Phthisis. Contrary to the usually-received opinion, it appears certain that pregnancy has no retarding influence on coexisting phthisis, nor does the disease necessarily advance with greater rapidity after delivery. Out of 27 cases of phthisis collected by Grisolle, 24 showed the first symptoms of the disease after pregnancy had commenced. Phthisical women are not apt to conceive a fact which may probably be explained by the frequent coexistence in such cases of uterine disease, especially severe leucorrhoea. The entire duration of the phthisis seems to be shortened, as it averaged only nine and a half months in the 27 cases collected a fact which proves, at least, that pregnancy has no material influence in arresting its progress. If we consider the tax on the vital powers which pregnancy naturally involves, we must admit that this view is more physiologically probable than the one generally received, and apparently adopted without any due grounds.

Heart Disease.-The evil effects of pregnancy and parturition on chronic heart disease have of late received much attention from Spiegelberg, Fritsch, Peter, and other writers. The subject has been ably discussed in a series of elaborate papers by Dr. Angus McDonald, which are well worthy of study. Out of 28 cases collected by him, 17, or 60 per cent., proved fatal. This, no doubt, is not altogether a reliable estimate of the probable risk of the complication, but, at any rate, it shows the serious anxiety which the occurrence of pregnancy in a patient suffering from chronic heart disease must cause. Dr. McDonald refers the evils resulting from pregnancy in connection with cardiac lesions to two causes: first, destruction of that equilibrium of the circulation which has been established by compensatory arrangements; secondly, the occurrence of fresh inflammatory lesions upon the valves of the heart already diseased.

The dangerous symptoms do not usually appear until after the first half of the pregnancy has passed, and the pregnancy seldom advances to term. The pathological phenomena generally met with in fatal cases are pulmonary congestion, especially of the bronchial mucous membrane, and pulmonary edema, with occasional pneumonia and pleurisy. Mitral stenosis seems to be the form of cardiac lesion most likely to prove serious, and next to this aortic incompetency. The obvious deduction from these facts is, that heart disease, especially when associated with serious symptoms, such as dyspnoea, palpitation, and the like, should be considered a strong contraindication of marriage. When pregnancy has actually occurred, all that can be done is to enjoin the careful regulation of the life of the patient, so as to avoid exposure to cold and all forms of severe exertion.

Syphilis.-The important influence of syphilis on the ovum is fully considered elsewhere. As regards the mother, its effects are not different from those at other times. It need only, therefore, be said that whenever indications of syphilis in a pregnant woman exist the appropriate treatment should be at once instituted and carried on during her gestation, not only with the view of checking the progress of the disease, but in the hope of preventing or lessening the risk of abortion or of the birth of an infected infant. So far from pregnancy contraindicating 1 1 Arch. gen. de Méd., vol. xxii. 2 Obst. Journ., 1877.

mercurial treatment, there rather is a reason for insisting on it more strongly. As to the precise medication, it is advisable to choose a form that can be exhibited continuously for a length of time without producing serious constitutional results. Small doses of the bichloride of mercury, such as one-sixteenth of a grain, thrice daily, or of the iodide of mercury, or of the hydrargyrum cum creta, in combination with reduced iron, answer this purpose well; or in the early stages of pregnancy the mercurial vapor bath or cutaneous inunction may be employed.

Dr. Weber of St. Petersburg1 has made some observations showing the superiority of the latter methods, which he found did not interfere with the course of pregnancy; the contrary was the case when the mercury was administered by the mouth, probably, as he supposes, from disturbance of the digestive system. It must be borne in mind that in married women it may sometimes be expedient to prescribe an antisyphilitic course without their knowledge of its nature, so that inunction is not always feasible.

Epilepsy. The influence of pregnancy on epilepsy does not appear to be as uniform as might perhaps be expected. In some cases the number and intensity of the fits have been lessened; in others the disease becomes aggravated. Some cases are even recorded in which epilepsy appeared for the first time during gestation. On account of the resemblance between epilepsy and eclampsia there is a natural apprehension that a pregnant epileptic may suffer from convulsions during delivery. Fortunately, this is by no means necessarily the case, and labor often goes on satisfactorily without any attack.

