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ANTENATAL PATHOLOGY AND HYGIENE
WILLIAM GKEEN k SONS
BV U0KRI80N AND OIBB LIMITRD.
Frhruury 1002.
MANUAL
OF
ANTENATAL PATHOLOGY
AND HYGIENE-
THE FOn'US
J. W. BALLANTYNE, M.D.. F.R.C.P.E.. F.R.S.Enix.
LECTURER OS MIDWIFERY AND GYNECOLOGY, MEDICAL COLLEGE KOR WOMEN, EDINBURGH ;
LECTURER ON ANTENATAL PATHOLOGY AND TERATOLOGY IN THE UNIVERSITY OF
EDINBURGH (IWKI): EXAMINER IN MIDWIFERY IN THE UNIVERSITY OF EDINBURGH;
ASSISTANT PHYSICIAN, ROYAL JIATERNITY HOSPITAL, EDINBURGH :
HONORARY FELLOW OF THE GLASGOW OBSTETRICAL AND GYNECOLOGICAL SOCIETY,
AND OF THE AMERICAN ASSOCIATION OF OBSTETRICIANS AND GYNECOLOGISTS.
E D I N B U E G H
WILLIAM GREEN cK: SONS
PUBLISHERS
1902
\- V-'
G7.NtRAL
NAT IS ET
NASGITUB.IS
1:^309:^
Qui in ufcro est, pro jam naio habe/ur
LEGAL MAXIM
PREFACE
1 HAD hoped within the compass of one vohinie to have presented the
whole subject of Antenatal Pathology and Hygiene. It was mj
purpose to have included not only the physiology and the diseases of
the fojtus, but also the monstrosities of the embryo and the morbid
states of the germ. I have been compelled, however, to devote this
volume to Fcetal Physiology and Pathology alone, leaving Teratology
and Morbid Heredity to be treated in a separate but a companion
book, which may be regarded as Section II. of this Manual. To have
done otherwise, would have been to swell the work to an unwieldy
size and to delay its appearance unduly.
There have been many workers in this field of research, and their
work has lieen most fruitful ; but each investigator has seldom had an
opportunity of studying more than a few specimens of foetal disease
and deformity, and has, in consequence, been led to concentrate his
attention upon the special pathological conditions which came in his
way. I, on the other hand, have had the extraordinary fortune to be
able personally to examine nearly three hundred specimens, embracing
almost all the leading types of antenatal morbid states, and I have
thus been enabled to take a somewhat wide view" of the whole subject.
Further, many other workers have been generously ready to put their
own material at my disposal for inspection ; and I have also read
very widely the literature of the subject and of allied departments of
medicine and biology.
I began this work in a spirit of something very like active
curiosity, I have prosecuted it with an ever-deepening interest, and
I have brought it thus far with the growing sense that I have been
dealing with a suljject of tremendous importance for the future of
the race and the individual, with, in fact, jrrcre7itivc medicine in its
simplest and most hopeful because in its earliest aspects. If we but
knew the laws which govern antenatal health and the causes which
produce antenatal disease aud death, what might we not expect the
possibilities of Hygiene to grow to 1
In writing the book, I have honestly tried to avoid the four grounds
viii IM'.KIACK
I if Jiiimaii ignorance set ff>rth so long ago by Eoger Bacon: trust in
ina(kM|iiate autliority, tlie force of custom, tlie opinion of tlie iuex-
]pcrienced crowd, and tiic liiding of one's own ignorance with the
jiarading of a superficial wisdom. I dare not liope that I have
always succeeded ; many times I ought perliaps to liave said, " I
'111 not know," where I liave set forth higli-sounding theories: l)ut
I have done what seemed at tlie time possible.
Only one or two furtlier prefatory sentences need be added. I
iiave avoided, as far as po.ssilile, Imrdening tlie te.vt witii liibliograiiliical
references, and have endeavoured rather to cite articles which tliem-
.selves contain full lists of literature; I have, for instance, often
referred to coutril)uti<)ns of my own, which iiave appeared elsewhere,
wliidi fulfil tiiis reipiirement. In the Appendi.x will l)e found a list
of my writings on Antenatal I'athology and cognate subjects, and the
nuiidiers within brackets which appear in the text refer to this list.
Tlie historical aspects of the subject have scarcely been touched : they
are described in detail in the first volume of my work. The Diseases
i)f the Fo'.fns. Tlie illustrations are nearly all from specimens in my
own collection; but for Figs. 9, 24, 28,32-44, and 50 I am indebted
to otlier workers. The investigatirm of most of tiie specimens was
carried out in the Laboratoiy of the Itoyal College of I'liysiciaiis,
Edinldirgh.
I cannot adiMpiately express my indelitedness to my friend, Dr.
Joiix Tho.msox, who has not only read every proof with painstaking
solicitude, but has also given me advice of great value ami that
unstintedly.
To my Publisher my best thanks go freely, and they are well
deserved, for he has constantly endeavoured to meet my wisiies with
regard to every detail.
J. W. BALLANTVNK.
21 Mei.vii.i.k Stuket, EiiiNmiKJii,
January i, 1902.
CONTENTS
BOOK I
ANTENATAL IX RELATIOX TO POSTNATAL AND
^ NEONATAL rATnOL(JGY
CHAPTER I
The Novelty of Antenatal Pathology : its Definition, Emergence, and
Literature ; Age-incidence of Morbid Processes ; Divisions of Ante-
natal Life ; Scheme of Antenatal Life ; Suljdivisions of Antenatal
Pathology ; Signs and Causes of Increased Interest in Antenatal
Pathology
CHAPTER II
The Relation of Antenatal Pathology to the other Branches of Study :
Scheme of Relationships ; Relation to General Pathology ; Relation to
the Biological Sciences — Anatomy, Embryology, Physiology, Bt)tany,
and Zoology ; Relation . to the Medical Sciences — Obstetrics, Public
Health, Pediatrics, Medicine, Psychology, Dermatology, Surgery, Ortho-
pedics, and Medical Jurisprudence ; Relation to Gynecology and
Neonatal Patholog}- .......
CHAPTER III
The Postponed Effect of Antenatal Pathology ; the Antenatal Factor in
Gynecology ; Traumatism, Infection, Antenatal Conditions ; the
Antenatal Factor in the Morbid Anatomy, Symptomatology, Etiology,
Diagnosis, Prognosis, Therapeutics, and .lurisprudence of Gynecology .
CHAPTER IV
The Immediate Effect of Antenatal Pathology ; the Antenatal Factor in
Neonatal Pathology ; the Neonatal Period of Life ; Physiology of
Neonatal Life ; Physiological Traumatism of Birth, including the
Pressure Effects and the Separation Effects ; Physiological Readjust-
ment at Birth, and its Influence upon the Characters of the Maladies
of the New-ljorn Infant ; Anatonncal Readjustment ; the Antenatal
Factor and its Influence upon Neonatal Pathological Processes .
CONTKNTS
CHAITKR V
Types of Neonatal Disease, illustrating the Intrusion of the Antenatal
Factor : (1 ) Inti-acranial Traumatisms, Cephalhiematoma Ntona-
toruni, Facial Panilysis, Frarlurcs of the Long Bone?, Dislocations;
(2) Intranatal Infections, (Ijilithalniia Neonatorum, Ha>matoma of the
Stcrno-Mastoiil, M;istitis Neunatnruni . . . . .44
L'HAPTEl! VI
Tj-pes of Neonatal Disease, illustrating the Intrusion of the Antenatal
Factor (aini.) ; (3) Neonatal Infections, Tetanus Neonatorum, Ery-
sipelas Neonatorum, Sepsis Neonatorum, Hiemoglohinuria Neona-
torum, Omphalorrhagia Neonatorum ; (4) Disturbed Neonatal Re-
adjustments, Icterus Neonatorum, Mela-na Neonatorum, Keratolysis
Neonatorum, Pemphigus Neonatorum, Sclerema Neonatorum, Asphyxia
Neonatorum, Neonatal Heart Disease ; Summary . . .57
BOOK II
THE PATHOLOGY AND HYGIENE OF THE FOiTUS
CHAPTER VII
Diseases of the Foetus ; General Characters of Ffetal Life ; Contrast between
Embryonic and Fa'tal Life ; The Neoftetal Period ; Anatomy and
Physiology of the Neofirtal Period ; External, Internal, and Environ-
mental I'hanges in the Neufotal Epoch ; Fivtal (Irowth and Develop-
ment at the Successive Months of Intrauterine Life ; Summary
CHAPTER VIII
Anatomy of the Mature Fcetus. Anatomy of the Region of the Head,
Spine, Neck, Thorax, Abdomen, Pelvis, and Limbs. Anatomy of the
Umbilical Cord, Placenta, and Membranes ....
CHAPTER IX
Physiology of the Fietus : General Statements ; Sources of Information ;
Ftctal Circulation, Extra-corporeal or Placental, Intra-corporeal with
Main Current and Secondary Circulations ; Cardiac Activity, Pecu-
liarities ; Pulse ; Blood in the Fictus, Characters ; Respiration in the
Fietus .........
CHAPTER X
Physiology of the Fretus (eonl.) : Tem]ierature of the Futvis ; Chemical
Com])05ition of Fietus, Placenta, and Li(iuor Amnii ; Nutrition of the
Fatus, by Liquor Amnii, Umbilical Vesicle, and Placenta ; Secretions
of the Futus, Hepatic, Buccal, IJastric, Pancreatic, etc.; Excretions of
the Fietus, Intestinal, Renal, Placental : Passjige of Substances from"'
Fietus to Mother ; Internal (Jlandular Secretions in Fietus, of
Thymus, Thyroid, Suprarenal Capsule, and Pituitary Body ; Growth
of the Fietus, Determining Factors ; Movements of the Fictus ; Sensa-
tion in the Fietus ........
CONTENTS
CHAPTER XI
Fa'tal Pathology : General Principles. ■ Scope of Fatal Patliology ; Causes
of Limited Knowledge ; Fn-tal Morbid States ; Classification ; Causes
of Peculiarities of Fa'tal Diseases — (1) Influence of Intrauterine
Environment; (2) The Placental Factor; (3) The Embryonic Factor . 17:
CHAPTER XII
Types of Transmitted Fcetal Diseases : Frrtal Variola ; Pathogenetic Possi-
bilities ; Clinical Peculiarities ; Diagnosis, Prognosis, and Treatment.
Fa-tal Vaccinia ; Antenatal Immunity. Fcetal Measles, Scarlet Fever,
Erysipelas, Parotitis, Influenza, Pertussis, Relapsing Fever, Yellow
Fever, and Cholera. Ftetal Typhoid ; Pathogenetic Possibilities ;
Widal Test in the Fcetus. Fietal Malaria ; Observations ; Patho-
genetic Possibilities . . . . . . . 18J
CHAPTER XIII
Types of Transmitted Ftctal Diseases : Ftetal Tubercle ; Evidence of its
Existence ; Causes of its Rarity ; Characters ; Baunigarten's Theory of
Latency ; Non-tubercular Manifestations of Antenatal Tubercle ; Pro-
phylaxis ; Fcetal Sepsis ; Fietal Epidemic Cerebro-spinal Meningitis ;
Fi-etal Purpura ; Fa'tal Pneumonia ; Fujtal Anthrax ; Foetal Rheu-
matic Fever ........ ;206
CHAPTER XIV
Types of Transmitted F(otal Diseases : Fa'tal Syphilis ; Limitation of the
Subject ; Definitions of Infantile, Neonatal, and Fcetal Syphilis ;
Morbid Anatomy, General and Special ; Dystrophies of Antenatal
Syphilis ; Pathogenesis ; Nature of the Morbid Agent ; Modes of
Transmission of the Syphilitic Virus ; Effects of Fatal S3-philis ;
Modifying Influences ; Treatment ..... 225
CHAPTER XV
Types of Transmitted Toxicological Conditions : Sources of Information ;
Problems ; Lead Poisoning ; Mercurial Poisoning ; Phosphorus Poison-
ing ; Arsenical Poisoning ; Poisoning with Copper and Sulphuric Acid ;
Carbonic Oxide and Coal Gas Poisoning ; Effects of Chloroform and
Ether ; Morphin Poisoning ; Tobacco Poisoning ; Alcoholism . . 258
CHAPTER XVI
Ill-defined Morbid States of the Fcetus : in Maternal Eclampsia ; Cancer ;
Diabetes: Leukaemia; Heart-Disease, etc. ; Conclusions . . 278
CHAPTER XVII
Idioijathic Diseases of the Fcetus — Types : General F<etal Dropsy — Defini-
tion, Clinical History, Symptomatology, Morbid Anatomy, Etiology,
Pathogenesis, Diagnosis, Treatment ; General Cystic Elephantiasis of
the Fa'tus — Definition, Clinical History, Morbid Anatomy, Patho-
genesis ; Congenital Elephantiasis — Definition, Clinical Hi.story,
Symptomatology, Physical Signs, Pathogenesis, Treatment ; Congenital
Myxa'dema ; Atrophic States of the Subcutaneous Tissue
CONTKNIS
CHAPTKI! .Will
Idiopathic Diseases of the F.iaus (rout.) : Tvpes of Skin Diseases : Fwtal
Ichthyosis (Grave Form)— Definition, Synonyms, Clinical History,
Syiiiiitoiiialolony, Apjiearances (Macroscopic and Microscopic); F(i-tal
Jclithyosis (Mild I''orni) ; Tylosis Paliiiie et I'lantu- ; F(utal Keratolysis ;
Hypertricliosis ((ingeiiita— Definition, Synonyms, Recorded Cases,
(,'linical History, I'atliogenesis ; Localised Form of Hypertrichosis;
Congenital Alopecia— Clinical Characters, Pathogenesis; AntenaWl
Pemphigus or Kpidermolysis hiillosa hereditaria ; Congenital Absence
of Skin; Acanthoma or Aninioiua of the Skin .... ."JOC
CHAPTER XIX
Types of Idiopatliic Diseases of the Fietus (conf.) : Diseases of the Bones ;
Xomenclature ; Classification ; Tyjie A, Cliaracters ; Type B, Char-
acters ; Type C, Characters; Type D, E.xternal Apjiearances- Clinical
History, Pathology, Pathogenesis ; Tyjie K, Characters ; Bibliography .'534
CHAPTER XX
Types of Idiopatliic Diseases of the Fiotus (ron(.) : Diseases of the Ali-
mentary System : Fivtal Ascites, Definition, Clinical Features and
History, E.vternal Appearances, Morbid Anatomy, Etiology, Pathology,
Treatment; Fetal Peritonitis: Congenital Obiilerationof the Bile-
Ducts, Definition, Clinical History, Symptomatology, Morliid Anatomv,
Pathology, Diagnosis, Treatment ; Congenital Hy"pertro])hic Stenosis
of the Pylorus, Definition, Symjitomatology, Jlorbid Anatomy, Patho-
genesis, Treatment . . . ' . . ' . . 3.-,,-,
CHAPTER XXI
Types of Idiopathic Diseases of the Fo'tus (cont.) : Diseases of the Circula-
tory Apparatus : Fatal Endocarditis— Relation to Congenital Cardiac
Anomalies, Frequency, Etiology, Characters, Diagnosis, Associated
Malformations, Treatment ; Antenatal Atheroma : Congenital Goitre ;
Definition, Illustrative Cases, Morliid Anatomv, Clinical Kesult.s,
Treatment, Pathology, and Ktiologv ; Diseases" of the Eespirator\-
^.^■^te'i' ■ • ■ - " . . . . ". :5e9
CHAPTKI! XXII
Tyi)es of Idioiiathic Diseases of the Fu tus (mnt.) : Diseases of the Urinarv
A]iparatus : Fotal Xepliritis, Distension of tlie Bladder, Hyi>ertrophic
Dilatation of the Jiladder, Hydronephrosis, Cystic Degeneration of the
Kidneys : Di.'ieases of the CJe'nital Organs : Congenital Prolapse of the
Uterus ; Diseases of the Nervous System : Hydrocephalus ; Little's
Disease ; Congenital Chorea ; Friedreich's Ataxia ; Tliomsen's Di.-^ease :
Congenital Clouding of the Cornea .... :!7S
CHAPTER XXIII
Traumatic Morbid States of the Fietus : Fatal Fractures, ■\Vound.s. and
Dislocations; Congenital Amputations. Diseases of the Foial
Anuexa ; Placental Hiemorrhages : Fibro-Fattv Degeneration of the
Placenta ; Morbi.l States of the Umbilical" Cord ; Hvdramnios
—Definition, Clinical History, Symptomatology, Physical Signs,
Diagnosis, Prognosis, Pathology, Patliogenesis, 'Treatn'ient ; Oligo-
hvdramnion . . ' . . so-j
CONTENTS xiii
I'AUK
CHAPTER XXIV
lutrautcrine Death uf the Fcotus ; Mechauisui, Firtal Asphyxia aucl
Uneniia, Rigor Mortis, Clinical History, Symptomatology, Physical
Examination, Diagnosis, Pathology of Maceration, etc.. Abortion,
Causes of Fatal Death, Treatment " -tiW
CHAPTER XXV
Diagnosis of Fulal Morbid States: Difficulties and Scope; Antenatal
Diatrnosis, Maternal, Medical, and Reproductive History, Paternal and
Family History, Maternal Symptomatology and Physical Examina-
tion, Physical Examination of the Fi.lus ; Intranatal and Postnatal
Diagnosis ...••■•••
CHAPTER XXVI
Therapeutics of Fo'tal Diseases: Erroneous Opinions; yaUie of FieUil
Life Estimation, Appreciation; Therapeutic Fcvticide ; Possibilities
of Antenatal Therapeutics ; Postnatal Treatment of Antenatal Morbul
States ; Intranatal Hygiene and Treatment . - • .4.)!
CHAPTER XXVII
Hygiene and Therapeutics of F.etal Life : the Hospitalisation of the
Pregnant- "Plea for a Pre-Maternity Hospital"; "Sanatom de
srossesse" ; Hygiene of Pregnancy ; Diet, Occupation, Exercise^ Dress,
itc ; Medication of the Fcetus, in Syphilis, Placental Disease, >eryous
Maladies, Ha'mophilia ; Transmission of Immunity ; Ciermmal ihera-
peutics ; Conclusion .■•••••
Appendix. List of Author's Contributions
Index of Authors . . • •
Index of Subjects . . • ■
465
489
499
507
LIST OF ILLUSTRATIONS
COLOURED PLATES
I. Transverse section througli neck of Full-time Ftutus at level of
4th Cervical Vertebra . . . . . .108
II. Transverse section at level of 1st Dorsal Vertebra in same Fujtus 108
III. Transverse section at level of 6th Dorsal Vertebra in same Fretus 110
IV. Transverse section at level of 9th Dorsal Vertebra in same Fcetus 110
V. Transverse section at level of 12tli Dorsal Vertebi'a in same Fcetus 112
VI. Transverse section at level of cartilage between 2nd and 3rd
Lumbar Vertebra? . . . . . .112
VII. Transverse section at level of 1st Sacral Vertebra in same Fcetus 114
VIII. Transverse section at level of 4th Sacral Vertebra in .same Fatus 114
IX. Transverse section at level of 3rd Coccygeal Vertebra in same
Fcetus . . . . . . . .116
X. Liver from case of Fcetal Syphilis ..... 233
XL Vertical Mesial section of Fa?tus with F(.L'tal Bone Disease (Type B) 339
XII. Vertical Lateral section of trunk of Fcutus with Ascites and Dis-
tension of Bladder . . . . . ' . 355
XIII. Vertical Mesial section of Pelvis of Infant with Prolapsus Uteri . 355
XIV. Vertical Mesial section of Macerated Ftctus . . .422
FIGURES IN THE TEXT
1. Divisions of Antenatal Life ...... 8
2. Scheme of Antenatal Life . . . . . .11
3. Relations of Antenatal Pathology . . . . .18
4. Scheme of Morbid Factors ...... 24
5. Cephalhieraatoma and Facial Paralysis in New-born Infant (left
side) ......... 47
6. 7. Microscopic appearances of Desquamation of Cuticle in New-born
Infant, High and Low Powers ..... 73
8. Microscopic appearancees of Skin in Sclerema Neonatorum . . 75
LIST OF ILLUSTRATIONS
9.
10.
n.
12.
13.
14.
1.5.
10.
17.
18.
ly.
20.
21.
22.
23.
24.
25.
20.
27.
28.
29.
30.
31.
32,
34.
3J.
30.
37.
38.
39.
40.
41-
45.
40.
47.
48.
49.
50.
Embryo of 38 days — " Transition Organi.sni "—After His
Fa'tus of 50 clays (circa) .....
Scheme of Ftrlal Growtli in Length ....
Scheme of Fdtal Growlli in Weiglit ....
Scheme of Phicental (irowth in Weiglit
Scheme of Relative Devcloimient of various jiarts of Ftetus .
Outline of Unmouldeil Fcital Head ....
Outline of Head of New-born Infant ....
Sagittal Mesial section of Full-time Fa^tus
Lateral Vertical .section of Full-time Fa'tus
Coronal section of Head of Full-time Fa'tu.s, through orbits .
Coronal section of Head of Full-time Fcitus, through ears
Vertical Sagittal section of Pelvis of Male Fulltime Fotus .
Vertical Sagittal section of Pelvis of Female Full-time Fcetus
Pelvic Viscera of Si.\ Months' Female Futus .
Scheme of Fietal Circulation. After W. Preyer
Sphygniogra])liic Tracing from Infant, 5 minutes after Birth
Sphygmographic Tracing from Infant, days old
Placenta with Persistent Unil)ilical Vesicle and Vitelline ^'essels
Fcetal Variola. After Laurens ....
Section of Tricuspid Valve of Heart from case of Fa-t;il Endocarditi
Vertical Mesial section of Fii-tus with General Dropsy
Appearances of Head and Face of Fcetus with General Dropsy
33. Cystic Elephantiasis in the Fa'tus. After A. Meckel
Infant with Congenital Elephantiasis of right lower limb. After
Moncorvo . . ....
Fa'tal Ichtliyosis. After Straube ....
Fatal Ichthyosis. After Kyber ....
Skin of Palm of Hand in Fatal Ichthyosis. After Kyber
Sections of Skin in Fatal Ichthyosis, Chest and Head. After Kybc
Skin of Normal Infant. After Caspary
Skin of Infant with Ichtliyosis of Minor Degree. After Caspary
44. The Hairy Family, Vo7i Ambriis ....
Infant with Acanthoma or Amnioma of the Hairy Scalji
Microscopical Appearances of Acanthoma or Amnioma
E.vternal Appearances of Foitus with Bone Disease (Type B)
E.xternal Appearances of Fa'tus with Bone Disease (Type C)
Appearances of Lower Limbs and Pelvic Region of the same .
E.Kternal Appearances of Fatus with Bone Disease (Type D). Afte
Villa
External Appearances of Fa'tus with Bone Disease (Type E)
External Appearances of Fietus with Ascites .
Microscopic Appearances of section of Abdominal Wall fioMi same
Apjiearances of External Genitals of same
External Ai>pearances of Fatus with Congenital Goitre
80
80
94
95
90
97
100
10 1
102
103
104
105
117
lis
119
128
138
138
155
191
197
291
293
299
302
309
310
311
312
310
317
322
331
332
338
341
341
347
351
359
300
301
374
.1
MANUAL OF
ANTENATAL PATHOLOGY AND
HYGIENE
BOOK I
ANTENATAL IN EELATION TO POSTNATAL AND
NEONATAL PATHOLOGY
CHAPTER I
The Novelty of Antenatal Pathology ; Its Definition, Emergence, and Literature ;
Age-incidence of Morbid Processes ; Divisions of Antenatal Life ; Scheme
of Antenatal Life ; Subdivisions of Antenatal Pathology ; Signs and
Causes of Increased Interest in Antenatal Pathology.
Antenatal Patholocjy is to some extent a new department of medi-
cine. With it, however, as with many other new things, the novelty
consists more in the point of view froua which the subject is regarded,
and in the mode of considering it which is adopted, than in the nature
of the subject itself. From the earhest times congenital diseases and
monstrosities and morbid predispositions have been known, and to
some extent studied ; but it is only within recent years that the
information gathered together regarding them has been systematised,
and that monstrosities as well as diseases have been shown to be capable
of scientific investigation, and to be possessed of practical interest.
Antenatal Pathology, therefore, is new, but only in a limited
sense. Nevertheless, Antenatal Pathology, more perhaps than any
other branch of medical study, requires an introduction which shall
be also an explanation. To some extent it may be thought to need
a vindication — to be in want of a reason for its existence. Lately
unborn among the sciences, it has but recently seen the light, and,
like all new-born things, has a hold on life which is uncertain. Full,
no one can doubt, of great possibilities, if it be able to reach maturity ;
but apparently so weak as to suggest to the careless observer little
chance of that. Yet not so long ago was bacteriology — even as
Antenatal Pathology now is — provoking the criticism, that the study
2 ANTKNATAI. I'A TllOLOdV AM) HVdlKNE
of organisiiis so minute as t<i need tlie niicroscoiie fur tlieir detection
was hardly likely, most unlikely indeed, to jirove of licneKt to the
human race, yet pregnant all the while with surgical antisepsis and
asepsis, and with tlie marvels of serum therajieutics. Antenatal
Pathology, too, deals with small organisms — to wit, the little fu'tus,
the tiny embryo, the altogether microscopic uvum and spermato-
zoon. It thus merits the same condemnatiiiu ; it may receive a like
justification.
Definition of Antenatal Pathology.
Antenatal I'athology is concerned with all tlie morliiil processes
which act upon the organism before birth, and with the ehecls which
they produce by their action. In a narrow sense only can its limits
be defined. It deals with the pathology of the individual during his
fcetal and embryonic existence, and in this res]iect may be regarded
as the pathology of intrauterine life, and have the period of its
action limited to ten lunar months ; but manifestly any such limit-
ation is unsupported liy the known facts. It cannot be doubted
that pathological agencies are at work even before the occurrence
of impregnation, and that they produce their ellects upon the special-
ised reproductive cells before these have united together, sperm
with germ, to form the first rudiments of the individual. Further,
the great doctrme of the continuity of the germ plasm ])ushes back
the terminus a quo of the action of morljid agents beyond the
innuediate progenitors of the individual, ami compels the student of
Antenatal Pathology to take into account the medical history of
earlier ancestors. Just as Ijirth marks not a beginning liut a stage
in the life of the indiviilual, so impregnation marks not a beginning
but a stage in the life of the family. Again, ami with regard now to
the terminus ad quern. Antenatal Pathology cannot be said to end
with the close of intrauterine life, for it is imjiossible to prevent
the morbid processes which occur before birth from projecting their
effects, often with disastrous results, far into the life that is after
birth. It is this projection of the antenatal into the jiostnatal which
hinders the formation of an e.xact definition of Antenatal I'athology.
It is necessary to think, not only of the effects of the action of morbid
agents upon the organism still in utero, but also of the results which
they produce upon the individual in extrauterine life. Incidentally
it may be remarked that this fact constitutes one of the most cogent
arguments in proof of the practical importance of the study of
Antenatal Pathology. Since it has come to be recognised that all
infants have not the same starting-point in their life race, so it has
been borne in upon the jmictical physician and surgeon that it may
be profitable to investigate the conditions which hinder them.
Truly it matters little that the projection of the antenatal into the
postnatal has interfered with the exactness of a definition, so long
as it has comjiellcd the attention of a medical public, until now
perhaps Init slightly inclined thereto. "Where the profession has
hung timidly back, the modern novelist has jjlunged boUlly in, and
has not hesitated to deal with any or all the problems of Antenatal
EMERGENCE OF ANTENATAL PATHOLOCiV 3
Pathology, from the trausmission of syphihs and the causation of
malformations, to the predisposition to tuberculosis and the inherited
tendency to insanity. It need hardly be said that the effect upon
the public mind has not always been for good. Disaster stares tlie
mariner in the face who sets out without rudder or compass. The
medical profession must in this matter provide the general public
with a rudder, perchance it may yet be able to supply also the
compass.
Emergence of Antenatal Pathology.
It is clear, then, that Antenatal Pathology has a novelty, wliich
consists not so much in the facts with which it has to deal, as
in the way in which they are approached, and in the standpoint
from which they are surveyed. It sets forth a new manner of
looking at old facts. The new manner is the scientific : and it
has been rendered possible by the marked advances that have taken
place in the other departments of medicine and biology. As has
been aptly said by Professor A. E. Simpson : " Antenatal Pathology
is one of the last provinces of medicine to have emerged from a
kind of mediaeval wonderland into the realm of science." This is
particularly true of a large and very characteristic subdivision of
the subject, which has been named Teratology, dealing, as it does, with
monstrosities {tcraia) and their mode of origin. It may be doubted
whether Teratology has yet emerged from its " mediaeval wonder-
land." The genera] public, it must at once be adnntted, looks upon
monstrosities to-day very much in the same way as did the general
public and the profession as well in the Middle Ages ; but it is a
trifle more tolerant of the progenitors of such prodigies. In this
respect, however, the general public is not to be too severely
censm'ed, for it is unfortunately true that many medical men,
when they meet with specimens of antenatal malformation, describe
them in a fashion that they would certainly never employ if the
case were one of nervous disease or tumour, using a terminology
which might with reason be called mediaeval. A monstrous fcetus
may, it is true, resemble, although the likeness is often far to
seek, a dog or a cat or an ape ; but in describing no other patho-
logical specimen would it be considered as sufficient or satisfactory
to rest content with such a comparison. Yet in many reported cases
of monstrosity the morbid anatomy is dismissed with a brief refer-
ence to a dog-like or frog-like look, while many lines of print are
devoted to the story of an alleged maternal impression during the
pregnancy of which the malformed infant was the product. If this
be so in the profession, what reason, then, is there for wonder if in
the public mind a veil of mystery shroud tlie birth of a monstrous
fcetus '^
Literature of Antenatal Pathology.
It has to be borne in mind that Antenatal Pathology has not
emerged directly out of the ignorance of the Middle and l3ark Ages ;
it has not sprung full of life immediately out of dead superstitiims
4 ANTKNATAL PA THOI.CXiY AND HYGIENE
and curious i|uestioiiiiig.s uf the folk-lore kind. Eather has it arisen
out of a sea of books and monograplis, out of u perfect ocean of
literature. In this ocean, as may well be imagined, there is much
that is of little worth ; nevertheless, the searcher will now and
again bring up in his net something that is of j>rime import. In
it.s alnsuuil depths are the teratological records of Chaldea (70),'
written in cuneiform character on the Ijrick tablets of the great
mound of Koyunjik near tiie Tigris, containing a long list of mon-
strous infants, with the divinatory meaning of each one of them :
for teratoscopy had reached a high development in Ijabylonia, and
the fall of a kingdom, the winning of a battle, and the occurrence
of a famine, and nmch else, were foretold from the birth of a
malformed fu'tus. Vanisiiing traces of the teratological occur-
rences of primitive times among primitive peoples are also to be
found in the deformed deities which the heathen ignorantly wor-
ship, and in the folk-hn-e of many nations. Of all the valualde
things rescued from the bibliographic sea of teratological literature,
nothing is of just so much value as the part of Aristotle's works
which deals with monstrosities, both human and of animals. In
the " Generatio " and the " Historia AnimaHum " is displayed a
knowledge of the meaning and cause of malformations such as
was not equalled in later history till the times of the Saint-
Hilaires, in tlie dawn of the nineteenth century. In the writings
that have come down to us under the name of Hippocrates, there
is not much tliat concerns monstrosities, but there are admirable
descriptions of congenital dislocations, and disquisitions on morbid
heredity, which cannot fail to interest the antenatal pathologist
(83). These things, however, are all deep down in the ocean of
literature, and it is not till we come near to the surface tliat
there is again much of value to reward our search. From 300
B.C. to 1700 A.D., works on monstrosities (it is imjiossible to men-
tion works on ftetal disease and morbid predisposition, for they
did not exist) have a value which is quite apart from the cases
and specimens which are described in them ; they throw interesting
side-lights upon the manners, customs, and beliefs of the times ; but
as to scientific Teratology they are singularly dark. During these
centuries deformed fictuses took their place alongside comets, earth-
quakes, showers of frogs, mock suns, and the like : aiul were com-
monly regarded as prodigies, or as warnings of impending evil, or
as manifestations of the divine anger. From the lieginning of the
eighteenth century scientific works on monstrosities began to appear,
and have continued to appear, until now one may easily gather together
many hundreds of treatises, atlases, monographs, theses, and articles
dealing with teratological subjects. In 1702, also, there appeared
the first separate work treating of ftctal diseases, as distinguished
from monstrosities, the treatise namely of Diittel, entitled "De
morbis fo'tuum in utero materno," and presented for the degree of
medicine in the University of Halle, under the presidency of F.
' The figures within parentheses refer to the bibliographical list of the author's
published works.
AGE-INCIDEXCK OF MOURIIJ I'ROCKSSES 5
Hoffmann (66). Since then the study of tlie diseases of the foetus,
as distinct from tlie monstrosities, has made great advances, until
now there has been accumulated a large library of books bearing
on this subdivision of Antenatal Pathology. Still more near the
surface of the ocean of literature (to return for a moment to our
comparison) lie the works in which the morbid predispositions to
diseases and deformity, and the mysterious phenomena of heredity,
are considered ; in them is to be found much that is of value, along
with much that is at the best hypothetical.
This, then, is the literature of Antenatal Pathology, or rather it is
the literature upon which it is hoped that the subject of Antenatal
I'athology may yet be built up ; for few, if any, attempts have been
made to bring together the monstrosities, and the fcetal diseases,
and the morbid predispositions, and treat them as subdivisions of
one separate and self-contained department of medicine. It is in
this that the novelty of Antenatal Pathology consists ; the subject is
surveyed from a new point of view, with a vastly widened horizon.
The Age-Incidence of Morbid Processes.
It is conceivable that morl.iid influences may act upon the
individual during thi-ee epochs in his existence : they may act after,
during, or before birth. In other words, their influence may be
exerted in postnatal, in intranatal, or in antenatal life. The results
of their action vary with the period during which they act, and hence
it conies that there is a postnatal, an intranatal, and an antenatal
subdivision of pathology. It goes without remark that it is about
postnatal pathology that most is known, for from birth up to death
morbid causes are seen at work, and their effects are patent to all.
Injuries, poisons, microbes, and parasites all play a part in producing
the numerous and varied changes in the structure and functions of
the body so fully described in medical and surgical text-books.
When pathology is spoken of, it is usually postnatal pathology tliat
is meant.
Even in postnatal pathology the age-incidence of morbid processes
can be i-ecognised as an important subdividing factor ; differences
tliere are between the pathological changes which are characteristic
of advanced age and those which occur in adult life, or in childhood,
or in infancy. The rheumatism of childhood, for instance, is very
different in its clinical manifestations from that of adult life. In the
former, erythema marginatum and papulatum, painless subcutaneous
nodules situated over the bony prominences of the knee, elbow, ankle,
and spine, and endocarditis and chorea are marked symptoms ; while
acute pain and tenderness in the joints, high fever, and profuse
sweating are often entirely absent. In the rheumatism of adult life,
on the other hand, erythemata, nodules, and cliorea are uncommon,
while grave arthritic developments are frequent. Heart disease also
differs in its characters according as it is met with in the child or
adult ; and there is the typical senile heart.
The differences, however, which mark off these epochs of post-
AM I'.NATAI, 1'A111()I.()(;Y AND llVdll'.NE
iiiital patholugifal life frmii inie ancjllier are small when contiasttil
with the characters whicli serve to distinguish neonatal from post-
natal niorhid chani^es, ami very small indeed when jjut alongside the
ileep-seated diversity of antenatal jiathology. The difi'erences found
in the diseases of tiie new-born have given origin to a separate nomen-
clature for them, a neonatal nosology ; and we speak of icterus
neonatorum, sy])hilis neonatorum, and mela-na neonatorum as if they
were superficially difl'erent, at any rate, from the jaundice and the
sypliilis and the mehena of the adult. But such dissimilarity exists
between the pathological phenomena which occur before birth, and
those which are met witli after it, as to suggest essential diHerences
in mxture and causation. This is specially true of teratological
phenomena. They are startlingly unlike anything else in the whole
range of piathology. Jt is to this peculiarity more than to any other
that Teratology owes the isolated position that it has so long occupied.
Like Corea among the nations has Teratology been among the sciences :
a hermit kingdom, a hermit science ! To the onlooker it has seemed
as if neither had any part to play outside its own narrow limit.s. Yet
is the whilom hermit subject capable of profoundly influencing the
other departments of medical research and of being influenced by
them. As the subject opens out we shall see in detail what these
age-incidence ditlerenees in pathology consist in ; meanwhile, it may
be repeated that from this standpoint there is a pathology of post-
natal life, of intranatal life, and of antenatal life.
The Divisions of Antenatal Life.
On first thoughts, the nine months of intrauterine life and the
twelve hours of intranatal transition seem small and of little imp(irt
in comparison with the threescore and ten years to which it is
expected that postnatal life may be prolonged. It is doubtful, how-
ever, if any twelve hours after birth are just so full of possibilities,
physiological and pathological, as is the time during which the foHus
is passing through the maternal canals ; and it is certain that no
period of nine mouths in childhood, in adult life, or in old age is so
replete with occurrences, so diverse in kind, and of such far-reaching
importance as is that spent by the unborn infant in utero. Thei'e
is an intensity and a variety in the processes of antenatal life which
have no equal at any other time. Therefore, notwithstanding
the shortness of intrauterine existence, it has become necessary to
sulidivide it into at least three periods, and between these there is the
same deep-seated diversity as that wiiich marks off antenatal life
from the rest of life. Further, it is no exaggeration to say that few
medical men have a very clear conception of the ]irogress of events
during antenatal life. The drama of embryonic and ftetal develop-
ment and growth is, so to speak, going on, but the curtain has not
been rung up, and the spectators get only confu.sed impressions from
the swaying of the drop-scene and from vague sounds, excursions and
alarms, coming from behind it : yet no one doubts the existence of
great activity post cortina^n thcatri, and some from superior know-
DIVISIONS OF ANTEXATAL LIFE 7
leds^'e can judge how preparations are progressing. The accompanying
scheme of the divisions will serve, taken in conjunction with the
descriptive notes, to give to the mind a somewhat clearer conception
of the chronology of the period of preparation for the great events of
postnatal life : it ^vill take the place of the prologue in explaining the
action of the to be enacted drama (Fig. 1).
In constructing the scheme 1 have employed the " space-for-
time ■' method introduced into medical case-recording by Mr. Jonathan
Hutchinson, and described by him in 1896 {Aivh. Stirr/., 1896, vol. vii.
p. 199). By this plan, all periods of time are repu'esented in the
schedule by equal e.xtents of space, no time is left out, and the whole
duration of the antenatal epoch, with its various events in their proper
places, is brought correctly before the eye. Each interspace in
the scheme represents a week ; and as pregnancy lasts normally for
forty weeks, there are forty interspaces intervening between its
beginning and end ; but as the month following birth is much
influenced by what has happened before birth, and is, indeed, a
transition period between antenatal and postnatal life, it also has
found a place in the scheme, and has four interspaces. Above the
neonatal period are to be imagined the many spaces indicating the
many weeks of postnatal existence. The great physiological event of
neonatal existence is the adaptation of the organism to its new environ-
ment ; the fcetus is suddenly brought into surroundings which demand
the functional awakening of several organs which have in intrauterine
life been almost if not quite dormant, and structures which have been
active have to atrophy, lie absorbed, or be utilised for other than their
antenatal purposes. Extrauterine life is linked, as it were, to intra-
uterine by this short period of the new-born infant.
