. She came to the hospital in active labor, and was deliv- 
ered on the day of her admission. Her early puerperal convalescence 
was trying from the fact that she had profuse pulmonary haemor- 
rhages which occasioned great prostration and weakness. Her 
strength, however, gradually improved ; her pulse averaged between 26 
Richard C. Norris, M. D. 
90 and ioo ; and, as you will observe on her temperature chart, there 
was at no time the slightest evidence of puerperal sepsis. After re- 
maining at the Retreat three weeks she was removed to the Lincoln 
Institute at the request of and by Mrs. Ashbridge, one of the mana- 
gers of that institution, who had planned to take the patient to the 
country to aid her convalescence. It has been asserted that this 
patient died, shortly after leaving the Retreat, of puerperal sepsis. 
In order that the history of this case may be complete, I have ap- 
pended a letter from Dr. Cochran McClelland, who had charge of the 
patient before she entered and after she left the Preston Retreat. 
“316 South Eleventh Street, Philadelphia, November 11, i8gy. 
“ Dear Dr. Norris : In answer to your request, permit me to say 
that the Indian girl, Nettie Roubadeau, had been suffering from 
phthisis several months prior to her admission into the Preston Re- 
treat. At the time she left the Lincoln Institute, May 14, 1894, the 
disease was far advanced; after her return, June 2, 1894, she ran 
down rapidly, and died of phthisis August n, 1894. 
“ (Signed.) Very truly yours, 
“C. McClelland.” 
Mastitis and Mammary Abscess.—The routine management at the 
Retreat of the breasts and nipples is as follows : When the flow of 
milk appears each patient wears a Murphy binder pinned in such a 
manner as to give support to the breasts, but not to compress them. 
The infant’s mouth before, and the mother’s nipples both before and 
after nursing are cleansed with a clean cloth and a saturated solution 
of boric acid. At the first appearance of sore nipples the latter are 
kept scrupulously clean and are covered with a disk of waxed paper 
upon which is spread a film of paste composed of equal parts of bis- 
muth subnitrate and castor oil with twenty grains of boric acid to the 
ounce of paste. A glass nipple shield is used if nursing is very pain- 
ful. Caked breasts are promptly relieved by massage combined with 
a cautious use of the breast pump. I have taught my nurses four dis- 
tinct manipulations in breast massage, as shown in the accompanying 
illustrations. Fig. 1 illustrates light but rapid strokes with the finger 
tips. Fig. 2 shows deeper pressure with the finger tips over an inflamed 
nodule. In Fig. 3 the hand is placed over the nodule, and pressure 
against the chest wall is alternated with gentle rotatory movements. 
Fig. 4 illustrates compression of the breast kept up so long as milk 
flows from the nipple. The first three movements are used in succes- 
sion, each for a period of about five minutes, and the manipulations A Report of Two Years Work at the Preston Retreat. 
27 
are repeated until the breast is soft and flaccid, when a firm compres- 
sion binder is applied. Massage of the breast is facilitated by anoint- 
ing the breast with camphorated or carbolated oil. I also try to 
teach the nurse the variety of mastitis in which massage is harm- 
ful—namely, the interstitial variety, which usually can be recog- 
Fig. i.—Breast massage. (Dickinson). 
nized by the following clinical signs: A gradual rise of temperature 
following a sore nipple which has refused to heal; a dull pain or aching 
in the breast rather than an exquisitely tender spot over an enlarged 
nodule ; early redness and oedema of the skin at a portion of the 
breast corresponding to the situation of the fissured nipple ; and 
sometimes slight enlargement and tenderness of the axillary glands. 
This group of clinical signs points to involvement of the connective 
Note.—The accompanying illustrations of “ Breast Massage ” are taken from An 
American Text-book of Obstetrics, by the kind permission of the publisher. 28 
Richard C. Norris, M. D. 
tissue and contraindicates all manipulations. Rest for the gland and 
the nipple is now indicated and is obtained by a Murphy binder, 
which is to give support, not compression, and under which is applied 
lead water and laudanum, and, if agreeable to the patient, an ice bag is 
kept in place outside the binder. Prompt measures are taken to heal 
the sore nipple. Forty-eight or seventy-two hours of rest will either 
cause resolution with a fall in temperature and slowing of the pulse, 
or more often the symptoms will be aggravated, indicating the forma- 
tion of pus which should promptly be evacuated. 