2

Jaundice, the result of acute yellow atrophy of the liver, is occasionally observed, and is said to have been sometimes epidemic. Independently of the grave risks to the mother, it is most likely to produce abortion or the death of the foetus. According to Davidson, it originates in catarrhal icterus, the excretion of the bile-products being impeded in consequence of pregnancy, and their retention giving rise to the fatal blood-poisoning which accompanies the severer forms of the disease. Slight and transient attacks of jaundice may occur without being accompanied by any bad consequences. Their production is probably favored by the mechanical pressure of the gravid uterus on the intestines and the bile-ducts.

Carcinoma. The occurrence of pregnancy in a woman suffering from malignant disease of the uterus is by no means so rare as might be supposed, and must naturally give rise to much anxiety as to the result. The obstetrical treatment of these cases will be discussed elsewhere. Should we be aware of the existence of the disease during gestation, the question will arise whether we should not attempt to lessen the risks of delivery by bringing on abortion or premature labor. The question is one which is by no means easy to settle. We have to deal with a disease which is certain to prove fatal to the mother before long, and the progress of which is probably accelerated after labor, while the manipulations necessary to induce delivery may very unfavorably influence the diseased structures. Again, by such a measure we necessarily sacrifice the child, 1 Allgem. Med. Cent. Zeit., Feb., 1875. 2 Monat. f. Geburt, 1867.

while we are by no means certain that we materially lessen the danger to the mother. The question cannot be settled except on a consideration of each particular case. If we see the patient early in pregnancy, by inducing abortion we may save her the dangers of labor at term-possibly of the Cæsarean section-if the obstruction be great. Under such circumstances the operation would be justifiable. If the pregnancy has advanced beyond the sixth or seventh month, unless the amount of malignant deposit be very small indeed, it is probable that the risks of labor would be as great to the mother as at term, and it would then be advisable to give her the advantage of the few months' delay.

Ovarian Tumor.-Cases are occasionally met with in which pregnancy occurs in women who are suffering from ovarian tumor, and their proper management has given rise to considerable discussion. There can be no doubt that such cases are attended with very dangerous and often fatal consequences, for the abdomen cannot well accommodate the gravid uterus and the ovarian tumor, both increasing simultaneously. The result is that the tumor is subject to much contusion and pressure, which have sometimes led to the rupture of the cyst and the escape of its contents into the peritoneal cavity; at others to a low form of inflammation, attended with much exhaustion, the death of the patient supervening either before or shortly after delivery. The danger during delivery from the same cause in the cases which go on to term is also very great. Of 13 cases of delivery by the natural powers, which I collected in a paper on "Labor Complicated with Ovarian Tumor," far more than one-half proved fatal. [In one instance in this city a lady well known to the editor gave birth to three of her four children during the existence of an ovarian tumor. The children all lived to grow up, and their mother died of her disease at the age of 75, after being repeatedly tapped during fifty years. The ovarian tumor was discovered by Dr. Benjamin Rush soon after her first child was born in 1809, and she was first tapped by Dr. Physick in 1811. In 1812, 1815, and 1818 she gave birth to the children mentioned, the third being delicate, sickly, and weighing six pounds. This last died of phthisis when 45; one still lives. According to the teaching of Mr. Lawson Tait, this may have been a parovarian cyst, and not an ovarian cystoma.-ED.] Another source of danger is twisting of the pedicle, and consequent strangulation of the cyst, of which several instances are recorded. It is obvious, then, that the risks are so manifold that in every case it is advisable to consider whether they can be lessened by surgical treatment.

Methods of Treatment.—The means at our disposal are either to induce labor prematurely, to treat the tumor by tapping, or to perform ovariotomy. The question has been particularly discussed by Spencer Wells in his works on Orariotomy, and by Barnes in his Obstetric Operations. The former holds that the proper course to pursue is to tap the tumor when there is any chance of its being materially lessened in size by that procedure, but that when it is multilocular or when its contents are solid ovariotomy should be performed at as early a period of pregnancy as possible. Barnes, on the other hand, maintains that the safer course is

1 Obst. Trans., vol. ix.

[2 Trans. Phila. Obstet. Soc., vol. i., 1873, p. 64, reported by ED.]