Immediately Ijefore the neonatal period (below it, therefore, in the
schedule ), and separated from it by the event of birth (indicated in
the schedule by a thick lilack line), is the fatal epoch. This occupies
by far the largest part of pregnancy ; without reckoning the neofo^tal
period, it extends from the eighth to the fortieth week, or thirty-two
weeks. During its progress the organism shows its vitality chiefly
by growth along lines which have been already definitely laid down.
In this respect it resembles the postnatal periods of infancy and
youth. It is true that the intrauterine environment has very dis-
tinctive and peculiar characters — the unborn infant exists in a fluid
medium of practically constant temperature, it is protected from
traumatism by the maternal structures, and it is shut in from the
light ; further, the fcetus has several of its organs almost inactive,
and its most important and most active organ, the placenta, is extra-
corporeal ; nevertheless, the chief phenomenon of fcetal life is growth,
rapid and continuous, along lines already indicated. Within seven
(calendar) months, which is the length, roughly speaking, of fcetal
life in the human subject, the organism increases from a structure
1 in. in length to one measuring 20 in., and its increase in weight
is from 1 oz. to 7 or 8 lbs.
During the cmhryonic period of antenatal life, which may be said
to begin with the laving down of the first rudiments of the embryo
8 ANT]:NAT.\I, l-ATllOUKiV AM) HV(;iKNK
FIG. 1.
THE DIVISIONS OF ANTENATAL LIFE
/
X
DIVISIONS OF ANTENATAL LIFE 9
iu the embryonic area of the blastodermic vesicle, and to end about
the close of the sixth week of intrauterine life, a very different pro-
cess is going on. Tiiere is growth, as in the fcetal period ; it is not,
however, simple increase, but evolution or development that is the
striking feature of the life of the embryo. The lines along which
future growth is to take place are nearly all fixed during the embryonic
period ; the outstanding phenomenon is the putting up of the scaflbld-
ing of the future body ; the vitality of the period shows itself in
organ formation or organogenesis. As in the history of the rise of a
great modern city, there is record of a stage in which the mam avenues
of traffic are sketched out, and natural olistacles overcome or utilised, to
be followed by a period during which growth goes on along the lines
of the plan ; so in the story of antenatal life there is the embrj-onic
period, in which the cellular elements are arraiiged in groups to form
organs, to be followed by the ftetal, iu which these organs simply
increase in size, and by their functional activity (in some instances)
lead to the growth of the whole organism. This embryonic epoch has
a duration of about five weeks, or, if the neofcetal period be included,
of about seven weeks. The neofivial is a sort of transition time during
which the placental circulation and economy are being fully
established ; in the scheme it has had two interspaces (two weeks)
allotted to it. Embryonic life, therefore, like foetal life, ends with a
transition time or period of adaptation to new conditions ; in the one
case, to the changes consequent upon the organism l:)econiing a
placentally nomished one, and in the other to the much more
radical clianges which atmospheric respiration and gastric digestion
entail.
Tiie earliest period of antenatal life is the germinal, and only a
small part of it, at its close, comes into the epoch of intrauterine
existence. It has a long, a very long primary dual period, during
which a semi-independent life of a cellular kind is going on in the
male and female reproductive cells, the ovum and the spermatozoon.
In the scheme a dividing line indicates this primary dual character of
early germinal life. The close of the dual period is marked in the
case of the ovum by the phase of maturation, and in that of the sperm
by the little known but probablj' analogous phenomena of spermato-
genesis. Then follows the anteconceptional period, during which there
is dehiscence of the ovisac in the female with passage of the ovum
along the Fallopian tube towards the uterus, and the spermatozoa are
deposited in the vagina ; insemination ends this and begins the next
period (intraconceptional), in which it may be said that ovular and
sperminal life run together iu impregnation. Inasmuch as it is known
that in.semination and impregnation are not of necessity simultaneous,
I have thought it well to leave half an interspace (half a week) in the
scheme for this e\'ent. The rest of ger-minal life is the unifieil post-
conceptional period, during which the morula mass and the blasto-
dermic vesicle are forming, and the first traces of the embryo
appearing in the embryonic area. In the scheme, therefore, the
dividing line is absent in the postconceptional period, to signify its
unified character. Germinal life may be said to pass into embryonic
10 ANTKNATAI. I'ATHOLOdV AM) IIYCUENK
about the end of tlie first week of iiiliauteiiiie existence, a fact
marked by a thick black Hne in the chart.
Thus it is seen that antenatiil Ufe can be marked olT into three
sub(hvisions — ftotal, embryonic, and germinal — of wliich two only (the
fcctal and the embryonic) fall entirely witiiin the i>eri(id of intra-
uterine existence, while one (the germinal) stretches back in its
beginnings into the cellular life of the jiarents of the individual. It
will become evident, as the study of Antenatal Pathology is jau'sued,
that each of these three periods is liable to morbid changes which are
in a sense jiecnliar to itself, that there is in fact a fo'tal, an endjryonic,
and a germinal pathology; but before this matter can be more fully
considered, it is necessary to note a somewhat important modification
which must be made in such a scheme of antenatal life as that which
has been described, if it is to represent what actually occurs.
Scheme of Antenatal Life.
The second schedule (Fig. 2) gives what may be called the
corrected scheme of antenatal life. It will probably have already
struck the reader that the division of antenatal existence by hard-and-
fast lines into germinal, embryonic, and fcetal periods is not free
from error. It is quite evident, for instance, that all the setting up
of scallbldings is not ended at the end of the sixth week, nor yet
indeed at the end of the thirteenth ; all organogenesis does not take
place in the embryonic period, some of it is still going on in the
fietal. One part of the organism may be in the embryonic stage
while the others are in the foetal phase. In order to represent this
fact graphically, I have carried a projection of embryonic life up
through the neofa>tal, fa'tal, and neonatal periods into the postnatal.
The skeleton and the limbs are good examples of parts of the body
whose end)ryology, so to speak, does not end with the endn-yonic
epoch ; the uterus and teeth are instances of the projection of the
endjryonic still further onwards, i.e. into postnatal life, rrobably
no two parts of the developing organism pass out of the end)ryonic
into the fojtal condition at just the same time. To revert to the
comparison I have already instituted, the progress of the growth of a
city is not equal throughout ; one part, e.g. the suburbs, may be little
more than planned when another, c.ff. the centre, is already built ; so
in the body, the evolution of the limbs is slower than the develop-
ment of tlic head and trunk. Again, the gernnnal period does not
alu-uptly stop at the end of the first week of pregnancy : the character
of abundant luxurious cell formation which so specially belongs to it
is projected through the embryonic and foetal periods, and is seen in
postnatal life normally in one organ, the reju'oductive gland, testicle or
ovary. This is indicated in the scheme, which also rejiresents in a
majihie form tlie continuitv of (he germ jilasm and of germinal
life.
DIVISIONS OF ANTENATAL LIFE
11
FIG. 2.
SCHEME OF ANTENATAL LIFE.
..NEONATAL PERIOD.
.RETAL PERIOD..
..NEOFCETAL PERIOD
■ EMBRYONIC PERIOD -
FCETAL PERIOD
- EMBRYONIC PERIOD -
(a) Ovular lite.
Sptnottagtatsia.
W 5periBln«l llle.
N
12 ANTKNATAI. I'All l()I,( )( l^' AND I1V(;1EN]-:
Subdivisions of Antenatal Pathology.
-lust as ill postnatal life there is an age incidence in disease, so that
the maladies of the infant, tiie adult, and tiie aged differ from each
other in certiiin details, so in antenatal life morbid processes take on
different characters, according as they occur in the fo'tal, in the
embryonic, or in the germinal period. There are three main sub-
divisions of Antenatal Pathology corresponding to tlie three main
subdivisions of antenatal jjhysiological life. There \ii fatal patliology,
which is concernetl with tlie diseases of tlie fo'tus ; and the diseases
of the foetus are in great measure the diseases of tlie child or adult,
modified by the peculiarities of the intrauterine surroundings and
the fu'tal economy. There is cmhryonic pathology, or, as it is more
commonly called. Teratology, which deals with the monsti'osities of
the embryo, for there is good reason to believe that morbid agencies
acting on the embryo produce not diseases but malformations and
monstrosities. "When the malformed embryo becomes a fo'tus, it
carries its malformation with it into the hctal period, and is born
with it at the full term of antenatal life ; but the malformation is not,
as has sometimes been supposed, the product of late but of early
intrauterine pathology. A third part of antenatal pathology is
concerned with the action of morbid causes upon the organism in the
germinal period, and with the results produced thereby. This may
be termed /;*'rj;( nia/ pathology. It includes the consideration of the
morbid processes which occur in the ovum at and immediately after
impregnation, and also of those that affect the re])roductive cells
(sperm as well as germ) before fertilisation : and it has probably to do
with double monstrosities (or diploteratology), hydatid moles, included
foetuses, blastoderms elliptically deformed and without embryos, and
the like. Here must also be considered the very springs of life with
their jealously guarded secrets and the hidden mysteries of heredity.
Roughly speaking, antenatal pathology may lie regarded as embracing
the study of congenital diseases, of monstrosities, and of niorliid
predispositions to disease or deformity. This subdivision of Antenatal
Pathohigy is not fanciful but real, more real certainly than the
separation of postnatal diseases into those of old age, adult life, and
childhood. Further, just as in antenatal life the three periods cannot
be sharply marked oft' from one another, so the three divisions of
Antenatal Pathology cannot be clearly delimited, but show a projection
one into another: but of this full details will be forthcoming in later
cha])ters of tliis work.
Increased Interest in Antenatal Pathology.
Of late years there have been several signs of an increasing
interest in Antenatal I'athology. A literature has grown u]> around
morbid liereility. and there has been much written on the vcxi'd
question of the possiljility of acquired characters becoming hereditai-y.
In the medical journals the number of articles devoted to subjects
of antenatal interest has greatly increased, and this has been specially
i l^'^'(VERSiTy j
INTEREST IN ANTENATAL PATHO'£6( flK)RNiJ^ l 3
noticeable in the journals of France, Italy, and the United States.
Some periodicals 1 now publish occasional periscopes of both
Teratology and Antenatal Pathology, and the subject bulks largely
in the yearly epitomes of scientific and medical investigation and
progress. In Edinburgh there is now (1900) a University Lecture-
ship on Antenatal Pathology, and lectures on the subject have also
been given (1899) in connection with the ]\Iedical Graduates' College
and Polyclinic in London ; and some years ago a quarterly journal
entirely devoted to Antenatal Pathology appeared and was continued
for two years, living long enough to demonstrate that there was at
any rate no lack of material wherewith to till the pages of such a
periodical. In a less evident but more permanent manner the ante-
natal factor has been making its presence felt in many of the branches
of medical study ; and in the diseases of the nervous system, for
instance, what may be called the teratological theory of degeneration
has of late excited miich interest.
The causes of this increased attention to matters of antenatal
interest are many and various ; they are economic, scientific, senti-
mental, practical, and political. In the first place, to take an
eminently practical cause, there has been an increase in the value
set upon fcetal life, due to the fact that in certain countries the
population is no longer going up by leaps and bounds. A falling
birth-rate and an increasing interest in Antenatal Pathology are
matters which have come together, not quite fortuitously, in the
dawn of a new centurj'. When the birth-rate begins to go down,
the value, economic as well as sentimental, of the unborn infant
begins to go up. When few infants are being born, it becomes
important that they shall come living to the light at the full term,
well-formed and healthily cajaable of independent extrauterine
existence; and these desirable conditions are evidently largely the
result of normal antenatal circumstances. When parents are un-
natural enough to determine voluntarily to limit their progeny to
two or three, it is natural enough that they should desire that the
limited family be a healthy family. " The infants are to be few,"
they say, " let them then be fine." An unworthy motive, doubtless,
but one that has drawn the attention of a nation to puericulture !
Paris has now hospitals where women can rest during the last two
months of pregnancy, for it has been found that the women who have
to do hard manual labour up to the term of gestation do not have
such healthy or such heavy infants as those who are able to rest.
Further evidence of the appreciation in the value of fcetal life which
has of late taken place, is seen in the crusade amongst obstetricians
against what is called therapeutic fa^ticide ; that is to say, against the
operations carried out on behalf of the mother which condemn the
foetus to certain or to probable death. Among such fceticidal operations
are reckoned craniotomy (and other embryulcic procedures) upon the
living fretus, prolonged and difficult forceps and version cases in
contracted pelves, and artificial premature labour. Into the questions
which this crusade has brought to the front it is not my purpose
' Archives of Pediatrics ; St. Zvuis Medical and Sunjical Jowrnal, etc.
14 ANTKNA'I'AI, 1' ATIIOLOCY AM) HY(;iKNK
here to enter : tluit there is a crusade is evidence that the life of the
fd^tuH is iiKirc lii^'hly valued. (Ireatercare is now taken to save alive
prematurely liorn infants, and Maternity Hospitals are in many cases
jirovided not only with rouvcuscs but even with specialised wet-
nurses; for witli a falling liirth-rate even the six-months fo-tus has
a certain, if undetermined, value. All these attempts to conserve
f(etal life have brought in their train a closer inquiry into foetal
physiology, and more direct investigation of the causes of fojtal
disease and deatli.
In the second place, the increasing burden, financial and otherwise,
upon tlie State, due to the presence in the community of the "unfit,"
has done something to direct attention more particularly to Antenatal
Pathology and Antenatal Therapeutics. There can be no doubt that
many of tlie unfit are congeuitally unfit: they come into the world
epile])tics or criminals or idiots or paralytics, from their mother's
womb. Manifestly it would be much better for the public lieallh and
less expensive for the State, if the jinijection of the congcnitally unfit
into societ)' could be prevented. I'reventive medicine will not have
attained to its highest developments until it has solved the problem
of antenatal prevention. I'revention in order to be truly prevention
must be antenatal. Within recent years the attempt has been made,
by means of the legal restriction of the marriage of the unfit, to ])revent
the procreation of the unfit. The attempt has had n<i conspicuous
success, a result due in part to 'the absence of accurate knowledge
regarding the laws that determine antenatal health and disease, so
that it was impossible to predict tliat the children of the unfit would
of necessity be equally or in the same way unfit. Its failure has
at least stimulated investigation into the problems of Antenatal
Pathology. In some cases, no doubt, the unfitness of the offspring
is the result of intranatal rather than antenatal causes, as is seen in
some of the obstetrical or birtli paralyses; but this fact increases
rather than diminishes our interest in the truly antenatal cases, for
the intranatally produced morbid conditions are generally more
ameualile to treatment.
In the third place, advances in other, but cognate, branches of
medical and biological science have directed attention to Antenatal
Pathology. There can be no doubt that tlie Darwinian hy))othesis of
evolution, with all the supporting or opposing theories to wiiicli it has
given rise, has, by exciting interest in lieredity, turned tlie attention of
many scientists to the problems of morliid heredity, predisjiosition. and
imnninity. Advances in embryology and in fu'tal physiology have
also done much to render possible the pronudgation of correct views
on foetal and embryonic pathology. At first tlie discover}' of the
niicrobic origin of many diseases, such as tuberculosis, tended to
divert attention from the older views of heredity ; but now the
interest is sliifting again, and discu.ssion is rife regarding, not so much
the germs of disease as the antcnatally ]ire]iared soil into wliich these
germs may fall. After many j-ears, in which the seed lias monopolised
attention, a time has arrived in which our thoughts are directed to
the soil. Even apart from this aspect of the subject, the scientific
INTEREST IX ANTENATAL PATHOLOGY 15
interest and attraction of many of tlie problems of Antenatal I'atlio-
logy, not excluding the causation of monstrosities, are N'ery real.
In the fourth place, and finally, it is to be hoped that the humane
desire to carry to the infant yet unborn some of the Ijenefits of
modern medicine and hygiene has been and is instrumental in
attracting many members of the medical profession to the study of
antenatal aflairs. In a retrospect of the medicine of the nineteenth
century, two lines of progress stand very prominently out : that which
has led to the development of gynaecology and so benefited many
millions of suffering women, and that which has produced pediatrics
and the pediatrist, and so saved much child life and ameliorated
much child suffering. jMay it not be that the twentieth century
will witness, among other good things, a wonderful extension and
development of beneficent Antenatal Therapeutics.
CHAPTER 11
The Relation of Aiiteniital Patlinlugy to the other I'lauches of Study ; Scheme
of Rehitioiisliips ; Kehition to General Pathology; Helatiou to the Bio-
logical Scienie- — Anatomy, Embryology, Physiology, Botany, and Zoology ;
Relation to the Medical Sciences — Obstetrics, Public Health, Pediatrics,
Medicine, Psychology, Dermatology, Surgery, Orthopedics, and Medical
Jurispruilence ; Relation to Gynecology and Neonatal Pathology.
Antenatal Pathology does not staud in splendid isolation among
the other departments of medical and biological science. If there
be any degree of aloofness, it is rather exhibited by the other
departments. There is indeed a very evident and constant antenatal
factor in most of the branches of medical and biological study ;
congenital diseases and deformities and morbid predispositions are
found, if looked for, playing their part and producing their etlect
in many ways in the various subdivisions of the healing art. Why,
then, bring together into one subject what is present in all the
other suljjects? Why make a new subject, when the subdivisimis
of medicine and surgery are already so numerous ? For the reason,
that there is much to be learned from such a centralisation of
knowledge regarding antenatal atl'airs, much that cannot be learned
ill any other way. Facts about antenatal conditions in Medicine,
or Surgery, or Dermatology, or Psychology, standing l)y themselves,
have not been of use in throwing light upon each other, and have
not had enough light in themselves to make their nature and origin
plain. The gathering together of all these scattered facts into one
subject, Antenatal Pathology, and the comparing of them there, one
with another, have not only added to our knowledge of tlie whole
subject, but have again increased our acquaintance witii each part
of it. The alternate assembling together and ditl'using of information
liave increased the sum of knowledge. In this respect Antenatal
Pathology may be compared to a river like the Nile, which by its
tributaries, White, Blue, ])ahr-el-Gebel, and the otiiers, draws supplies
from various soils and diflerent geological formations, sweeps them
down in one broad stream, to lie again broken ujt and redistributed
as a fructifying Hood dver all the Delta lands. It is for the good
of each deparlnient of Jledicine that the contribution which it is
able to make to Antenatal Pathology be brought alongside the con-
tributions from the other departments, and contrasted and compared
with them. Congenital conditions of the eye, or tlie ear, or the
skin, all help in making it possilde to understand the general laws
RELATIOXSHIPS OF AXTP:NATAL I'ATHOLOCiY 17
which govern Antenatal Pathology, and the understaniling of these
laws again makes it far easier to understand the special working
of them in each individual snljject. In this way centralisation, with
a view to further decentralisation, and again to recentralisation,
makes progress possible, and helps to read many a hard riddle.
But Antenatal Pathology is not equally related to all the
departments of Medicine and Biology ; it is more immediately bound
up with some than with others. Its connections, near and remote,
are represented in the accompanying scheme (Fig. 3).
With General Pathology the subject of Antenatal Pathology lias
a very intimate relation, for it is truly a part of it, although it has
received but scant recognition in many of the text-books. In the
same sense that the pathology of the skin or of the female organs of
generation belongs to Pathology, the study of the morbid changes
of the foetus anil embryo belongs to Pathology ; l_)ut in the case of
the latter the union is or ought to be an even closer one. Nearly
every pathological problem has an antenatal aspect, and it may soon
lie found necessary to revise the current views on Pathology in the
light of recent investigations into the morliid processes of embryonic
and fretal life. It seems more than likely that the whole question
of tumours and their origin will require to Ije approached from this
side : while, in such matters as immunity and predisposition, the
antenatal element must always play an important part. The rela-
tion of Antenatal, Xeonatal, and General Pathology to one another
is represented in the scheme by concentric circles. Antenatal Path-
ology is also related to the biological sciences. With Anatomy it
has a very real connection through Embryology, for the normal
and the abnormal throw light upon each other ; with Physiology
there is a bond in Fu?tal Physiology, a subject as yet comparatively
luiworked, but certain to Ije fertile in results, and through it
with Chemistry. It is chietly through the existence of a Teratology
of Plants that the subject comes into relation with Botany ; possibly
the botanist and the pathologist have not proved so mutually pro-
fitable as they might have done ; certainly Vegetable Teratology,
dealing as it does with comparatively simple structures, may be
exjiected to elucidate the problems of malformations in the animal
world. With Zoology there exists a firm bon<l (if uniiin in Ciim-
parative Teratology (the study of fcetal diseases in animals, or Com-
parative Foetal Pathology, has scarcely yet made a beginning); in
fact one can hardly separate Human and Comparative Teratology
even in thought. Over and over again Comparative Embryology
has proved of great value in clearing up moot points in Teratology,
and conversely Teratology has helped in the study of Zoology. It
may be noted here, in passing, that of late the invertelirata have
been much employed in experimental work in Teratology (Terato-
genesis). In the scheme the relations of Antenatal Pathology to
the biological sciences ai-e represented by ailjacent circles with con-
necting lines ; the arrangement speaks for itself.
But Antenatal Pathology is related not only to the liiological
but also to the purely medical sciences, and its relations in this
I
I
I
kf:lationships of antenatal pathology 10
direction are indicated diagranimatically likewise. From time imme-
morial the obstetrician has looked upon the diseased or monstrous
fietus as peculiarly in his field of study ; although, doubtless, he has
too often neglected to study it, and simply recorded, or (still
worse) only bottled it. He is the first in order of time to see speci-
mens of Antenatal Pathology, and he can enjoy the great privilege
(of which, imfortunately, he does not often avail himself) of exam-
inhig the parts of his intrauterine environment which the new-born
infant brings with him into the world, namely, the placenta, mem-
branes, and cord. Apart from the unworthy tendency to hoard,
without dissecting, the specimens which come into his possession,
the obstetrician has done much to forward the understanding of
antenatal problems. It must not be forgotten, also, that he knows
the clinical details of the ease, which are often conspicuous by their
absence in reports from the pathological laboratory ; and that by
him the way must of necessity be opened up for antenatal diagnosis.
The connection between Antenatal Pathology and Obstetrics is one
which affects not only the fcptus, but also the motlier ; for in the
maternal organisms may be found the results of morbid processes
which occurred before birth, and which are now interfering with
the birth of the ne.\t generation. Among them may be mentioned
the congenital deformities of the pelvis, due to mal-development of
the sacrum, to premature ossification of the sacro-iliac synchondroses,
to dislocation of the hip, and to the presence of antenatal exostoses
growing from the margin of the pelvic inlet : labours complicated
by these anomalies are necessarily delayed and thus rendered danger-
ous. Uterine malformations, also, such as the didelphic and sub-
septate or septate condition, do not exist in parturition without
disturbance of its mechanism. In these ways the antenatal patho-
logical history of the mother projects its infiuence into her later
postnatal life.
Through Obstetrics, Antenatal Pathology finds a connecting link
with Puljlie Health, for it is obvious that if the community is to
be strong and well alile to resist epidemics, it must be constantly
reinforced by the healthy oflspring of normal pregnancies. It is
doubtful if this, the highest development of preventive medicine,
has yet received the attention that it certainly deserves. At any
rate, the tremendously high mortality among infants of less than a
year old which prevails, goes to show that many children are Isrouglit
into the world very little fit to cope with the environmental trials
tliat there await them. Some progress has been made in the hygiene
of antenatal life, and it is recognised that certain trades and occupa-
tions are injurious to pregnant women, not solely because they
interfere witli the maternal health, but because they have an evil
influence upon the infant unborn. There is, however, much still to
be done in this Ijranch of Public Healtli.
Obstetrics is linked on to Medicine by means of Pediatrics, and
in this way a connection is established between Antenatal Pathology
and Medicine, for the study of the diseases of the child serves to
explain both the diseases of the adult and the maladies of the foetus,
20 ANTF.NATAI, I'A'lHOI.CXiY AND HYCUKNK
;ui(l 1k'1|)s also to I'ccdiicili' a]i]iar('iit <liireiuiR-e.s lictwuLMi the jiatho-
liit;ical jirocesses of ailvaiicoil jiostiiatal lifi' ami of early antenatal
life. Bill Meilieine is directly unitetl with Antenatal ralimlogy in
several ways, a])art from the connection tlirougli Olistetries. One
of tliese ways is I'syeholoiiy and the Diseases of the Xervons System ;
in fact, it is specially in the department of the maladies of tlie liraiii
and cord that the antenatal factor in medicine has lieen recognised.
Without referring to conditions such as idiocy and deaf-niutisni, the
congenital nature of which is midoubted, instances nmy he cited in
the so-called obstetrical paralyses, Thomsen's disease, epilepsy. Fried-
reich's disease, and syringomyelia. Dana, in his contribution to the
pathology of hereditary chorea {Journ. Ncrv. and Mcnt. iJi^., xxii.
565, 1895), comes to the conclusion that " the disease belongs to
Teratology"; and Fere has advanced a teratological theory to
explain the neuropathic family and its relations with heredity,
morbid predisposition, and degeneration. In other departments of
medicine the presence of the antenatal factor can also be noted if
looked for. In Dermatology, for instance, it is present, fur it is
admitted that many skin diseases, even if not actually evident
at bii-th, are predisposed to antenatally. To name only a few,
there are the various forms of ichthyosis, tylosis pahme et plant ;e,
hypertrichosis, hypotrichosis, albinismus, and the na:'vi. C(ingenital
heart disease, h;emophilia, and syphilis are conditions which pro-
foundlj' influence the whole life of the individual who is unfortunate
enough to l.)e thus luuidicajiped antenatally; and recent observations
go to show that congenital tuljerculosis is a much more imjiortant
factor in pathology than has been hitherto supposed. Chlnrosis
also, and other blood disorders, are now known to be often associated
in a very striking way with antenatal malformations.
Little requires to be said about the relation in which Antenatal
I'athology stands to Surgery. The two subjects are connected
together very obviously by the department of surgical practice
known as Orthopedics. It is a striking fact that many of the
most recent advances in surgery have been made in the rejiarative
treatment of congenital deformities and malformations, sn that at
the present time Orthopedics is one of the most jirogressive branches
of practice. Hare-lip, cleft palate, club-foot, ectopia vesica-, irnjier-
forate anus, phimosis, congenital dislocation of the hip, and cervical
tistuke are some of the antenatal morbid states that are constantly
forcing themselves upon the notice of the surgeon, and there are
many more, including several for the repair of which the operator
has yet to find a successful method. There can be no doubt, also,
that the more the causation and niode of production of deformities
are understood, the more ratiimnl will their treatment become. AVhat
has been said with regard to Cieneral Surgery might be re]ieated in
reference to the Special Surgery of the Eye, Ear, Throat, and Genitals,
for in all these specialities the antenatal factor can be traced in the
form of malformations or of congenital diseases.
Even ]\Iedical Jurispnulence or Legal ^ledicine must be counted
as a subject containing many matters ('.;/. the social and ]Hilitical
RELATIONSHIPS OF AXTEXATAI, PATHOLOGY 21
rights of so-called heniuiphrodites, questions of identity, and of
concealment of pregnancy, etc.), upon which Antenatal Pathology
can throw light.
It is therefore clear that Antenatal Pathology occupies no isolated
position among the other subjects of study, but is related, in some
instances closely, with them all. The degrees of relationshij) have
been diagrammatically represented in the scheme (Fig. 3). There
is, however, a somewhat noteworthy fact about these relations which
is not brought out in the scheme ; it is with regard to the time
after birth when the antenatally determined morbid state may make
its influence felt. In some cases, as in the diseases of the new-born
infant, the eft'ect of antenatal states is practically immediate ; in
other instances, as in the pathology of the female genital organs,
the antenatal factor is during many years inactive, or at least hidden
in its action, and it is only when reproductive life begins that
malformations or congenital diseases of the uterus and its annexa
commence to show themselves in disordered function. In the next
chapter the antenatal factor in Gynecology will be taken as a type
of the postponed action of states determined before birth upon con-
ditions existing long after birth ; the following three chapters will
be devoted to the immediate relation of Antenatal to Neonatal
Pathology.
CHAPTER III
The Postponed Effect of Antenatal Pathology : the Antenatal Factor in Gynecology ;
Traumatism, Infection, Antenatal Conditions ; the Antenatal Factor in
the Morbid Anatomy, Symptomatology, Etiology, Diagnosis, Prognosis,
Therapeutics, and Juiisprudence of Gynecology.
As was pointed out in the preceding cliaiiter, Antenatal ratholog}-
has with some of the subjects of medical practice an immeiliate
relation, and with otliers what may lie termed a remote <ir postponed
connection. It is on account of the postponed rather than of the
immediate action of the antenatal factor, however, that the attcntinn of
the medical profession has hitherto lieen drawn to the consideration
of Antenatal Patholooy. The reason is evident : in its postponed
action the science is dealing with the morbid states of adults, or at
any rate of children and youths, while in its immediate eH'ects the
foetus or embryo, or at most the new-born infant alone, is interested.
The postponed action of the antenatal factor, or, as it may be called,
the projection of the antenatal into the after life of the individual,
has, at least at first sight, the greater economic importance, inasmuch
as the life of the adult or child is of more value than the life of the
fcetus or new-born infant. Without admitting that this is the right
view, either from the high standpoint of science and morality or from
the more prosaic one nf practice, it will be convenient iiere to con-
sider this postponed action of Antenatal Pathology. I select tlie
antenatal factor in Gynecology simply because it will serve as a very
clear instance of the element of ]iostponement to which I have l)een
referring.
The Antenatal Factor in Gynecology.
"While it is generally conceded that in the etiology of gynecological
affections there are two factors of jiarann)unt importance, the trau-
matic and the infective or toxic, it is probable that too little heed lias
been given to a third factor, the antenatal. Evident traumatic and
infective causes hx\e overshadowed less evident predisposing causes ; mi
etiological factors immediately preceding the resulting diseases have f:
bulked more largely in the mind of the gynecologist than antenatal
causes, which had their origin years ago before tlie uterus and ovaiies
awoke to functional life. Yet sue!) e.xist, and it is necessary for the
full iniderstanding of gynecological jiroblems that attention be ]iaid
to the antenatal factor.
ETIOLOGICAL FACTORS IX (JYNECOLOGY 23
Traumatism and Infection.
Ill cervical, vaginal, perineal, and vulvar lacerations every one
recognises the traumatic factor. Year by year such lacerations liave
diminished in frequency, as the direct result of improvements in the
construction of obstetric iiistrunients, and of the growth of correct
opinions as to their use. There has been in the last decade a note-
worthy decrease in the number of cases calling for operation for
repair of vesico-vaginal listuLe, and instances of grave laceration of the
perineum are not so common. The great importance of the role of
the infective factor in gynecological etiology is now well established.
Every text-book devoted to gynecology and every medical journal
teems with allusions to the part played by sepsis, gonorrhoea, and
tubercle in the production of inflammatory processes in the uterus,
its annexa, and in the vagina, vulva, and pelvic cellular and peritoneal
tissues. Uterine and ovarian displacements, and hypertrophic,
atrophic, and httmorrhagic changes in the generative organs, must in
many instances Ije ascribed to this cause, acting either alone or in
conjunction with traumatism. In this group are included not only
the morbid states due to the action of micro-organisms, such as
streptococci and gouococci, but also those caused by parasites such as
echinococci and pediculi. A great part of the work of the gyneco-
logist of the present day consists in the making of attempts, sometimes
by medicinal means alone, but more often and more effectivelj* by
operative procedures, to undo the results of acute and chronic infective
conditions of the genital organs. Most of the cases which he is con-
stantly meeting can be traced in their origin either to immediate
infection or to infection following after traumatism. Further, even
in the cases in which operative interference is required for non-
infective states, such as ovarian cystomata and uterine neoplasms, it is
still infection, septic or otherwise, that the operator most dreads, and
it is against infection that his best eflbrts are directed. Xevertheless,
while all this is perfectly true, no gynecologist can be long in active
practice without perceiving that traumatism, microbic and parasitic
infection, and toxic influences do not serve to explain all the morbid
conditions and all the phenomena connected with them, which he is
every day encountering and having to treat. Ere long he suspects
the existence of another factor : this is the antenatal.
The Antenatal Factor.
By tlie antenatal factor in gynecology, I mean something more
than the existence of gross malformations of the uterus, with
tlieir etiects upon the performance of the functions of reproductive
life. These, of course, are included ; but I mean, also, all those
abnormalities in structure, predispositions towards certain diseased
processes, and inherited functional peculiarities, which there is good
reason to believe are determined antenatally, and which have often-
times so powerful an effect upon the progress of gynecological cases.
24
ANTKNA'lAI, I'A 11 lOIXXiY AND 1 1 'X i 1 KN K
The nccurrence of sucli aiininalies as atresia of tlie vaj,niia, (loul)le
utenus, and ilefeetive formation of the ovaries, is well known to every
gynecologist: every one is ahle fairly accurately to forecast what the
jn-ohahle result of this or thai malformation will be. P>nt there are
otiicr and more suljtle ways in which conditions and tendencies, jiro-
dueed before the birth of the individual, project themselves into her
later life ; these are not so generally known, at least theii far-reaching
eH'ects are not so fully appreciated. It may at once be admitted that
it i.s not possible to arrange all the morbid states which att'ect tlie
female generative organs \nider one or other of these three factors :
an etiological classification of gynecological comj)laints is not so
simple a matter. It is not practicable, for instance, to group together
all the diseases of the uterus that are due to infection, and then all
those that are due to traumatism, and then all those due to antenatal
states, in a linear series. It would
l)e coming more nearly to tiie truth
if the three factors were represented
by three circles, two of whicli (the
traumatic and the infective) liisccted
one another, while the third, the ante-
natal, touched the circumferences of
the first and second, thus :
I do not forget that other causal
factors than the three just named
liave been recognised in gynecology;
they act chiefly through the nervous
system, and consist chiefly in un-
hygienic methods of education, in
delayed marriage, in prevented con-
Yk; j ception, and in irrational modes of
dress. These errors practised by one
generation of women Ijecome the antenatal causes of defective develop-
ment of the whole system, and especially of the re])roductive organs
of tlie individuals of the next feneration.
The Antenatal Factor in the Morbid Anatomy of Gynecology.
The antenatal factor is very evident in the morbid anatomy of
gynecology. All the major malformations of the female generative
organs and nearly all the minor ones are truly antenatal in origin.
Trifling exceptions are found in the uterus pubescens,in atresia vulvre
superficialis, arising from adhesive vulvitis in infancy, and in some
hypertrophic conditions of the labia and clitoris. The various types
of doulile uterus (didelphic, liicornate, septate), the uterus unicornis,
the uterus rudimentarius, the uterus fa>talis, the minor uterine mal-
formations (incudiformis, parvicollis, etc.), and absence of the uterus;
absence and atresia of the vagina, double vagina, unilateral vagina,
and stenosis vagina; ; vulvar and hymeneal anomalies ; absence and
rudimentary development of the ovary, accessory ovaries, accessory
tubal diverticula and ostia, and rudimentarv tubes : and the various
ANTENATAL FACTOR IN GYNFXOLOGICAL PATHOI.OCiV 2.")
fmius of pseuilo-heniiapbruilitisiu ; — these are some of the admilteilly
antenatal niorhid states of the female genitals. They are dealt witli
in greater or less detail in all the text-books of gynecology (6, lo, 14).
It may be noted in pa.ssing that all these anomalies are arrestments
of normal emlnyologieal processes ; they are the expression of the
pathology of the genital organs during the stage of their evolution or
construction ; they represent morbid emljryogenesis ; and, judging by
what is known of the causation of malformations of other x>arts of the
Iwdy in the human subject and among animals, it may lie presumed
that the disturljance of embryogenesis is brought aliout liy the action
of traumatism, microbes, or toxines upon the embryo in utero.
But antenatal diseases, as well as antenatal malformations of the
female generative organs, are met with and leave their impress upon
the later history of the indi\idual in whom they occur. I have
recorded several cases (131, 197, 221) of tVetal peritonitis, and in two
of these there was displacement of the ovaries and Pallopian tubes of
such a nature that, had the infants lived to the years of reproductive
activity, they could hardly liave escaped much suffering during men-
struation, and would probably have lieen sterile. F(,etal pelvic peri-
tonitis may also lie instrumental in producing congenital or patho-
logical retroflexion or anteflexion of the uterus, with or without
concomitant shortness of the vagina and conical cervix with pin-hole
OS ; the far-reaching effects of these morliid conditions are well known
to every gynecologist. Even prolapsus uteri, with or without hyper-
trophic elongation of the cervix, has lieen found so soon after birth as
to prove that it existed potentially liefore liirth. Two cases of this
congenital form of prolapsus uteii were reported by J. Tin imson and
myself in 1897 (2o) ; these were the seventh and eighth known
examples of the anomaly, and since then four or Ave further cases
have been recorded : and it is a striking fact that in nearly all the
uterine displacement coexisted with spina bifida in the lumbo-sacral
region. These occurrences suggest that perhajis some of the instances
of prolapsus in the unmarried and in nulliparous married women may
have an antenatal origin or be antenatally predisposed to ; and,
bearing in mind the association of the prolapsus with spina bifida,
it will lie well in future to examine cases of procidentia and
descent of the uterus for spinal defects and especially for spina liifida
occulta.
Even the tumours which affect the female organs of generation
may in some instances have an origin in antenatal life. This is
especially true of the deimoid cysts, or teratomata of the ovary. These
growths are generally met with in early reproductive life, even in
some cases in childhood. Eecent researches have revealed the exist-
ence of a long series of types of dermoid cysts, showing all the
gradations, from a growth containing only some hairs and skin, to one
containmg a rudimentary liut perfectly recognisable embryo. Their
origin maj' be explained by regarding them as the result of foetal
inclusion or enclavement, or of parthenogenetic and imperfect seg-
nientation of ova in Graafian follicles : in any case, the antenatal
factor is invoked in one form or another. Further, many of the
26 AN'I'KNAIAI. I'ATIlOI.OdY AND HYCIKNE
neoi)la.snis wliit-h call for alidiuuinal section for tlieir removal in
gynecological i>racLi('e, ari.so in the cystic degeneration of structures
which existed in antenatal life, and ought to have completely atrojihied.
I refer to jiaruoiilioronic and ]>arovarian cystoniata.
The Antenatal Factor in the Symptomatology of
Gynecolog:y.
It is true that the symptuins that call atlentiim to the maladies
of the female generative organs are usually separated hy a long
interval of time from antenatal life, nevertheless they are not very
rarely due to conditions developed before hirth. The dysmenorrho a
and sterility associated with congenital Hexions of the uterus, and
with defective developments of the Graafian follicles in the ovary
from f(ptal ])elvic peritonitis, may be justly ascribed to the antenatal
factor. Similarly, dyspareunia and jirofuse hainorrhage during the
first attempts at coitus are sometimes due to antenatal anomalies in
structui-e or form of the hymen and external genitals. Anienorrho->a,
although most frequently due to physiological conditions, is yet some-
times caused by such antenatal states as rudimentary development of
the uterus, tubes, and ovaries, vaginal atresia, or hymeneal imjier-
foration, in cases of amenoiThcea in the unmarried ; therefore, the
physical examination of the genitals ought not to be too long post-
poned ; for one or other of these congenital states may exist, and, if
this be so, medicinal treatment need be no longer persisted in and time
wasted. Irregularities in menstruatinn also may be due to malforma-
tions, especially of the uterus; thus, in the double uterus, menstruation
may occur every fortnight, every month, or once in two months.