Parenchymatous inflammation following a caked breast and con- 
fined wholly or largely to the milk-secreting structures of the gland 
can almost always be made to undergo resolution by the skillful use 
Fig. 2.—Breast massage. (Dickinson). 
of massage and the breast pump, with early healing of the sore nipple, 
a firm compression binder, and prompt derivative action of a saline 
cathartic. Sometimes all the signs of breast inflammation subside, A Report of Two Years' Work at the Preston Retreat. 
29 
and immediately, or even after several days, a small amount of pus is 
rubbed or sucked from the breast, which is a matter of surprise to 
those who have not observed this sequel. Three of the cases of ab- 
scess included in this report were of this character. 
Fig. 3.—Breast massage. (Dickinson). 
Mastitis.—There have been four cases of mammary abscesses which 
required incision and drainage. Two of these cases were found in 
the convalescent ward when I took charge of the institution. In 
three other cases, after all symptoms of mastitis had disappeared and 
after the temperature had returned to normal, a small amount of pus 
was removed by massage. In three other cases small abscesses of the 
areola were observed. In one case, that of Mrs. C. (No. 3,940), 
whose chart I exhibit, the temperature rose to 102° F. on the sev- 
enth day. The breasts were found caked and the nipples sore. 
The woman was a very unruly patient, and invariably removed the 
breast bandages and other dressings applied to the nipples. She reso- Richard C. Norris, M. D. 
lutely refused to allow the nurse to keep the nipples clean. Despite 
all our efforts, the mastitis could not be held in check, and on the 
eleventh day pus was removed from each breast by massage. The pulse 
at no time was above ioo° F. and the parturient tract was in every re- 
spect normal. Immediately after the removal of the small amount of 
pus from the breasts the temperature fell to normal and remained so 
for four days. The patient, being ashamed of her willfulness, desired 
Fig. 4.—Breast massage. (Dickinson). 
to leave the hospital, but her request was refused, since her mother-in- 
law told me there was no one at her home to give the patient proper 
attention. An interview with her mother-in-law at the hospital caused 
a family quarrel; under the emotion and excitement the patient’s 
temperature became elevated. That evening at nine o’clock the 
woman dressed herself and eloped from the institution. Since it has 
been asserted that this patient also died of puerperal sepsis I desire 
to append as a portion of the history of this case the following letter : A Report of 1'wo Years' Work at the Preston Retreat. 
“ Municipal Hospital, Twenty-second Street and Lehigh Avenue, 
Philadelphia, A ugust 4, i8q§. 
“ Dr. Richard C. Norris, Philadelphia, Pa. 
“ Dear Doctor : Mrs. Cunningham was admitted to this hospital 
on July 27, 1895, suffering from what was believed to be scarlatina. 
The rash was very intense and of a livid color. Desquamation was 
noticed on admission, and a little later it became very profuse. The 
disease rapidly assumed a malignant type and death resulted on July 
30th. Yours very truly, 
“ (Signed.) “ W. VV. Welch, Physician in Charge." 
Since receiving this letter I have had a conversation with Dr. 
Welch in which he told me that he had carefully examined the pa- 
tient’s parturient canal to detect possible puerperal sepsis and that he 
was not able to find any evidence of such infection. His opinion was 
and is that the case was one of scarlet fever. 
The patient was admitted to the Retreat June 18, 1895, and was 
delivered June 30th. Her temperature and pulse were normal through- 
out four days before she eloped from the Retreat July 15th. I vis- 
ited the patient at the request of her husband after she returned to 
her home. Her breasts were giving her trouble and the child was ill 
with vomiting and purging. The woman refused to permit lancing 
the breasts. 
A day or two later I referred the case to Dr. H. W. Hassel. A 
few days later the patient was referred to the city district physician. 