to imitate the means by which nature often meets this complication, and bring on premature labor without interfering with the tumor. He thinks that ovariotomy is out of the question, and that tapping may be insufficient and leave enough of the tumor to interfere seriously with labor. So far as recorded cases go, they unquestionably seem to show that tapping is not more dangerous than at other times, and that ovariotomy may be practised during pregnancy with a fair amount of success. Wells records 10 cases which were surgically interfered with. In 1 tapping was performed, and in 9 ovariotomy; and of these 8 recovered, the pregnancy going on to term in 5. On the other hand, 5 cases were left alone, and either went to term or spontaneous premature labor supervened; and of these 3 died. The cases are not sufficiently numerous to settle the question, but they certainly favor the view taken by Wells rather than that by Barnes. It is to be observed that unless we give up all hope of saving the child and induce abortion, the risk of induced premature labor, when the pregnancy is sufficiently advanced to hope for a viable child, would almost be as great as that of labor at term; for the question of interference will only have to be considered with regard to large tumors, which would be nearly as much affected by the pressure of a gravid uterus at seven or eight months as by one at term. Small tumors generally escape attention, and are more apt to be impacted before the presenting part in delivery. The success of ovariotomy during pregnancy has certainly been great, and we have to bear in mind that the woman must necessarily be subjected to the risk of the operation sooner or later, so that we cannot judge of the case as one in which abortion terminates the risk. Even if the operation should put an end to the nancy and there is at least a fair chance that it will not do so-there is no certainty that that would increase the risk of the operation to the mother, while as regards the child we should only have the same result as if we intentionally produced abortion. On the whole, then, it seems that the best chance to the mother, and certainly the best to the child, is to resort to the apparently heroic practice recommended by Wells. The determination must, however, be to some extent influenced by the skill and experience of the operator. If the medical attendant has not gained that experience which is so essential for a successful ovariotomist, the interests of the mother would be best consulted by the induction of abortion at as early a period as possible. One or other procedure is essential; for, in spite of a few cases in which several successive pregnancies have occurred in women who have had ovarian tumors, the risks are such as not to justify an expectant practice. Should rupture of the cyst occur, there can be no doubt that ovariotomy should at once be resorted to, with the view of removing the lacerated cyst and its extravasated

contents.

preg

Fibroid Tumors.—Pregnancy may occur in a uterus in which there are one or more fibroid tumors. If these are situated low down and in a position likely to obstruct the passage of the foetus, they may very seriously complicate delivery. When they are situated in the fundus or body of the uterus they may give rise to risk from hemorrhage or from inflammation of their own structure. Inasmuch as they are structurally similar to the uterine walls, they partake of the growth of the uterus

during pregnancy, and frequently increase remarkably in size. Cazeaux says: "I have known them in several instances to acquire a size in three or four months which they would not have done in several years in the non-pregnant condition." Conversely, they share in the involution of the uterus after delivery, and often lessen greatly in size, or even entirely disappear. Of this fact I have elsewhere recorded several curious examples; and many other instances of the complete disappearance of even large tumors have been described by authors whose accuracy of observation cannot be questioned.

Treatment. The treatment will vary with the position of the tumor. If it is such as to be certain to obstruct the passage of the child, abortion should be induced as soon as possible. If the tumor is well out of the way, this is not so urgently called for. The principal danger, then, is that the tumor will impede the post-partum contraction of the uterus and favor hemorrhage. Even if this should happen, the flooding could be controlled by the usual means, especially by the injection of the perchloride of iron. I have seen several cases in which delivery has taken place under such circumstances without any untoward accident. The danger from inflammation and subsequent extrusion of the fibroid masses would probably be as great after abortion or premature labor as after delivery at term. It seems, therefore, to be the proper rule to interfere when the tumors are likely to impede delivery, and in other cases to allow the pregnancy to go on, and be prepared to cope with any complications as they arise. The risks of pregnancy should be avoided in every case in which uterine fibroids of any size exist, the patients being advised to lead a celibate life.

[Fibroid tumors may so obstruct the pelvis as to make delivery per vias naturales impossible. If the obstacle cannot be forced up out of the pelvis with the hand, delivery by the abdomen will be required if the child is to be saved. This form of obstruction makes the Cæsarean operation more than usually hazardous, and likewise its modification by Porro. Ten Caesarean operations have been performed in consequence of obstruction by uterine fibroids in the United States, with the saving of four women and five children. Two fatal Porro operations have also been performed.-ED.]

CHAPTER IX.

PATHOLOGY OF THE DECIDUA AND OVUM.

Pathology of the Decidua.-Comparatively little is, unfortunately, known of the pathological changes which occur in the mucous membrane of the uterus during pregnancy. It is probable that they are of much more consequence than is generally believed to be the case, and it is certain that they are a frequent cause of abortion.

1 Obst. Trans., vols. v., xiii., and xix.