Fortnightly menstruation may be explained by the monthlj- occur-
rence of a discharge from each horn of the uterus, the dates, how-
ever, of the occiUTence not synchronising. Menstruation once in
twf) months, again, may be due to a How from one half of a double
uterus at intervals of two nKJUliis, the other half of the uterus being
imperfectly developed or imperforate, and therefore giving rise to
no discharge. It is possible that the anomalous form of dysmenor-
rhcea known as the mid-{)ain, or Mittchrhmcrz, may be occasionally
caused by uterine contractions in the imperforate half of a double
uterus, striving ineflectually to expel menstrual blood. Symptoms
])oinling ap])arently to disea.se of the nervous system may in certain
cases be the result of congenital anomalies of the genital organs, such
as adhesion of the clitoris, a condition resembling in many ways
jihimosis in the male. The history of the passiige of f;eces from tlie
vagina prf)bably jioints, in the case of the nullii>ara at any rate, to
the existence of the antenatal anomalj- known as vulvar anus.
IMeeding from the bladder at intervals of a month has been known
to lie due to vaginal atresia, and the existence of a congenital com-
munication lielween the uterus and the liladder. Examides miglit
be niulti]ilied, but sufficient instiinces have been cited to ])rove that
even in the sym]ilomatology of gynecology the antenatal factor nnist
not be neglected.
I
ANTENATAL FACTOR IN GYNFXOLOGICAL ETIOLOGY
The Antenatal Factor in the Etiology of Gynecology.
I have ah-eady referred to the presence of an antenatal factor in
the causation of the malformations of the uterus and the other
organs of generation, of the so-called pathological Hexions of the
uterus and displacements of the ovaries and tubes, and of the
ovarian dermoids and parovarian and paroophoronic cystomata ; but
there are yet other gynecological morbid states, of which the cause
must lie looked for in the life that precedes l.iirth. For instance,
extrauterine pregnancy has recently had two new theories advanced
to explain its etiology, and both of these may Ije correctly described
as antenatal. According to one, it is occasioned by the presence of
an accessory tubal ostium abdominale or of a tubal diverticulum, and
cases have been reported of ectopic gestation in which these mal-
formations have been found (Henrotin, F., et Herzog, Ii'er. dc gynic.
et dc chir. alklom., ii. 633, 189S). According to the other theory, the
power to form a decidua is normally confined to the mucous
membrane of the body of the uterus, but under certain circumstances
this power may be po.ssessed also by the mucosa of the Fallopian
tube, for both the tube and the uterus are derived from the duct of
Mtiller: it may be that through an arrest of the development of
the tulial mucous membrane it retains this decidual reaction or
power of responding to the genetic influence by the occurrence of
decidual changes. As it has been stated by J. C. Webster
("Ectopic Pregnancy," 12, 1895), "this is probably because of some
developmental fault, whereby there is reversion either of structure
or reaction tendency in the tubal mucosa to an earlier type in
mammalian evolution — I mean that in which a larger portion of the
Miillerian ducts showed decidual reaction."
Even tibro-myomata of the uterus have of late years come to be
regarded as occasionally due in some measure to antenatal causes,
and a very curious family history of the heredity of tiViroids has been
put on record by T. Spannochi {Annali di ostetricia e ginecologia,
xxi. 331, 1899). " There were three brothers, called M., S., and P. ;
of these M. and S. married two sisters, A. and B. The descend-
ants of M. and A. were free from abdominal tumours, but those
of S. and B. showed in a very striking way the tendency to
uterine fibroids, and also to heart disease. There were nine
children, of whom seven were females, and of the seven four had
fibroids, and two had also concomitant heart disease, while one of
the three who had not fibroids had a daughter who developed a
filiroid ; and of the four daughters who suffered from fibroids one had
three daughters, all of whom had fibroids and lieart disease, and of
these two were twins. The third brother. P., married a woman, E.,
not related to A. and B. : there were five daughters and six sons from
this marriage, in which, let it be remembered, that the mother had
no fibroid lierself ; two of the daughters had filii-oids, while a third
suffered from heart disease, and gave birth to three daughters, one of
whom suffered from a fibroid : further, one of the six sons married
28 ANTKNAlAl, I'ATHOLOdY AND HV(;1KNK
ami lieyat a diuigliter, wlio had botli a Kbroid tuiiimir of tlie uterus
and a t-vst nf the ovary, and she in lier turn 'j,;ivc birtli to three
daughters, one of whom liad now been operated u])on for a
uterine tibro-inyoma. In this remarkable family history, not onlj*
does there seem to have lieen a tendency to the production of
female children, with a predisposition to develop fibroids ; but
this tendency, curiously enough, seems to have been transmitted
through the males, for it affected the progeny of two brothers
married tn women of different families, and again one of tlie sons
handed it on to his daughter. T])c association of heart disease in the
family pathological legacy is also of interest, as is the twin-bearing.
Of course, this antenatally transmitted tendency to produce fibroids
is not incompatible with the theory of origin of such tumours from
the muscular coat of the small uterine arteries or from proliferating
congenital germs. It may be objected that uterine fibroids are so
common in women that the occurrence of them in the above history
might be ex]ilained in that way; but the ordinary degree of frequency
of noticeable and symjitom-producing myomata is not nearly so
great as that which prevailed in the progeny of S. and 1'. with B.
and E. Engstrom {Finska Lukaresulhkapets Handlingar, No. 12,
1899) has also noted family jirevalence and heredity in cases of
myoma uteri ; in eight instances two sisters were affected, in one
instance three sisters, in two instances two sisters and their mother,
in one instance three sisters and their mother, and in yet another
instance four sisters and their mother, had uterine fibroids.
In this relation reference may also be made to the curious family
histories in which all the female offspring either develo2)ed cancer or
were twins : and this is but another suggestion that cancer or the
tendency to it is prenatally predisposed to. Deciduoma malignum
stands in an altogether peculiar relation to antenatal life. It would
seem, according to one theory of origin at any rate, to he the result
of an engrafting of the remains of an abnormal antenatal formation,
the syncytium of a hydatid mole, in the wall of the maternal uterus.
It is, therefore, the consequence of abnormal developments, not in
the antenatal life of the woman who suffers (and may die) from it,
but in that of her progeny in utero.
The Antenatal Factor in Gynecological Diagnosis.
It is jierhaps unnecessary to insist upon the necessitj-, in making
a diagnosis in a gynecological case, to keep in mind the possible
presence of antenatal malformations of the genital organs; at the
•same time many of these malformations are so rare that even an
experienced gynecologist may not liave had the chance of seeing
more than one or two of them in a life-time. Further, the medical
periodicals contain not infrc(iuent records of errors in diagnosis which
havearisen through a wantof a just recognition of the ])ossiliility of the
antenatal factor. Thus the abdomen has been o]iened for the removal
of a uterine or ovarian tvunour, to find a pregnancy in the rudimentary
half of a uterus bicornis ; fibroids of the uterus have been mistaken
r
(
THK ANTENATAL FACTOR IN GYNEC()L()(;V 29
for inalforinatinns of that organ, and, more frequently, nialfurmations
liave been mistaken for fibroids ; and atresia of the vagina leading to
hiematometra has been diagnosticated (through insufficient examina-
tion) as a normal pregnancy, and has led to unjust imputations upon
the moiul character of the girl who has been the subject of the
vaginal anomaly. But doubtless the worst errors in diagnosis have
been due to the non -recognition of male pseudo-hermaiihrodites in
early life. The association of amenorrhoea with the secondary sex
characters of the male in an individual apparently of the female sex
should always excite the suspicion of the gynecologist who may be
consulted, and he ought to insist upon a physical examination of the
patient. J. Halliday Croom {Trans. Edin. Obsi. Soc, xxiii. p. 102,
1899) and Chiarleoni (Gi/ni'cologic, v. p. 55, 1900) have both reported
cases in which supposed sisters turned out, on physical examination,
to be really hypospadiac brothers. It is interesting to note the
family prevalence in these two cases, for in this, as in other morbid
states which the gynecologist may be called upon to diagnose, more
than one member of the same family may lie affected with the same
condition. Thus, Lolilein {Monats. f. Geburts. u. Gynclk., iii. p. 91,
1896) has referred to an instance in which three sisters all suffered
from bilateral ovarian cystoma, and in two of them development
of tlie cyst was liomochronous, i.e. commenced when the patient
reached the same age in life.
It is well to bear in mind that truly antenatal anomalies of the
genitals are apt to be found in association with want of postnatal
sexual evolutionary change, and with minor malformations of the
other parts of the body. Women showing this condition of infantilism,
as it has been termed, may therefore be expected to possess a more or
less malformed uterus, and tubes, and ovaries, an important fact for
the gynecologist to remember. They present the picture of a weakly
vertebral column, with a marked anterior concavity ; a narrow or
kyphotic pelvis ; flat nates, and a slightly marked mons ; poorly
developed labia majora leaving the labia minora and clitoris exposed ;
a vagina with some traces of its original duplicity ; a congenitally
anteflexed iiterus with a cervix showing a long posterior lip and a
shorter anterior one, leading to a long and curved cervical canal, and
a small corpus with a thick and convex posterior wall, and a thinner
and concave anterior one ; Fallopian tubes showing fretal spirality ;
tliin ligamenta rotuuda and small pointed ovaries : a cylindrical
liladder, with a pointed urachal end ; a narrow rectum ; lij'poplasia
of the heart and aorta ; a marked representative of the thymus
gland ; a small and transversely placed stomach ; a long vermiform
appendix with a wide entrance and lobulated kidneys (W. A. Freund,
Samml. Jdin. Vortrclge, Gynakologiv, No. 93, p. 2338, 1888). In the
presence, therefore, of a woman with such a habitus, the gynecologist
will be able to form a provisional diagnosis of the state of the internal
organs, and may simplify the further management of the case.
30 ANTENATAL I'ATHOlXKiV AND lIVdlKNK
The Antenatal Factor in Gynecological Prognosis.
The iuiti'iiatal factor lias occasLoiiiiUy intervened in a suniewliat
unexpected fashiou in gynecological prognosis. Thus, a case (ISlondel,
Ann. de i/i/inr., 1. 137, 1898) was reported in 1898 in which an
operator, engaged in curetting a uterus, thought that he felt the
curette pass tiirough tlie wall of the organ ; in alarm lie ceased
iiis interference, and awaited results with considerable fear; but
no ill eft'eels followed, and on a subsequent occasion he discovered
that he had lieen dealing with a double uterus, and that the curette
had simply passed from one cavity of the viscus into tiie other,
giving to the hand of the operator the sen.sation of perforation. The
removal of the ovaries, to induce a premature menopause in cases
of uterine h;emorrhage and in some kinds of nervous disease, has not
always been followed by the anticipated results, and it has been
suggested that sometimes the error in prognosis has been the outcome
of the existence of an accessory ovary or of a constricted piece of an
ovary. It must not he foi'gotten that in gynecology, as in other
dejiartments of medicine, antenatal conditions have seldom so hopeful
a prognosis as have the maladies which are developed during post-
natal life; instances of this are forthcoming in the congenital dis-
placements of the uterus, and in malformations of that organ and of
the ovaries. Freund (Lor. cit. SKjira) specially dwells ujion the prog-
nostic importance of evolutionary anomalies of the Fallo]iian tubes in
the diseases of these structures which arise in later life. For instance,
if the tubes retain the fu?tal spirality, which normally reaches its
maximum degree about the thirty-second week of antenatal existence,
it will not only interfei-e with the normal function of the tubes in
adult life, but will seriously modify the chances of successful treatment
of diseases arising in the tulies from other causes. Secretions, both
normal and pathological, will tend to accumulate in such twisted
organs, and so infection will more readily occur, or, having already
occurred, will be more intense and more widely diffused. Freund
does not hesitate to divide all the diseases of the Fallopian tul>es
into two classes, those with and these without developmental
anomalies: tiie prognosis for all things is worse in the former than
in the latter.
The Antenatal Factor in Gynecological Therapeutics.
Considerable progress has been made in the rectification of the
malformations of the genital organs which arise from antenatal
causes. The operation for imperforate hymen may be described as
perfected, and the treatment of atresia vulva' superficialis may also
be regarded as satisfactory. Further, recent improvements in the
management of atresia vagin;e and of vulvar anus have been intro-
duced ; and it may l)e noted that the opening into tlie ]ieritoneal
cavity, once so dreaded in the operation for the construction of an
artificial vagina, is now rather the auxiliary object aimed at than
I
ANTKNATAL lACTOU IN (iYNEC'OLOCV ;jl
the contretdiips avoided. At any rate, it is found advantageous
to open into the pouch of Douglas, in order to determine at once the
condition of the uterus and ovaries, and tiuis gain a guide as to the
future steps of the operation (27). It must, however, be confessed
that much still remains to be done in the reparative surgery of
antenatal defects of the genital organs in women. Even in the
management of the congenital flexions of the uterus and of the results
of ftetal peritonitis there is great roi:)ni for improvement in present-
day therapeutics. Xot only are the embryonic malformations and
the fo?tal diseases of the genital organs difficult in themselves to
treat, but the inflammatory and (.)ther morbid eonditinns of these
parts which arise in later life are always less tractable when associated
with these antenatal anomalies. For instance, salpingitis is a more
formidable process, and requires a more radical method of treatment,
when it is found in a tube with the spiral twists of ftetal life fully
preserved. "When the normal process of pregnancy takes place
abnormally in the rudimentary horn of a bicornate uterus, it calls for
the same interference as does the worst case of ectopic gestation.
The problem of the prevention of the malformations of the uterus
and its anne.xa has scarcely yet been seriousl}' investigated, for the
sutficient reason that little has been known of the mode of origin of
these anomalies. Of course, it has been recognised that arrest in
the normal process of development of the ducts of Miiller and of the
mesonephros and the anlage of the ovaries, explains the nature of
most of the malformations ; but in the absence of information con-
cerning the causes of the arrest, this knowledge avails little. Some
light, perhaps, has of late years been thrown upon the whole
question of malformations and monstrosities, jnore especially by the
methods of experimental teratogenesis ; and clinical observation has
so far given some support to the conclusions thus arrived at, namely,
that malformations are due to the causes of disease acting on the
organism during the embryonic or formative period. It is therefore
to be expected that it will yet be shown that microbes and their
toxines, and toxic agencies such as alcohol and lead and other
poisons, and possibly also traumatism, are the ultimate causes of
malformations. It may also be expected, therefore, that the
anomalies of the genital organs will be more commonly met with
in the descendants of parents who have been alcoholic, syphilitic,
tuberculai-, or otherwise unhealthy. The true antenatal therapeutics
of gynecology will therefore come to be the prevention of the causes
of disease in the preceding generation and the raising of the
standard of health in marriage. In this respect the antenatal factor
in gynecological therapeutics does not differ from that in general
therapeutics.
The Antenatal Factor in Gynecological Jurisprudence.
Certain questions in medical jurisprudence in which the antenatal
factor plays a part have already been alluded to, namely, the registra-
tion of the sex of pseudo-hermaphrodites, nullity of marriage for
32 AMl'.NAI'AI, I'ArilOl.OCY AM) IlYdllAK
malformation, etc. ; hut tliere are several other <iuestions, besides
those connected with individuals of doubtful sex, wliicli may come
into tlie law courts and reiiuire an answer from tiie specialist in
gynecology. It lias, for instance, been affirmed that a woman with
a split or lacerated cervix uteri must have been pregnant at one time
or another ; but it is plain that she might have had the cei'vix split
artiticially to permit the removal of a filjroid tumour i>r intrauterine
polypus. It is not, liowever, so plain or so generally known that
laceration of tlie cervix may be present in a new-born infant as a
congenital condition : yet this is true, for Penrose (American J. Med.
He. X.S., cxi. 50:3, 189«), Jettenson {Med. Sentinel, iv. 552, 189G), and
Kd wards ("Keating's Cyclopadia of the Diseases of Cliildren," v. 899,
1899) liave all met with undoubted cases of congenital split of the
cervix uteri witli erosion. Tlie condition is proliably an abnormality
in the arrangement of tlie mucous membrane of the cervical canal, a
congenital histological ectrojjion. In addition to its purely medico-
legal importance, it may also be that congenital laceration of the cervix
has some bearing upon the later development of cerviciil erosions in
women, and even upon the origin of cancer of the cervix uteri. One
must take great care in the witness-box not to be too emphatic in
stating which structural conditions may and which may not be com-
patible with chastity. As has been shown, even prolapsus uteri may
be met with in an infant of a few hours !
There is, therefore, in many directions a projection of Antenatal
Pathology into gynecology, although years must elapse before the
results of the events which occur before birth are seen in tlie
consulting-room of the gynecologist.
I
CHAPTER IV
The Immediate Efl'ect of Antenatal Pathology ; Tlie Antenatal Factor in Neonatal
Pathology. The Neonatal Period of Life ; Physiology of Neonatal Life ;
Physiological Traumatism of Birth, including the Pressure Effects and the
Sejjaration Effects ; Physiological Keadjustment at Birtli, and its Intiuence
upon the Characters of the JIaladies of the New-born Infant ; Anatomical
Readjustment ; The Antenatal Factor and its Intiuence upon Neonatal
Pathological Processes.
As has been pointed out in the preceding chapter, the effect which
antenatal morbid states exert upon gynecological disorders is a
jDostponed one and is not manifested for many years, during which the
genital organs and their abnormal or normal potentialities are dor-
mant. In this and in the following chapters fall to be considered the
immediate effects of antenatal pathological conditions, those which
have a bearing upon the characters of the diseases of the new-born
infant.
On the dividing line between Antenatal and Postnatal Pathology
lies Neonatal Pathology, a sort of unexplored territory, a " No Man's
Land," liable, however, to incursions from both sides, those of the
weaker kind coming over the antenatal boundary. Between the
surgical injuries and maladies of the life that is after birth, and the
diseases and deformities of the fojtus and embryo, are situated the
morbid conditions of the new-born infant, conditions which interest
both the pediatrist and the oljstetrician. Investigation of them has
indeed gone on from lioth the pediatric and the obstetric standpoint, but
with more activity, it has seemed, from the former than from the latter.
Nevertheless, it is well to bear in mind that the maladies of the new-
born have relations, not only with the diseases which occur later, but
also with the pathological states which have happened earlier in life.
Just as neonatal life is the link between j)ostnatal and antenatal life,
so Neonatal Pathology is the link lietween Postnatal and Antenatal
Pathology. It offers problems for solution which require that we
take into account both the conditions which precede and those which
follow birth ; its study, further, is helpful in throwing light on them
Iioth. That neonatal morbid states offer jieculiarities of a very
marked kind hardly calls for proof. It need only be pointed out
that, in order to emphasise these peculiarities, a nomenclature has
come into use which adds to the name of the disease the word " neo-
natorum." In this way the terms "cephalh;ematoma neonatorum," "pem-
phigus neonatorum," "icterus neonatorum," "mekena neonatorum,"
:j4 ANTIAATAL I'A TllOLOCiV AM) IIVOIENI'.
ami uiany others have got a place in medical terminology. Sometimes
the word is " nascentiiim," as in " trismus nascentium," Imt the
meaning is the same. That iicculiarities exist is not (jiiestioned, but
attempts to explain them have not been altogether satisfactory ;
possibly this failure has been due, in part at least, to the want of
recognition of the antenatal element in their origin. It w-ill be well
to consider the various possible influences which may determine the
characters of the maladies of the new-born infants, and among them
the auteualal iufluenee.
The Neonatal Period.
In every period of life physiology largely dominates patho-
logy; the diseases of the child or of the aged relleet in their
characters the physiology of childhood or of old age. The age
peculiarities of di.sease are in great measure the expression of the
age peculiarities of health. The greater the ditl'erence between the
pliysiological conditions of two epochs of life, the greater will be
the (iifCerences between their pathological manifestations. The physio-
logy of the new-born stands out very prominently from that of all
other periods of extrauterine life, and in like manner its pathology
differs markedly from that of childhood, adult life, and age.
Physiology of Neonatal Life.
The period of life which has been termed that of the new-born
infant may lie regarded as beginning with the first maternal labour
pain, and ending about the close of the Hrst month of infantile life.
It includes, therefore, a period of time which may be called intranatal,
that during which the infant is passing through the birth canal ;
and another, truly neonatal, during which the infant's body is adapt-
ing itself to its new environment. These two periods of the infant's
life correspond in time to the periods of laljour and the jiuerperium
in the mother's life ; it is for this reason that sepsis of the new-
born infant has, somewhat unfortunately, been termed by some writers
" puerperal sejisis " of the infant, " sepsis neonatorum " being a name
in every way iireferable. The intranatal period is of varying length
(from a few hours to two or three days), but is always much shorter
than the truly neonatal period. Theoretically, it may be objected that
the intranatal and neonatal periods ought not to be ]iut together under
the one heading of neonatal, as they are separated by the momentous
occurrence of the conuueneement of extrauterine life ; Init, practically,
there is no sharp line of demarcation, for the infant, during his
passage through the birth canals, may use his lungs iu breathing,
may pass meconium and urine, and may even cry before he is quite
free of the vagina. Further, the two epochs are very closely
ctmnected, the neonatal being the complement and continuation
of the intranatal ; the infant during his neonatal life is occupied
in recovering from the effects of his birth, or, we may say, in
learning to utilise the possibilities thrust upon him by his birth.
TRAUMATISM OF 151 KTH 35
Neonatal life is the period of adaiitatiou to the new conditions
brought aliout Ijv intranatal life. We may call tlie morbid phe-
nomena of this period of life " intranatal " or " neonatal " pathology ;
it matters not which, so long as we realise that they possess characters
which are in many ways peculiar.
Physiological Traumatism of Birth.
To the infant the intranatal period of his life, short thougli it be,
is one of much strain and stress. Is is true that he does not, as
was erroneously supposed by the ancients, have to make his way,
liy his own little aided efforts, to the world outside the womb;
and nowadays we do not admit that he has much to do witli
his birth, save in a sort of passive fashion, by means of his
weight of 9 lb. or less, which, by gravity, may possibly to some
slight extent expedite his progress, if his mother be erect; but,
none the less, his transit from intrauterine to extrauterine sur-
roundings is to him an eventful and often a dangerous time. By
uterine efforts, the sum total of which is by no means inconsiderable,
he is propelled through curved canals, with unequal diameters,
encountering no little resistance by the way. His body is not a
plastic mass ; but it is capable of a certain degree of moulding,
even in its hardest part, the head ; and the maternal canals, which
are denominated soft, ai'e in their turn slightly moulded by the
foital structures which they surround. Thus, by means of uterine
propulsive forces, with the help of head and body moulding, the
ftetus is driven along the canals, undergoing some rotation in his
passage, and expelled into a new and trying environment. Birth,
then, without being abnormally difficult, is the traumatic transition
from an intrauterine to an extrauterine existence ; this may be
termed the physiological traumatism of birth. Under certain cir-
cumstances, as in the multipara with a large roomy pelvis and a
fu;'tus of moderate dimensions, the traumatism is reduced to a
minimum ; possibly at one time in the history of the human race
there was little or no traumatism at all ; but the effects of civilised
life and other causes have exacted payment in the form of increased
birth traumatism, and to this the headward development of the
fcctus has in no small degree added. Natural labour, then, is a
traumatism ; not, of course, a necessarily or even probably fatal one ;
but none the less a traumatism. It will be convenient here to look
a little more particularly at the details of this traumatic transition.
It consists, in the first place, of the effects produced by pressure
upon the fcetus, and more especially, but not solely, upon the head
of the fcetus ; and, in the second place, of the separation of parts
in structural and vital continuity, with resulting h;cmorrhage. The
pressure effects may be described as contusions, and the separation
results as injuries to the effusion of blood.
1. The pressure effeets of labour are most evident upon the foetal
head, for in the large proportion of cases it passes first through the
canals ; and for the reason that it is resistant to pressure and has large
36 ANTENATAL l'Alll()l.()(;V AND 1 1'>( ill-.NK
diameters. The effects consist of the fipiinatiou nf tlie uaput suc-
cedaneum, or Ijirth - bruise, and the nioidding of the head, with
disi)lacement of the bones. The former is the serous or sero-
sauguineous effusion, which takes place into the tisstie of the skin
of the presentini; part of tiie fn'tus; usually the area of tin' cranium
in the neighbourhood of the posterior fontanelle, which lie-; within
the girdle of contact of the maternal canals. Every part of the
surface of the foetus save this is under great pressure, so into tliis
unsupported part the effusion of serum takes place. It forms, as
might be expected, during the second stage of labour; but it is
noteworthy that it has lieen found occasionally before the rupture
of the membranes (Barbour. A. H. F., "Anatomy of Labour." 2nd
edition, p. 192, 1899). It differs from the ordinary postnatal bruise,
in being the result, not of pressure applied directly to it, and
quickly removed, but of long - continued circumferential pressure ;
nevertheless, it is essentially a contusion. Further, there is some
reason to believe that it is sometimes caused by direct pressure
also ; but this is exceptional. The epidermis covering it is often
found raised in blelis, or separated altogetlier. When the face
presents, the caput forms over the cheek, the eyelids are swollen
and discoloured, and there is congestion of the conjunctiva; but
the nose and chin are not much affected, as the skin is there tightly
fixed to the underlying parts. The caput, in ordinary labour,
elongates the cephalic ovoid, and in some measure serves a useful
purpose in the mechanism of parturition ; but the greater part
of the moulding of the head is due to changes in the relation
of the cranial bones to each other. In a communication on the
"Head of the Infant at Birth," made to the Edinliurgh (Obstetrical
Society some years ago (37), I gave a series of cranial measurements,
which showed that five or six days require to elapse after birth
before the head returns to the form which it had anterior to the
commencement of labour. To ascertain the shape of the unmoulded
head, I took the head diameters of infants removed bj' tlie Ciisarean
sectitm ; of ftetuses in puldished cases, where maternal death had
occurred in the later months of pregnancy, and where frozen
sections had been made ; and of an infant removed post-mortem
from the uterus of a woman, who had died of pneumonia before
labour set in. It appeared that, although the heads differed in
actual size, their cranial diameters (maximum, occipito-mental,
occipito-frontal, suboccipito-bregmatic, biparietal, and liitemjioral),
all had the same relative lengtii, l)ore the same proportion to
each other. T then measured a series of heads, at or soon after
birth, and found that these cranial diameters no longer had the
same relation to each other : in all the cases there was a diminu-
tion in the occipito-mental, occipito-frontal, and suboccipito-bregmatic
diameters, and an increase in the maximum. In other words, the
birth traumatism had produced a compression of tiie head in tiie
suboccipito-bregmatic plane, and a com]»ensatory enlargement in the
plane of the maximum diameter. This moulding of the fo'tal head
is, as is well known, due to the overlapping of the bones at tlie
TRAUMATISM OF BIRTH o?
sutures (one parietal over-rides the other at the sagittal suture,
the two halves of the frontal underlie the contiguous parietals
anteriorly, and the occiput underlies the parietals posteriorly) ;
and it is accompanied by a bulging of one side of the liead (that
which lies anterior in the mother's pelvis) producing asymmetry.
So constant is this head-moulding, that it forms part of the jihysio-
logical traumatism of 1 )irth ; but it is very certain that the same
amount of distortion of parts, occurring at a later period of life,
would be termed pathological. At the end of about a week the
head has again taken its normal (or antenatal) form ; the effects
of the birtli - traumatism have then passed off, and the cranial
diameters have regained their antenatal relative length.
To a less evident extent the pressure effects are visible upon
the trunk of the fcetus. At the end of pregnancy (as Barbour
describes it, o/a cif., p. 23), "the general contour of the fa-tus is
an oval, of which the long axis is not greatly in excess of the
short ; the flexures of the different parts are not acute, the limbs
being not compressed ; but, so to speak, comfortably disposed, and
the spine gently curved." In the second stage of labour all this
is changed, for the foetal contour is now an elongated oval, the
flexures of the limbs are increased, and the appearances suggest
compression, the outlines being more regular. The firessure effects
upon the fcetal trunk and limbs disappear almost immediately after
birth, and in this respect contrast witli the head changes. When
any part of the trunk presents {e.g. breech, shoulder) a caput suc-
cedaneum forms upon it; but even iu this respect the deformity
thus produced is much more transitory than that seen in the
case of the head. Such are the plastic phenomena of the birth
traumatism.
2. The reparation results of the physiological traumatism of
birth have an importance not less than that of the pressure effects.
In some of the mammalia placentalia the connection between the
maternal and foetal parts in the placenta is very slight, the
fcetal villi lieing simply withdrawn from the maternal crypts ; the
separation in them cannot be termed traumatic, for it involves
no laceration of tissues. In the mammals, however, with a caducous
or deciduate placenta, and more especially in the human female,
the maternal and ftetal portions of the placenta are intimately
interwoven, and almost fused together; a real tearing apart takes
place in laliour, with a blood loss varying considerably in amount
but of constant occurrence. As a result of this separation, an
exposed surface (placental site) of at least 4^ by -i in. is left
in the interior of the uterus ; this is the maternal side of the
traumatism; and Nature diminishes as much as possible the
consequent risks by the property of the uterine muscle called
retraction, whereby the exposed surface is lessened in extent. The
separation of the placenta takes place through the spongy layer
which is derived from the maternal decidua serotina. To what
extent the fcetal portion of the placenta (the villi) is exposed in
this sm'face of separation (placental area) is uncertain, but doubtless
38 ANTKNATAl. I'A TllOLOC'i' AND llVdlKNF.
simu' of the choiinnic villi loacli down as far as the sjiongy layer;
it may tlierel'ore be said that here is tlie fa>tal side of the traumat-
ism. At the same time, it must be borne in mind that changes
have been occurring in tiie villi, during the last weeks of pregnancy,
which tend to obliterate the vessels, and so lessen the risks following
the sejjaration (ha-morrhage an<l sei>tic absorption). As stated by
Eden {Jonrn. Path, and JjactcrioL, ]i. 4GG, Jan. 1.S9G), the villi which
become embedded in the scrotina "are devascularised and function-
less"; further {ihid.,\\ 268, Dec. 1896), the same author has found
that "the fuctus takes decided measures to cut itself off from its
placenta during the last weeks of intrauterine life." It is therefore
very probable that by natural processes the separation of the placenta
is prevented from bringing much risk to the f<i-tus, and we cannot
look upon the uterine as]iect of the placenta as an exjiosed fo4al
surface; but, artificially, the obstetrician ]»roduccs an exposed surface
when he cuts the cord, although he diminishes the risks resulting
from it (h;emorrhage and septic alisorption) when he ligatures it
before .section.
It is evident, then, that birtli is traumatic. In the best circum-
stances, however, liy a wonderful series of precautiims, the dangers
of the traumatism are reduced to a minimum, justifying the descrip-
tion of it as physiological. It is physiology, however, which very
readily passes over into pathology; for both the pressure effects and
the separation results may very easily set up morltid changes in
the ftctus, or bring pathological conditions as their secpiehc. These
morbid processes will be descrilied in the next chapter.
Physiological Readjustment at Birth.
Birth, then, is the more or less traumatic transition from the
l)rotected semiparasitic life of tlie foetus to the more exposed and
ultimately independent existence of the infant ; but traumatism is
not the only occurrence in the physiology of this neonatal period of
life, for it is during the three or four weeks that follow birth that the
organs of the new-born infant take uji the work now thrust upon
them, and formerly performed in great part by the placenta. It is a time
of rcailjustment, of adaptation, of alteration, and of metamorphosis.
Hirth, it must be remendjcred, does not mark a l)eginning, but
a stage in life's progress ; at any rate, it marks only the beginning
of a stage — the beginning of postnatal life. The transition is abrujit,
and the sm-roundings are very unlike, nevertheless the life is con-
tinuous. The more perfect and complete our knowledge of the
physiology that ])recedes and of that which follows birth becomes, the
more clearly and undeniably this ]irinci]ile is cstalilishcd. There are
differences between the life of the fietus and that of the new-born
infant ; but by means of a marvellous series of adaptive mechanisms, the
life that is before liirth becomes continuous with the life that is after
birth, and the transition is accomi)lishcd with a minimum of change and
with but a ]iassing dislocation of function. Some only of the organs
of the infant are tndv liorn at birth, in the sense that thev be^in
READJUSTMENT AT BIRTH 39
then for the first tune to perform the special functions for which they
are intended ; most of them continue to functionate in postnatal life
in nearly the same way as was foreshadowed liy their antenatal
activities, in some instances with increase, in others with diminu-
tion, and in yet others with some modification of the special activity ;
some few of the organs may be said to die at birth, as far as pliysio-
logical activity peculiar to them is concerned. To this complicated
series of adaptive processes the name of the physiological readjust-
ment of birth may be given; and since it has much to do with the
peculiarities of the pathrilogy of the new-born infant, it demands further
cmisideration.
The adaptive functional changes at liirth may be grouped in three
classes : —
1. Increase or commencement of function I ,-, ,•, ,•
o i> 1 i-f <■ f *• -Quantitative.
2. Decrease or abolition ot function |
3. Alteration or modification of function — Qualitative.
There is much that is yet uncertain aliout the functions of the fcetal
organs and tissues, and even the pliysiology of the new-born presents
unsolved proVilems, so that what follows must be regarded as in some
degree hypothetical and lialile to correction with advancing know-
ledge.
The abolition of the functional activity of the placenta is the most
outstanding of the liirth changes, and all the other alterations and
modifications are directly or indirectly the results of it. At the end
the transition is sudden, and tlie placental economy ceases, as it were,
with the tying of the umbilical cord : but it is well to remember that
there has been a period of a few weeks during which vascular changes
have been occurring in the placenta which have slowly been cutting
it off from the foetus. The placenta, so to speak, has not been
abolished without warning ; herein possibly lies one of the many
reasons why premature delivery is borne so badly by the fcetus, the
preparatory changes in the after-birth not having had time for their
completion. Xow, the cutting off of the placenta, with the consequent
stoppage of all the functions performed by it in intrauterine life,
necessarily entails the awakening to functional activity or increased
activity of intracorporeal organs belonging to the new-liorn infant ;
and if all the functions that are performed by the placenta were
definitely known, then it miglit be possible to distribute and rearrange
these functions among the infantile organs. In the meantime, there
are many lacuiue in our knowledge, and it is not, for instance, clearly
made out to what extent bio-chemical changes actually take place in
the placenta, and to what extent that organ acts simply as a means of
conveying the results of maternal bio-chemical changes to the foetus.
All that can be said with any assurance is that the cessation of
l)lacental activity synchroni.ses with the commencement of pulmonary
respiration, and with the increased action of several other organs,
such as the kidneys and stomach.
The first group of tlie adaptive functional changes at birth includes
those characterised by increase or commencement of function. The
luiiffs at once sugcjest themselves as orcrans wliich commence to
40 ANTKNATAI- rA'lIlOI.OGY AND IIYdlEXE
functionate at birth. Very evidently and almost eonstantly the
infant gives a cry and begins to breathe as soon as he is fully expelled
from the maternal jjassages, and before the complete severance from
the ])lacenta has taken jilace ; in this respect, the commencement of
pulmonary nspiralion marks the begiiniing of postnatal life. Even
this change, however, is less sudden than it apjiears, for in fietal life
it has been found that regular movements of the thora.x are taking
place, which, although they do not of course result in the admission
of air to the foi'tal lungs, may yet be preparatory to the awakening of
the pulmonary activity, and may become after birth the movements
of respiration. Further, under (piite exceptional circumstances, as in
face cases and during version, especially with twins, respiration and
even audible crying may take place while the child is still in the
maternal passages, the condition necessary for this preniature activity
of the pulmonary organs being the rupture of the ftntal membranes
and the admission of air. The cause of the first respiration is still
matter of discussion (it has been ascribed to the action of the cold air
upon the skin of the child, to the passage of blood containing carbonic
acid in excess to the medulla on account of the stoppage of the gaseous
interchanges in the placenta, and to the convenient but not very
luminous alistraction, "a i)rimitive law of nature ") ; but its etl'ect is
to usher in the adaptatioual changes of birth, being indeed itself the
first and most important member of the series. Auscultation over the
chest of the new-born infant elicits the presence of a fine crepitant
nlle which indicates the opening up of the pulmonary air vesicles,
and is evidence that the child is beginning to do for himself what was
])reviously done for him by the matei^nal lungs. For some little time
the new function is not performed with that completeness and
regularity to wliich it afterwards attains, but it immediately draws to
the lungs an increased fiow of blood, and so inaugurates the wonderful
succession of circulatory readjustments which follow birth.
Among the increased activities supervening upon birth must be
reckoned the digestive functions of the salivary glands (at least of
the parotid), and stomach, and intestine, and the excretory function
of the kidneys. The urinary Idadder of the new-born contains a
small quantity of lu'ine, and in its intestines are about 70 grnis.
of the dark green liile-stained material to which the name of meconium
has been given, and which consists of intestinal secretions, fat, bile,
epithelial cells, some hairs, and epidermic squames. It is therefore
clear that there is some digestion going on in fa>tal life, and some
urinary secretion, even if it be denied that there is any excretion.
Gradually, all the digestive functions come into play, although it is
some time before the jiancreas is etlective, and the submaxillary and
sulilingual glands do not at first take much part in buccal digestion.
Another organ which must be regarded as increasing its activity
greatly at birth is the brain, but it even shows an increase and not a
commencement of function with the change of environment ; for
some parts of the great afferent tract of nerve fibres in the brain are
already myelinated when birth takes jilace, ami it is known that only
filires which have been conveying imjiressions show myelination.
READJUSTMENT AT BIRTH 41
The movements, therefore, which the fcL'tus has been making in
utero have been sending impressions to the receptive centres in its
cerebral cortex ; in the new-born infant the impression-sending goes
ou apace, and the consec^nent myelination extends rapidly. It is,
however, quite correct to say, that functionally some parts of the
brain commence to act, are born, at birth.
An instance of the cessation of function following upon birth is
found in the vessels connected witli the umbilical cord, which carry
blood to and from the placenta. These vessels, including the
umbilical vein and arteries and the ductus venosus, soon become
obliterated and fuuctionless ; and any delay in their closure may
lead to dangerous consequences, as will be shown immediately.
Another physiological activity which diminishes, is growth. No
doubt, the new-born infant increases in weight and length with
wonderful rapidit}' ; but it is none the less true that the postnatal
rate of growth is small compared with what prevailed in utero, and
indeed the slackening had already begun to show itself before the
infant left his uterine abode. Organ formation has practically
ceased before birth, and only slight changes in the shape and
relations of the viscera occur after it, although, of course, the
osseous, as distinguished from the cartilaginous skeleton, is largely a
postnatal formation.
Certain alterations in function, qualitative changes, take place at
or soon after birth. Through the gradual closure of the foramen
ovale and ductus arteriosus, the direction of tiie blood current in the
heart is altered, and the function of that viscus as the centre of a
double instead of an almost single circulation is established ; no
longer a mixed, but a pure, blood goes to the tissues as the result of
this change. Another organ which, no doubt, to some extent,
modifies its functions at birth is the liver; the portal circulation
gains in importance with the commencement of more active gastric
and intestinal digestion, and proliably the liver takes on the function
of storing up mineral poisons, a duty which there is reason to believe
was previously performed by the placenta.