I never saw the patient in consultation with any physician, and sub- 
sequently hearing of her death, which was a matter of great surprise 
to me, I immediately wrote to Dr. Welch, sending him her history and 
asking the cause of death. The above letter is his reply, received 
August 5, 1895. 
The most instructive case (No. 3,807) of mammary abscess was 
that of Mrs. K., II-gravida. Until the thirteenth day of her puer- 
perium the temperature and pulse had been normal. She now be- 
gan to suffer from a sore nipple, which was soon followed by mas- 
titis, ending in the formation of a virulent mammary abscess. The 
patient had cleansed her nipples with the water used to wash her 
child after it had evacuated the bowel. Infection of the nipple from 
this water was unmistakable. The abscess which followed presented 
the most virulent characteristics of any mammary abscess I have ever 
observed. Disseminated foci of suppuration were found throughout 
the entire breast, and in the post-mammary connective tissue extend- 32 
Richard C. Norris, M. D. 
ing up to and over the left shoulder. A large number of multiple 
incisions were required to obtain free drainage. The overlying skin 
was intensely red and presented the appearance of erysipelatous in- 
flammation extending to the shoulder and to the opposite breast. 
The patient was soon profoundly septic; she was drowsy; her face 
and eyelids were pale and cedematous, and the urine now for the first 
time showed numerous casts and one third albumin by bulk. Prior 
to delivery her urine had been normal. Free stimulation was re- 
quired to tide the patient over the critical period of her disease, and 
she finally entirely recovered after a most desperate illness. The 
parturient tract was at all times normal. Pus from the mammary 
abscess was critically examined bv my friend, Dr. S. S. Kneass. The 
mode of infection indicated the possibility of the presence of the 
Bacillus coli communis, but diligent search was unable to find the 
latter. The results of the examination made by Dr. Kneass are 
shown in the following letter : 
“ January 14, i8g§. 
“ Dear Dr. Norris : A culture from the pus of the case of mam- 
mary abscess shows only an orange coccus, in all probability the 
orange pyogenic variety. Petri plate growths give pure cultures of 
the same organism, and a microscopical examination of the pus itself 
gives the same result. No streptococcus is present. I have injected 
guinea-pigs in order to test the virulence of the microbe, and will re- 
port results. Yours truly, 
“ (Signed.) Samuel S. Kneass.” 
The injection experiments failed to discover other micro-organ- 
isms. 
One case of galactorrhoea and one of polythelia should be re- 
corded. 
Curettage.—I have found it desirable in ten cases to explore the 
interior of the womb with the finger and to resort to a single intra- 
uterine irrigation, curettage, and gauze packing. This is a very much 
smaller proportion (five per cent.) than I have observed in the cases 
which I am called upon to treat outside the hospital. When pa- 
tients are delivered under aseptic surroundings with scrupulous care 
to employ a rigid antiseptic technique, the frequency for using the 
curette will certainly be small. In the cases here recorded, only one 
had an offensive discharge, and this latter case is the only one of 
offensive discharge that I have observed in my work at the Re- 
treat. This patient had a sharply anteflexed uterus which prevented A Report of Two Years' Work at the Preston Retreat. 