There are, as has already been stated, many parts of this series
of readjustment and adaptation changes of birth about which little
is definitely known, and about which much will yet be learned
by careful investigation. How long, for instance, are the mammary
glands active before birth, and how long after birth does their
secretory activity continue ? Do the Graafian follicles in the
ovaries rupture before birth ; and if so, is this period of activity
followed by one of quiescence until puberty ? What is the function
of the thymus gland in the foetus, and does it continue to act in
the same or in a different way, or not at all, in the new-born
infant ? Does the thyroid gland act as a regulator of metabolism
and growth before as well as after liirth, or is this duty performed
by the thymus ? What exactly are the functions of the spleen
and suprarenal capsules before birth, and are these modified by
liirth ? These and several other questions call for an answer before
the whole process of functional readjustment at birth can be
42 ANIl-.NAIAI. l'A■|■ll()I.()(i^• AM) ll^(ilF,NE
described iu all its delails. It may be udilrd thai the spinal cord
is jnobably an instance of an organ wliose functional activities alter
little at liiitli, for in the fa-tus it is well developed and active;
and it is in the cerebral rather tlian in the sjiinal part of the nervous
system that development of function goes on postnatally.
j\Iany of these functional alterations at birth, possibly all of
them, are accompanied by changes in structure which are directly
related to them, or which may be only synchronf)US with them. For
instance, there are the well-known obliterative clianges in the blood
vessels connected with the fictal circulation, and the closure of the
conmmnication between the right and left auricles of the heart ;
there are changes in the appearances of the blood and in the composi-
tion of the urine ; there is the extension of myelination to the eti'erent
nerve fibres in the higher centres ; there is tlie desquamation of the
cuticle ; and there is the disappearance of the ftetal lobulation of the
kidneys. These are the anatomical readjustments of the neonatal
epoch. Finally, birth is followed by an invasion of the new-born
organism by a multitude of microbes, and tlieir ett'ects upon the
developing functions must be taken into account in attempting to
understand this most interesting part of the earlier period of post-
natal life.
Such, then, is an outline of the physiology of birth, and of the
four weeks which follow birth : there is the i)hysiological traumatism
of birth, characteristic more especially of the intranatal i)eriod ; and
there is the physiological readjn.stnient at and after birth, commencing
in the intranatal period, Init extending into and through the strictly
neonatal epoch. As will be seen immediateh", when som.e of the
individual diseases and morliid states of the new-born fall to be con-
sidered, these pliA'siological peculiarities of the period have much to
do with the peculiarities of the pathology of the period, and many
things that are difficult to understand about neonatal morbid
conditions become easy of explanation when regarded in the light of
the ]ihysiological traumatism of birtli, and the physiological readjust-
ment at Ijirth ; lint all the peculiarities are not explicable liy these
two factors, either acting singly or working in combination. There
is a third factor which plays its part in the evolution of the special
character of neonatal pathological cliange ; it is the antenatal
factor.
The Antenatal Factor in Neonatal Pathology.
Not only does the physiology of birth and the neonatal period
leave its distinctive impress upon the pathology of the neonatal
period, but the pathology of antenatal life also has its etlect upon the
characters of the diseases and disorders of the new-born, and serves
to explain some phenomena otherwi.se most obscure, liirth, let it
always be remembered, is not the beginning of life; it is only the
beginning of a stage of an individual life. The impress of nine
months' very active life, intrauterine, it is true, l)ut none the less
vital, is already on the infant at the moment of birth. Its ett'ects,
THE ANTENATAL FACTOR 43
pathological as well as jiliysiological, are projected into neonatal life,
and in many cases constitute the missing key to the explanation of
the special characters of neonatal disease. Thus morbid conditions
which have arisen in fictal life, such as fa'tal peritonitis, or mal-
formations which have originated in the embyronic or germinal
periods, may, by their projection into neonatal life, give an altogether
peculiar character to the maladies of the new born.
Many instances might be given of the effect of the antenatal
factor on the pathological manifestations of the neonatal period of
life, and to several of them reference will be made in the following
chapters, which deal with individual neonatal maladies ; but in the
meantime it will sufhce if allusion be made to one. Jaundice in the
new-born is a frequent condition, which occurs soon after birth. It
is generally one of the results of the readjustment changes which
are going on in the liver and blood on account of the circulatory
modifications which follow the replacement of the placental by the
pulmonary respiration ; it is in these cases almost physiological in
its nature. Sometimes, however, as is well known, the jaundice is
of a much more persistent type, and may even prove fatal within
some days or weeks of birth. Under these circumstances it has
sometimes been found that its persistence and lethal character have
been due to conditions developed before birth, e.g. congenital
obliteration of the bile ducts, or antenatal hepatitis. The jaundice
then indicates a truly pathological state of affairs, and is further-
more the expression of morbid states, the results of which in intra-
uterine life were dormant ; the antenatal factor makes its influence
felt immediately after birth.
CHAPTER V
Types of Xeonatal Disease, illustrating the Intru.sion of the Antenatal Factor:
(1) Intracranial Traumatisms, Cei^halhiiMuatonia Xeonatoruin, Farial
Paralysis, Fractures of the Long Bones, Dislocations ; (2) Intranatal
Infections, Ophthalmia Neonatorum, H;ematoma of the Steruo-MastoiLl,
Mastitis Neonatonini.
Ix this chapter and iu the next is described a series of tj'pes of
neonatal diseases and disorders. No attempt is made to consider all
the maladies of the new-born, for that would entail the
description of a very large number of diseases : but certain tyjies
are selected which serve to illustrate the manner in wliicii
the physiological traumatism of l)irth, the jihysiological reail-
justment at birth, and the antenatal factor, tend to give pecidiar
characters to the manifestations of disease at this time in life. Even
the types that have lieeu selected are not each described iu all
their details, Ijut only in those which have special reference to the
effect of antenatal influence, for this work is concerned primarily with
Antenatal Patholog}-, and with Neonatal Pathology only in so far
as it throws light upon antenatal morbid changes. At the same time
it must not lie forgotten that there exists a very close connection
between the pathnlogy of the neonatal and that of the antenatal
jieridil.
I. Intranatal Traumatisms.
Cephalh.i:matuma Neoxatokuji.
Attention has been already drawn to the fact that the birth
traumatism is the cause in tlie great majority of cases of a serous nr
scro-sanguinolent swelling upon the presenting jiart of the fcctal
head; to this swelhng the name caput succedaneum is commonly
given. When labour is undidy prolongetl, or when the natural
traumatism of birth is reinforced by the artificial traumatism of tlie
f<ircei)S, there may be a very considerable effusion of blood into the
scalp tissues, and the caput becomes a hannatoma. It is not, how-
ever, to this e.xaggerated caput or birth-bruise that llie name cephal-
hicmatoina neonatorum has been usually given, but tn a swelling which
appears two or three days after birtii. If any special name were
given to the caput, it might lie that of " intranatal cephalluvmatoma,"
CEPHALH.EMATOMA NEONATOUUM 45
for it is produced during the intranatal period uf life; the term
neonatal cephalh;ematonia would then be restricted to the swelling
which develops, or at any rate is recognised, during the first few
days of neonatal life (Fig. 5).
This cephalluvmatoma varies in size from a hazel-nut to an apple ;
is more or less rounded ; is situated usually' near the postero-superior
angle of the right parietal Ixine, hut nuiy be found on the opposite
siile, or more rarely, on the occipital, temporal, or frontal bones ; and
is generally covered by normal scalp. It is tense and fluctuating, is
usually unilateral, biit is occasionally Ijilateral, and may even l^e
multiple ; and is limited exactly by the sutures and fontanelles, not
crossing from one bone to another. Pressure upon it does not
affect its size or cause convulsions or coma. From its first appear-
ance it has a well-defined margin, and later there is a distinct hard
rim surrounding its base; it may on this account l)e mistaken for
a cranial perforation, with herniation of brain substance, or for a
circular depressed fracture, but the absence of pulsation, and the
detection on deep palpation of the underlying cranial bone, ought
to prevent this error being made. Its existence may be masked
for the first few days of life by the caput succedaneum, wliich usually
(iccupies tlie same region of the head ; it slowly diiuinishes in size
by absorption, save in the cases where suppuration occurs, liut it
may be several months before all traces of it disappear. In its
pathology it consists of an effusion of blood between the peri-
cranium and the cranial lioue underlying, and the hard rim is a bony
ring which forms round its base at the point where the pericranium
is still attached to the bone. The effused blood may be found in
various stages of absorption. A fracture of the underlying lione,
with haemorrhage between the dura mater and the skull, may occur
as a complication. It does not usually endanger the life of the
infant, save when pus forms ; and the method of treatment which
has hitherto given the best results has been expectancy, but it is
questionable whether the safety conferred by aseptic surgery ought
not to cause us to i-econsider the whole matter, and possibly to adopt
more radical measures.
In attempting to explain the pathogenesis of the sul)perieranial
cephalhiematoma, authors have had recourse to the intranatal factor
(birth-traumatism), to the physiological readjustment at birth, and
to the antenatal factor. It is a rare condition, occurring only once
in two hundred or two hundred and fifty labours, therefore it cannot
1)6 due to an ordinary circumstance or set of circumstances. It is
more common with male than with female infants, and in primi-
parous rather than in multiparous mothers. It has therefore been
confidently ascribed to pressure on the head in labour, to the same
causes as are effective in producing the caput ; but it has been found
in cases in which the head did not present, and even in cases, such
as that reported by me in 1893 (158), where the labour was easy,
rapid, and non-instrumental. The intranatal or traumatic factor
cannot then be the only or the constant cause of the h;cmatoma, and
the same objection applies to traumatism apart from labour. The
4ii ANll'.NAIAI. I'ATllOLOCY AM) indlFAK
cause lias lieen lonkiMl for in the circiilaUny cuiiilitifnis wliicli exist
iniiueiliateJy alter Mrtli, ami which are the result of the change to
ail extrauterine eiiviroiiiueiit ; and the hrittleiiess of the lilood
vessels, and the ease with which the pericranium can he sejiarated
from the underlying bone in the new-liorii infant, have been lirought
forward as at least ])redisposiii<^ causes. These exiilanations, how-
ever, all fail to account for the rarity of its occurrence, and it is
found necessary ti) look to antenatal conditions. Several have been
suggested ; but reference need only be made to that with which
Fere's name has been associated (Mcv. mens, de med. et dc chir., iv.
112, 1880). He found that at the site of predilection of the
cephalhtematoma, the postero-superior angle of the right parietal
bone, there were occasionally seen fissures running in the bone in
a radiate manner, one towards the sagittal suture, another towards
the lambdoidal. The sagittal fissure sometimes united with a
similar one on the opposite side to form the fontanelle of
(lerdy. To this arrest of development, as shown by defective
ossification in this region {obclion), Fere looked for an explana-
tion of the pathogenesis of sulipericranial cephalhaniatoma. Even
slight pressure on the part of the head which shows this anomaly
will cause extension of these fissures, and rupture of the small
blood vessels which cross them; effusion of blood will quickly
take place under the pericranium, which is at this point easily
separable from the underlying bone. In this instance, therefore, the
traumatism of birth is not in itself sufficient to account for the
neonatal morliid condition, neither does the physiological readjust-
ment at birth form a complete explanation ; the antenatal factor has
to be invoked, and is found in arrested development or delayed
ossification of the region ohclion.
Facial 1'aralysis of the Xew-ISokx.
It is not unconinion to find infants who have l)een extracted by
means of the forceps showing a transitory form of facial hemiplegia,
or " facial paralysis of the new-born." When the child cries, or wiien
it is at the breast, the unilateral deformity of the face, due to the
paralysis of one of the facial or seventh nerves, becomes very notice-
able : the lines on the paralysed side are obliterated and the eye
cannot be closed (Fig. 5), the angle of the mouth is drawn to the
opposite or sound side, and the lines are there deepened. The infant
is suffering from the peripheral form of facial jiaralysis, due in the
great majority of cases to jiressure of one of the blades of the forceps
upon the seventh nerve at the point where it emerges from the stylo-
mastoid foramen, or where it breaks up into its branches in front of
the ear ; the nerve is specially liable to injury, on account of the
absence of the mastoid apophysis, and the small degree of develop-
ment of the auditory meatus at this time of life. In most cases the
]iaralysis gradunlly jiasses oft', from two days to six weeks being the
time necessary for its comiilete disajipearance. Generally, there is
the distinct history of forceps application to account for the paralysis ;
or THE
UMVE;^SITy
NEONATAL FACIAL PARALYSIS
47
hut ill a few instances it would seem that the i^ressure upon tlie nerve
has heen caused hy a projection in the maternal pelvis (promontory
of sacrum or ischial spine), or by a tumour. Sometimes, as in a case
about which I was consulted l>y Dr. Dickson, of Lochgelly, in 1899,
the long persistence of the j)aralytic condition throws doubt npon the
peripheral nature and traumatic origin of the palsy. Under these
circumstances, it is reasonable to turn from an intranatal to an ante-
natal mode of origin of the nerve lesion. It may then be due to a lesion
in the facial nuclei in the pons, or in the fibres connecting them with
the cortical centres ; but, of coiu'se, even this central or cerebral
form may be of intranatal origin, although it is unlikely. The
instance of unilateral facial paralysis reported by M. Bernhardt
(Xcu7-ol. CciitrcdhJ., xiii. 1, 1894), in a man of 24 years of age,
was probably of this central type ; it had been first noticed
when the patient was a fortnight old, and the birth had been
non-instrumental. Another instance of persisting paralysis of
congenital origin in a man of 40 has been recorded by Mr.
•Tonathan Hutchinson {Arch. Surg., xi. 20, 1900). In the central
type the paralysis is seldom so complete as in the peripheral,
and there usually is, for example, power to close the eye ; by
this means it may bie possible to diagnose Itetween the cases of peri-
pheral and intranatal paralysis and those of the central and probably
antenatal type — a matter of very considerable importance, when it
is borne in mind that the former have a good prognosis, while the
latter are usually incurable. But facial paralysis of the new-born
may be both peripheral and antenatal, and it is then due to some
48 ANll'.NAI'Al. l'AriI()I,()(;V AM) IIY(;iKNK
uialtoniiatiiiu (ir defeclive duvulciimu'iit uf the muscles suj)]ilifil liy
the seventh nerve. Tliis seems t" have heen the cause of the
paralysis in tlie two brothers descriljed hy 11. M. Thomas {Journ.
Xerr. and Mcnt. JJis., xxv. .')71, 1898); in this, an instance of the
family type, there was antenatal absence of some of the facial
muscles. It ought to be added that the nature of the antenatal
lesion in the central form of facial paralysis of the new-born lias not
yet been determined ; but iiejl {Ccntrlbl. f. Gymik., xx. 634, 1896)
has described a ca.se of tlie peripheral form of antenatal origin in
whicli he suggests that pressure ui)()n the cheek by an anmiotic band
was the active cause of the defective development of the seveiitli nerve.
The relation of facial paralysis of the new-lioru to the intranatal (trau-
matic) and antenatal factors may thus be summarised : the peripheral
form, usually complete, is nearly alwaj's due to intranatal ])ressure from
the forceps or maternal pelvic walls, and it is then (puckly recovered
from ; but it is occasionally due to antenatal causes, one of which
may be amniotic pressure, and is then much le.ss amenable to treat-
ment ; the less complete central form, on the other hand, is probably
rarely due to traumatism acting upim tlie liead in lalxiur, and most
often to oljscure antenatal clianges in the cerebrum or pons, and it
has ahvays a more unfavourable prognosis.
Fkactures of the Long P)Oxes of the XEw-lior.x.
The common cause of the fractures of tlie long hemes wliicli may
l)e met with at birth is the traumatism of an abnormal lalmur, and
more especially of a confinement which is terminated artiticially liy
version. Further, the new^-born infant, like the child or adult, may
suffer from fractures which are the result of direct and considerable
violence. In l)oth cases, the incompletely developed state of the
skeleton will predispose to the occurrence of separation of the
epiphysis of the long bones rather than to actual solution of con-
tinuity of the diaphysis. Such fractures and sejiaratious usually
heal quickly, if recognised and treated at the time of their occur-
rence. There are, however, other cases, in which, either at birth
or soon thereafter, fractures occur either subsequent to very little
traiuuatism, or without the history of any injury at all. In such
instances it becomes necessary to postulate the existence of ante-
natal fragility of the bones. The extraction of the child from the
maternal passages or some slight handling of it afterwards may
still be the determining cause of the fracture, but it is (juite
evident that the predisposing factor lies in defective ossificatiem.
Especially is tliis clear when tlie l)reak occurs one or two days
after birth, and without any evident cause. Such a case was
brought under my notice in May 1899, by Dr. J. S. Fowler. The
child was apparently quite healthy when born : it was an ordinary
head presentation, and no interference was required. Four daj'S
later it began to cry, and cried all night, and in the morning a great
swelling of the left thigli was noticed. There was a distinct fracture
in the middle of llic femur, not near the epiphysis. The break mended
NEONATAL DISLOCATIONS 49
well, but with a large amount of callus. There was no historj' of any
injury ; there was no enlargement of any of the epiphyses ; the limbs
were well formed ; and the child showed no signs of prematurity. It
was significant, however, that the cranial bones exhibited very defect-
ive ossification ; although there was no increase in the size of the head,
nor any sign of abnormally high intracranial pressure, yet the state
of the bones was exactly like that met with in hydrocephalus. Ante-
natal fragility seems the only possible explanation of the fracture in
this case. It is not unlikely that it may have been an instance,
although not a very marked one, of osteogenesis imperfecta, or osteo-
psathyrosis (8) : in such cases, a striking example of which has been
recorded by J. P. Crozer Griffith (Am. J. Med. Sc, cxiii. 426, 1897),
fractures of the long liones begin to occur a few ho\xrs or days after
birth, without evident and sufficient cause ; they continue to occur
at intervals during infancy (Griffith's patient developed seventeen
of them in his first two years), and even during childhood and
adult life, and they usually unite very C[uickly. Syj)hilis, nervous
diseases, and rickets can generally be exclucled from the list of
possible causes; and there is much doulit as to the osteomalacic
nature of the fractures. One remarkable fact has been clearly
proved : the tendency to be affected with numerous fractures is often
transmitted by direct heredity ; and even when this is not the case,
family predisposition can be distinctly recognised — a fact which
certainly points to an antenatal mode of origin. It may therefore
he regarded as certain that all the fractures that are met with
during the neonatal period of life are not the result of birth-
traumatism, or of injury received after birth, even when the
skeleton has been weakened by syphilis ; some are due to an ante-
natal fragility, so great in degree that trifling causes lead to solution
of osseous continuity.
Dislocations in the Xew-Borx Infant.
That dislocations of various joints may occur as the result of
the traumatism of birth, and more particularly of artificially aided
birth, is an obstetric commonplace ; possibly, however, it is an ill-
founded commonplace. Certain it is that by far the most common
congenital dislocation is that of the hip ; equally certain is it that
in the great majority of the recorded cases the child suffering from
this dislocation has been Ijorn after a labour, non-instrumental in
character, not even abnormally prolonged, in which also the head
has presented, and in which, consequently, neither blunt hook nor
iibstetrician's fingers can have been dragging traumatically upon
the infant's hips. Furthermore, can it be doubted that if the
dislocation were of this intranatal kind, that it would be easily
possible to correct it ? Yet within recent years there is probably
no subject in orthopedic surgery about the treatment of whicli
more has been written of a controversial kind than congenital dis-
location of the hip-joint. Manifestly, such a difference of opinion
as to the best method of surgically correcting this distortion
4
50 ANTENATAL I'ATl 1( )l.()( -N AND HVCill'.Nl-:
betokeus that no way yet devised is supremely good ; herein lies the
suggestion that the luxation is no sinijile displacement of perfectly
adajited articular surfaces, due to the tractions and contractions of
labour. The ilislocatinn itself is much more common in girls than
in boys ; it may be bilateral or unilateral ; it is commonly not
noticed immediately after Ijirth, but only later, when walking is
begun ; and it is noteworthy that in about 25 per cent, of the
cases there is heredity, usually on the mother's side. These facts
do not support the idea of olistetric origin. Indeed, the theory that
tlie dislocation is entirely due to intranatal traumatism may l)e .said
at the present time to be alianiloned. Of the theories that remain,
all look to an antenatal morljid state as the primary cause. Accord-
ing to one view, the dislocation is due to external violence, applied
to the mother's abdomen during her pregnancy; according to another,
it is the prolonged but less active pressure of the anniion that is
tlie pathogenic factor. An intrauterine destruction of the tissues
of the joint is the leading feature in a third hypothesis: yet another
regards all the changes as due to a priiuar}- alteration of the fa-tal
nervous system, causing either retraction or paralysis of the peri-
articular muscles. These are theories ])ased upon fwtal pathologj";
but embryonic morl)id changes have also been invoked, and several
forms of arrested development of the acetaliulum and surrounding
parts have been adduced in explanation. In their diversity these
theories have it in common that they look to a time before the
Ijirth-traiunatism for the causal factor : in this at least they agree.
Not less diverse have lieen the recommendations for treatment.
According to one suggestion, which has at least the merit of
age, the dislocation is to be treated by traction, by fixation, by pro-
tection — " for eight or ten hours out of the twenty-four the children
lie in an apparatus, holding the leg extended, abducted, and rotated
outwards " — and this is to be carried on for years ; truly a weary
prospect, even when it is added that for the rest of the twenty-
fciur hours of each day "they move about freely." Corsets, also,
" with perineal bands," to press down upon the trochanters, are
said to be " much in favour in Germanj'." If, however, the patient
be older than three or four years, little benefit can be expecte<l
from the mechanical plan, and, consequently, recourse has been liad
to forcible reposition of the head of the femur into the acetabulum- —
under aniesthesia, with nnich rotating and abducting and ficxing and
extending of the limb. This method, first advocated by I'aci, lately
modified and elaljorated by Lorenz, retpiires for its complete success
the existence of a normal acetabulum and a normal femoral head ;
but Antenatal Pathology has revealed that these are precisely
the conditions which do not exist. Therefore, at best, we are to
hope for a pseudo-arthrosis ; that, too, only after prolonged fixation,
following the forcible reduction. Xeed it be wondered at that Hoffa
has advocated operative measures, and that Lorenz has lieen led to
tiie same, or a modified plan of iiroccdure. Their methods have, at
any rate, this in their favour, tliat they .seriously attempt to deal
with the ditliculties — HotVa bv cutting into tiie acetaliulum, enlarging
OPHTHALMIA NEONATORUM 51
it, for it is generally very rudimentary, with the wharp spoon, and
replacing the head of the femur in it ; Lcjrenz by directing jiis
attention also to the capsular ligament. But with these operative
procedures comes, of course, the risk of death ; at the same time, it
is to be noted that in good hands the risk is small. When all this is
taken into account, is it surprising that a recent writer (E. W. Lovett,
" Keating's Cyclopaedia of the Diseases of Children," Supplementary
Vol., p. 988, 1899) warns his readers that " it is a time of transition and
general distrust." Antenatal Pathology nray yet do much to remove
this distrust and throw light upon operative measures. Let it, in the
meantime, lie borne in mind that congenital dislocation of the hip
has an antenatal origin, even when the actual separation of the
articular surfaces takes place in the stress of the labour-traumatism ;
that it is to be looked upon as a malformation rather than as a
dislocation; that it occurs at a time when the hip -joint is not
fully formed and Solidified (the relation of the depth of the cavity
to the diameter of the head of the femur at birth is one to three,
at 5 years one to two); that it ought to be diagnosed far earlier
in life than it commonly is (a matter which involves the establish-
ment of the diagnostic signs of it prior to the commencement of
walking) ; and that in these days of surgical safety it is well worth
considering the propriety of advising immediate opening of the
defective joint rather than the prolonged methods of traction and
fixation, and the like.
II. Intranatal Infections.
In the neonatal morbid conditions to which reference has been
made (viz. cephalhtematoma, facial paralysis, fractures, dislocations),
it has lieen shown that the antenatal exists alongside of the birth-
traumatism factor, replaces it even in some cases, so that it is now
recognised that an intranatal cause is not of so much etiologic
importance as an antenatal one ; these mrirbid conditions arise not
always from the traumatism, physiological or pathological, of labour ;
but sometimes, at least, from states originating before birth. There
are, however, diseases of the new-born which are not so evidently
predisposed to antenatally : such are, for instance, some of the
intranatal infections. Some reference may be made here to
ophthalmia neonatorum, mastitis neonatorum, and hematoma of
the sterno-mastoid muscle.
QPHTH.'lLMIA NeOXATOEU.M.
Ophthalmia neonatorum, or blennorrhcea neonatorum, once the
great, or one of the great, scourges of the Lying - in Hospitals
— occurring as it did in 10, 12, even in 15 per cent, of the babies
born in Maternities — is now but a shadow, mercifully, of its former
malignant self. It is known, and has for some twenty years been
known, to be due to the entrance of the gonococcus into the con-
52 ANII'.NATAI. I'ATllOLOd^' AM) HVCilKNK
jiiiictiviil sac of tlie lu-w-lmni. The goiiococcus was hukiiiL; in
the maternal vagina, tiie mother having snfVereil from gonorrhcea,
at any rate from a "discharge" of some kind in pregnancy; and
the infant's head, having been detained in the canal, e.g. on the
perineum, for ])erhaps some minutes, had come in contact with the
gonorrhu^al secretion containing the gonococcus ; the result was
infection of the mouth or nose or eyes of tlie child, unless, as even
in pre-antiseptic days sometimes happened, great care were taken
to wasli away all discharge from the infant's face. A great scourge
once upon a time. For it led on to blindness, through such inter-
mediate stages as conjunctivitis, recognisable on the third day of
life, becoming purulent a day or two later, corneal ulceration,
corneal perforation, dislocation perhaps (of the lens), pyramidal
cataract, adherent leueoma, anterior staphyloma, panophtiialmilis,
and atrophy of the Inilb. There were many morbid possiliilities ;
liut the end was too often the same — blindness for the individual,
and economic loss to the State. Primarily an intranatal infection,
it did not, unfortunately, remain so, for, secondarily, it Ijecame a
neonatal one ; the discharge from the one eye trickled over the
liridge of the nose and infected the other, or was carried by the
midwife to the e^yes of another child, or got into the eyes of
the nurse or doctor treating the case. The first woman graduate
in medicine lost the sight of one eye through infection from a
new-born infant suffering from ophthalmia, whose eyes she was
syringing (130). Now this disease is happily in process of abolition,
"almost expelled from our Maternities"; almost, but not entirely,
as the following case shows. A young woman, pregnant for the
first time, and at about the eighth month, was admitted to tlie
Edinburgh Maternity in August 1900, sulfering from unilateral
Bartholinitis, gonorrhceal in origin ; was operated on with all care :
and soon thereafter was discharged till labour super\-ened. She
returned for her confinement in September, when she was seen by
me ; during lier labour all the approved prophylactic measures
(to be immediately referred to) were adoi)ted : ne\'erthele.ss, two
or three days after birth, the infant developed signs of gonorrlupal
conjunctivitis in the right eye. Under treatment the infiammatiun
ran a comparatively mild course, and the left eye was scarcely
affected at all. There was no other case in the Hosiiital. The
treatment necessary to prevent such cases has passed through three
stages, if we regard it from the standjioint of the time when it is
a]>])lie(l. It was first neonatal, when obstetricians took pains to
cleanse the face and eyes of the new-l)orn. Afterwards it became
intranatal, when Crede, and those who adopted his methods, began
to apply to the eyes of the infant, l)efore the section of the cord,
a drop or two of a 2 per cent, solution of nitrate of silver, and
to use corrosive sulilimate vaginal injections during labour, for the
purpose of disinfecting the maternal passages. It has now to
some extent become antenatal, for it is beginning to Ije recognised
to be desirable to c(mimence the vaginal disinfection before the
supervention of parturition. It is no longer thought to lie necessary
H.EMATOMA OF STERNO-MASTOIl) 53
to use nitrate of silver solution us a prophylactic, for it has been
founil that iusufflatiou of iodoform powder into the new-born's eyes
does as well ; even a few drops of boiled water, say some teachers,
will serve. It is to be concluded, therefore, that during all the
years when prophylaxis was not yet thought of in the manage-
ment of this disease, thousands of infants suffered from ophthalmia,
and became, in many cases, blind and burdensome to the community,
through the absence of a few drops of a 2 per cent, solution of
nitrate of silver, or of pure water, applied to the right place, at
the right thne. But, and herein lies the antenatal factor in
this apparently entirely intranatal matter, in some instances there
is evidence to show that the eyes have been infected before the
passage of the child through the vagina, for the eyes may show at,
or a few hours after liirth, changes which jjoint to the second stage
of the ophthalmia. This, however, is a subject to which reference
will again be made in dealing with intrauterine infection. Let it
be understood that it is not always necessary that it be gonococcic
infection that produces conjunctivitis neonatorum ; neither is it the
conjunctival membrane alone that is ati'ected; for Bond (Virginia
Med. Scini-Monflily, xxi., 1074, 1895) has reported a case in which
the eyes, umbilicus, vuh'a, and skin glands of a new-born infant all
seem to have been infected by septic matter from an old lacerated
cervix uteri during labour.
H.EMATOMA OF THE StERNO-MaSTOID MuSCLE IN
THE New-Born.
The occurrence of an extravasation of blood into the substance of
the sterno-mastoid muscle has an importance which is projected
beyond the neonatal period of life ; for it is currently, and it may
be correctly, regarded as one of the causes of congenital torticollis :
and that unfortunate condition is often projected onward for many
years, as, it is said, Alexander the Great found, who was well able to
conquer the world, but had a wry neck. Occasionally one notes
after birth a swelling (" size of a pigeon's egg," " shape of a pencil ")
in one or other, rarely in both sterno-mastoids. This is due to an
effusion of blood into the substance of the muscle, and in time this
gives place to a fibrous thickening of it following upon a myositis of
a parenchymatous kind. It is easy also to believe that in delayed
or instrumental labours, especially in those in which the breech is
born first, traction on the neck or the pressure of a blade of the
forceps will lead to such lesions in the cervical muscles, and more
particularly in the sterno-cleido-mastoid. But then, some of the
labours have been spontaneous and easy ' Under these circum-
stances, ingenuity has alleged that attempts at respiration have
been made prematurely while the infant's neck was still grasped
in the maternal passages, and that these muscles, being thus put
on the stretch, have been ruptured. This notion seems at any rate
to be accepted by Bronislaw Kader {Przcrjlad. Chir., iv. 93, 1898), in
54 ANTKNATAL I'ATHOLCXiV AND HYdll'.NK
iiu elaborate contrihutiou on llie subject of toi'tieollis of muscular
origin, how valuable one is not quite able to say, for it appears
in the Tolish language, with but a short summary in a tongue more
generally understood in Western Euro]ie, but evidently a lengthy
and learned paper. To explain some dilliculties, it has been
suggested that the myositis which follows the injury and leads
to the contraction which brings about the torticollis, is of infective
origin, and Kader (in the French summary of his article) is reported
as believing that the infection is rid the blood from the alimentary
canal. But, in tracing this connection between the birth-trauniatism
and hiematoma of the sterno - mastoid, and again between it and
muscular torticollis, there are other difficulties; for it is not at all
certain that a lueuiorrhage into a muscle will lead to a shortening of
that muscle, either with or without rupture and myositis. Further,
there is the associated cranial asymmetry to be accounted for.
It seems at any rate as reasonable to look for an antenatal as
for an intranatal or neonatal origin. No doubt ha-matoma of
the sterno-mastoid occurs as the result of a labour in which the
breech has presented : but there is a doubt whether it leads on
to muscular torticollis, and it is certainly a possibility that the
latter may be due to intrauterine causes, such as pressure (amniotic
or other), which distort the head and neck of the fcetus. One
matter, however, we need be in no manner of doubt alxiut : that
it is wise to inspect with care the state of the sterno-mastoids in
infants born as breech presentations, or after instrumental deliveries.
If the h;ematoma be there, then let there be massage and inunction :
it will be well to relieve somewhat the torticollis, for, after all,
that is of more importance than the proving or disproving of a
theory.
M.\STiTis Xeonatorum.
Not a few medical men are surprised once in a while to observe
that the breasts of a new-born infant are distended with a milky
Huid ; sometimes some of them send to a convenient medical journal,
which has a column of replies to correspondents, a startled imiuiry
as to the meaning of this curious phenomenon, adding occasiunally,
to make it more curious, that it was a male and not a female infant
that showed this remarkable mammary activity. And, look at it as
we like, and even after familiarity with it has lessened its strangeness,
it is a curious phenomenon ! — worthy to lie put alongside the occa-
sional discharge of a red sanguinolent fluid from the vagina during
the first days of life, "menstruation of the new-born." Both have a
meaning, doubtless, but a meaning yet to lie found out ; and only to
be found out after we have discovered all the details of that mar-
vellous series of changes known as the " jihysiological readjustment
at birth." Some things are known, or at least guessed at : during
fVetal life the sebaceous glands are active, secreting freely, and
helping thus to make up the vernix caseosa, " cheesy varnish," of
the infant's skin : it is thought that the mammarv glands have been
MASTITIS NEONATORUM 55
evolved from sebaceous glauds, for in the secretion of both there is
much fat; but other embryologists are of opinion that they are
nioditied sweat glands, an opinion which Minot regards as resting
" upon strong evidence " ; the neonatal mammary secretion is
undoubtedly lacteal, chemical analyses all agree about this.
Chemically milk then, but something queer about it, Hcxenmikli
the Germans call it. The human new-born is not peculiar in this
lactescent character, but shares it with some of the young of the other
mammals — the witches, presumably, not restricting their attentions
to him alone (!) Is it possilile, it may be hazarded, that as the foetus
from its semi-parasitism shares so intimately in tlie bio-cliemical
changes of the mother, changes which terminate for her in the
establishment of lactation, so even after birth the character of the
chemistry of the body goes on at first along similar lines, and causes
activity of the mammary glands in the infant also ? Whether this
be so or not, there need be no hesitation in taking measures io
prevent meddlesome midwives or mothers squeezing the breasts of
the new-born, with the notion (most erroneous) that they are in
this way doing the infant a service — " breaking the breast-strings,"
they say, perhaps in justification. Truly the most malicious of the
witches could wish for nothing else than this squeezing of the
secreting mammary glauds of the new-born to " Ijreak the breast-
strings," leading, as it not uncommonly does, to mastitis neonatorum,
mammary alDScess, cicatricial contraction, and years afterwards, when
the infant, if a girl, has become a mother, to lactational ineptitude.
It is said that some medical men even believe in this squeezing as a
prophylactic against mastitis neonatorum, a belief which provokes
from Dr. J. Comby (" Traite des maladies de I'enfance," v. 258,
1898) the indignant protest, " C'est a cette opinion que je m'attaque."
Surely it is to he expected that glands in a state of physiological
activity, if subjected to pressure, amounting generally to traumatic
pressure, and at the same time not kept aseptic, will readily pass on
into inflammation, aljscess formation, and cicatrisation. Evidently,
then, mastitis neonatorum is a clearly estaljlished neonatal condition.
Possibly, however, both the traumatism and the infection may in
some instances be intranatal, as in a delayed labour in a vaginal
canal infected with gonococci. More than this, there is some
evidence in support of the idea that antenatal predisposing factors
may be at work in some instances. Two cases, occurring in my
practice about seven and six j'ears ago, contain to my mind
suggestions of some such antenatal predisposition. In one, the
infant, a first child and a female, had when born a skin as
absolutely free from any trace of vernix caseosa as it is possible
to imagine ; so striking was it, that both my attention and that
of the nurse were drawn to it at once. During the first month of
life, that infant had a very severe and widespread attack of
eczema neonatorum, for which no apparent cause could be found :
the crusts were very marked. Little more than a year afterwards,
the brother of this infant was born : he exhibited the same remark-
able ab.sence of the vernix, although in not so striking a way ; he
5G ANTKNATAI, I'A'II lOl.OdV AM) IIVCIKNR
also developed trouljlesomo eczema and intertrigo : and, furtlier,
line I if his lireasts became greatly enlarged ami inllanied, but
fortunately did not go on to pus formation. It is reasonable to
ask whether in these two infants, born of the same mother, the
absence of the vernix caseosa at birth had any relation to the
after-development of the eczema and the mastitis neonatorum.
The circumstances are at anv rate suggestive.
CHAPTEE YI
Types of Xeonatal Disease, illustrating the Intrusion of the Antenatal Factor
(contd.) : (3) Keonatal Infections, Tetanus Xeonatoruni, Erysipelas
Xeonatorum, Sepsis Xeonatorum, Hannoglobinuria Xeonatonun, Om-
phalorrhagia Neonatorum ; (4) Disturbed Xeonatal Readjustments,
Icterus Xeonatorum, Mehena Xeonatorum, Keratolysis Xeonatorum,
Pemphigus Xeonatoruni, Sclerema Xeonatoruni, Aspliyxia Xeonatorum,
Xeonatal Heart Disease ; Summary.
The new-born is lialile ii(.)t (jiily to morbid conditions arising
from the traumatism of labour, and from infection during labour
(intranatal traumatism and infection), but also to maladies
which originate in infection after birth, and in disturbances
or arrests of the physiological readjustment which occurs at
this transitional time (neonatal infection and disturbed readjust-
ment). Into these neonatal morbid entities, just as into those
described in the previous chapter, the antenatal factor occasion-
ally, perhaps frequently, intrudes itself. It may be profitable to note
the manner of the intrusion.
III. Neonatal Infection.
Tetanus Xeonatouum.
The " Scourge of St. Kilda " is happily no longer so to be called,
for tetanus neonatorum, once so fatal to the new-born St. Kildans
as to justify that appellation, has been shown to be preventible, and
is accordingly now prevented, in St. Kilda, at least, and soon it will
be everywhere else, let us hope. Truly a scourge indeed, once upon a
time, not long ago either, in that most western of the Western
Heluides, lying " fully forty miles west of North Uist," called " Isle
of Feathers," also for many birds thereon and few human beings
(population in 1841, 105, but much less now). Up to the year 189-1:
it seemed likely that there would be fewer men and women and more
birds as the years went on, for the babies born on the island,
although all "proper bairns" up to the age of two or three days,
generally gave up sucking on the fourth or fifth day, on the se\'enth
" clenched their gums together, so that it was impossible to get
anything down their throats," were seized with convulsive fits, and,
" after struggling against excessive torments till their strength was
exhausted, died," most often on the eighth day, the disease thereby
58 ANll'.NATAL I'A THOI.OCV AND lIVdlKNK
getting till' name of the " eij,dit-(lay sickness.'' Many things ahout
tliis sifkiK'ss (if St. Kiltla have heen leeently told to the nietlical
woild hy Dr. (r. A. Turner {Glasgow Med. Jovrn., xliii. 161,
1895), to whom and to Dr. W. L. Keid, as well as to the Eev.
Angus Fiddes, the islanders are much beholden, for through
their eflbrts a mortality of at one time nearly 80 per cent, of
new-liorn infants ("the disease proved fatal to eight out of every
ten children horn alive") has been reduced to notliing or nearly so.
Various were the alleged causes of this terrible malady. Tliere are
many birds in the island, one a " particularly oleaginous bird," the
fulmar by name, found in no other place in the United Kingdom,
and greatly used by the inhabitants for food; possibly its oil, some
said, getting into the milk of the mother, proved too strong for the
new-l)oru infant. Others have found i'auses in deficient ventilation
of the huts, in exposure of the infants to sudden alternations of
heat and cold, and in the zinc roofs of tlie newer houses, which did
not protect the innuites. Some suggested mismanagement of
the umbilical cord, although others, and among them Sir Arthur
Mitchell, were satisfied that there was " nothing exceptional in the
mode of dressing the umbilical cord to account for the results." An
antenatal cause was looked for in race deterioration, through the
intermarriages which have of necessity been common in so sparsely
popvdated an island ; and this view was advanced to comljat the
theories founded upon defective hygiene, and careless dressing of the
cord. Nevertheless, it is now abundantly demonstrated that the
management of the cord had at any rate much to do with the
etiology of the disease ; for since the midwifery nurse has secured
surgical cleanliness of the umbilical region by cutting tlie
cord with a pair of clean scissors, dusting the stump with
iodoform powder, and dressing it with iodoform gauze and
sublimate wool, the infants of St. Kilda have been ]iractically
free from tetanus. The tetanus bacillus (" jiin-headcd. bristle-
shaped" in sjiorulation), although doubtless still jiresent on the
island, does not any longer make his way through the umbilical
wound into the bodies of the new-borns. Nasccntcs morimur
(" being born we die ") is not now applicable to the infants
of St Kilda; not the infant but the epitaph is for ever buried, not
to 1)6 resuscitated I Along with freedom from the daily newspaper
and the post, and almost complete freedom from the tourist, St.
Kilda enjoys immunity, after long years, from tetanus neonatorum.
In other parts of the world, however, the disease still lingers, and
sporadic cases occasionally occur both in cities and in countr}'
places; the aseptic treatment of the cord and navel is necessary
to eradicate these few remaining cases. The di.sease is tetanus,
but tetanus modified by the neonatal state, the chief modi-
fication being that the bacilli gain access through the umbilical
wound. It may bo that some infants are antenatally jiredisposed to
this invasion on account of cougeuital weakness, and conseiiuent
imperfect closure of the umbilical avenue of entrance at the time
when the cord drops otl'; but the antenaUil factor is not prominent
ERYSIPFXAS NEONATORUM 59
ill this neonatal disease, mir likely to lie unless consauguiuous
marriages can be shown to be of etioldgii-al importance.
Erysipelas Neonatorum.
Trousseau, in his remarkable " Cliniqiie mi'dicale de I'Hotel-Dieu
de Paris " (tome i. p. 174, 1865) has a fine chapter on erysipelas
iieonatoruiu, a chapter which leaves us wishing, after its perusal, that
the author had given us more from his pen upon this and other
diseases of the new-born. In it he describes, with wonderful insight,
the malady, nearly constantly fatal, " pres(|ue fatalement mortel,"
which is still known as erysipelas neonatorum, " erysipele des
nouveau-nes." He had been struck by the fact that when puerperal
fever prevailed at the JMaternite, many of the uew-liorn infants
suH'ered from erysipelas, ophthalmia, and peritonitis, and he had
called all these morbid manifestations "' puerperal," regarding them
as essentially the same. This opinion he liad freely expressed
twelve or fifteen years before (in 1850 or 1853), but the view had
not got outside the hospital walls, had not at any rate been made
widely known, had at the most been gliding gliost-like through the
pages of some medical journals (" se glissant silencieusement dans
les colonnes de quelques journaux de mcdeciiie "). P. Lorain had,
liowever, brought the matter prominently forward in his thesis, " Sur
la, fievre puerperale chez la feinme, le fo?tus, et le nouveau-ne "
(I'aris, 1855). He had absolutely demonstrated, with facts really
incontrovertible, the association of septic conditions of mother and
infant — thirty infants dying from peritonitis, simple, or with
erysipelas, ten of the mothers had died with the same lesions as the
infants ; fif tj- women whose infants had died from peritonitis had
themselves jjuerperal affections, but had recovered. Solidarity in
pathology had thus been established between mother and infant.
" 11 est impossible de ne pas accepter en patliologie la solidaritc qui
unit entre les meres et les enfants, le tronc et la branche qui en
emane." But Trousseau and Lorain did more for the elucidation of
erysipelas neonatorum : they pointed out the peculiarities of its
symptomatology and the gravity of its prognosis in a way that left
little for later writers to add. The infant's umljilicus is the common,
almost constant, avenue of entrance for infection ; it is a wounded
surface like the interior of the mother's uterus ; the infant then
takes erysi]>elas by the umbilicus. But the first signs of the
erysipelatous change are to be seen, not immediately round the navel,
liut near the symphysis, the infection having travelled thither along
the vessels (hypogastric arteries). Slowly the disease passes to the
scrotum (or vulva), then to the thighs, gluteal regions, and legs, and
finally to other parts. There is bright redness of the skm, with
hardness of the subjacent tissues, there is sometimes oedema also, and
bulliu containing yellowish serum. The swelling of the parts may be
very great, and may be followed by desquamation of the cuticle.
There is fever, with a rapid, small pulse ; tlie breast is refused ;
collapse follows, and death, often unexpected, cliises the scene.
00 ANTHNAl Al. I'A I I lOl.OCV AM) IIVCIENK
Uiicoiiiiiioii ciiiinilicatiiju.s are gangrene of tlie aljiloiuiiial walls and
elsL'where, phlebitis uf the unil)ilical vein, witii hejiatitis and jaiuidic-e,
peritiinitis, jiieurisy, etc. Trousseau pointed out that when abscesses
t'ornied in the sulicutaueous tissue, recovery sonielinies (jccurred,
which very seldom, if ever, happened under other circumstances.
The explanation of this fact has been furnished lately by P. J.
Achalme (Thcsi.t, Paris, 1892). He fomid that the streptococci (the
bacterial cause of erysipelas) were present in great numbers iu the
connective tissue separating the lobules of fat in the subcutane-
ous tissue. They were also very numerous in the walls of the
lymphatics. Nowhere was there any trace of a multiplication
of leucocytes; nowhere was there any evidence of the phagocytic
defence, of the leucocytic reaction. Herein lies the e.xplanation of
the extraordinary gravity of erysipelas neonatorum ; it may not
be the only explanation, neither need it be all the explanation, but
it is a working hypothesis to fotuul an explanation upon. When,
however, abscesses form in the subcutaneous tissue, there is evidence
of the phagocytic reaction, albeit of a tardy or delayed kind (" reaction
phagocytaire tardive"); and under these exceptional circumstances
the patient may recover.
Generally, it cannot be doubted, the streptococcic invasion takes
place at or soon after birth, and the di.sease is to be reckoned as a true
neonatal infection ; sometimes, however, it may be supposed to have
occurred in labour (intranatal), and rarely it has been intrauterine
(antenatal). Of the antenatal oases more must he said in another
chapter. There is, however, another antenatal aspect to the
question, for causes existing l)efore birth may have contributed to
weaken the tissues of the umbilicus and its vessels, and so to hinder
the sejjaration of the cord and the closure of the arteries and vein,
and thus to predispose to the onslaughts of the streptococci. At
any rate, the proper treatment of erysipelas neonatorum, as of tetanus
neonatorum, is prevention: and that, in a word, is to be obtained by
aseptic treatment of the umbilical cord. When the separation of the
cord leaves a surface from which a catarrhal discharge (" und)ilical
lochia" of Lorain) is coming, or from which there is actual sup-
puration, then the time for prevention is past, and an active
treatment with nitrate of silver solution is indicated. If erysipelas
neonatorum have declared itself, then moist antiseptic applii'ations
may be made, the anti-streptococcic serum tried, and possibly saline
injections used. A healtliy antenatal life, terminating not pre-
maturely, along with the aseptic management of the cord, at and
after birth, these con.stitute the best treatment of erysipelas
neonatorum — a " wise prophylaxis."
Ski'sls Xeonatoku.m.
In certain cases, when the umbilical cord separates, tlie umliilicus
does not look unhealthy, but stains of blood, and even of pus, are
seen on the dressings, and, on separating the edges of the cicatrix,
one can see a small ulcer; this may be regarded as tlie mildest
SEPSIS NEONATORUM Gl
form of sepsis, and requires washing with huric lotion, and dusting
witli iodoform powder. In otlier cases the ulcer has led on to the
formation of a small rounded mass or granulation (granuloma) in
the position of the umbilical cicatrix ; myxomatous in its pathology,
pale red in its colour, of the size of a pinhead or a pea, bleeding
when handled, throwing off a constant watery or purulent secretion,
with or without excoriation of the surrounding parts ; the little
mass calls for antiseptic treatment, for it indicates that septic
germs are at work in the innbilical cicatrix, and are preventing
normal union of surfaces. There is no clear line of demarcation
between such cases and those in which the skin margin surrounding
the navel has become involved ; in this condition of periumbilical
lymphangitis, the intlammation tends to be superficial, and is
attended liy some pain and redness, but is not productive of much
systemic disturbance. When the periumbilical cellular tissue is
also involved, another stage of septic invasion has been reached,
and omphalitis is present ; the local symptoms are more marked,
and systemic disturbance is now to Ije observed ; pus forms, and there
may be abscesses in the umbilical region, with resolution after rupture
or after surgical evacuation. There is again no line of demarcation
between omphalitis and erysipelas neonatorum {rid the nmbilicus)
such as has just been described ; both are due to an invasion of
the tissues with the streptococcus through the innbilical wound.
With or without the appearance of erysipelatous changes, the septic
series of umbilical manifestations may progress still further, and
widespread ulceration, and even gangrene of the tissues, may result,
manifestations which fortunately are rare nowadays. There are ■
yet other possibilities of neonatal gepsis through the umbilical avenue
of entrance : the arteries or vein may become the special seat of
infection, the streptococci or staphylococci setting up thrombo-
arteritis, or periarteritis, or thrombo-phlebifis, and from these foci
the germs may be carried to distant parts of the body. In such
cases the umbilicus and the tissues in its immediate neighboiu'hood
may remain apparently quite healthy ; at any rate, a ease reported
liy L. P. Audion (Bull, et mhn. Soc. anat. de Paris, 6. s. ii. 241,
1900) and two others by Pierre Audion (ibid., p. 291) suggest
this conclusion. In one of these, the infant of an albuminuric
mother, born fifteen days before term, showed nothing abnormal
at the fall of the cord stump (no discharge or secondary haemorrhage)
on the fifth day of life. The undjilicus was apparently healthy and
cicatrising, yet death occurred on the seventh day, the infant having
lost 350 grms. in weight, and having had convulsions prior to
his decease. The autopsy revealed an apparently healthy umbilicus ;
lint a probe covdd be passed in easily and deeply in the direction
of the umbilical vein, which was wide, smooth, white, and sur-
rounded by some vascularity ; there was no unhealthy appearance
of the neighbouring peritoneum ; the probe passed on easily by
the ductus venosus into the vena cava. There was also a per-
sistence of permeability of the umbilical arteries, from defect of
retraction. The cause of death was suppurative cereliral meningitis,
G2 ANTKNATAI. I'A THOI.OC^ AND HVCilKNK '
affecting the right lemiMiral, jiaiietiil. ami occijiital lolies, with super-
ficial (pileiiia (iver the fniTilal. Stre]iti)e<)cci were found in the ]iu.s.
In the unihilical vein was a small clot, slightly adherent to the
interior. In the other two cases the conditions were somewhat
ilitlerent, but pointed to the same mechanism of ndcrobic invasion.
It is ]irobal>le that in these cases, and in others like them, there
is also an antenatal factor at work as well as the neonatal ; the
prematurity of tlie infants (they were all under weight) may pre-
dispose to an arrest in the process of closure of the vessels of
the uudjilieus, and so jiermit invasion of the organism by germs
passing along the distinctively ftetal route. It will thus be seen
that there is a series of cases of sepsis neonatorum, varying in degree
and in locality, but agreeing in the mode of entrance of the infection.
They may be grouped, as Finkelstein {Jahrh. f. Kinderhlk., S. o.
Bd. 1. 560, 1900) proposes, in three divisions, with subdivisions,
thus: —
1. Local intluinniation of undiilical wound.
(a) Surface infection = pyorrha'a ; with infection of the
adjoining arterial thromlii = bleuorrhcea umbilici.
(1)) Ulcerative process = ulcus umbilici.
2. Local umbilical disease, with infection of the umbilical ring
and adjoining abdominal wall = omphalitis simplex, absce-
dens, gangra-nosa, ulcerosa.
3. Progressive umbilical diseases.
{a) Thromlw-phlebitis and periphlebitis nmbilicalis.
(6) Thrombo-arteritis = supiiuration of the thrombus in
the whole length of the arteries.
{c) I'eriarteritis = lymphangitis nmbilicalis.
(rt) Primary process.
(&) Secondary to omphalitis or idcus.
{d) Phlegmone nmbilicalis interna s. pr;vi)eritonealis.
In the preceding paragraph the umbilicus alone has lieen con-
sidered as the route by which septic infection takes place in the
new-born infant; but although it is a very characteristic route, it
is not the only one. Abrasions of the cuticle, or actual wounds
of the skin, may occur in labour, or after birth, and through this
cutaneous avenue of entrance streptococci and staphylococci may
pass. The infant may, during his progress through the pielvic canals,
make premature efforts at respiration, and draw septic vaginal
discharge, or even liquor amnii, into his lungs or stomach, and
so lead to infection of these organs. The conjunctival membranes
may also be inoculated with septic germs, although, as has been
already noted, it is more commonly the gonococcus than the strepto-
coccus that gains a lodgment there, and the same remark applies
to the genito-urinary nuicous membrane. The conditions produced
by septic invasion along these different routes are all to be regarded
as forms of neonatal sepsis; they arise, some of tliem, in the intra-
natal, and some of them in the neonatal, and some of them even in
the antenatal period of life, but they exhibit their characteristic
si:psis nkoxatorum 0:5
pheuuiiiena just after birth. Tliesu phenoiiiuua may, accordiiiu' to
the route of invasion, take the form of erythematous, pemphigoid,
and hamorrhagic cutaneous manifestations ; of bronchitis, pneumonia,
I ir pleurisy ; of stomatitis, gastro-enteritis, or cholera infantum : of
ophthalmia, or of vulvitis, urethritis, and vaginitis. In this way
there occur in the new-born such affections as septic diarrhcea, and
septic pneumonia ; but the true nature of these conditions has onh"
lieen appreciated within recent years. It seems probable, also, that
in this group of the septic neonatal infections must be placed certain
little understood morbid processes, to which the names of Eitter's
disease, Winckel's disease, Buhl's disease, and the h;emophilia of the
new-born have been applied. In doing so, however, it is necessary
to widen greatly the definition which used to be accepted of
the germs which are to be regarded as septic ; it must include,
not onlj- the streptococcus, and the staphylococcus, but also the
Bacterium coli commune, a bacillus analogous to the Bacillus
pncumonicc of Friedliinder, the B. entcriditis, etc. Some words of
description will be given to the diseases which are thus admitted
within the scope of "sepsis neonatorum," but, in the first place,
it will be well to complete the reference which is being made to
neonatal sepsis in its more restricted sense. All the septic con-
ditions of the new-born have this in common, that they are very
liable to prove fatal. This lethal character may be due in part
to the weakness of the phagocytic or leucocytic reaction at this
time of life, and this in its turn may be a persistence of a foetal
peculiarity, for in intrauterine life (life normally in sterile sur-
roundings) there can be little need for such a reaction. It may
Ije also associated with the small degree of development of the
lymphatic glands and the spleen. There can l)e no doubt that
congenital debility, premature Ijirth, the presence of malformations
(such as hare-lip), cleft palate, umbilical hernia), and the coincidence
of an antenatal disease (e.g. syphilis), will increase the receptivity
of the infant to pathogenic, and specially to pyogenic, microbes.
In this way there is both an increased septic mortality and mor-
bidity in neonatal life, and in the production of both there is the
antenatal factor evidently at work. The germs are everywhere
present — in clothes, in baths, in CiV(vcuses, in maternal secretions,
in the mouth of the infant, round the umbilicus, in the folds of
the skin ; the new-born is prone to their attacks, by reason of
the peculiarities of his neonatal physiology, and antenatal pathology,
and intranatal traumatism ; therefore, there is need for an enlightened
prophylaxis, which shall not only endeavcnir to prevent the entrance
of microbes along the avenues which have been referred to, but
shall also attempt to strengthen all the defences of the organism
against their onslaughts when they have entered.
H J': MOGLOBIN UKIA NEONATORUM.
A plurality of names and an obscurity of pathology often go
together, the former being bred of the latter ; so, at any rate, it is
64 ANTEXATAI, I'ATIlOI.Od^' AM) IlVdlENK
with regaid to tlie inalaily nf tlic iiew-liniii called haMuoglohiiuiria
iieoiuitoiuui. Many iiaiiiL's, truly. " Wiiifkel's diseaso" (lui^lit,
with enual appropiiatL'iieHS, be "I'dllak's" disease, or " Uigelow's "
disease, or " Laroyeniie's," or " Ciiarrin's " disease), " liroiized hamatic
disease," " renal tubal ha'iuatia " (Parrot), " pernicious icteric cyan-
osis " (Winckel's own name for it), and " bronzed lucniaturic disease
of the new-born." There is one value, at least, in the plurality
of names : a suggestion is contained therein of the outstanding
features of the malady. It is rare, but wlien it occurs it is usually
in an epidemic form, and in a Maternity Hospital. The victims
(nineteen perished out of twenty-three attacked in one ei)idemic)
are healthy and strong at birth ; two or three days after birth they
liegin to be ill, very ill in fact, dying in tliirty-twu hours, and even
in a shorter time in some cases. They have a cyanotic-icteric colour
of their skin, each one appearing like a " little mulatto," a peculiar
lironzed colour, almost violet on the palms of the hands and the soles
of the feet, the conjunctiva sub-icteric. There are fits of crying, alter-
nating with somnolent states. The blood is black as ink, or has
a chocolate colour. The stools are black-green, and leave on the
napkins a stain with a sanguinolent areola. The urine is sanguinolent
also, very markedly so, drawing the attention of the clinician at
once. There is no fever, but a rapid pulse. There are head sym]itonis
also, such as convulsions and squinting. As already hinted, death
usually follows. The autopsy reveals to a verj' considerable extent
the changes which the syn;ptonuitology has led one to expect ;
there are hiemorrhages in many situations, the lungs are lilack, the
cerebro-spinal fluid and that from the pericardial sac are sanguin-
olent, the Idadder contains sanguinolent urine, the liver and spleen
have a lirownish black colour, the kidneys are marone-coloured,
and the pelvis and calyces are filled with a black-grained clot.
There is no disease of the umbilical vessels : about this point all
oliservers seem agreed. The microscopical examination of the tissues
throws a faint tlicker of light into the pathological darkness of the
malady. In the urine are to be found epithelial cells from the
bladder, epithelial masses from the calyces, granular cylinders of
blood corpuscles, and micrococci in great numbers: there are
hu-moglobinuric infarcts at the level of the papilLe in the kidneys.
Thus Winckel. The renal change is descrilied more minutely by Bar :
there is a blood ell'usion into the convoluted tubules at the pajiilla-,
and the effusion has acted uixm the renal epitlielium liy compres-
sion : the straight tubes show similar changes, especially marked
at the level of the " })yramids of Ferrein " ; in the latter he found
elongated bacteria, and in the former micrococci in large numliers,
arranged in chains or clusters. A micrococcus also is to be
observed in the blood, according to Hirst, and in the liver, spleen,
and lungs ; rapid diminution in the red blood cells, 5,700,000 one
<lay, 3,400,000 three days later; ratio of white to red, 1: IS'o,
luemoglobin, 89 per cent.
It was and is an obscure disease. Eesembling in some details
the malady known as IJuhl's disease, or acute fatty degeneration of
OMPHALORRHAGIA NEONATORUM Go
the new-born, for in both there are ha-morrhages and fatty de-
generation of the internal organs, but differing in others. Obscure
as to its etiology, when it occurred in an epidemic form (Max
Kunge {Die Krankheiten der crstcn Lchcnstaije, p. 175, 1893) says:
" Die xEtiologie dieser Epidemic blieb demnach dunkel "), it was
also obscure when it was met with sporadically (" auch blieb die
^Etiologie uuklar," Eunge). One or two things alone seem certain :
it is an infection; it does not, primarily at any rate, aftect the
umbiUcus ; it is htemorrliagic ; anil it specially attacks the tubules
of tlie kidney and the blood. Buhl's disease has been referred to.
In it the fatty degeneration of several of the internal organs is a
marked feature : something similar has been described in the new-
born of other mammals, namely, the " La^hme " (" foot-halt ") of lambs.
In " Buhl'sche Krankheit," there are infarcts, bleeding from the
bowel and stomach, and jaundice. In some details the disease
differs from ha?moglobinuria neonatorum: hjemorrhage from the
umbilicus is common, and the subject has often been in an asphyx-
iated condition at birth. Sepsis may be expected yet to be clearly
demonstrated in both, although it is difficult to understand by what
avenue of entrance micro-organisms have invaded the body ; but
with such cases as those of Audion {loc. cif.) in the nrind, it is
quite conceivable that germs may have passed in through unclosed
umbilical vessels, without there being any signs of disease in the
umbilicus itself (persistence of antenatal permeability ?). " Bleibt
die -.Etiologie unklar ! "
Omphalokrhagia Xeonatoru.m.
Htemorrhage from the umbilicus is " not a disease but a symptom
of different morbid states " (" keine Krankheit, sondern ein Symptom
verschiedener krankhafter Zustande," Bunffc) ; this, at any rate, is
the modern view taken of the idiopathic, or secondary, or spontaneous
form of omphalorrhagia in the new-born. With primary bleeding
from the stump of the umliilical cord from slipping of the ligature,
abdominal constriction from the binder, etc., we are not here concerned.
Idiopathic omphalorrhagia begins after the fall of the cord ; often in
insidious fashion, bleeding having begun and for some time continued
before it has been observed, perhaps when the infant is being un-
dressed, and the gravity of the case then for the first time recognised.
The time of commencement, then, may be fixed as between the
fifth and seventh days of life. The sex more often affected is the
male (males, 65 i| per cent. ; females, 34{ per cent.) ; but the disease
is rare (once in 5000 new-liorn infants, Winclcd) ; is very fatal when
it does occur (mortality, 83 per cent., Grandidkr) ; and runs its
course in a short time as a general rule (a few hours, at most a few
days). The umbiUcus, when inspectetl, shows rather a steady and
general oozing or sweating of blood than a distinct htemorrhage from
any vessel or vessels ; some clots may be found in the neighbourhood
of the umbilicus, but commonly the blood shows no tendency to
coagulate. There may or may not have been premonitory, at any
5
GG ANTENATAL I'ATHOI.OdV AND HVOIllM':
rate precedent si^ns, such as vuiiiiting, souiunleiice, Jaundice, colic,
and purpuric si)Ots.
It is inevitalile that .such a lui-morrhage sliould be regarded as of
tlie nature of the hereditary malady haanophilia, but then omphalor-
rhagia is rare in families with tliis hereditary tendency (1 know
of but one) ; and it does not clear up matters to suggest that it
represents a sort of " transitory hicmorrhagic diathesis " due to the
transition from the fwtal to the neonatal mode of respiration (" natiir-
lich ist dies keine Erkliirung, sondern nur eine I'mschreibung der
Thatsachen," Biitufe). It would seem that it is sometimes the result
of congenital syphilis, altliougli it must be freely confessed that all
evidence of the j)resence of parental syphilis is often al)sent. It may,
as has already been noted, be associated with Ihihl's disease, an
association which does not help us much in our search for its causa-
tion, the etiology of Buhl'sche Krankheit itself l)eing "unklar" u]>
to this time. Sepsis neonatorum has also been regarded as the
cause of omphalorrhagia with some increasing degree of probability,
for various microbes have been foimd in such cases (streptococcus,
staphylococcus albus, sta]>bvlococcus aureus, special di])lo-bacillus).
Finally, the antenatal factor has been invoked, and the condition
has been ascribed to malformations of the heart and bh)od vessels.
Whether there is any degree of truth in this opinion or not, is not
easily decided, but there can he no doubt that two and even more
cases of omphalorrhagia may occur in the same family ; further, 1
have notes of a family history in which the first infant died of um-
bilical hicmorrhage, and the second was dead-born with grave mal-
formations of the intestine and urinary bladder'. Some evidence,
therefore, exists to prove that the antenatal factor is not to be
neglected in endeavouring to distrilnite the etiological blame aright.
In presence of such a grave condition as omphalorrhagia, mild re-
medial measures are comraonlj' of little use, and only occupy valuable
time. The application of various styptics and the tilling of the imi-
bilical fossa with plaster have been tried ; but it is generally necessary
to resort to compression of the umbilicus or to mass ligatin'e of it
with the aid of hare-lip ])ins. The umbilical vessels may l)e sought
for and ligatured separately, but there is no strong evidence that the
l)leetling is specially from the vessels. The abdominal cavity has
been opened in one or two cases, and the vessels tied on the inside,
but with no good effect. Constitutional treatment (e.t/. anti-syphilitic)
has not been forgotten ; Imt all means too often fail. Of this disease,
as of some others which aftVct the iiew-liorn, it may lie sadly said,
" prescjue fatalement morld."
IV. Disturbed Neonatal Readjustments.
It is impossible to separ^e ofV the maladies which are due to
neonatal infection from tliose ni which the chief morbid factor seems
to lie a disturbance of the ]i]iysiological readjustment which follows
liirth. There can be no duulit that to some extent they overlap, lioth
factors being present. What I am trying to do is to group together
ICTERUS NEONATORUM 67
those iu which the infection-factor seems to lie the more important,
and those in which the disturbed readjustment plays the greater
part. The classificatiou, however, is not insisted upon, for the object
of the chapter is to show the intrusion of the antenatal factor into
all, or nearly all, the diseases of the new-born.
Icterus Neoxatoru.m.
Surely there is no question in neonatal prognosis more difficult to
settle than the significance of jaundice of the new-born in any given
case. Certainly there is no problem in neonatal pathogenesis farther
from solution. So common and generally so benign as to have gained
for itself the name " physiological," jaundice of the new-born may
yet be due sometimes to one of the rarest of malformations, and may
have a mortality that is appalling. Hypotheses there are in plenty ;
but of solid, incontrovertible facts few are to be found, although
sought for with care. One fact among the few is worth remembering,
even if much else be forgotten : jaundice of the new-born is, like
omphalorrhagia neonatorum (but even more), to be regarded as a
sj'mptoni rather' than a morbid entity or separate disease. Another
fact is its frequency, and the evident deduction (but not a fact !)
would seem to be that it must therefore depend upon a fre(;[uent
condition or group of conditions ; it is safer, however, to conclude
that it generally depends upon a frequent conjunction of circum-
stances, and ravel 1/ may be due to quite exceptional states. There is
certainly one group of cases in which the jaundice is slight and
transient, and so often met with that one is justified in regarding it
as a symptom of a physiological state of affairs, the outward sign and
manifestation of the inner processes of functional readjustment and
adaptation which take place at and soon after birth ; in this group,
the jaundice is by some termed idiopathic or spurious icterus, or
icterus neonatorum in the narrower sense. It is equally certahi
that there is another group of cases in which the jaundice is again a
symptom, but now a symptom of a pathological condition — nay
rather of several pathological C(3nditions of various degrees of gravity :
symptomatic icterus, then, may be its name. It is possilile, but there
is no great strength of possibility about it, that in such a disease as
hffimoglobinuria neonatorum it is the jaundice that is the pathological
condition that constitutes the disease itself. Thus, to summarise,
there are, or may he, three groups : —
1. Idiopathic icterus — the symptom of a physiological process
or processes — a sign of neonatal readjustment in
progress.
2. Symptomatic icterus — the sympitom of a pathological pro-
cess or processes — a sign of neonatal pathology in
action.
3. Essential icterus — not a symptom but the disease itself — a
doulitful entity and class — possibly will turn out to
be a form of symptomatic icterus, variety septic.
68 ANTRXATAL PATHOLOGY AND HYGIENE
In enduavouriii^' to liiiil a suitalile pathogenesis for idiopathic
jaundice, the patliologist lias run riot, and what witli his liepatogcnous
theories and his h;L'niatogeuous ones, there is confusion in the minds
of not a few writers and readers both. Here are some of the hepato-
genous theories : desquamation of tlie epitliehum in the bile-ducts
leading to blocking; slowing of the portal circulation due to the
circulatory changes resulting from birth and the ligature of the
cord ; stasis in the bile-ducts from their compression by the anlema of
Glisson's capsule due to the phenomena folhnving birth ; persistence
of permeability of the ductus venosus ; retention of the meconium ;
and late ligature of tlie umljilical cord. With respect to most, if not
all, of these, Eunge's remark {op. cit., p. 228) holds true, " Keinc
einzige dieser Anschauungen ist anatomisch begriindet, sie sind
sJimmtlich hypothetscher Natnr." They agree, let it be noted, in one
thing, that they all look for a cause of the jaundice in one or other
of the phenomena which follow Ijirth as a result of the rearrange-
ment of functions made necessary by the marked change in environ-
ment then taking place ; they regard the icterus as due in some way
to disturbance of an absolutely perfect performance of the neo-
natal readjustment. Tlien, again, there have lieen the lui-matogenous
theories which seem to have Ijeen widely held in France ; the hejmto-
genous apparently Ijeing popular in tJermany. Destruction of red
blood corpuscles after birth, setting free of much pigment in tlie
blood, changes in the blood plasma leading to tlie breaking down (if
blood corpuscles; these and other changes in the blood have been
advanced, but not of late with any great boldness, tlie demonstration
of bile acids in the pericardial fluid having given apparently a deadly
blow to the hicmatogenous theories. This much, however, it is worth
while remembering: that the luematogenous, in common with the
hepatogenous theories, look to the readjustment phenomena in the
new-born, or to a slight disturliance of them, as the causes of the
blood or liver changes which produce the jaundice. Some investi-
gators carry the inquiry further liack, and ask what cause or causes
contribute to the slight di.sarrangement of the physiological readjust-
ment of birth : some find an explanation in errors of feeding during
the first days of life; while others conclude that delay in laliour, or
unilue interference with its mechanism, has been the disturbing
condition ; and yet others are compelled to look for the antenatal
factor, and find it in congenital weakness or prematurity. Thus,
idiopathic icterus neonatorum is due, according to the opinion of
most, to a disturbance of the iihysiological readjustment of hirtli,
and this distiu'bance is caused by a neonatal, an intranatal, or an
antenatal factor, by one of these, or perhaps by all. At any rate, and
to the physician this is a matter of moment, the condition usually
disappears quickly and leaves no evil efiects behind it ; it is an
almost harmless disorder, all)eit having "a well-marked clinical indi-
viduality " (" une individualitc clini(iue bien marquee ").
A different group of circumstances and conditions goes to make up
the malady known as aiimptomalic icterus neonatorum. Its causes are
not unknown, are in fact well known, but they are numerous and not
MEL.ENA NEONATORUM GO
easily to be ditlerentiated from each other durmg the life of the infant
affected therewith. It is in some instances due to hepatic lesions,
neonatal or antenatal. In this group must be placed the jaundice
which follows umbilical infection with sepsis ; that which is caiised
by syphilitic hepatitis of the congenital type ; and that produced by
interstitial hepatitis, the syphilitic nature of which cannot be proved.
It is in other instances due to obstacles to the How of the bile,
obstacles which have arisen in the neonatal period or in the ante-
natal. Thus it may originate in a catarrhal blocking of the common
bile-duct, at the point where it passes through the wall of the duo-
denum ; or it may arise in that interesting malformation, or result of
antenatal disease, known as congenital obliteration of the bile-ducts,
and it may then be justly termed " malignant icterus," for it is always
fatal sooner or later ; or it may be caused by the impaction of a small
gall-stone in the ductus communis choledochus or in the cystic duct,
it being necessary in such a case to believe that the calculus was
formed in intrauterine life (antenatal) ; or it may, finally, be the
result of an over-production of bile leading to obstruction in the
ducts. In this multitude of causes it is to be noted again that the
antenatal factor occupies a not unimportant place, and when it is
present in any given case it largely increases the difficulty of treating
the jaundice, and makes the prognosis correspondingly worse. The
hope of the physician, in one sense, lies in the confirmation of the
diagnosis of catarrhal lilocking or of syphilitic hepatitis, for castor-
oil in the one case and mercury in the other may, and does, work
wonders ; the diagnosis of congenital obliteration of bile-ducts or
impaction of an antenatally formed gall-stone, a diagnosis made
largely as a matter of exclusion, raises little therapeutic expectation.
MEL.EXA NeONATOKU.M.
In cases of gastro-intestinal hiemorrhage in the new-born, the
lileeding is generally from the bowel (mekena), and rarely from the
mouth (h;ematemesis) ; it has therefore become customary to apply
the name " mekena neonatorum " to the disease. That it is to be
regarded as a disease is, however, more than doubtful ; it is, in fact,
no more a disease than icterus ; it is, like icterus, a symptom of several
different morbid states. Generally a symptom among other symptoms,
it may in some rare instances stand alone as the only symptom ; then,
and then only, is it justifiable to call it a disease — a morbid entity.
Unlike jaundice of the new-born, it is a very rare condition, occurring
but once in 500 or 700 new-born infants ; there is no great resem-
blance either in the matter of prognosis, for melfena neonatorum is
very often fatal, mortality being from 35 per cent, to 50 per cent.,
even from 50 per cent, to 60 per cent, according to Eunge. In one
thing the two conditions fully and entirely agree : in the multitude
of theories which pathologists and physicians have lirought forward
to explain their patlmgenesis. Many of the theories are not founded
upon even the slightest stratum of anatomical fact, there being no trace
of solid bed-rock in the .shifting sand. Some of the theories condenm
70 AXTKNATAL 1*ATH()L()(;Y AND HV(;iENE
themselves to llic tliiiikin<^ iiiiiid at once ; those, namely, in wliicli a
very common occurrence, such as early or late ligature of the umbilical
cord, is blamed for the production of mekena neonatorum, ailmittedly
a very rare condition. Surely it must be conceded at (jnce that a rare
morbid state demands for its causation a condition which is also rare,
or at least a rare conjunction of common conditiims. As it is, the
pathogenetic theories of mehena neonatorum are in a state of hopeless,
bewildering confusion. There is, perhaps, little service to be got out
of an attemi)t to arrange them ; but there is for our present ]iurpose
some interest in so far as it gives a demonstration of the way in which
the four great factors, traumatism, infection, disturbed neonatal re-
adjustment, and the antenatal factor, are all in turn invoked and com-
bined in various ways, and shutHed like a pack of cards in the hope
that here or there, in this circumstance or that, a feasible explanation
may be forthcoming. A little simplification is possible : there are
some cases, at any rate, in which the melsna is evidently tlie result
of blood swallowed, e.g. from a hare-lip or cleft palate, or from the
nose or lungs ; more, the blood may not even belong to the infant, but
come from the maternal nipple : certainly there is justiticatiou in
separating ott' these cases and giving them a special name, with a
warning that they are not to intrude any more into the etiology of
mehena neonatorum. Separated otl', therefore, they have been, and
have been called " mehena spuria." With the remainder, what is to
be done ? Let us see how they arrange themselves under the four
great etiologic factors. Perchance this uietlmd cif regarding tliem
may be of some small service.
First, then, there is traumatism, intranatal or neonatal. Com-
pression of the trunk of the infant in birth, violent procedures adopted
to restore the half asphyxiated child, swinging movements, for instance,
after birth, have been suggested. Two difficulties immediately suggest
themselves : such traumatic occurrences are common, while melaena
is rare ; cases of mehena rarely follow sucli traumatic occurrences.
Traumatic factor, however, is not to be driven out of the field so
easily ; according to F. von Preuscheu {Ccntrlhl. /'. (r'l/niil:, xviii. 201,
1894), the traumatic part of the process is to be looked for in the
cranium, where h;emorrhages have destroyed some portion of the
central nervous system — a theory founded upon the exjieriments of
Scliift" and others upon the production of gastric luemorrhage in dogs,
and supported to some extent by Schiitze's case, in which there was
a small hivmorrhage under the tentorium cerebelli {ibid., p. 207).
Intracranial hajmorrhages, it must be borne in mind, are not so rare as
sujiposeil, and are certainly many times present when melfeua is
absent.
Second, there is infection, intranatal or neonatal. The theories
founded upon some sort of infection are wonderfully popular at the
present time. Tiie special form which the infection takes may be
septic, and it is not doubted that gastro-intestinal liiFmorrhages occur
in sejisis neonatorum : it may also take the form of Buhl's disea.se,
and be caused by the microlie ]ieculiar to it; or, it niaj' be due to
a bacillus jieculiar altogether, as F. Giirtner (Arch. f. Gi/mik. xlv.
MEL.EXA NEOXATOHLM 71
272, 1893) aud those who have followed his lead have maintained.
It is unfortunate for the acceptance of this theory, that so many
microhes have been discovered : streptococcus alone or with the
diplococcus of pneumonia, bacillus pyocyaneus alone or with the
staphylococcus, bacillus lactis aerogenes, a bacilhis like Friedliinder's,
a bacillus like Kolb's found in purpura luemorrhagica, Gartner's bacillus
above referred to, and a micro-organism suggesting, but not to be
identified, with the diplococcus of pneumonia. A bacteriological
"embarras des richesses" is thus created, which, as has been pointed
out by Kilham and Mercelis {Arch. Pcdiat., xvi. 161, 1899), adds to
the confusion, aud does not increase the jirobability of the existence
of any specific microbe.
Third, there is disturbed neonatal readjust]nent. A large number
of pathogenetic theories is associated with this factor. Further, most
of the theories look to a disturbance in one part of the readjustment
phenomenon, in that, namely, which has to do with the circulation.
Of course it is at once apparent that any irregularity in the com-
plicated series of changes (physiological and anatomical) which marks
the transition from the foetal to the neonatal circulation, will be likely
to produce congestive conditions in one part of the vascular system
and anaemic conditions in another. It is in this way that early or
late ligature of the cord, thrombosis in the iimliilical vein from
delayeil establishment of the pulmonary circidation, and other
frequently occurring irregularities, have been invoked as pathogenetic
factors. The fact that it is common to find at the autopsies of infants
who have died from melajna erosions, defects, and even ulcers in the
mucous memljrane of the duodenum, stomach, and oesophagus, is not
regarded as weakening this theory. For it is ingenioiisly argued : there
has been slackening of the circulation in the umbilical vein with
formation of a thrombus, and later from that thrombus pieces have
separated and have been carried as emboli into the small arteries in
the gastric or intestinal walls, where the}' have produced local death
of the tissues, and partial digestion of the mucous membrane has taken
place, with exposure of the vessels and hemorrhage. These little de-
fects or ulcers are, it is said, found in 45 per cent, of the cases. It is an
ingenious theory, but still a theory only. Another purely theoretic view
is that the haemorrhage is due to the closure of the ductus arteriosus
at a relatively slower rate than the foramen ovale, causing increased
pressure in the abdominal arteries. Other theories are retention of
the meconium and the exposure of the infant to cold. That in many
of the cases of melajna neonatorum the bleeding is concerned in some
way with disarrangement of the readjustment processes, and more
especially with the vascular part of the adaptation, must, I think, be
admitted as exceedingly probable ; but here again the pathologist is
lirought face to face with the ol ijection that such vascular disturbances
must be very common, while melwna is very rare. Consequently
many observers have welcomed the idea of an antenatal cause or pre-
disposition.
Fourth, the idea that an antenatal factor must be looked for in
melffiua neonatorum is not new. Further, it has taken many forms ;
7l' ANTI'.NAIAI. I' Al IIOI.OCY AM) HYCilKNE
and it has cither stood liy itself or lias Ijeeii regarded as accessory to
other factors. In one of its simplest forms it is the recognition of
meli«na as a manifestation of h;emoi)hilia ; and the obvious objection
that there is no hereditary history of that disease, nor indeed any
otlier sign of it, then or later, is explained away by regarding it as a
teinporar}- lucniorrhagic diathesis in the new-horn. Nevertheless, in
some eases, it is prolialdy a correct explanation ; for in women ha-nio-
])hiHa may show itself only as post-i>artum iKcmorrhage, and ])(issibly
the new-born may under certain circumstances show it only as melana.