33 
drainage of the lochia. Excepting this case, the indications for 
exploring the uterus with the finger and using the curette have in- 
variably been a moderately elevated temperature ; the pulse rarely 
above ioo° or iio° F., and always a •subinvoluted uterus which was 
found to contain hypertrophied decidua that gave rise to prolonga- 
tion of the bloody lochia. The odor of the lochial discharge in 
these cases is not offensive, and although there is no evidence of 
putrefaction, some toxic principle is surely absorbed by the patient, 
otherwise the elevated temperature and quickened pulse are hard 
to explain. In one case an enormous amount of hypertrophied de- 
cidua was removed ; in three of the cases a sharp flexion produced 
angulation of the uterine canal, and thus interfered with free drainage 
and with uterine retraction. In two cases a blood examination final- 
ly made the diagnosis of malaria. In one case the removal of the 
gauze packing was intrusted to a nurse. One strip of the gauze 
employed was overlooked. Although the patient was up and about 
the ward, it is noteworthy that the gauze produced no elevation of 
temperature until seven days had passed, when a rise in temperature 
and intermittent uterine pains led to an investigation, which brought 
to light the fact that a strip of gauze was yet in the uterus ; the gauze 
was removed and presented a perfectly healthy odor. The uterus 
was irrigated, and within twenty-four hours the temperature was nor- 
mal and remained so. I am convinced that the use of the curette in 
such cases as I have reported is a valuable means of preventing pos- 
sible infection of serious character. An intelligent use of this in- 
strument usually requires a preliminary introduction of the finger, 
often under ether, to locate the site of the tissue to be removed, and 
thus to avoid scraping and injuring areas of the uterine cavity that 
not only do not need curetting but may, by the trauma produced, 
open avenues for widespread infection. 
Malaria.—There have been six cases of malaria complicating the 
puerperium. The diagnosis in three of the cases was made by a blood 
examination which found the malarial plasmodium. In the other cases 
a blood examination was not obtained, and the diagnosis was made 
by the absence of any sign of puerperal sepsis, by the periodicity of 
the chill and the fever, and by the efficacy of quinine. A study of 
the charts brings out a fact with reference to the ratio between the 
pulse and temperature that I have observed in other cases. I have 
never seen a case of puerperal sepsis that was not accompanied by 
greater rapidity of pulse in proportion to the temperature than is 
observed in malaria complicating the puerperium. It is not improb- 34 
Richard C. Norris, M. D. 
able that the physiological slowing of the pulse in the puerperium is 
more rapidly overcome by sepsis than by malaria. The tonic action 
of quinine upon the circulation is not enough to explain the relative 
slowing of the pulse. For example, in one of the cases the tempera- 
ture remained at 105° F. throughout twenty-four hours, and the pulse 
varied between 100 and 116. In another case the temperature re- 
mained for a time at 104° F., the pulse varying between 88 and 96. 
And in another the temperature wras 102° F., with the pulse 80. I 
believe this point is of some value in diagnosis. The necessity some- 
times of employing large doses of quinine was also exemplified. In 
one of the cases it was necessary to administer one hundred grains of 
quinine in forty-eight hours before cinchonism appeared and before 
the temperature fell to normal. In two other cases a reduction of the 
daily dose from thirty to fifteen grains was invariably followed by a 
rise in temperature and recurrence of chill. When cinchonism was 
produced a smaller dose was sufficient to control the fever. The his- 
tories of three of the cases pointed to the fact that the patients had 
suffered from malarial fever within a year. Three other patients, in 
two of whom the malarial plasmodium was found, gave no such his- 
tory. In five cases the first evidence of fever appeared on the fourth 
or fifth day. In one case there was a fluctuation in the tempera- 
ture curve from the very first day. It has been my experience that 
when very large doses of quinine are administered to a nursing 
woman the milk is likely to disagree with the child, and for this rea- 
son it is better temporarily to discontinue nursing. A daily dose of 
fifteen to twenty grains apparently produced no ill effect upon the 
child. 
Phlegmasia.—There have been two mild cases of phlegmasia alba 
dolens. In one case (No. 3,923) the patient, Mrs. H., a primi- 
gravida, had an attack of phlegmasia during her pregnancy for which 
she was treated before she was admitted to the Preston Retreat. Her 
labor was a natural one, and her temperature remained below 990 F. 
until the eighth day, when there was a gradual rise of temperature 
which remained between ioo° F. and 101° F. until the seventeenth 
day, after which time it was practically normal; the pulse very rarely 
was above 90, the average being about 85. She was kept in the hos- 
pital until the swelling of her left leg had entirely disappeared. 
In another patient (No. 3,933), with extensive varicose veins of the 
legs, a clot evidently formed in a vein in the calf of the left leg and 
gave the patient considerable pain for several days. This woman had 
phlegmasia in childhood as a sequel of scarlatina. 
Both patients left the hospital completely convalescent. A Report of Two Years' Work at the Preston Retreat. 