Another view is that the disease is congenital purpura, and has been
transmitted from the mother ; Diehl {Ztxchr. f. Gvhurtsh. v. Gyiuik.,
xli. 218, 1899) has reported a case in which this transmission seems
to have taken place, but it is exceedingly rare. Malformation of the
heart or great vessels is another form the antenatal factor lias taken,
and fongenital syphilis of the ha^morrhagic type is another.
Sucli, then, are the etiological theories of mela-na neonatorum.
Their enumeration has at least demonstrated the presence of the
antenatal factor ; it has possilily done nothing else of any value. Let
it be added to the foregoing, that in some cases of mehena no patho-
logical changes at all have been found, and the reader will be impelled
to say with Demelin (Comby's Traitd dcs mal dc I'enf., ii. 143, 1S97),
" la pathogenie est loin d'etre simple." And as to treatment ? That,
likewise, is " far from simple," save in the cases where it is just
nothing at all ; in sucli it has a simplicity truly, but not one of the
right kind. Doubtless prevention is l>etter in niekena neonatorum
than any attempt to cure ; but a wise prophjdaxis depends upon a
knowledge of the pathogenesis and etiology, and that is still wanting.
Theoretically, it may l)e said that we ought to endeavour to favour
the readjustment of functions at birth ; but, practically, this is not
easy to do unless we know wherein and how the readjustment is fail-
ing. In tlie presence of a well-marked case of mcla-na, it will
generally be wise to keep the body of the infant warm (for the
application of cold, e.;/. ice, to the abdomen has met with no con-
spicuous success), and to give some styptic internally. Possibly it
may be found that the injection of a solution of gelatin (5 per cent,
to 10 per cent.) into the bowel will give good results.
Kekatolysis Xeoxatokum.
Under this name, or under its synonyms (Dermatitis exfoliativa
neonatorum, Eitter's disease, Dermatitis erysipelatosa) is known
an affection of the new-born, whose most prominent symptom is
an exaggerated cuticular desquamation. I say " exaggerated," for
there is a physiological furfuraceous or finely lamellar exfoliation
of the epidermis wliicli occurs in all new-born infants. It is one
of tlie outward manifestations of the readjustment changes which
follow birth : but there is some degree of mystery as to its causation,
possibly it may be produced simi)ly by tlie drying of the epidermis
in the absence of the liquor aninii, possibly there is a deeper seated
and more recondite cause than that. At any rate, a clearing up
KERATOLYSIS XEOXATORUM
of our knowledge of tlie physiological desquamation of the new-ljoru
could not but prove of value in elucidating the pathogenesis of Eitter's
disease. In Figs. 6 and 7 are high and low power niicro-plintcigraphs
I if the appearances of tlie
skin in a new-born infant,
with perhaps an excessive
degree of desquamation,
certainly with a well
marked degree of it. The
looseness of attachment of
the layers of the stratum
corneum is in these clearl}-
displayed, and there can
lie no doubt that in the
new-born the normal in
this respect very easily
may pass over into the
pathological. In Eitter's
disease, however, there are
other signs than epidermic
des([uaniation. There are,
according to Eitter him-
self (1) a prodromal stage,
in which there is a dry scaly condition of the epidermis ; (2) a stage
of erythema and exudation; (3) one of exfoliation and drying, the
desquamation following progressively the march of the redness ; (4)
one of reintegration of the epidermis, accompanied liy a fading of the
erythema ; and (5) a stage
of sequeke, such as boils,
abscesses, and eczema.
Often the whole process,
prior to the sequeke, is
completed without severe
constitutional symptoms ;
but there may in some
cases be diarrhcea and
pneumonia. I have met
with a case of keratolysis
neonatorum in which the
symptoms were torpidity,
rejection of food from the
mouth, unless it were put
far back on the tongue,
highly coloured stools, and
swelling of the parotid
glands ; at ten days after
birth the cord had not
separated ; the child died when a fortnight old ; it had been born
after a dry labour, and the dcsc^uamation was going on at birth.
A most puzzling malady this has proved to the physicians who
74 ANTKNATAI. I'Al'HOI.OGV AND HYCilKNK
have met with it, a charat'lcr which it lias in I'liiiiinnii with maiij' other
neonatal diseases. Possibly it is to be lenaidwl. like suvciai other
morbid states of tlie new-born, as a syni])tom rather than a disease
by itself. It may, for instance, be a symptom of sepsis, in which case
we invoke the factor of neonatal infection ; it may be the resnlt
of an exaggeration of the phy.siologicaI exfoliation of the cuticle,
in which case the readjustment factor is brought into the etiology;
or it may be the consequence or accompaidment of an intrauterine
disease, such as fa>tal measles, scarlet fever, or erysipelas, in which
case it is the antenatal factor that is being advanced. We must,
it is to be feared, leave it where Caspary {Vicrtdjahrschr. f. Derm,
u. Si/ph., xi. 122, 1884) left it sixteen years ago — "an epidermolysis
of unknown nature, with secondary hyjiencmia of the cutis."
I'EMi'Hii ;i:s Neonatorum.
Another disease (or symptom of disease) of the new-born, which
is probably connected with a disturbance of the readjustment pro-
cess, in so far as it affects the skin, is i)emphigus neonatorum. A
great deal has been done within recent years to elucidate the bullous
conditions of the skin of the new-born, and there has been an attempt
to get rid of the term " pemphigus," and to put in its place such
names as "congenital bullous dermatitis," "epidermolysis liullosa,"
"congenital dermatitis herpetiformis." Reference will be made to
it in another part of this work ; in the meantime, it may be said
that for its explanation it has been found necessary not only to
invoke the readjustment and infection factors, but also the antenatal,
in so far as most authorities have been led to ascribe the malady
to a congenital and often hereditary vulnerability of the skin, even
when there have been no lesions present at birth.
SCLERE.MA NeONATOKUM.
Sclerema of the new-born is a grave disease, characterised by
induration of the subcutaneous cellular tissue, and a lowering of the
body temperature ; and more widely diffei-ent and even conflicting
theories have been advanced to explain its origin than have been
brought forward in connection with any other neonatal morbid
condition. Truly a ])lurality of theories is present, with not a
little of the "gnesser's darkening of knowledge"; a bad omen for
the emergence of truth. It can, at any rate, generally be separated
from " oedema neonatorum," which is almost certainly a symjitom
rather than a disease per sc. The readjustment factor has been
sought for and found in the conditii)n of the subcutaneous fat
at and about the time of birth ; it is more easily solidified by
a fall in temperature, and the new-liorn infant which is not kept
warm becomes scleremic. But it may very fairly be asked, why,
then, is sclerema neonatorum comparatively so rare, for certainly
many infants ai-e allowed to become chilled ? Further, in a case
which I .saw some years ago (35), the microscopical appearances
SCLEREMA NEONATORUM 75
of 'the_ subcutaneous tissue suggested something very different from
simple" solidification of the adipose layer ; they showed an invasion
of the layer by bands of connective tissue, and an atrophy of the
fat cells (Fig. 8). Another origin for the disease was found in
the cardio-vascular readjustments at birth, or in the disturbance
of them. Some writers identified sclerema with morbus coeruleus ;
others grouped it with the infections, and saw in it an unusual
form of erysipelas neonatorum. The antenatal factor (a convenient
one in the.se cases, about whicli our ignorance is the densest) has
of course been long in the field, and has ranged from icctal syphilis
and myocarditis, to anomalies of the lymphatics and antenatal lesions
of the thermic nervous centres. What I wrote in 1895 (4, p. 53)
I may with safety place again here : " It would seem as if nothing
lessjthan the labours of an international connnittee of investigation
might succeed in clearing up the confusion, and in undoing the
results of the erroneous generalisations of the past century." Spes
incerta! At any rate, the malady affords another instance of the
intrusion of the antenatal factor into the pathology of the new-born,
and to illustrate this intrusion has been the chief object of this and
of the preceding chapter.
There are yet other morbid states of the new-born, such as
asphyxia neonatorum, and neonatal heart disease, in which a dis-
turbance, or rather a complete arrestment of the physiological
readjustment at birth, is very evidently present. In them, also,
it is not difficult to recognise the antenatal factor in the background
of the etiologv.
70 ANTENATAL I'ATI lOI.OdV AND HYGIENE
Summary.
From lliL' fads wliicli have been euuiiierated, it is clearly evident
that if the characters of the diseases of the new-born infant are to be
understood, it is essential that account lie taken not only of the circum-
stances that the infant's organism has just passed through a period of
traumatism, and is passing through one of readjustment to meet
new requirements in a new environment in which microbes are
plentiful, but also that during the nine months of intrauterine
life which precede birth, it may have been the sphere of morbid
processes which have left their impress upon it. It may come
into its extrauterine surroundings already diseased, or malformed,
or predisposed to some pathological development. Like pregnancy,
neonatal life is an epoch which has a physiology in many respects
peculiar to itself, and which borders very closely on the patho-
logical, tending very easily to pass over into it. Further, just as
eveiy woman l)rings with her into her pregnancy the results of
her past iiathological history, so the new-born infant brings with
him, out of his antenatal life into his neonatal existence, the effects
of any morbid processes which may have attacked him in utero.
In this way the j)athology of pregnancy and the maladies of the
new'-born infant are both invested with jjeculiarities ; in the former
there is, among other things, the pathology of pre-reproductive
maternal life ; and in the latter there is, among other factors, the
pathology of antenatal ftetal and endjryonic life.
BOOK II
THE PATHOLOGY AND HYGIENE OF THE F(ETUS
CHAPTER VII
Diseases of the Foetus ; General Characters of Fcetal Life ; Contrast between
Embryonic and Fcetal Life ; The Neofcctal Period ; Anatomy and Physio-
logy of the Xeofretal Period ; External, Internal, and Environmental
Changes in the Xeoftetal Epoch ; F(etal Growth and Development at the
successive Months of Intrauterine Life ; Summary.
Ix this chapter a beginuing is made. In previous chapters the
general relations of Antenatal Pathology to Postnatal and Neonatal
Pathology were considered ; in this chapter, and in those that follow
till the end of the volume is reached, it is Antenatal Pathology itself
in all its wonderful variety of phenomena that is the subject of study.
A beguuiing, then, is made with Antenatal Pathology ; but it is not
purposed to begin at the beginning of Antenatal Pathology. To do
so would be to begin with the most obscure and most difficult part
of it, namely, Germinal Pathology. It is Ijetter, in every way, to
commence with Fcetal Pathology. When that has been mastered, it
will be easier to deal with Embryonic Pathology ; and, thereafter, even
Germinal Pathology will have its darkness to some degree illumined.
For the fcetal period of antenatal life is that lying nearest to post-
natal, and in this case proximity means some degree of similarity.
Fcetal Pathology has, indeed, much in common with Neonatal and
Postnatal Pathology, has certainly much more in common with them
than Embryonic Pathology, which at first sight seems to have nothing
at all in common, to be entirely foreign to them. This, however, is
not quite true, and the study of Fcetal Pathology will show it. It is,
then, convenient and reasonable to begin Antenatal Pathology with
the part which in its manifestations most closely resembles the
morbid processes of later life. What we know of Postnatal Pathology
is thus made to throw light upon the darkness of Fa^tal Pathology,
and by and by what we shall find out about Fu^tal Pathology will
carry the light onward, not intensifying it in transmission, into
the thick darkness of Embryonic and Germinal Pathology. Natura
in o2}crationibi(s suis non facit saltum ; let us try to imitate nature
by endeavouring pi-ogressively to find out the secrets of these opera-
tions with which she astonishes and humbles us.
78 ANll-AATAl. 1'ATH()L()(;Y AND HYGIENE
General Characters of Foetal Life.
As it is ueci'ssiiry Id be afiiuaiiiluil wilh ihe ]iliysiology and
anatomy of the new-liorn infant in order to understand the peculiar-
ities of neonatal diseases, so a knowledge of the physiology and
anatomy of the fcetus throws much light upon fo'tal patholog}'.
There are many, many problems connected with these subjects still
awaiting solution; but enough is known of intrauterine life and
health to help materially in elucidating the causes of intrauterine
death and disease. Let us try to form a general conception of the
ciiaracters of fcetal life.
The chief feature of intrauterine life is its parasitism or semi-
parasitism. The fietus spends the whole of its existence, which
lasts, roughly speaking, aliout seven and a half calendar or eight
lunar months, in the interior of the uterus. It is immediately
surrounded by the liquor amnii, which, serving as a natural water-
cushion, protects it from sudden shocks and jars ; the uterine walls, by
their growth and distensibility, allow increase in size and freedom of
movement to the ftetus, while they shield it from harm, and maintain
by their vascularity that constant temperature .so needful for healthy
development ; and, external to the uterus, are the ]iartly osseous,
partly muscular pelvic and abdominal walls, which serve still f\uther
to secure the safety of the tender organism. In its protected position
the foetus makes little call upon several of its organs ; its lungs are
absolutely quiescent; its stomach, intestine, kidneys, lymphatic
glands, and skin are largely in a resting state. The heart and liver,
however, are active ; and the thymus, thyroid, suprarenal glands and
sympathetic system play a very considerable part in the physiology
of intrauterine life. The brain and spinal cord, more especially the
cord, are (piite capable of replying to all the demands which are
made upon them, their activity lieing chiefly of the reflex type during
this period of existence.
The most important and the most active of the fcetal organs lias
not yet been referred to ; it is doubtless extra-corporeal, and the
foetus is only part jiossessor in it ; nevertheless it is the dominating
influence in foetal life, and is absolutely essential to the unborn infant.
Without the jilacenta, intrauterine existence in the fcetal periotl is
impossible ; with it, in a healthy condition, almost all the other organs
can be dispensed with. Ftx'tal vitality, although not structural
integrity, may be maintained by the aid of the placenta alone. The
brain and the spinal cord may be absent; the intestines may l)e
occluded at several places or reduced to a few coils ; the mouth
and anus and nares and pharynx may be imperforate : the lungs,
kidneys, liver, and spleen may be wanting; and the heart may be
little more than a dilatation upon the chief blood vessels ; yet so long
as the placenta is available, fretal life can go on. Nay more, tlu^
headless, ami limbless, and almost trunkless fa;tus known as an
allantoido-angiopagous twin of the anidean type, does not require
even a heait in order to continue in life, so long as he can maintain a
EMBRYONIC AND Fayi'AL LIFK 70
connection with a corner of his twin-l)rother's placenta. The placenta,
then, is physiologically necessary to the fa>tus, and the fa'tal economy
is complete only when it inclndes the umbilical cord, the placenta,
and the membranes. The important facts in foetal physiology, there-
fore, are — (1) The preponderating influence of the placenta, which is
really lungs, kidneys, stomach, and perhaps even liver to the unborn
infant; and (2) the characters of the intrauterine environment,
which may be described, in a phrase, as life in a fluid medium of high
and practicall}- constant temperature, in the dark, and with almost
complete protection from external violence. Fcetal life, in short, is
semi-parasitism upon the mother through the placenta.
Contrast between Embryonic and Foetal Life.
The chief result of the physiological activity of the fcetus is
growth, growth of a remarkable kind and taking place at a remark-
able rate, but growth alone ; there are no striking alterations in the
relation of the various parts of the organism to one another, no
fusions, no separations of parts ; and in the head, and the limbs, and
the liver, and the intestine of a full time fcetus we can recognise with
no ditticulty these structures as they occurred in the foetus of three
mouths, only they were then much smaller in size. In this respect,
the result of foetal pihysiological activity contrasts very sharply with
that of embryonic vital processes. From the apparent chaos of the
germinal globe comes the oixlerly arrangement of the embryonic
world. Not simple increase but evolution is the great accomplish-
ment of the life of the embryo. Not at once either is the evolution
manifest and complete, but after a time of arrangement, of re-arrau,ue-
ment, and of remodelling, and through a series of changes kaleido-
scopic in their variety and in the rapidity of their transposition.
The foetus of nine or ten months is, although greatly enlarged,
evidently the same organisna as the foetus of three or four months.
Put a magnifying glass over the latter, and you may <|uite well
imagine that you are looking at the former. Quite otherwise is it
with the emljryo. What dissimilarity there is between the embryo
of forty and the embryo of fourteen days ! In appearance, what
resemblance can be seen between the embryo of fourteen days and
the blastodermic vesicle ? Trnly, there is a deep-seated, a funda-
mental difference between the results of vital activities in the fa'tus
and in the embryo. At the same time, there is no sharp line of
division between the two periods ; there is no special day, far less
minute, when it can be said the embryo has now become a fwtus, the
time of modelling is past and that of growth begun. On the contrary,
some traces of the peculiar activities of the embryo continue to appear
throughout the whole foetal epoch ; and growth is not, of course,
alisent in the embryonic period. Indeed, there is a sort of transition
time, the neofretal, and to that it will be well to direct attention, for
it has a very evident importance, as in fact all transition times have.
80
ANTENAIAI. I'AII lOI.OC'i' AM) HYGIENE
The Neofcetal Period.
Just as postnatal litV lii-tiin.s willi a iieiiiKl of tiaiisitiou or read-
justment to suit new environmental conditions, a period named the
neonatal ; so the passage from embryonic to fcctal life is marked by
a transition time of adaptation {Natura non facit saltus — Nature
makes no leaps) which we may call the neofa'tal, during wliicli, among
other notable phenomena, the placental economy is being established.
The neofo-tal period coincides roughly (there are no sharp limits,
Nature, as has been said, making no leaps) with the second half of
second (lunar) month of intrauterine life. Its commencement is
on or about the fortietli day (end of sixth week), when the new
organism takes on a form which can he recognised as distinctly
human ; this somewhat indefinite change Minot regards as marking
tlie end of the emljryonic epoch
(Human Embri/olof/i/, p. 391,
1892) and the beginning of the
fcetal. It is, however, better
to regard it as marking the
beginning of a jieriod which
is neither embryonic nor fcetal,
but a transition lietween or
combination of the two — the
organism is putting off its
distinctively embryonic and
putting on its fcetal characters,
is becoming human, i.e. re-
cognisably similar to child or
adult. The " transition " form
is seen in His' enibryo x.xxiv.
(Dr.), the estimated age of which was thirty-eight days, and the length
of which from neck-bend to coccygeal bend was l"o cm. (Fig. 9).
" Transition organism," we may call it, yet it is probably more
correct to regard organisms of all ages lietween six weeks and two
months as transition forms, the transition itself being not sudden,
but gradual, recpiiring two weeks at least. For, during the seventh
and eighth weeks (neofcetal period), several changes take place in the
appearance of the organism ; and some of these can lie recognised by
comparing the His embryo (Fig. 9) with a fcetus (Fig. 10) in my
collection, measuring 2'5 cms. in length (cephalo-coccygeal length),
and of an estimated age of fifty-six days (end of neofu>tal period).
Fig. 9.
Fin. 10.
Anatomy and Physiology of Neofcetal Period.
The changes which occur in the neofcetal period are external and
internal ; they are less marked than those which have occurred in
the emltryo, Init they are much more marked than those tliat are to
occur in the fa?tus.
With regard, in the first plarc, to crtenial appearances, the following
may be emphasised a.s noteworthy. The greater part of the head of the
i
NEOFCETAL PKUIOD 81
six weeks' embryo is sharply flexed at right angles to the back part of the
head and neck, so that the eye lies in front of the ear and below its level.
The point where the back part of the head is continuous with the trunk is
marked by a concavit\', called the Nackengruhe. In the fcetus eight weeks
old, elevation of the greater part of the head has taken place, so that now
the mid-brain lies above instead of anterior to the hind brain, the eye lies
in front of the ear, but more nearly at the same level, and the Narlcengruhe
is almost obliterated. In the six weeks' embryo there are no traces of
eyelids, the external ear is scarcely recognisable, and the maxillary processes
have little more than united in the median line anteriorly ; in the eight
weeks' foetus the eyelids are present, although not fully formed, the concha
is quite distinguishable, the anterior fusion of the maxillary processes is com-
plete, and the face has taken on the human appearance (eyes, nose, mouth,
chin). In the six weeks' embryo the upper limbs (in profile views) reach
beyond the level of the heart, show the tripartite division, but are still
strikingly bud-like : in the eight weeks' fcetus they reach beyond the
anterior margin of the chest (in profile views), show clearly their three
segments and five separate digits, and are flexed at the elbows and bent
upwards towards the face. Similar but less marked changes take place in
the lower limbs. The anterior contour of the trunk in the six weeks'
embryo shows very evident bulging, due to the presence of the heart and
liver : this character is not so noticeable in the eight weeks' fo?tus, although
in it also the liver is of " relatively enormous dimensions," and reaches well
into the hypogastric region. The epidermis at the end of the first month
consists of two layers, and this two-lavered stage lasts till the end of the
neofoetal period ; probably the outer layer of cells represents the epitri-
chium. The dermis is not yet dift'erentiated into corium and subdermal
laj'er ; but the aniaf/e of the mammar}' gland can be seen at the eighth
week. The caudal projection (true tail), which attains its maximum about
the thirty-fifth day (end of fifth week), becomes less and less marked during
the neofoetal period, and has disappeared as a free appendage at the end of
it (attainment of " human " form). During this eventful period, also, the
protrusion of intestine into the umbilical cord increases to reach its maxi-
mum in about seven and a half weeks : the genital tubercle, which at first lies
anterior to or within the orifice of the cloaca, becomes more prominent,
although it cannot yet be distinguished as penis or clitoris. Such are the
external changes taking place in the organism during this transition time of
neofcetal life, those most noteworthy being the elevation of the head, the
disappearance of the tail, and the specialisation of the face and limbs.
The internal changes are no less wonderful and epoch-making. They
are also numerous, and call for some kind of classification. They may be
conveniently subdivided into^(l) the more marked or more typically
embryonic changes, and (2) the less marked and more specially fcetal
changes. In the former group I place the changes which occur in the
skeleton, in the cranium and its contents, and in the pelvis and lower
part of the abdomen and their viscera. In the latter group may be ranged
the changes, slight in character, which take place in the organs of the
thorax and upper part of the abdomen.
1. The slcelefal changes. — The changes which occur in the skeleton are
chiefly of the nature of commencing ossification. Ossification begins in
the neofoetal epoch, to end far on in post-natal life — a developmental
change late of appearance, late also of completion. At the seventh week
ossific nuclei appear in the clavicle (first bone, then, to become bone) ; in
8-' ANTKNATAL I'A TIlOLOCiY AND IIVCIKNK
the shaft of ffiiuir anil of tiliia ; in tlie frontal, piirictal, interparietal, and,
jierhaps, in the sijuaniosal and palatine bones ; in tlic bodies of the
veitebrje, at any rate in the dorsal region ; and in the ribs (in this week or
tlie next). In the eiglith week the nuralier of ossific nuclei is increased by
tlie appearance of tliose for the shafts of tlie hnnierus, radius, and fibida ;
for the nasals, laclirymals, vomer, superior niaxillaries, and malars ; for
most of the vertebrop ; and possibly also for the metatarsals and meta-
carpals. Ossification then has made a commencement at the end of tlie
second month of intrauterine life. The rest of the skeleton, tliougli not
ossified, is already definitely mapped out in cartilage or membrane, e.g. the
skeletal pieces of the Hmbs. It is noteworthy tliat the sternum consists of
two cartilaginous lateral halves, still .separate ; and that the neural arches
have not yet met on the ilorsal side of the spinal cord. The condition of
the spinal cord may be referred to here. It equals in length the vertebral
column, the lumbar and cervical enlargements are indicated, the central
canal begins to contract towards the close of the neofcetal jjeriod, and the
anterior fissure begins to appear and the grey matter rapidly to increase.
The notochord has begun to disappear.
2. 27(6 cepl/alir clicaujes. — In the region of the face during the neofoetal
period there are noteworthy changes. The nasal processes grow to form
the external nose ; the anlage of the lachrymal duct is present at the sixth
week as a solid ridge ; the development of the teeth begins with the formation
of the dental gmove and ridge at the seventh week, and the liuddiiig of the
enamel organs at the eighth week. The anlage of the submaxillary gland is
present at the beginning of neofoetal life, that of the sublingual appear .soon
after, and that of the parotid at the eighth week ; about the same time
chondrification of the larj'nx begins. Of all the internal changes in the
head-end of the foetus at this time, those of the brain are of most importance.
The unequal growth of the various parts of the brain, which has alreadj'
led to the production of mid-brain flexure and neck-bend, continues : the
wonderful expansion of the cerebral hemispheres makes a commencement,
and at the end of the period these structures have expanded to the edge of
the mid-brain ; the Sylvian fissure or fossa was evident at the fifth week,
marking ott' tlie frontal from the temporal lobe, and in addition there can
now be seen the Bogenfurrhe or callosal fi.ssure, these two being total
grooves or true folds of the brain ; and the base of the olfactory lobe is carried
forward by tliis same cerebral hemispherical expansion. The axes of the eyes
become parallel ; and there is fusion of some of the tubercles which go to
form the external ear. There are already indications of all the cranial nerves,
but at this time the cavity which exists in the optic stalk begins to close.
3. The pelvic changes. — At the opposite or pelvic end of the fcetus
important changes are also taking place. The WoltiSan boily reaches its
maximum of development at the seventh week, and at the eighth begins to
resorb ; the kidney, which measures barely '1 mms. in length at the sixth
week, is 2 "5 mms. at the end of the neofoetal period, shows commencing
lobulation, and in it Malphigian corpuscles begin to form. It is stated that
a dilatation of the allantois to constitute the urinary bladder takes place, but
the details of the development of this part of the urino-genital a]iparatus have
not been yet ascertained. The testis is histologically distinguishable from
the ovary at the sixth week by the smaller number of Ureier (primitive ova or
ovic cells) in it. The fusion of the iliillerian ducts has begun at the eighth
week. Sex, therefore, is already recognisable in the neofoetal period,
albeit the distinguishing character is microscopical.
NEOFGETAL PERIOD 83
i. The fltoraco-ahilominal cJiamjes. — It is a remarkable fact that after
the sixth week of intrauterine life the organs of the thorax ami upper
part of the abdomen may be said to have completed their development :
during the remaining thirty-four weeks they grow indeed, but show no
changes in their construction till birth forces new functions upon them ;
some of them do not change even then. This is specially true of the heart
and great vessels, for they change little, if at all, between the beginning of
the neofoetal and the end of the foetal period. In the circulating blood
red cells (nucleated) are the most ntimerous, but the red plastids (non-
nucleated) have begun to appear. The liver also is well developed,
and grows enormously in size in the second month, and the gall-
blailder is present. The spleen is quite recognisable. There is a
slight change in the pancreas, but in its position onlj^ ; it lies at first
parallel to the long axis of the body, and later comes to be directed trans-
versely. The asymmetry of the lungs is seen even at six weeks, and the
lobes are marked off as branches. The typical form of the stomach is
indicated at the fifth week, before, therefore, the beginning of the neofcetal
epoch ; and the villi and glands of the intestine have begun to develop at
the second month, although the intestinal coils continue to elongate during
foetal life, and may not have taken up their permanent position and
relations even at the time of birth. The development of the thymus gland
from the entoderm of the third gill-cleft has begun. The two lateral
anlarjes of the thyroid gland have united with the single median anlcuje at
the seventh week ; tlie ductus thyreoglossus may remain open till the
eighth week ; and at the same time the formation of hollow acini has com-
■menced. lu oiie detail, however, development in this region is incomplete :
the separation between tlie pleural and abdominal cavities has not taken place
in a two months' fostus.
Xot only are there changes, external and internal, in the embryo-foetus
during the neofoetal period, but there are also alterations in the foetal append-
ages of very considerable importance. The organism lies in the sac formed by
the decidual membranes, the reflexa being still distinct from the vera ; the
chorion is villous all over, but the villi in the region where the placenta is
soon to form are larger than the others, and are already vascularised to a
greater degree by the allantoic or umbilical vessels ; the decidual membranes
and chorion weigh together from 11 to 1-5 grms.; the liquor amnii is pre-
sent in the amniotic cavity to the amount of 10 to 13 grms.; the umbilical
vesicle has atrophietl, but is still to be seen attached to the abdomen of
the neofoetus by a thin cord, and doubtless there is still some circulation
going on in the vitelline or omphalo-mesenteric vessels. As has been
already stated, the projection of intestine into the umbilical cord is
increased during the first week of the neofcetal period. The great changes
seen in the environment of the foetus at this epoch are the replacement of the
vitelline by the allantoic or umbilical circulation, and the progressive growth
in importance of the placental over the general chorionic circulation.
The end of the ueofoetal period therefore coiucides with the
beginning of the placental connections. There is thus a sort of birth
before birth, a transition not so sharp as that which occurs at the
tenth month of intrauterine life, but nevertheless definite enough
and of great importance. Further, just as there are many traces of
the foetus to be seen iu the new-born infant, so in the neofcctus there
are not a few indications of the embryo ; there are in it still some
84 ANTENATAL I'ATHOl.OCY AND I1Y(;IKNK
signs of typical eiiihiyoiiic or devolopiuenlul acliviLy, as tlie ]ire-
cediug paragiaplis abumlaiitly have demonstiated. ]iy the end of
tiie third month, as will he seen, tlie new-horn fo'tus is fairly estah-
lished under the jilacental n'ginie, its yolk-sac (vitelline) connections
can be dispensed with and all its circulatory activities can he con-
centrated in the allantoidal union with the decidua serotina. The
transition thus accomplished is not without its element of danger;
and just as the neonatal period is commonly one of danger to the
new-horn infant, so the neofcetal is full of risk to the " new-horn
fa>tus." It is, at any rate, a fact well known that intrauterine life
is often brought to an untimely end liy abortion at the third month.
The incidence of abortion so immediately after the neofo'tal period
suggests want of eomiilete adajitation tn the new condition of life, in
other words, a defective establishment of the placental cunnections.
Fcetal Growth and Development.
Such being the characters of the neofcetus, it remains for us to
trace the stages through which the organism passes in order to become
a neonatus ; in other words, it is necessary for us to possess some know-
ledge of the changes which occur month by month in the growth and
development of the fcetus from the eighth to the fortieth week of
intrauterine life. It is essential that we have some idea of the body,
the diseases of which we are preparing to study ; that is, if we wish
in any measure to make progress in our knowledge. Dry details,
(lou].)tless, but peculiarly essential. Details which the reader skimming
lightly over the surface of the subject will pass by. Let them he put
in small type to warn off such readers ; let them also be compressed
within reasonable limits. Perchance a reader here and there will
read, and remember, and even form visual images of the IVetus
at the different months. Unfortunately for him and for Antenatal
Pathology, only glimpses of antenatal life are yet possible : it is not
practicable, through imperfect knowledge, to give a cinematographic
procession of fietal forms at different stages and of dih'erent ages.
Third Month.
The third month of intrauterine life is, let it he borne in mind, the first
mouth of typically foetal life. In it, a.s in all the months that follow it,
there are changes to he recorded: changes which may be grouitcd into
external, internal, and environmental. These may be taken in order.
The foetus by the end of the month measures from 7 to 9 cms. in length,
and weighs 30 grms. (460 grs.). The iirntruding abdnmcn has receded. At
the ninth week two lines are very evident nn the face, one from the eye to
the angle of the mouth, the other passing down alongside of the nose ; the
external nares are closed with a jihig of epithelium, wliich disappears later
(at the fifth month). The eyes are now jn'otected by eyelids, ami the mouth
is closed by lips; if the mouth be opened it can be seen that the shutting
off of the buccal from the nasal cavity has begun in this month and is
finished at the end of it, when also the uvula has appeared. In the ex-
ternal ear the upper and posterior part of the concha bends forward so as to
FCETUS AT THIRD MONTH 85
cover the anthelix : this stage of anteversiou of the ear has a short duration
of possibly a fortnight. The toes as well as the fingers are now separate.
In this month there is the first indication of nails, as tliickenings of the
epitrichiuni over the end of the digits ; but the primary terminal position
of the thickened epitrichiuni ("eponychium," Unna) is quite transitory, and
soon " the ungual area migrates to the dorsal side of the digit " (!Minot, op.
cii., p. 554), througli growth and expansion of the palmar side. The
epidermis at this age has reached the " several-layered stage " ; there is a
basal layer of cuboidal cells, then two or three rows of irregular large cells,
and an outer epitrichial layer of distinctive " dome " cells. On parts which
are to be hairy the epitrichiuni does not advance beyond this stage, but on
hairless parts it persists as several layers. Later, it is probable that the
epitrichiuni undergoes cornification, becoming the stratum corneum or liorny
layer, while the stratum lucidum has become difierentiated and is continuous
at the ends of the digits with the nails. The dermis shows two layers at
the third month : (1) A true dermal layer or corium, and (2) a subdermal
stratum. Hair anlage-i appear at this time over the foreliead and eyebrows.
At the pelvic end of the ten weeks' foetus the genital tubercle is prominent,
and on each side of it is a " genital labium " ; later (in the fourth month),
the genital labia unite to form tlie scrotum in the male, or remain separate
to constitute the labia majora of the female. It is hardly possible at the
end of the third month to tell the sex of the foetus from the inspection of
the external genitals, but sometimes in the male the urethral groove in the
genital tubercle has closed, and then it can be said that the distinctive stage
of the penis as compared with the clitoris has been attained. Finally, with
regard to these external characters and changes, it has to be noted that by
a mechanism, the nature of which is at present unknown, the loop of
intestine in the root of the umbilical cord is retracted within the abdomen.
The internal changes during the third month are, like those in the
neofcetal perioil, of very considerable importance. In respect, in the first
place, to the skeleton, it is to be noted that the neural arches have met
posteriorly in the dorsal, but not yet in the lumbar and sacral regions of
the spine. In addition to the ossific nuclei which have already apjieared,
deposits of bone have to be recorded in the ulna, phalanges, prsemaxillaries,
tympanals, iliinn, ischium, occipital and sphenoidal regions of the cranium, in
the mandible, and also in the lower end of ^Meckel's cartilage which is in-
corporated in tlie mandible. By the end of the third month, the joints of
the limbs are true articulating surfaces, having passed at this early date out
of the synarthrodia! stage ; the articulating surfaces are therefore shaped
before any free motion can begin. In the spinal cord the contraction of the
central canal continues till, at the tenth week, the walls have met everywhere
except at the dorsal part ; the cords of Durdach have arisen, the anterior and
posterior horns of grey matter are of equal size and of the same shape, and
are connected by a broad band ; the cord itself is still as long as the spine,
and its cervical and lumbar enlargements are quite well developed. In the
brain the aidages of the cerebellar hemispheres and vermis are recognis-
able, ami the characteristic transverse fibres of the pons Varolii liave
appeared as a narrow, thin band ; the raid-brain, which has had a precocious
expansion, continues to grow, but at a much slower rate, and at the third
month the cerebral peduncles are just recognisable; in the fore-brain, the
anlages of the septum lucidum, corpus callosum, fornix, and anterior
commissure are well seen ; the cerebral hemispheres continue their remark-
able expansion, and now cover fully one-half of the mid-brain (the stage
SG ANTl'.NATAL I'AlHOLOCiY AND HVCilllNK
of (levelo]imcnt wliicli is pi^nnaiieiil in reptiles); the Sylvian fossa begins
to deepen int" a tissnre, and the Bogenfitrche is now well marked : and a
iliflerentiatiiiiymd forward bending of the olfactory lobe takes place. In
the eye, atr^^^Mif the arteria centralis and of its branches begins, folds
appear on the n^ffibiie to its rapid growth, and the lachrymal gland can
1)6 recognised in a soua state. The tymjianic cavity is very small. Further
dcveloimient takes place in connection with the dental germs of the milk
teeth, and the follicular w-all ajipears.
There are changes at the jielvie end of the fa-tus during the third
month. The testis can now lie distinguishe(l from the ovary by its external
form ; its descent begins about the tenth week, and is due in the first
instance, at any rate, to atrophy of the i)art of the uro-genital ridge lying
taihvard of the sexual gland. The resorption of the Wolftian body con-
tinues, but traces of the glomeruli can usually be made out till the end of
the month. The fusion of the ^Miillerian ducts to form the uterus is
generally complete at this time, so that the sex can now be determined by
the presence or absence of that structure.
The thoraco-abdominal changes are comparatively unimportant. The
heart shows little alteration ; but the blood is now mainly made up of red
plastids (non-nucleated), and nucleated red cells form a small minority. The
lumen of the anlaije of tlie thymus is obliterated about the twelfth week ; in
the thyroid the formation of hollow acini is continued. The changes in the
stomach consist in the development of the peptic and mucous glands, and in
the appearance of prominences between the gland openings, which have been
called villi, but are not truly so. In tiie liver (which is very large, extending
into the hypogastric region) the vascular territories of the portal ami hepatic
veins are distinguishable ; and islands of tissue appear, each of which is the
anlage of a group of lobules ; the j)ortal system cuts into these islands and so
forms the lobules. The suprarenal glands assume the cap-shape at this time,
and clusters of cells (symi)athetic part?) can be recognised in them, but only
during the third month. ]!oth the kidneys and the suprarenals show rapid
growth, with the result that they are brought into contact, the adrenal rest-
ing upon the kidney. The diaphragmatic .separation of pleural from the
peritoneal cavity has now completelv taken place. — {Mall in Hookfr's article,
Airh. Perliat., xiv. 649, 1897.)
The foetal environment has altered little at this month. The decidua
reflexa diminishes in thickness and shows marked degenerative changes —
presence of a hyaline substance, fibrin so called, and vagueness of the
cellular outlines. The chorionic villi are limited to the part in connection
with the decidua serotina, wliere, now, the small placenta (weight, 23 J grms.)
is quite distinct. The whole decidual sac with its ovular contents is about
the size of "a goose's egg" ; more exactly, its length is from 'J'5 to 11 cms.
The umbilical cord is from 7 to 12 cms. long, shows some degree of torsion,
and has the umbilical vesicle attached to it at its placental end by the yolk-
stalk ; the rest of the yolk-stalk is embedded in the cord. The amount of
liquor amnii is about 42 grms.
FofRTH ^loxTH.
During the fourth month of intrauterine or the second month of foetal
life (13 to IG weeks) the fo'tus has a length of from 10 to 17 cms., and a
weight of about 55 grms. (850 gr.s.). Some hairs are to be seen on the
scalp, and over the body the fine down (lanugo) is beginning to sprout forth.
FCETUS AT FOURTH MONTH 87
^licroscopic sections of the .skin sliiiw riilges on the umler side of the
epidermis, and the appearance of fat cells in the subdermal tissue ( 1 -1 weeks).
Slight changes take place in the external ear ; the tultercnlum anterior
encroaches npon the fossa angularis, and reduces the lowe^^pt of it to a
fissure, and so the tuberculum itself comes almost h^^^lmact with the
anthelix and the anti-tragus ; through the growth of ^Htlge the upper part
of the fossa is separated from the lower, and the latter becomes the opening
of the meatus ; and later (in the fifth month) the lobule is marked oft' as
the tienia lobularis. The eyelids are now fully united. An inspection of
the posterior end of the fcetus is at this month sufficient to determine the
sex of the oti'spring, as the scrotum in the male is evident.
The internal changes which occur in the fourth month are important,
although not so extensive as those iif the third. With respect, in the first
place, to the development of the skeleton, the scapula is one-half cssified at
this age; ossification has begun in the pterygoids, although these do not
unite with the alisphenoids till the fifth or even the sixth month ; the centres
for the body and odontoid [irocess of the axis vertebra appear in this or in
the next month ; a point of ossification can be seen in the asceniling ramus
of the pubis ; the neural arches have closed throughout the whole length of
the spinal column ; and, according to Professor Arthur Thomson {Joiirn.
Anat. ami P/ii/sioL, xxxiii. 359, 1899) the sexual differences of the pelvis
are already indicated. The ossification of the cranial bones is proceeding,
but the spaces between them are still widely open. In the brain it is to be
noted that there is a rapid increase of the ]ions Varolii, that transverse
grooves appear upon the cerebellum, that a rapid growth of the choroid
plexus takes ])lace which quite fills the lateral ventricle, and that the corpora
albicantia can be seen on the floor of the third ventricle. The cerebral hemi-
spheres cover nearly the whole of the mid-brain. The Sylvian fissure
becomes deeper, and at the posterior end of the Bogenfuirhe appear the
aniages of the parieto-occipital and calcarine fissures, diverging to form the
future cuneate lobe. In this month, also, the cartilage of the Eustachian
tube can be recognised ; the enamel organ of the milk teeth is fullj^ differ-
entiated about the fifteenth week ; and a commencement is made with the
<levelopment of the tonsils in the shallow pouch representing the second
gill-cleft behind the arcus palato-glossus (Gulland, Lahorat. Rep. R. C. Phys.
Edin., iii. 163, 1891). The trachea shows the high cylinder epithelium
which remains throughout life. At the pelvic end of the fcetus the division
of the cloaca into uro-genital and anal openings has taken place (14 weeks) ;
the evagination which is to form the prostate and that which is to give rise
to Bartholin's gland can be recognised ; and the testis has its permanent
form, but the sexual cords in it remain solid throughout foetal life. The
conversion of the hind remnant of the genital fold into the gul lernaculum is
going on, but is not completed during the fiiurth month. In the female,
the lumen of the vagina is closed. The kidneys show well-marked Henle's
loops. The musculature of the stomach is clearly evident at this time in
intrauterine life.
With regaril to the foetal environment, it is tci be mited that the decidua
reflexa is in contact with the vera, and exhibits still further signs nf
coagulation-necrosis antecedent to its disintegration and removal, for it is
probable that !Minot {op. rit., p. 20) is right in thinking that there is no
fusion but a complete disappearance of the reflexa. The meaning of the
phenomenon is not clear; "as to the purpose or advantage of the sacrifices
of maternal tissue we are in the dark," says Minot {op. cif., p. 21); in the
UNIVERSITY
OF
88 ANTKNATAL I'A rH()L()(;Y AND HV(iIKNE
(lurk, truly, :il]nut tlu'sc and many ntlicr tilings in anti-natal lift', but
licginninf; tn sit a pin-imint nf light here and there. The placenta has
increased in size in tlie fnurth ninnth, and weighs from ."^O tn 50 grnis. ; the
liquor amnii^kdis 00 grms. ; so that the foetus now weighs a little more
than the placfflWIl^id a little less than the liquor amnii. The mnhilieal
cord shows a rertaii^liKiunt of twisting; in it tlie cadom is nearly or quite
ohliterateil ; the vitelline duct remains till the sixtli month ; and the now
solidified allanti lie duct may persist till the full term. The external cover-
ing of the cord exhibits a double layer of ectodermic cells, the outer stratum
of which may possibly l)e the representative of the epitrichium, at any rate,
some of its cells are (hime-shaped. The lengtli of tlie cord will be about
19 cms. (Hecker). The foetus, if expelled from the uterus at this mimtli,
may live for some hours; and at this time its limbs may show vital
tremblings and twitchings.
The chief clianges found in the foetus at the fourth month are still
situated at its two extremities (cephalic and pelvic) and in tlie skeleton.
The developmental or embryonic changes are fewer now than previously,
and affect particularly the external ear, the brain, and the genital organs.
Ossification is actively proceeding. Foetal growth in size and weight is
wonderfully rapid.
Fifth Month.
In the fifth month (third of foetal life) the same rapid growth is con-
tinued ; the foetus measures from 18 to 27 cms. in lengtli, and weighs
about 273 grms. (8 oz.). The face and body of the foetus have a wrinkled
appearance, " senile " look, a character to be ascribed to the small quantity
of subcutaneous adipose tissue which is as yet present. At the same time,
the subdermal fat is increasing, and can be seen in little whitish islands in
sections of the skin. The cells of the epitrichium are very large, much
larger than those of the subjacent layers. Xear the beginning of the fifth
month hairs have appeared over the whole head, and by the end of the
month (twentieth week) practically all the hair areas have been mapjied
out all over the body. The nails are becoming more horizontal and less
oblique in relation to the dermis. Sebaceous glands begin to ajipear on
the head at. this time, and by the end of the month they are plentiful
there and elsewhere, with the result that traces of the vernix caseosa are to
be seen. Sudoriparous glands also make their first appearance, but have as
yet no lumen, and consequently no secretion. The eyelids begin to show
signs of separation. "Wax glands are developed in connection with the
external auditory meatus. The hymen is differentiated.
The internal changes consist, in the first place, in the extension of the
jirocess of ossification, thus the osseous centres of the vertebral bodies reach
the surface of the cartilage during this month, and several of the bones of
the cranium take on their more permanent form. In the second place, the
brain shows further developmental changes : the cerebral hemispheres
now cover not only the thalameiicephalou and mesencephalon, but also the
cerebellum and medulla ; the fissure of Sylvius has become deeper and more
oblique, but still leaves the island of Eeil ex]iosed to view ; the fissure of
Rolando is sometimes found during this month, and the colloso-marginal or
splenial fissure is generally recognisable, marking off the gyrus fornicatus ;
and the corpora quadrigemina on the dorsal wall of the mid-brain are
marked off by oblique grooves. At this time in intrauterine life the siiiiial
cord has greatly grown ; but the central ciinal is now relatively small, for it
I
I
FCETL'S AT SIXTH MONTH 89
is strttionary. In the cerebellum the cells of I'urkinje are recognisable ; the
cerebral peduncles begin markedly to enlarge, an enlargement due in great
part to their penetration by the pyramids of the medulla oblongata. In the
third i)lace, further chauges occur in the developing teeth jn the jaw ; in
the case of the milk teeth the follicle closes above the gfrm, the neck of
the enamel organ is resorbed, and dentine appears ; wlfile the enamel buds
of the permanent teeth can be recognised (the enamel bud of the first
molar, it may be noted, was seen earlier, at the fifteenth week). In the
fourth place, some minor changes occur in the abdominal and thoracic
viscera ; the development of the vagina (in the female) continues ; the
jiaucreas loses the mesentery which it has till this time possessed, and with
it its movability ; in the omentum the «?i/a(/es of lymphatics and-fat cells
are recognisable ; and in the heart the chordse tendinese apjiear.
The foetal environment now shows more than ever the predominance of
the placenta (Fig. 13), which weighs from 12-5 to 300 grms. (178 grms.,
Hecker). The umbilical cord measures about 31 cms. in length ; and the
weight of the liquor amnii generally exceeds that of the foetus at this date.
The foetus is now capable of making movements which can be easily
recognised by the mother as indications of the life of her unborn child,
" quickening " as the phenomenon is called. If born alive, the infant may
make some respiratory etibrts, and may even survive for some hours.
Sixth Month.
During this month there is a further slackening in developmental
changes, but the extraordinarily rapid growtli in size and weight continues,
so that now the foetus measures from 28 to 34 cms. in length (Fig. 11),
and weighs 676 grms. (23i oz.). The length in the preceding month was,
as will be remembered, 18 to 27 cms., and the weight 273 grms. or 8 oz.
(Fig. 12). There is more hair on the head, and eyebrows and eyelashes
can be recognised ; the lanugo (" that ancestral simian characteristic ") is
still present in large amount, and doubtless in this, as in other later months,
much hair is shed into the liquor amnii. The skin is still somewhat
wrinkled (" senile "), but a greater amount of fat is being deposited in the
subcutaneous tissue. The free margin of the nails still projects from tlje
tmderlying skin (persistence of ungual obliquity). The vernix caseosa,
consisting of sebaceous secretion, hairs, and epidermic cells, is now conspicu-
ously present. In the case of the skin of the hands and feet, the papillfe
of the dermis are well marked.
There are in this month internal changes which are again, as in pre-
vious months, largely located in the skeleton, in the brain, and in the
pelvic end of the fcetus. Ossific nuclei now appear in the os calcis, in the
presternum, and in the first piece of the meso-sternum (Paterson, Journ.
Anat. and Physiol., xxxv. 21, 1900). The marking-off of the cerebral
convolutions continues : there can, at this time, be quite well seen the
fissure of Rolando ; the preecentral fissure of the frontal lobe ; the intra-
parietal of the parietal lobe ; the superior, inferior, and occipito-temporal
fissures of the temporal lobe ; and tlie post-central fissure of the island of
Reil. An angular notch is noticeable in the anterior margin of the fissure
of Sylvius. At this age the arteria centralis of the eye and most of its
branches have aborted ; and the development of the definite form of the
internal ear is complete.
At the posterior end of the foetus the chief change is found in the
90 ANTKNATAI. l'Aril()I.()(;Y AND HVCIENK
descent of the testicle. At tlir I'lul of thr mcinlli the male sexual
gland lies opposite the internal inguinal ring. This descent is the
last great alteration in the relation of organs to occur in ante-
natal life, and it occurs only in the male, although there is a less
marked downward movement of the ovary in the female fa'tus. Aboiit
the exact mechanism of the descensus lestindm'tun conflicting statements
have been made and )nuch mystery ha.s existed. It lias to be borne in
mind, however, that most of the relation-changes which occur in intra-
uterine life are due to differences in growtli or develo]iment of contiguous
parts; one organ or part grows in size, that next to it diminishes or
atrophies ; or one organ grows or atrophies at a faster rate than its neigh-
bour ; and so one organ may pass by or overlap or take the place of another
in the kaleidoscopic life of the unborn infant. Some jirocess .sucli as this
brings the testis from its first position down to the level of the internal
inguinal ring. As will be remembered, tlie descent has already begun at
the second month with the nearly complete disappearance of tlie uro-
genital fold lying taihvard of the testis; the remnant of this fold is con-
verted into the gubernaculum, a change occupying from the fourth to the
sixth month; at first the growth of the gubernaculum causes the testicle to
move forward, and, afterwards, its atrophy accounts for the passage of the
gland along the wall of the processus vaginalis (which is due to an evagina-
tion of the peritoneum at the inguinal ring). This stage in testicular
descent is that which is permanent in some rodents and other mammals :
the further descent (into the scrotum) is late of occurrence in the liuman
foetus, late also of occurrence in the zoological series, being high up in
the ]\Iammalia.
In the abdominal cavity the liver is still disproportionately large com-
pared with the other organs ; but these other viscera are now beginning to
overtake the liver, the growth of which is slackening. The appendix
vermiformis of the intestine is long, slender, and relatively better developed
than in the adult ; four well-marked ridges of mucous menilirane can be
recognised in the oesophagus ; and in the trachea the glands and cartilages
are clearly developed.
The placenta weighs from 22.5 to 4.55 grms. (273 grms., Hecker).
and the cord measures 37 cms. in length. Life after birth at the sixth
month may be carried on for several days, and jtossibly for longer, if
sufficient care be taken to imitate the intrauterine environment in thi-
matters of temperature and protection from injury.
Seve.vth Month.
The seventh month (fifth of foetal life) lias many characters in common
with the sixth. In it, again, there is rapid growth in length and weight :
at its termination, the foetus measures 38 cms., and weighs 1170 grms. or
41 oz. Lanugo covers the whole body except on the ]ialmar and plantar
surfaces of the hands and feet respectively ; and the vernix caseosa is
plentiful, although it is to be borne in mind that in some foetuses the
vernix is never present in great amount. In the eye the portion of the
tunica vasculosa which lies in front of the lens (memhrana ■pupiUaris) is
very marked, but begins to atrophy before the end of the month. If
sections be made of the skin at this age, elastic fibres will be seen in it, and
the sweat glands will be found with the excretory ducts extending thniugh
the epidermis. There is branching of the glands which comiiose the
mainmse, biit these do not yet show a lumen.
V- ' c /■( .^
LATER MONTHS OF FCETAL Llpfis^
Ossitie nuclei appear in the seecmil ami third pieces nf the meso-stenunn,
in the ethmoiilal region (although the ethmoid itself does not ossify till
after birth), and in the astragalus. In the brain the fissure of Sylvius is
deeper and narrower, and its margins are ajjproaohing each other to
hide from view the island of Eeil ; and the retro-central fissure of the
parietal lobe is marked off. The dentine increases in amount on the germs
of the temporary teeth, it is to be recognised in the first molars ; and the
(ither permanent teeth have the enamel organ fully differentiated. In the
male the descent of the testicle is continued, for it is now drawn into the
niimth of the sac of the tunica vaginalis behind the processus vaginalis ;
and it may, before the end of the month, lie in the scrotum. Meconium is
fi lund in most of the large intestine.
The placenta weighs from 210 to 250 grms. (374 grms., Hecker), and
the umbilical cord measures 42 cms. in length. The foetus, if born alive
at this month, may quite well survive its birth, and continue to live if
well cared for, but it is specially susceptible to changes of temiaerature and
to the onslaughts of pathogenic microbes.
Eighth Month.
The eighth month of intrauterine and the sixth of fwtal life (29 to 32
weeks) is marked by comparatively trifling changes, the truly epoch-making
jieriods of antenatal existence having now all passed. The length of the
foetus is from 39 to 41 cms., and the weight has increased to 1571 grms.
or 3^ lbs. There is more hair on the scalp and less lanugo on the body
than in the earlier months, much of the lanugo having been shed into the
liquor amnii. The nails are now quite horizontal as regards the underlying
skin, but they do not project beyond the finger-tips. The testicles of the
male foetus will be found in the scrotum.
The placenta weighs about 451 grms. (one-third of the weight of the
foetus, circa) and the umbilical cord measures 46 cms. in length. Birth at
this month ought not to be followed by early death, although, of course,
such an infant is less likely to survive than nne honi at the full
time.
Ninth JNIonth.
The ninth month is comparatively featureless save for continued rapid
growth; the length is now from 42 to 44 cms. (15'25 to 16 inches) and the
weight 1942 grms. (4|- and later 5 J lbs.). There is a marked amount of
aiUpose tissue beneath the skin, and there are often miliaria about the tip
of the nose. The vernix caseosa is very evident. Towards the close of
this month the ossific nucleus in the lower epiphysis of the femur may
occasionally be made out as " a more or less circular blood-red spot in the
midst of milk-white cartilage " ; but more commonly it is not visible till
the middle of the tenth (lunar) month. The placenta weighs about 461
grms. (one-fourth of the weight of the foetus), and the umbilical cord
measures 47 cms. in length.
Tenth Month.
The tenth (lunar) month of intrauterine life, or the eighth month of
truly foetal life, culminates in the attamment of the maturity or ripeness of
the foetus — further developments of the organism will take place m its extra-
uterine environment, but the end of profitable intrauterine life has been
9:^ AXTENATAI. I'ATHOLOOY AND HY(;IKN"F.
reached. In tlic'su lust four weeks (thivty-.seveii tn f(irty) tlicre is still
great activity of growtli, and by tlie end iif the ninutli a weight nf 7^ lbs.
or thereby has been attained, anil a length nf .51 cms. (20 in.) reached.
The skin is now of a j)aler pink and may be almost white ; and the lanugo
has all, or nearly all, disajipeareil. The eyelids are quite Kei)arate, the eye-
brows anil eyelashes are well developed, and tlie cartilages of the nose and
ears are firm. The nasal miliaria are scanty as (•onqiared with the ninth
month. The venii.x caseo.sa is evident, and the nails project beyond tin-
finger-tips. Further, the infant has a general appearance of maturity,
which is difficult to express in words, but which is known to the expert ;
there is also a certain immovability of the cranial bones ; and the umbilicus
is near the centre of the Ixidy. Ossification shows further progress: an
ossific nucleus is now to be found in the cuboid ami one in the hyoid bone,
while " the circular blood-red spot in the midst of the milk-white cartilage "
of the lower epiphysis of the femur is now recognisable, and measures from
two to three lines in diameter. There is an indication of a similar but
smaller "blood-red spot" in the upper end of the tibia. During this
month accessory cerebral fissures api)ear, and the margins of tlie fissure of
Sylvius approximate and completely hide from view the island of Eeil. In
the convolutions there is a certain amount of myelination, as well as in
the spinal cord, medulla, pons, corpora cpiadrigemina, and optic thalamus ;
and the myelination is situated round the primary fissures (Sylvian,
Eolandic, calcarine) and in areas which are the end-stations of the
afferent projection systems (F. W. ]\Iott, Brit. Med. Journ., vol. i. for 1900,
p. 1517). The meconium is found in the rectum, at least in the sigmoid
flexure, at the end of the tenth month ; and there is often some urine in
the bladder.
The environmental changes are preparatory to the separation of the
fcetus from its maternal connections. The umbilical cord is about 51 cms.
in length. The placenta has increased but little in weight — it now weighs
about 481 grms. — and, since the weight of the foetus is about 3400 grms.,
it follows that the placenta is only a seventh, instead of a fourth, of the
foetal weight. At the time when the foetus is increasing by so many
pounds a month, the placenta is only adiling a few grammes. It is evident
that the time of placental activity is nearly over ; and vascular changes in
the structure of that organ have been taking place during the tenth month,
which facilitate the separation of parts soon to occur. The full-time infant,
when born ali\'e, soon breathes freely, cries loudly, makes active move-
ments of the limbs, and takes the breast.
Summary.
Such are the changes which take place during the life of the
fcetus as nieasureil by months. Wonderful clianges they are, yielding
in wonderfulness only to the changes of the embryonic jieriod. They
are worthy of careful stud)' by the student of Antenatal Pathology;
they must, in very trutli, be studied by him with assiduity if he is to
make any progress at all in clearing away the dust antl rubbish which
have been cast all o\-er the subject. The dust and rubbish of mis-
taken views of firtal growth and development and function liave in
the past done mucli to almost crush the life out of our subject and to
bury it deep. Yet a subject with wonderful vitality ! For it has not
FCETAL CiROWTH 93
been crushed and stifled, no, not even by all the erroneous notions
and theories which have been cast upon it bj- those who believe in
•' maternal impressions," and would explain all antenatal phenomena
by them. Let us therefore take heart of courage, and proceed — •
more slowly, doubtless ; more really, it is confidently anticipated.
The changes characteristic of or occurring in fo'tal life may be all
arranged in two groups : those which are typically ftetal in one, and
those which are embryonic or reminiscent of the embryonic in
another. In the former must be placed the growth in weight and
the increase in length of the foBtus during the eight lunar months of
fa?tal existence. The schemes (Figs. 11 and 12) are of service in giving
a graphic and diagrammatic representation of these two outstanding
phenomena of fcetal life. If the neofcetal period be included, the
increase in weight is from one-ninth of an ounce at six weeks to seven
and a half pounds at full term, while that in length is from IS cms.
at six weeks to 51 cms. at the full tei-m. The increase in weight will
serve best for forming an estimate of vital activity, for there is a
fallacy in the calculation of the length. It will be seen that the
period of most active growth in weight is between the fourth and
fifth months (from the sixteenth to the twentieth week), when the
weight quadruples ; during the next month it nearly trebles ; during
the next it does not double ; and thereafter its monthly gain is about
a half. The period of most active growth in weight therefore corre-
sponds to the time just following the full establishment of the placental
economy. If, now, the weight of the placenta at the various mouths
of fcetal life be inquired into, it will be found that its period of most
active increase in weight coincides with that of the fostus ; in other
words, is the fourth month, the sixteenth to the twentieth week. In
the scheme of placental growth in weight (Fig. 13) this is brought
out. The placenta more than quadruples its weight between the
fourth and fifth months ; in the next month, it does not even double,
only aliout a half being added ; in the next, less than a half is added ;
in tlie next, about a sixth is the increment ; in the next, less than a
fifteenth ; and in the last month, less than a sixteenth. Both the
fcetus and the placenta have their maximum rate of growth at the
same time in intrauterine life ; but the latter much sooner shows
signs of lessening growth-rate, having a much shorter life-history, so
to say, and is akeady ready to perish when expulsion from the uterus
occurs.
The second group of changes, those which are reminiscent of
embryonic life, contains phenomena of development in contradistinc-
tion to the alterations in size and weight which characterise the
purely foetal changes. The embryonic changes are much more
marked in the early than in the later months ; in fact, in the ninth
and tenth months they have to be closely looked for, being then
almost insignificant. Further, even in the early months they do not
aftect equally all the organs or all the regions of the body. Speaking
broadly, the central part of the body and the viscera of the thorax
and upper part of the abdomen therein contained show little or no
changes of any importance, while the cephalic and caudal ends with
Ltn^tli ill cms. 'A
Months . . 10
Weeks . 40
FCETAL GROWTH
95
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96
ANI'KNATAl. I'A 11 1( )I.()( l^'
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ORDER OF DE\ELOFMFAT OF ORCJANS
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98 ANrKNATAI. I'ATHOI.OCiY AND IIVCIENK
their viscera, the skeleton, the skin, and tlie linilis, exliibit certain
evident alterations of a tlevelopniental kind. There are, for instance,
few changes to be recorded in connection with the heart, lungs, liver,
stomach, intestine, pancreas, spleen, kidneys, and thymus ; on the
other hand, there are alterations, both many. and important, to be
noted in the skeleton, lirain, face, ears, eyes, teeth, genitals (male and
female), spinal cord, blood, joints, skin, and skin ajipendages. To
revert to a comparison I have already instituted when writing of the
emljrj'o — the fietus may be compared to a city, the centre of which
with its main avenues of traftic and its chief buildings is almost
complete, while its suburbs are scarcely yet fully marked out, far less
definitely constructed. Tn the foHus the thoraco-abdominal cavity
and contents constitute the centre of the city, and the lirain, genitals,
many of the bones, skin, etc., are the rudimentary but fast-extending
and developing suburbs. Some idea of this conception may be
obtained from the accompanying scheme (Fig. 14).
In this chapter have been considered the changes which occur in
the organism and convert it from an emlnyo into a " new-ljorn "
foetus, and again from a " new-born " into a full-time or mature
fcetus, ready for and capalile of surviving its transference into the
world outside the maternal womb. There are many parts of this
complicated series of changes about which we are in darkness. Our
knowledge of it is similar to that which we at night olitain of a land-
scape over which an occasional flash of sheet-lightning ])lays fitfully,
illuminating it for a moment and then leaving the ilarkness almost
more intense. For no one has ever been able to watch month by
month and day by day the fwtus growing and developing in the
womb ; and our knowledge of its growth and development has been
made up from glimpses of it — sheet-lightning flashes — obtained
through its more or less accidental expulsion prematurely from the
uterus. Glimpses of its life truly they are, for death ipiickly follows
any such early expulsion from the natural en\ironment. Even
regarding the last two or three months our information is scanty,
and in some measure incomplete ; but such as it is we now set it
forth — in the following chapters.
CHAPTER YIII
Anatomy of the Mature Fietus. Anatomy of the region of the Head, Spine,
Neck, Thorax, Alidomen, Pelvis, and Limbs. Anatomy of the Umbilical
ford, Placenta, and Membranes.
Ix this chapter and in the two that follow an attempt is made to state
what is known regarding the anatomy and physiology of the f idl-time
or nearly full-time foetus. To be more exact, the attempt is made to
state wherein the anatomy and physiology of the foetus ditler from
the anatomy and pliysiology of the child and adult. With regard to
foetal anatomy we are on fairly sure ground, for it is, alas ! a too
common circumstance that a foetus comes into the world dead and of
use only for dissection : by such dissections and sections a knowledge
of the structural peculiarities of the unborn infant has been built
up. By a sad hap it sometimes comes about that a mother dies with
her infant undelivered in her woml i ; from the examination of such
cases certain details of foetal anatomy have been more accurately
ascertained. With fa?tal physiology there is no such certainty of
information ; there is much speculation and there are many theories,
and the investigator has not always " avoided the guesser's darkening
of knowledge." The defects in our acquaintance with the peculiar-
ities of fcetal physiology are responsible for our ignorance of many of
the phenomena of fcetal pathology ; as a matter of fact, we have had
to deduce several of our conclusions regarding the physiology of
intra-uterine life from the studv' of the disturbances of fu^tal function,
i.e. from the diseases of the foetus. There is accordingly much un-
certainty and an appallmg paucity of facts — facts, therefore, in this
subject are of more than usual value. May their number increase !
Anatomy of the Fcetus.
Within recent years our knowledge of the anatomy of the full-
time fiptus has been added to and conlirmed liy the sectional method
of study. In 1891 I published the results of the investigation of a
number of foettises by means of frozen sections (1, 37, 38, 39,42,47) ;
and since then have appeared the works of H. Mettenheimer (in
Schwalbe's Morphol. Arheiten, Bd. iii., Hft. 2, 1893), of F. Merkel
{Mcnschliche Embryonm, Gottingen, 1894), and of J. H. Chievitz
{Topo[irttphical Anatomy of Full-term Human Fcetus, Copenhagen,
1899). Merkel has endeavoured to extend the investigation to
foetuses of different ages from three months onwards, and 0. Scbiifler
100
ANTKXATAL I'ATHOLOCiY AND HYCIKNK
(ill F. von Wiiiki'l's Beric/ttr tnid Studicn in Miuirhni. pp. 13G-205,
478-G54, Leii)zi<:', 1892) lias made many accurate measviremeiits ; but
tlie number of sjiecimens j-et dealt witb is ton small to permit of the
safe formation of general conclusions with regard to any l)Ut full-time
fcrtuses. I do not pretend here U> discuss all the anatnmical char-
acters of even the full-time fu'tus (for sudi fiUl discussion the
reader is referred to my work, An Introdndiun to the Biscasr; of
Infancy, or to the other books above mentioned), but will deal only
with the more prominent peculiarities. The details will be taken up
according to the regional method of anatomical studv.
The Head of the Foetus.
The head of the foetus is relatively large, if we regard the adult
proportion as the normal : and the younger the fo'tus the greater
is the relative largeness.
Of the two parts of the
head — cranium and face
— the former is relat-
ively larger than the
latter. The cranium,
which is composed (if
eight bones, is divideil
into two parts, vault and
base : the cranial arch
(distance from the root
(if the nose round to the
liack of the foramen
magnum) in the fu'tiis
is to the cranial base
approximately as o to 1 ;
this is the highest pro-
Fic:. i:,. portionate length which
it attains, and in the
adult it is as 2"7 or 2-8 td 1. Tiie bones which make up the vaidt
of the fa^tal cranium are loosely j( lined together by membrane at the
sutures and fontanelles ; every student of Obstetrics knows the sutures
and fontanelles, for they are the parts which are to be felt during
the progress of labour. It is presumed that the reader, too, is well
acquainted with them. The base of the cranium is made up of the
basiocciput, the sphenoid, the ethmoid, and the petrous-temporals :
these bones, unlike tho.se of the vault, do not change their relati\-e
position as the result of pressure brought to bear uiion them ; there
is no moulding nf the basis eranii during labour, and it is fortunate
for the fcctus that there is not.
The form and diameters of the head of the full-time foetus (Fig. 15)
are not those of the new-b(U-n infant (Fig. IG). Only a few hours
may sejiarate the fcctal from the neonatal state, but in those few
hours happens liirtli, and in liirth the unmoulded head of the fietus
becomes the moulded head of tlie new-born infant. The form (if the
REGION OF THI". HKAD
101
uiiiiioul<leil or normal head is expressed by the relative lengths of
its antero-posterior and lateral diameters. For a full-time fa'tus,
measuring from 48 to 51 cms. (19 to 20 inches) in length the
diameters will be approximately as follow : Maximum antero-
posterior, 13 cms.: occipito-mental, 12-5 cms.; occipito-frontal,
11-5 cms.; sub-occipito-bregmatic, 10"3 cms.; bi-parietal, 10 cms.;
and bi-temporal, 8'7 cms. During labour the maximum diameter
greatly increases and most of the others diminish, the form of the
head becoming obliqiiely sugar-loaf-shaped from before baclcwards
and upwards. The ilistortion of labour usually passes ott' about a
week afterwards, but it may be to a greater or less extent permanent.
In the meantime, let it lie borne in mind that the form of the fretal
head is not the same as that of the infant during and just after liirth.
It is not yet known with certainty whether the fiotal head shows a
primitive asymmetry ; the head of the new-1iorn infant often is dis-
tinctly asymmet-
rical, but, mani-
festly, unilateral
depressions may
he due to the
birth-traumatism
which has just
taken place.
The brain, like
the c r a n i u m
which contains
it, is relatively
large in the ma-
ture foetus — ■' big
but inactive " is
the description
which has some- yia le
times been given
of it ; big it certainly is. The relatiiin of the lirain landmarks to
the cranial landmarks is in some details different from what it
is in the adult ; but the facts are difficult to get, fV>r the topography
of the brain of the unborn fretus is practically unknown, and it is
manifestly fallacious to draw conclusions from the moulded head
after birth. The following statements, therefore, may require
revision. The Sylvian fissure is at a higher level in the fcetus,
and lies above the squamous suture instead of coinciding with it as
in the adult : it has been stated that the lower end of the fissure
of liolando lies in front of the coronal suture in the fa^tus, but
my observations do not support this opinion, although they show
that the fissure is apparently less vertical than in later life ; the
parieto-occipital fissure corresponds with some accuracy with the
tip of the occipital bone at the posterior fontanelle, and lies behind
rather than in front of tlie laml)doidal suture: and the calcarine
fissure is situated approximately opposite the occipital protuberance.
It has Ijeen said that the cerebrum overlaps the cerebellum to a less
102
ANTKN.Vr.M, l'ArH()I.<)(i'>' AND lIVdIKNK
extent in the fuHus, Imt my sections do not sliuw tliis iieculiaiity
(Figs. 17 and 18).
' .: rr Thr- ceiebral
convolutions arc
les.s complex in
tiie fu'lus than in
the adult, and the
sulci arc less deep.
It may he that
siimc accessiiry
fissures are not
developed till
after hirth, and
are therefore
postnatal forma-
' tions, but about
this matter there
is little know-
ledge. The study
of the miinitc
anatomy of the
foetal brain has
recently received
a great impulse
by the discovery
of Flechsig that
there is a currcla-
tion between the
functions of sys-
tems of neuriines
and the myelina-
tion "f their
axons: in the full-
time fcEtus, the
whole aflerciii
tract conveyin-
tactile, articular,
muscular, aiul
visceral sensa-
tions by the ]ios-
terior columns.
Fig. 17.— Mesial sagittal section of fii'tii.s. In the upper part of ^ii j. tleilniiiis
the region of the head the section has passed slightly to the '""-'•• ^H'l''""' • .
right of the middle line, leaving the fal.x cerebri unexposed, and coroua radl-
rt, Anterior fontanelle ; b, presphenoid ; c, thyroid cartilage ;it;;i is mvcliuatcd ;
oflavyuxirf, tongue : «, left innominate vein ; /", thymus i -^ V,-,ll.->«t; if
1 1 1. • ■ 1 ■ • ii 1 ». 1 *i !;...,« . ; anil IL I<.)ll()\Ns, H
gland; g, tricuspid opening in the heart ; n, the liver; '• , , ,, • f
the pylorus ; k, transverse colon ; I, the ]iancrea.s ; m, lobus the llVpotlieSlS 01
spigeiii of liver ; n, first lunihar vertebra ; o, left auricle ; Flechsig be COV-
;< aorta; r, trachea ; s, .seventh cervical vertebra ; t, the j. ^^^.^^ jnipres-
iiharynx ; r, cerebelluni ; i''. posteiior lontaiicUe. . ' , ' .
sions have, during
the last three or four months of intrauterine life, been ]iassing along
REGION OF THE FAC
these bundles of fibres to the receptive centres in the cortex, Eolandic
area. From these observations niucli light may be expected to be
thrown upon the
physiology of the foetal
brain (vide W. W.
Ireland's Digest of
])apers by Flechsig,
Dullken, and Nissl, in
Journ. Mcnt. Sc, Janu-
ary 1899).
The small size of
the face of the foetus
as compared with the
cranium is partly due
to the small size of the
superior maxilla ; the
antrum of Highmore
and the alveolar pro-
cess of the upper jaw
are both ill-developed.
The inferior maxilla
also is small in the
foetus; its symphysis
is not fully ossified ;
and its angle is obtuse.
In a well-nourished
full-time infant the
cheeks are pi'ominent,
and this prominence
is partly caused b}' the
presence of a special
encapsulated mass of
adipose tissue (Fig.
19) ; this mass of fat
lies upon the bucci-
nator and partly upon
the masseter muscle,
and has the risorius
.superficial to it ; it is
called the sucking-pad
(" Saugpolster "). Two
anatomical peculiar-
ities of the Ijuccal
cavity in the foetus
are revealed by frozen
sections : the gums are
not in contact even
when the jaws are
Fig. 18. — Left lateral vertical section of foetus. Eight
face of section seen, a, anterior i'ontanelle ; 6, jios-
terior fontanelle ; c, eerelielluni ; d, tliynnis gland ;
c, left lung, upper and lower lobes ; /, spleen ; cj, left
supra-renal capsule ; h, left kidney ; i, left psoas
muscle ; j, twelfth rib ; k, umbilical cord ; I, trans-
verse colon ; m, liver, left lobe ; n, stomach ; o, left
ventricle of heart ; ji, right ventricle of heart ; r,
left sucking-pad ; s, left malar bone ; t, left eye.
tightly closed, and the lower jaw lies in a plane posterior to that of
the upper jaw. The nasal cavities are relatively small; the orbits
104
ANTIAAIAI. I'AIIIOI.OCY AM) H^dlKNT.
and their Cdiiteiits do not dilltT in tliuir anatomy frmn these parts in
the child (ir aihilt.
The ear of the full-time fcetus has certain characters in which it
resembles the ear of the adidt, and others in which it differs from it.
The internal ear, for instance, is very completely developed, and s(j
are the tympanic cavity and ossicles and the mastoid antrum. It is Xi<
be borne in nund, however, that in the ri>oi of the tympanic cavity
there is an unclosed siit\n-e, the petro-.s(|uamous (Fi^'. 20). The
ivity is said tn
I' tilled with a
gelatinous sub-
stance, e m -
l>ryonic connect-
ive tissue whicli
has undergone re-
gressive change ;
air enters after
liirtii. The re-
maining parts of
tl]e ear, on the
other hand, arc
far from coni-
te develiip-
nient. The Eus-
tachian tube is
short, runs al-
most horizontal,
and cau hardly
be said t<.i possess
an osseous part.
The external
auditory meatus
is osseous in its
inner third alone
and tliat onlv in
. J». — Loi'onai .secuon or neaa oi muis in ]iiaiie iiosienor in . c fi ij
tlie eyeballs (viewed from behind), | natnral size, a, Frontal t'le root, the tloov
suture; b, longitudinal sinus; c, longitudinal fissure with being made U]i
I'alx cerebri ; d, beginning of sylvian Kssure : c, left optic ]),. jjjg tibrOUS
nerve;/, left sufking-pad ; y, cystic tumour below tongue ; "_ . 1. t .
h, tongue out transversely : h, right ua.sal fossa, showing tympanic platl^ ,
superior, middle, and inferior meatuses ; I, orbital jilate of the mastoid air
frontal bone ; ///., zygoma near its root ; ji, tooth germ in cgUs are not de-
ui)i)er maxilla. , , ,\,
" veloped; and the
annulus tympanicus forms a very slight projection. The meatus with
the soft pirts in situ is proliably of about the same relative length as
in the child or adult; it has no anterior or posterior curve ujion it :
and its inner or tym])anic end is somewhat enlarged to form the
sinus. The external ear, then, is in a transition state in the fa't\is ;
so is the skull in its neighbourhood. Anterior to the meatus is tlie
antero-lateral fontanelle (region " pterion"), while jiosterior to it is
the postero-lateral fontanelle (region " astei'ion "), and between these
Fig. 19. — Coronal section of head of futus in jilane posterior to
THE EAR OF THl'. IXKTUS
105
two foiitanelles is a medley of small bones ami cartilage islands,
.showing that development is not far advanced in this neighbourhood.
Buntaro Adachi (Zfschr. f. Morjiliol. u. Anthrop., ii. p. 223, 1900) has
given an interesting description of the changes which occur in this
neighbourhood in the fcetus and new-born infant. Post-natal develop-
ment is necessary before the tympanic and snuamoso-zygomatic parts
Fig. 20. — Coronal section of head of fietus in plane of the middle ear, viewed
from behind, right side slightly jiosterior to left, ;} natural size, a.
External auditory meatus (left) ; /<, membrana tympani ; r, lobule of left
ear ; d, helix of ear ; c, odontoid jirocess of axis vertebra ; /, basi-
s{)henoid ; g, incus, with stapes in fenestra ovalis ; h, petro-squamous
sutiu'e in roof of tympanic cavity : j, sylvian fissure ; k, squamous
suture ; I, sagittal sutui'e ; m, superior longitudinal sinus ; n, lateral
A'entricle ; o, third cerebral ventricle.
of the temporal bone are fully formed. The pharyngeal tonsil is said
to be poorly developed in the fa;tus.
In frozen sections of the head the hypoiihysis cerebri can be seen
in the middle line lying in the sella turcica (Fig. 17). Below it, in
the sphenoid, can sometimes be seen traces of the early canalis
cranio-pharyngeus ; I have seen these traces in one case, a dropsical
fcetus.
lOG ANTKNATAI. l'AllI()I.()(iV AM) HVCIIKNE
The Region of the Spine.
The spine nf the I'li'tiis is "a Wdiuler (if li<;htuess aud flexibility,"
for its ossiticatiiiii is incomplete (is not indeed complete till far on in
postnatal life) and there is much cartilaffe in it. Any one who has
handled a ne\v-l)orn infant must have been struck by the flexibility
of the s|)ine and the facile manner in whicli the head swun^' forwards
and backwards and to the side ; the movements of the head are due
to the flexibility of the cervical part of the vertebral column rather
than to great range of movement at the occipito-atlantoid articula-
tions ; indeed, tlie condyles of the occiput are nearly flat, and .so are
the articular surfaces on the lateral masses of the atlas, cliaracters
whicli little fit them for extensive mcnement.
In the fwtus in utero, lying as it does with a greater or less
degree of flexion of its trunk and of its head upon its trunk, the
spine shows a general anterior concavity. The single arch, with
concavity forwards, is slightly broken, however, liy the yiromontory
of the sacrum, which produces two unequal secondary curves witli
anterior concavity. Other curves have been desci'ilied as present at
birth, but the truth is that any curves may be given to the s)iine liy
altering the po.sition of the ftetus ; none of them are flxed. Further,
by extension of the head, the cohunn may be made almost straight.
There is a slight lateral deviation in the dorsal region.
Inspection of the liack of the fojtus reveals the vertelu-al spines as
a row of ])i'ojectious on a rounded surface, tor the median depression
does not appear till later, when it is caused by develojiment of the
spinal muscles. The spine of the seventh cervical vertebra is not
specially prominent ; it certainly does not yet deserve the name
" prominens." On account of the forward flexion of the head upon
the trunk of the fcetus in utero, the back part of the head aud the
back of the trunk tVirm a continuous curve with Init slight indication
of a neck grom-e.
In the adult the length of the cervical region of tlie sjiine is to
that of the hnnbar as '1 to 3; in the foBtus it has been stated by snmo
that the cervical is e(|ual to the hunbar part of the verteliral cuhinin :
it is, however, more exact to say that before birth the lumbar region
is only slightly longer than the cervical. My measurements give
18 per cent, of the length of the spine for the cervical region, 40 jier
cent, for the dorsal, 22'5 per cent, for the lumliar, aud about 19 jier
cent, for the sacro-coccygeal. The relation of the spinal cord to the
spinal column varies at ditt'erent jieriods in intrauterine life : at the
tliird and fourth months the cord and the colunni are of practically
equal length, the conus terminalis ending opposite the second
coccygeal vertelira; at the full term, however, it ends opposite tlie
first or second lumliar; at the fifth month it is opposite the fourtli
lumbar (Chievitz, op. cit., p. 20).