35 
Pathology of Early Infancy. 
Ophthalmia.—Finding that the ante-partum sublimated vaginal 
douche had been relied upon at the Retreat to prevent gonorrhoea 
ophthalmia, I was induced to rely on this means for the prevention 
of this unfortunate disease. At the end of the first eight months of 
my service three cases of ophthalmia had occurred, and a fourth case- 
developed within a few days. The infection of the latter child oc- 
curred in a very curious manner. The child’s mother had a scant 
supply of milk, and she clandestinely permitted her infant to be 
nursed by a patient whose child at the time was suffering from oph- 
thalmia. A violent attack occurred in the child thus exposed, who 
had presented no signs of ophthalmia for ten days after its birth. 
All the cases were isolated and recovered without loss of vision. 
The treatment employed was a ten-grain solution of silver nitrate care- 
fully applied to the everted eyelids night and morning, while a free 
discharge of pus occurred ; the use of atropine to secure dilatation of 
the pupil when the cornea was much involved ; hourly douches of 
boric-acid solution ; and iced compresses to reduce the swelling in 
the early stages. Hot applications were made in one case in which 
the tendency to corneal ulceration was imminent. Since the occur- 
rence of these cases—in December, 1894—the Cred£ method of in- 
stilling one drop of a two-per-cent, solution of nitrate of silver in both 
eyes of the child immediately after birth has been routinely followed. 
Of the two hundred and forty-six children delivered since that 
date, there has been but one mild case of ophthalmia, which devel- 
oped nine days after birth, and which was readily controlled by four 
or five days’ active treatment. This experience has convinced me 
that the Cred£ method of preventing ophthalmia should never be 
neglected in hospital practice. 
There have been two cases of very marked ancemia. The mother 
of one of the infants was herself very anaemic, and presented mild de- 
lusions at intervals during the puerperium. There was no haemor- 
rhage from the child’s navel or from its bowels to account for the 
pronounced anaemia. The child nursed regularly, and left the hos- 
pital in apparently good health with the exception of its pale appear- 
ance. The second case was that of a child born of a blind, poorly 
nourished, and very feeble mother. The infant was put to the breasts 
of another patient, but failed to thrive, and died within a few days. 
Two cases of infection of the umbilicus should be recorded. In 
one case, on the seventh day, the nurse noticed spasmodic twitch- 36 
Richard C. Norris, M. D. 
ing of the child’s arms and legs. The spasms were more pronounced 
on the right side, and by evening they had become general. The 
area of the umbilical wound was healthy, but deep in the cavity there 
was some thick yellow pus and dirty gray membrane. The ulcer was 
touched with a i-to-500 bichloride solution, and was dusted with 
iodoform. Bromide of potassium in two-grain doses was given every 
two hours. After forty-eight hours the spasms ceased, the umbilicus 
was healthy, and the little patient had no further trouble. 
A case of suppurative otitis was observed in a newborn infant on 
the eleventh day. The umbilicus of this child showed a slight amount 
of inflammation with a film of pus. Both the ear and umbilicus were 
kept antiseptically clean thereafter, and the discharge from the ear 
soon ceased. 
Two cases of suppuration in the tissues surrounding but not involving 
the knee joint were observed. One case was that of a child with dou- 
ble harelip and cleft palate. On the thirteenth day the right knee 
was swollen, red, and painful. Two days later the abscess was 
opened and was found not to communicate with the joint cavity. 
The pus from the abscess was examined for tubercle bacilli, as there 
was a very strong tubercular family history, but the tubercle bacillus 
was not discovered. I considered the joint abscess metastatic, possibly 
from the child’s nasopharynx, which had a muco-purulent discharge 
due to the irritation caused by feeding the child. 
The second case of abscess of the knee occurred in a child whose 
umbilicus had never presented any signs of inflammation or infection. 
The child’s mother had mastitis, and it is quite possible that infec- 
tion originated from the milk. 
Twelve cases of mastitis, four of which were followed by suppura- 
tion, have occurred in the newborn infants in spite of all precautions. 
Of the infants, five were males and seven were females. I have 
found it impossible to prevent the mother from squeezing and other- 
wise handling the child’s breast when the latter is swollen, and to 
this fact the large proportion of abscesses is doubtless due. 
One of the cases was especially interesting by reason of its re- 
markable virulence. The left breast was somewhat enlarged and 
slightly red. Within forty-eight hours pus formed beneath the skin 
and the child presented constitutional signs of serious illness. The 
pulse and temperature were respectively 190 and 104° F. Despite 
free incision, drainage, and antisepsis, the destructive inflammation 
exposed the ribs, penetrated the pleural cavity, and caused the child’s 
death within three days. I regret that a bacteriological study of this A Report of Two Years' Work at the Preston Retreat. 
37 
case was not made. The infecting agent was doubtless a very viru- 
lent streptococcus. 
Appended is a tabulated statement of the affections of the new- 
born infant that seem worth recording, and a table of infantile deaths : 
Cases. 
Recovered. 
Died. 
Asphyxia pallida 
15 
8 
7 
Anaemia 
2 
1 
I 
Pneumonia (inspiration) 
Q 
5 
4 
Omphalorrhagia 
2 
2 
Ophthalmia 
5 
5 
Infection of the umbilicus 
2 
2 
Harelip 
1 
Cleft palate 
1 
Sclerema 
1 
1 (5 days after 
leaving hosp.) 
Mastitis 
8 
8 
Mammary abscess 
4 
3 
1 
Tongue-tie 
5 
5 
Bloody discharge from genitals of female chil- 
dren 
2 
2 
Table of Infantile Deaths. Mortality, 7.02 Per Cent. 
No. of 
deaths. 
Remarks. 
Anaemia. 
I 
The infant’s mother nearly perished from lack of food 
before entering the hospital. 
Anencephalic monster. 
I 
Premature labor at 7th month of pregnancy. 
Asphyxia neonatorum : 
3 
Following natural 
delivery. 
Do., following instru- 
4 
1 case ; heart sounds inaudible before forceps applied. 
mental delivery. 
1 “ delivery during maternal eclampsia. 
1 “ prolonged labor ; forceps used on account of 
feeble heart sounds. 
1 case ; presentation right occipito-posterior and pro- 
lapsed arm. Neither foetal heart sounds nor foetal 
movements detected after labor began. 
Congenital anomaly of 
i 
Death 10 hours after delivery ; congenital cyanosis. 
heart. 
Intracranial li senior- 
2 
1 case ; death on 3d day after version for flat pelvis. 
rhage. 
1 “ rapid extraction of natural breech presenta- 
tion ; death on the 13th day. 
Death on the 12th day ; rapid suppuration exposing 
the child’s ribs in 72 hours. 
Mammary abscess. 
I 
Overlying by mother. (?) 
I 
Natural delivery ; infant healthy ; found dead in bed 
with mother on 2d day. 
Premature birth. 
4 
Births occurred prior to 7th month of pregnancy. 
Premature detachment 
r 
Heart sounds feeble before rapid forceps delivery. 
of normally situated 
Dlacenta. 
Pneumonia (inspira- 
4 
1 forceps delivery ; death occurred respectively 24,, 
tion). 
48, 6o, and 70 hours after birth. 
1 labor complicated by hydramnion. 38 
Richard C. Norris, AT. D. 
No. of 
deaths. 
Remarks. 
Prolapse of umbilical 
cord. 
3 
Rapid delivery with forceps in all the cases after 
efforts at reposition failed. 
Cephalic version in one case for labor obstructed by 
ventrofixation of the uterus. 
Stillborn and macer- 
ated. 
3 
1 case ; extensive fibroid degeneration of placenta. 
1 “ umbilical cord knotted. 
Syphilis. 
7 
The diagnosis in all cases made by autopsy and by 
maternal and paternal histories. 
Total, 
36 
An autopsy was made in each case when the cause of 
death was in doubt. 
The autopsies were made by Dr. C. W. Burr by Dr. Alfred Stengel.