In the full-time fcetus there are, as a ndc, tlnee laimary centres
of ossification in each vertebra — one central for the Ixidy, and two
lateral for the arches and jirocesses ; but certain vertelira- oiler
exceptions. The atlas has its anterior arch cartilaginous ; but then
REGION OF THK NFXK 107
its real body is doubtless the oddiitoid iirncess of tliu axis, and in it
one, sometimes two ossific centimes are found. The tive parts of tlie
saerum usually follow the general jilan, and exhibit one central and
two lateral primary centres in each; liut the coccyx is commonly
quite cartilaginous, altliough a single ossific nucleus may be occasion-
ally noted its first part (Lambertz, Die Entwicliunfi des menschlichen
Knochcngerustcs wdhrcnd des fdtidcn Lehrns dargestellt an Rijntyen-
lildern, p. 18, Hamburg, 1900).
The Region of the Neck.
The ueck of the full-time foetus is noteworthy for its apparent
shortness. This character is due in part to the high position of the
sternum, in part to the alnindance of suljcutaneous fat in the region,
and in part to the relatively large size of the head. As has been
noted, the cervical part of the spine is not relatively short, but
relatively long in the foetus. In connection with this region, I may
refer to the hyoid bone, the larynx, the trachea, the pharynx, and
the thyroid gland. All these structures lie at a higher level in the
ueck than in the adult.
On account of the tiexed attitude assumed by the foetus in utero,
a vertical line drawn through the hyoid Isone falls in front of the
manubrium sterni. The hyoid lies almost in contact with the
thyroid cartilage, and opposite the lower part of the body of the third
cervical vertebra ; but with tlie head extended there is a distinct
thyro-hyoid interspace, and the hyoid then lies on the level of the
body of the axis vertebra. The ossification of the basi-hyal and
of the great wings has begun in the full-time foetus.
The larynx, like the hyoid, lies at a higher level in the ueck in
the fcetus than it does in the child and adult. With the head
sharply flexed (intra-uterine attitude), the epiglottis lies opposite to
the cartilage between the liody and odontoid process of the axis
vertebra, and the lower border of the cricoid is in the plane of the
disc between the fifth and sixth cervical vertebne. With the head
erect the larynx is about a vertebra higher. The length of the
larynx is approximately one-half the length of the cervical region of
the spine. A finger's breadth (a fcetal finger's breadth) below the
hjwer border of the cricoid is the isthnnis of the thyroid gland ; the
thyro-hyoid and crico-thyroid membranes, also, have each the breadth
of a foetal finger. The trachea extends from the level of the body of
the fifth cer\'ical vertebra to that of the third dorsal, where it
bifurcates ; its level is a little higher when the head is sharply flexed ;
in the adult the l)ifurcation is one vertebra lower, i.e. opposite the
body of the fourth dorsal. Part of the trachea is in the neck and
part in the chest. Its length is about 3 cms., and its diameter from
2 to 3 nims. ; in a seven months' ftetus it may lie only 1 mm. in
diameter. Its truly fmtal fnrm shows au antero-posterior flattening,
so that, while the antero-posterior diameter may be not more thau
3 mms., the transverse may lie 5 mms. (Mettenheimer, he. eit., p. 310).
The pharynx has a vertical extent of about 4 cms. ; the naso-pharynx
108 ANTKNATAI. I'ATHOI.OdV AND HY(iIKNE
is a very small s])ace. It ln'cmnes coiitiuiioiis with the ti}so])haL,'iis
at tlie level of the fifth or sixth cervical vertelira ]iosteriorly, ami of
the cricoid cartilafie aiiterinrly.
The isthiiuis of the thyroid gland lies in front of the trachea
(upper four or five rings) opposite tlie liody of the fifth or sixth
cervical vertelira (Fig. 17); with tlie head flexed it is in contact with
the iqijier border of the thymus : its lateral lobes usually extend from
the lower border of the thyroid cartilage to the level <if the fourth or
fifth tracheal ring; the weight of the gland is about 7 grannnes.
The high level of the cervical structures in the full-time foetus is
an interesting anatomical fact, reminding us, as it does, of the
emliryonic origin of these parts from the visceral arches. The
gradual descent of the organs in the neck, which takes place after
birth, is in jiart due to the straightening of the body and head which
then occurs, but in greater jiart it is caused by the downward growth
of the tongue and lower jaw.
The Region of the Thorax.
The thorax of the full-time tVetus (Plates II. and III.) difl'ers in
certain anatomical details from that regi(jn of the body in the adult
or child ; it differs even fi-om the thorax of the uew-born infant,
although the foetus may be separated in age from the new-born infant
by only some minutes — important minutes, however, for in them
respiration has or may have begun. It will be convenient to con-
sider, first, the thoracic framework, and, second, the thoracic contents.
The thorax as a whole is situated at a higher level qua the spine
in the foetus (Fig. 17) : its upper limit, tlie iijiper liorder of the
manubrium sterni, lies opposite the body of the first dorsal vertebra
(Plate II.); the central tendon of the diaphragm lies opposite the
disc between the eighth and ninth dorsal vertebne. Its high jiosition
is probably due to the non-develo]anent of the spinal curves. In the
interior of the chest it is noticed that the sulcus pulmonalis on each
side of the spine is shallower and less capacious than in later life.
The external transverse diameter of the thorax is not quite twice
as great as the external antero-posterior, while the internal transverse
diameter is fulh' twice as great as the internal antero-jiosterior : in the
adult the transverse is three times as great as the antero-posterior.
The mesial vertical diameter varies from 4 cms. anteriorly to C"5 cms.
posteriorly. All the diameters are increased when respiration has
been established, Init the antero-posterior relatively more so llian the
transverse and vertical. The thoracic walls are flattened somewhat
in the foetus; after birth they show a more maiked external
convexity. A transver.se furrow can be distinguished which marks
off the upper narrow part of the chest, which contains the thoracic
viscera, from the lower broad part which exjiands over the upper
aspect of the abdominal organs: there is also a slightly indicated
vertical furrow on each side which divides the anterior ]>art of the
cavitv containin"' the heart and thvmus from the iiosterior containint?
spinal cord.
Plate 1
Lower part of Body o/fourth CervictU vertehrt
Blood in spinal canal ,
Plate u
upper part of Body of first dorsal vertebra.
Spimtl cord.
Apex o/ Right lung.
Apex o/ Left lung.
REGION OF THE THORAX 109-
only the luii,ys. These furrows are more evident in fu/tuses before-
tlie full time.
The hones of the shoulder <;irdle (Plate II.) also occuiiy a higher
position than in the adult. Further, the liody of the sca])ula lies
more nearly in a sagittal plane on account of the shape of the-
external aspect of the thorax ; in this respect it resendiles the same
bone in the quadrupeds. It is also rotated so that the "lenoid fossa
is directed markedly upwards and the inferior angle carried forwards.
The eoracoitl and acromion processes and the greater i)art of the-
glenoid fossa lie aboye the level of the first rib, and the inferior angle-
readies the lower l)order of the fifth rib; so that the whole bone is-
about one rib higher than in the adult. The result is that the outer
end of the clavicle is directed upwards, and the nerves of the brachial!
plexus piass outwards instead of downwards to the arm. The high
fietal p(_)sition of parts reminds us that the upper Yimh was at first a
cervical appendage (Chievitz, op. cit., p. 12). The transverse diameter
of the shoulders is large : it is from 12 to 14 cms. in the foetus, but
this measurement is doubtless reduced b}' compaction during the-
passage of the infant through the birth-canals ; moreover, the division^
of one or both clavicles (unilateral or bilateral cleidotomy) will still
further diminish this diameter, for it is due to the clavicles that it is so-
large and that the shoulders so much resist moulding in laljour (125)..
The sternum occupies a high level, for its upper border lies
opposite to the first dorsal vertebra or even to the disc between it
and the seventh cervical : the lower end of the liody of the bone is.
at the level of the fifth dorsal vertel.ira. The position of the sternum
is remarkably oblique, so that the distance of the xiphi-sternal joint
from the spine is three times that of the manubrium from the spine..
The shortness of the anterior chest wall is largely due to this-
obliquity, for the sternum itself is not short. The ribs are directed
somewhat more horizontal than in the child and adult ; the-
extremities of the first three ascend slightly to their costal
cartilages, those of the remaining ones, slightly downwards. The-
subcostal angle is obtuse, being 100" in the foetus as comjiared with
67' to 80° in the adult.
The contents of the thorax are the thymus, heart, lungs, great
vessels, and oesophagus. The large size of the thymus gland (Figs. 17
and 18, Plate III.) is one of the most striking characters of the fcEtal
thoracic contents. Its two loljes, right and left, are often unequal in
size, and are in contact in the middle line ; but there may be a small
central lobe. The greater part of the gland lies in the thorax, the cer-
vical part being almost insignificant : this is to some extent due to the-
high level of the thoracic orifice and manulirium sterni. It corresponds
in vertical extent to the first four dorsal vertebral bodies posteriorly,,
and to the manulirium and upper ])art of the body of the sternum and
upper three costal cartilages anteriorly. The thymus rests upon the
anterior surface of the pericardium, covering the auricles and part of
the ventricles of the heart : laterally it is in contact with the pleura
covering the lungs : above the level of the heart it rests upon the-
arch of the aorta, the innominate artery, the left innominate vein, audi
no ANTKNATAI, I'Al'HOl.OCiY AND HV(;IKNK
the trachea. It may reat'h tlie ilia])luai,'iii iiiferimly. It has liecu
(lescril)ed as an eloii-^ated body ; hut, in the fcctiis at any rate, I have
found its vertical diameter sometimes not much longer than its trans-
verse ; its antero-])oslerior measurement is usually its smallest. It
varies in weight from 8 to 13 grms.,and bears a relation to the general
body weight of from 1 :2r)0 to 1 : S'tO. It is noteworthy, as Sehiift'er
has pointed out (loc. cii., p. 591), that up to tiie end <jf the sixth month
of antenatal life its weight is to the body weight as 1 : oOO or so ; at
the end of the si.xth month it suddenly increases in weight (1:250),
and retains the relationship to the body-weight then assvuued up to
the end of fcetal existence.
The heart (Figs. 17 and 18, Plate III.) is relatively Jicavicr in tlie
fu'tus than in po.stnatal life; the relation of the heart-weight to the
general body-weight in the full-time ftetus varies from 1 : 114 to 1 :211:
in the adult it is as 1 : 21G (0. Schiitt'er, /oc. ciL, p. 551). It is situated
more transversely in the thorax and at a somewhat higher level qu<>
the spine. The upper limit (the base) I found to be the disc between
the fourth and fifth dorsal vertebne, and the lower that between the
eighth and ninth dorsal vertebne. According to Chievitz {oj>. cit., y.
22), however, when the foetus is in its flexed intra-uterine attitude,
the heart limits are two hoi-izontal planes passing thiough the tliinl
and seventh dorsal vertebra' respectively. The posterior end of tlu'
lower surface of the heart is at a slightly lower level than the anteri( ir,
on account of the backward slope of the diaphragm. The long axis of
the organ is placed horizontally, and the apex is directed forwards
almost in the sagittal i)lane ; but after birth it comes to lie move
transversely in the thorax, and the inter-ventricular furrow which had
touched the chest wall at the left margin of the sternum is deflected
to a considerable distance from that bone. In the fcetus a great ])art
of the anterior surface of the heart is uncovered l)y the lungs, but in
the upper part the thymus gland intervenes between the heart and
great vessels and the posterior aspect of the sternum ; the lower por-
tion of the anterior surface is separated only Ijy pericardimn from the
posterior sternal surface. On the left side of the middle line the
anterior relations are the costal cartilages and sternal ends of the
upper six ribs, with, in the case of the first and second cartilages and
ribs, the thymus intervening ; at a lower level the pericardium alone
lies between the heart and tlie ribs, cartilages, and intercostal spaces.
The sharp anterior margin of the left lung insinuates itself to a vary-
ing degree between the heart and the left anterior chest wall (Plati'
Hi.); of course, after l)irth has occurred and respiration been estali-
lished, this pulmonary insinuation becomes very marked, and at the
same time the anterior margin of the right lung comes forward and
covers the part of the anterior surface of the heart which lies to the
right of the miildle line of the sternum. In the foptus, however, let it
be borne in mind, the chief anterior relations of the heart are with
the chest wall and the thymus. The heart may be said to lie mid-
way between the cephalic and pelvic extremities of the foetus ; but
with regard to the sjiinal column, its central point is nearer the upper
end than the lower (Fig. 17).
Lower part of Body of ninth dorsal vertebra.
REGION OF THP: THORAX 111
The wall of the right ventricle is relatively thick as compare J
with the wall of the left cavity in the fcetup (Fig. 18) ; in fact it may
he absolutely as thick (0-5 cm. :0'5 cm.), it may even he thicker (07
cm. :0-o cm.). The surfaces of the right ventricle meet in a distinct
margin, which is, however, more obtuse than in the adult lieart
(Chievitz, op. cit., p. 22). The foramen ovale (communication between
the right and left auricle) is, save in quite exceptional and patho-
logical conditions, open in the full-time foetus ; but both the valvular
structures (valve of the fossa ovalis and limbus of Vieussens), which
lead to its closure, are easily recognised ; l)y their union the foramen
is closed at a variable period after birth, sometimes as early as the
second day. During the last three-and-a-half months of fcetal life
the valve of the fossa is sufficiently developed to prevent the passage
of blood back from the left into the right auricle. Another structural
peculiarity in the fa?tal heart is the ]»resence, in a complete form,
of the valve of Eustachius, the crescentic fold of endocardium in the
right auricle, which directs the blood from the inferior vena cava into
the foramen ovale.
The lungs (Fig. 18, Plates II., III., and IV.) occupy a comparatively
narrow space in the posterior part of the thorax of the fcetns ; the right
is both heavier and larger than the left. After birth and the establish-
ment of respiration, all the pulmonary diameters show an increase, hut
it would seem that the right lung expands to a greater extent in the
antero-posterior and transverse directions than does the left (1, p. 70).
In the foetus the margins of the lungs are " sharp, well-defined, and
curve inwards " ; the organs are of a " uniformly dense, Hrm, fleshy,
and liver-like consistency " ; they do not crepitate, little or no lihiod
oozes out from an incision, and no air bubbles escape when they are
firmly squeezed under water. In colour they are of a dark Ijrownish
red. All these characters change with the estaljlishnieut of breath-
ing : and their change is well known by, and of great value to the
medical jurist. A large part of the surface of the right lung comes
into relation with the thymus, but only a narrow strip of the left
lung above the level of the cardiac impression is in touch with that
gland.
The chief peculiarity of the great vessels of the thorax in the
foetus is the presence of an open comnnmicating canal between the
pulmonary artery and the aorta, the ductus arteriosus or ductus
Botalli. From the posterior end of the upper surface of the heart (as
it lies in the foetal thorax) the pulmonary artery arises and passes
backwards in a horizontal and nearly sagittal direction ; it gives off
from its lower aspect the right and left pulmonary arteries, and is
continued as this communicating trunk or ductus arteriosus to join
the aorta ; it is crossed at the point of junction by the vagus nerve.
The aorta proceeds from the heart in a more vertical direction ; the
highest point reached by the arch is opposite the body of the second
dorsal vertebra or the disc between the second and third bodies, and
there it gives off the innominate artery ; it gives off the left subclavian
opposite the third dorsal vertebra; and it is joined by the ductus
arteriosus opposite the fourth dorsal vertebra where also the aorta
112 ANTKXATAl, I'ATHOUXiV AND HYCilENK
comes iiit" contact with the spine. Tlie vena cava su])erior is sliort
and has a vertical direction ; the left innominate veui runs trans-
versely -and is clearly seen (iu vertical mesial sagittal sections)
posterior to the thymus gland at its upper part. The relation of the
great vessels to the s])ine alters little at birth.
If tile ductus arteriosus he studied more in detail, it is found to he
at its (jrigin a distinct continuation of the trunk of tlie ]iulmonary
artery. Botli in direction and in size it looks like the main trunk,
with the right and left ])ulmonary arteries as almost insignificant
branches of it. It narrows slightly as it approaches the aoi'ta, and
passes somewhat obli(juely through its wall ; it opens into the aorta
at a point not ijuite opposite to the point of origin of the left sub-
clavian artery ; the orifice of the ductus is l)ordered by a valvular
projection of the aortic wall, with a sliglitly C(jncave free margin ; and
the space between the opening of the left subclavian artery and that
of the ductus has been called, and appropriately enough, the pars
communicans of the festal circulation (Ziegenspeck). Strassmaun
(Arch. /. Gynack., xlv., p. 408, 1894) points out that the opening of
the ductus differs from all the other openings into the aorta in its
neighbourhood, in being elliptical in shape instead of round, and in
having the aortic wall in its vicinity raised in ridges (valvular ]irn-
jection) instead of being quite smooth. These anatomical peculiarities
of the ductus serve in some measure to explain the manner of its
closure after birth {vide infra, Chap. IX.).
The oesophagus leaves the middle line and inclines to the left at
about the level of the sixth cervical vertebra; at the level of tlie
fourth dorsal vertebra it turns forwards beside tlie aorta, and conies
to lie in front of it : it then inclines again to the left at the level of
the ninth dorsal (disc between the seventli and eighth dor.sal, accord-
ing to Chievitz), where it pierces the diaphragm. The thoracic duet
follows its usual course, but is not very evident in the foetus.
The Region of the Abdomen.
The abdomen in the fietus (Figs. 17 and 18, Plates IV., V.,
VI., VII., and VIII.) is large, and has the peculiarity of being con-
nected with the placenta 1:)V means of the umbilical cord. The
umbilicus may be described as occupying the central point of
the body, half-way between the vertex and the heels, or, according
to my measurements, a little nearer to the latter than to the
former. The attachment of the cord (Plate VII.) is at the
level of the disc between the fourth and fifth lumbar vertebne;
but doubtless considerable variations occur with the degree of
distention of thealidominal cavity, etc. On the internal aspect of the
anterior alidominal wall the constituent parts of the umlulical cord ran
be seen to break iip ; the umbilical veiu passes u])wards in the middle
line to the liver; the lu-achus passes downwards in the middle line to
the bladder ; and the two umbilical (hypogastric) arteries also proceed
downwards. Init diverge from the middle line to the sides of the
lilndder. where they join the internal iliacs, or rather appear to lie
Plate v
Upfer margin 0/ Body c/ tlvti/lh dorsal verlihra.
Plate vi
Cartilage between Second and Third lumbar Z'ertebrae.
'ght kidney.
I Call bladder.
AHDOMINAI. OUCiANS H3
joined by the internal iliacs, fnr the latter are at this a^e small in
size in comparison to them.
When the foetal abdomen is opened, eertain ontstandinj^- peculi-
arities are evident at once. The great omentum is markedly trans-
parent and delicate in textm-e; the liver is very large (Plates IV., V.,
VI., and VII.) and appears to occup}' nearly one-half of the whole
cavity : the left hepatic lobe is relatively very large, and hides from
view the stomach (Fig. 18); the large intestine is full of dark green
meconium ; and the urinary bladder is an abdominal content. As
Eibemont has shown, a plane passing along the inferior surface of
the liver dix'ides the abdomen into two compartments, each pyramidal
in form and nearly symmetrical : one has its liase above, occupying
the right hypochondrium and epigastric region, its apex below
turned towards the right iliac crest, and contains the liver ; the
other has its base inferior, its apex turned towards the posterior part
of the left hypochondrium, and contains the intestinal coils, the
spleen, and the stomach.
The liver, as has been stated, is large, very large, in the fai'tus :
but in the full-time foetus it is not relatively so large as in the
earlier months ; its weight is to the body-weight as 1:15 or 1 : 16,
and in the full-time foetus as 1:18 or 1:19. The form of the fcetal
liver has been made clear chiefly by the study of frozen sections. It
has five (sometimes six) surfaces : there is a superior surface iu
contact with the lower surface of the diaphragm to which it is
accurately moulded, generally convex but with a localised concavity
corresponding to the heart ; an anterior surface in contact with the
anterior aliiliiHiinal wall, having a quadrangular shape (triangular iu
the adult), and sharply marked oH' from the left inferior siu'face by
the thin anterior border ; a right lateral surface, less clearly de-
limited ; a posterior surface, small in extent, very evident in sagittal
sections, inclmling the notch for the cesophageal end of the stomach,
the posterior part of the longitudinal fissure, the groove for the vena
cava inferior, and the lobus Spigelii ; a left inferior surface, marked
off' from the others by the anterior border and by the groove anterior
to the lobus Spigelii, of considerable extent, showing the impressions
left upon it by the various organs which come in contact with it,
being made up of the under surfaces of the right and left lobes
and of the quadrate and caudate loljes, and being ti'aversed by the
longitudinal and transverse fissures and the fissure for the gall-
bladder ; and an ill-defined left surface which in later life is merged
with the superior surface. Of all these sui'faces the anterior and
left inferior are the largest, and then, in order, come the superior,
right, and posterior. The whole organ is " a right-angled triangular
prism with the right angles rounded off'," sometimes it is a trape-
zoid (Mettenheimer, loc. cit., p. 337). The gall-liladder lies about
1'5 cm. to the right of the middle line, is more cylindrical in form
than in later life, and is distended with bile.
The stomach (Fig. 18, Plates IV. and V.) is small in size at birth,
and can contain only about 1 or lA fl. oz. without being over-disteuded.
The fundus is relatively small, and the lesser curvature forms a
114 ANTKNATAI, I'ATHOI.OdY AND HYCIF.NI'.
more acute au.^le than in imslnatal life. At liirth the viscus may he
empty, or it may cnntain a ihiid like li([U(>r amnii ; in one case in
which labour had heen instrumental, I found some meconium in it.
It lies under cover of the left lolie of the liver, and doe.s not extend
to the right of the middle line of the ])ody, the p3'lorus being situated
immediately in front of the body of the fir.st lumbar vertebra (lower
border of ninth dorsal, according to Chievitz). The anterior relations
of the fcetal stomach, therefore, are with the left inferior surface of
tlie liver; while posteriorly it is in contact from above downwards
with the anterior surface of the spleen, the left supra-renal cajisule,
tlie upper end of the left kidney, and with the tail and body of the
pancreas. Below the greater curvature is the transverse colon ; the
lesser curvature runs first parallel to the left side of the vertebral
column, and then passes transversely to the right side in front of the
spine.
The pancreas in the fa>tus weighs about 4'5 grammes, and is to the
total body weight as 1 : 700 or thereljy ; it measures about 3'5 cms. in
length, and its antero-posterior diameter in the middle line is aliout
1 cm. It lies opposite the first and second lumbar vertebrae It has
practically the same relations with surrounding j)arts as in postnatal
life, but does not come into immediate contact with the left kidney.
The spleen (Plate IV.) lies almost horizontal with the foetus in the
intrauterine attitude of flexion, and is opposite to the eighth, ninth,
and tenth dorsal vertebrje. The liver comes into contact with it
behind and external to the stomach, and it has a direct relationship
with the left supra-renal capsule instead of with the left kidney. It
has therefore four instead of three surfaces : a phrenic posteriorly ;
a gastric or antero-internal which is in contact with the tail of the
pancreas as well as with the stomach ; a supra-renal inferiorly ; and
a hepatic anteriorly. Near the middle Hue the spleen sIkiws only
three surfaces on section, phrenic, gastric, and supra-renal.
The intestinal canal (Figs. 17 and 18, Plates V., VI., VII., VIII., and
IX.) increases remarkably in length during tVTtal life; the increase is
also continuous; and at the tenth month the total length is 410 cms.
or so (Merkel, op. cit., p. 22), the addition during the last month ha\'ing
been 25 per cent. No doulit there are great individual variations.
With regard to the small intestine a few words of description will
suffice. The duodenum commences at the pyloric end of the stomach,
opposite the first lumbar vertebra : there it crosses to the right side
of the l)ody, its third part crossing over again to the left side of the
spine at the level of the second lumbar. According to Chievitz {ojh
cit., p. 33), the levels are the tenth dorsal and the first lumbar. The
jejunum and ileum are less fixed in position than the duodenum ;
the line of attachment of the mesentery is nearly horizontal : and
the coils of intestine follow one another progressively from left to
right. There is usually little meconium in the small intestine. The
ciecum may be found occujiying its adult position in the right iliac
and right lumbar regions, with the ileum entering it at the ileo-ca'cal
valve aliout the level of the right iliac crest or a few mms. above it ;
but I have met with several cases in which this part of the large
Plate '."ir
spinal cord.
Body o/Jirtt sacral vertebra.
Psoas {ie/t).
^Lpop o/sigitwid
ABDOMINAL OKdANS 115
intestine lay at a, considerahly higher point in the aluliinien, and one,
at least, in which it oecnpied the niidtlle line inuuediately l)ehind the
ninbilicus, positions which recall the changes which occur during
development. It is probable that the ciccuni, in the full-time fcetns,
has not always reached its permanent position. The appendix
verniiformis is well marked at this time in life ; it comes off in a
conical form from the Ciccuni ; measures from 3 to 4 cms. in length ;
and has a thin mesentery attaching it to the bowel. The ascending
colon may pass upwards to the under surface of the right lobe of the
liver and form there a distinct hepatic Hexure, liut often its course is
a very short one and the flexure very feebly marked. The trans-
verse colon has not a direction so definitely transverse as in later
life, and not infrequently forms a wide loop passing downwards
towards the pelvic lirini. The descending colon has a similar
arrangement to that seen in the adult ; but the sigmoid flexure
is of relatively great length, and generally forms a large loop, part
of which, in the male fa'tus at any rate, lies in the posterior part of
the pelvic cavity ; there is often a rather long meso-sigmoid. The
large intestine in the fcctus is distended with meconium. The length
of the whole bowel is to that of the fcetal body as 570 : 100 ; in adult
life the relation is as 450 : 100.
The sujjra-renal capsules (Fig. 18, Plate V.) are relatively large in
the full-time foetus, each being equal in size to one-third of the
kidney. The weight of both together is from 7 to 8 grannnes, and
their relation to tlie general body -weight is as 1:400 (circa).
According to 0. Scliiiffer (loc. cif., p. 532), the right capsule is larger
than the left in the tenth month of antenatal life, while in the
earlier months the left is larger than the right. They have the form
of a triangular pyramid, and each rests upon the upper end of the
kidney, covering it like a cap ; the base descends upon the anterior
renal surface as low as the level of the hilum, and is hollowed out to
fit its convexity. The apex of the right adrenal lies between the
liver and the right crus of the diaphragm, at about the level of the
tenth rib ; that of the left is wedged in between the spleen and
the left diaphragmatic crus, at a point a little above the level of the
eleventh rili. The posterior surface rests upon the diaphragm at the
side of the vertebral column. Anteriorly the right adrenal comes
into contact with the left inferior surface of the liver, and with its
posterior surface ; the left supra-renal gland is related to the spleen,
stomach, pancreas, and small intestine.
The kidneys (Fig. 18, Plates V. and VI.) correspond in level with
part of the vertebral column lying between the disc between the twelfth
dorsal and first lumbar vertebne, and that between the third and
fourth lumbar vertebrte. In the full-time foetus the' left kidney is
usually longer than the right, but this is not an invarialile rule.
Each weighs about 11 grannnes ; and their joint weight is to the
general Ijody-weight as 1 : 130 (circa), in the adult it is as 1 : 225.
The hilum lies at the level of the second lumbar verteljra. In the
full-time fcetus the renal lobulation is still evident, but is not so
marked as in earlier antenatal life. The kidneys have much the
116 ANTENATAL I'ATHOLOCiY ANT) HY(;1KNK
same relations with other viscera, save in so far as tliey are more
extensively covered l)y the supra-renal cajjsules. Tlie ureters ])ass
downwards and inwards forming a curve, with siigiit LMjnvexity
towards the middle line, and ojien into the Idadder at or immediately
aliove the ]ielvic brim. Tlie relation of the ureteric o])eiiings to the
plane of the l)rim is due to the fact that in the fo'tus the bladder
(Plate Vlll.) is almost entirely an abdominal organ. In the case of
two full-time male fretuses (examined by me) in which the liladder
contained nrine, a small part of the jiosterior lower portion lay
below the brim ; in three full-time female fcetuses, in which the
viscus was empty, an almost inappreciable part lay lielow the brim.
The position of the u])per end of the bladder varies with the degree
of distension: when empty, I have noted it about 2'5 cms. al]0ve the
symphysis pubis, and when full as high as a few mms. above the
umbilicus at one side thereof. The form of the empty bladder is
simply that of a tube continuing the urethra ; when nujderately full
it has an ovoid shape, the broad end being du-ected downwards and
Ijackwards : and when greatly distended, an ovoid with the broad
end uppermost. The anterior vesical wall is in close contact with
the anterior abdominal w"all, and there is no intervening pouch of
peritoneum. Posteriorly the peritoneum passes over the liladder
wall, reaching in the male foetus to a level immediately below that of
the vesical orifice, and here comes into relation with the small
prostate gland; in the female foetus it does not descend so low-
posteriorly, its point of reflexion on to the anterior urine wall being
above the level of the internal urethral orifice. The organs that lie
posterior to the bladder in the male fcetus vary : in some cases a
loop of sigmoid lies Ijehind it; in other instances, some coils of small
intestine ; and in yet others, simply the rectum, the intervening
pouch of peritoneum being empty.
The bifurcation of the abdominal aorta takes place opposite the
third lumbar vertebra (Chievitz, o/;. cif., p. 38). The umbilical
arteries, in their curved course from their origin in the internal
iliacs to the anterior abdominal wall, lie entirely aliove the plane of
the brim; they ai-e so large in the fietus as to look like direct con-
tinuations of the internal iliacs, even of the common iliacs ; in their
abdominal part thej' are commonly called hypogasti'ic arteries, and
in their funic part, umbilical ; the portion of each hypogastric wliich
remains pervious after the readjustment changes of l.iirth, is the
superior vesical artery.
The Region of the Pelvis.
The region of the jielvis (Plates VIII. and IX.) is comparatively
poorly develojied in the full-time fictus. It has been already noted
that the bladder is an abdominal, not a jielvic, organ at this time of
life, and the same statement has now to be made about the uterus, the
Fallojiian tubes, and ovaries ; the reason is that the pelvis is not yet
capacious enough to contain all the structures which afterwards lie
within it.
Plate ix
third coccygeal Vertebra.
THK PELVIS
ir
The sacrum is qixite straight, or lias ouly a slight anterior cdu-
cavity in the foetus. Its wings are little developed, so that the length
of the bone is greater than its lireadth, dolichohieric, and the sacral
index 76' ; but, while this is the generally accepted statement, A.
Thomson (loc. cit., p. 372) has asserted that it is platyhieric with an
index of 100°. The iliac bones have an almost inappreciable anterior
concavity, and their angle of divarication is large. The pubic l)(ines
are stumpy, and the symphysis is short. The interspino\is diameter of
the false pelvis may be given as 5'5 cms., and the intercristal as 6 cms.
The foetal characters of the true pelvis are interesting. The canal is
somewhat funnel shaped, and the pelvic brim is very olilicpie to the
horizon, a character due to the higli level at which the promontory lies
Fig. 21. — Vei'tical sagittal section of peh-ic region of full-time male fcetus
(section slightly to right of middle line anteriorly), a, Anal aperture ; b,
bladfler, gi'eatly distended with urine ; c, opening of left ureter ; d,
vesical trigone ; c, loop of sigmoid flexure in jielvis ; /, rectum ; i/, coccyx ;
h, third sacral vertebra ; i, jirostate gland.
aliove the symphysis. The plane of the pelvic outlet is practically parallel
to the horizon. With regard to the pelvic measurements in the fcetus,
somewhat conflicting statements are to be found. It seems generally
to have l.ieen accepted that at this time in life the antero-posterior
diameter at the brim, instead of l)eing less, is greater than the trans-
verse ; Ijut both Sir William Turner and A. Thomson have found that
the foetal pelvis is platypellic, and does not, therefore, ditler in
this respect from the adult. In my own observations I found that
while the diameter from the promontory to the symphysis had always
a greater length than the transverse, that from the upper border of
the third sacral vertebra to the symphysis (which more truly corre-
sponds to the antero-posterior in the adult) was sometimes less than
Lliu transverse, iuul only occasioiiiilly ,i;reater than the latter diameter.
It must therefore be cunchuled that the antern-posterior diameter at
the true pelvic brim is not constantly longer than the transverse in
tlie fojtus. As a matter of fact I found the ol)li([ue diameter to be
the longest at the brim. An interesting point in tiiis relation, which
has lieen emphasised by A. Thomson (kic. ciL, ]>. -"iGS), is that even in
Fig. i2. — Vortical sagittal .section ol'pelvi(^ ivgion of full-time female fcetiis (fiozeii in
geuu-pectoral position), a, Coecvx ; h, first sacral vertebra ; c, liodj- of uterus ;
(/, cervix uteri ; c, vagina ;/, empty bladder ; r/, symphysis pubis ; h, riglit ovary
and Fallopian tube ; i, rectum ; I:, anal aperture.
foetal life the pelvis shows in its diameters and other characters the
pecidiarities that (hstiiiguish the male from the female skeleton ; thus
the male ])elvis has a more funnel shape than the female, the ischial
spines are more inturned (bi-ischial diameter iu male fu'tus, 12 mms.,
in female, 14 mms.), the suli-pubic angle measures in the male 50°,
and in the female 68°, and the sacro-sciatic notch and hinder part of
the ilium are nairower in the male than in the female. The last-
PELVIC ORGANS
119
named iioint has a further interest, for Thomson beheves that the
increase in width of the jielvic brim and cavity which occurs in post-
natal life is due not to transverse growth of the sacrum, liut to growth
of the posterior parts of the ilia, and that this holds for both sexes.
It may thei'efore be concluded that the foetal pelvis does not ditt'er so
much from the adult type as has lieen supposed, and that the sexual
characters are all present before l)irth. In the adult the ilia are pro-
portionately wider than in the foetus ; this is i-eally tlie one outstanding
character in which the fcetal pelvis differs from the adult, and it serves
to account for the altered relations of the viscera.
The pelvic viscera in the male fa^tus (Fig. 21) are the rectum,
the prostate, and a loop of sigmoid flexure. The rectum is relatively
larger and more vertically placed in the foetus than in the adult ; it
is more nearly straight. The peritoneum descends in front of this
part of the intestine to the level of the fourth sacral vertebra. The
position of a loop of sig-
moid flexure in the pelvis
has been already referred
to.
In the pelvis of the
female fcetus (Fig. 22) the
lower part of the uterus ,,
constitutes an additional \
content, but a certain part
of that organ, with the
ovaries and Fallopian
tu1)es, lies above the plane
of the brim and is there-
fore abdominal. From a
third to fully a half of the Fig. 23.— Dissectional view of pelvic viscera in six-
entire uterine length lies months fcetus tVom above and from the front, a,
above the 1 )rim ; possibly ^'^''^'''' V*' 5""4;'.^ "'eri ; c left Fallopian tube,
',." ", showing tortuosities; d, left ovary ; c, rectum.
the empty or distended
condition of the bowel may account for variations. The body of
the uterus generally lies forward upon the posterior aspect of the
bladder ; in one of the cases which I examined there was a certain
amount of uterine torsion, so that the anterior surface looked towards
the left as well as the front, a condition due possibly to the presence
of a loop of sigmoid in the right lateral pouch of Douglas. The
cervix uteri is relatively thicker and longer than the corptis ; in the
uterine interior the folds of the arbor vitic are prolonged to the
fundus ; the os is not uncommonly gaping ; and some rugai may be
seen on the vaginal aspect of the cervix, especially on the anterior
lip. The Fallopian tubes (Fig. 23) measure about 2-5 cms. in the full-
time foetus, each has from three to five sinuosities on it, and each
runs outwards, backwards, and downwards to the level of the pelvic
Ijrim (3). The ovaries, also, lie aliove the brim ; they have an elong-
ated, almost cylindrical form ; and they show on section a very large
number of ovi-sacs. The vaginal canal is another pelvic content of the
female fcetus ; in fact, in sagittal sections it appears as if it were almost
120 ANTENATAL PATHOl.OCiV AND HYCIKNE
the only pelvic content. It has a relatively great length ; in its uiiper
])ortion it has an almost vertical direction, Init in its lower ]>:nt it
runs downwards and slightly forwards ; and its walls are covered with
numerous ruga^ Tiic urethra in the female fcetus is about 4 cms. in
length, and ahout 6 cms. in liie male ; in the former se.x it terminates
at the meatus uriuarius externus, aliout 1 cm. in front of a line drawn
vertically downwards from the lower border of the symphysis puliis.
Between the meatus and the liase of the clitoris may be .seen a ridge,
the male vestibular band (18). With regard to the external ajipear-
ances of the pelvic end of the foetus, it is to lie noted that the external
genital organs in both sexes are somewhat incompletely developed as
compared witli the later life. Tlie labia majora, for instance, are relat-
ively small, and therefore tiie labia minora and other jjarts are less
concealed from view than in the adult. On account of the slight
development of the gluteal regions in the foetus, there is a lack of the
distinct groove between the buttocks which exists in later life, and si >
the anal aperture may seem to be situated on an elevation rather
than in a depression.
The Extremities.
Both the upper and lower limbs of the fcetus, liut the lower more
than the upper, are relatively small. Further, the ossification of the
limb bones is not yet far advanced (Lambertz, op. cit.) ; but there is
great vascularity in tlie cartilage, in the o-sseous tissue, and in the
bone-producing periosteum. The marrow is red. The limbs are
disposed in a natural attitude of flexion in utero, and the feet are so
placed as to look as if there were talipca varus, l)ut there is of cour.se
no real club foot in normal circumstances. The muscles of the
fcetus are softer than those of the child or adult; and Chievitz
(op. cit., p. 12) has pointed out that they all pursue a straight course.
The Umbilical Cord.
The umbilical cord or funis is the organ of communication between
the foetal body and the fcetal part of the placenta. It is therefore a
festal structure in its entirety, for even its sheath, which used to be
regarded as amniotic in nature, is now known to be by develojiment
foetal skin (Minot, Human Umbri/oloi/r/, p. 362, 1892 ; Foulis, J.,
Trans. Mcd.-Chir. Soe. Edinh., xix., p. 164, 1900).
The unil)ilical cord has an average lengtli of about 20 inches (45
to 00 cms.), but it varies witliin wide limits. In tliickiicss it is com-
parable to the little finger, lint again there are wide dilferences in
measurement : the degree of thickness will depend in great part u])on
the amount of nnicoid tissue in its structure. It is wliite and cord-
like in appearance, and through the glistening sheath the vessels are
shadowed forth as liluish streak.s. Like a cord of rope, it is rounded
without being (|uite cylindrical, f<n- it is twisted <ui itself. Looking
from the ftetal undiilicus towards tlu']ilacental end of the funis, it can
be seen that in most cases the twist is from right to left ovei" the
UMBILICAL CORD 121
anterior surface of the cord, then round tlie left side to tlie posteri(jr
aspect, and from left to right over it to reach again tlie anterior sur-
face ; rarely the spiral is in the opposite direction. The various
structures in the cord are not equally twisted, for the arteries are
coiled round the vein (Tarnier), and the total number of twists varies
from or two to twenty or even more, but the large numbers are
pathological. Here and there on the cord may sometimes be recog-
nised swellings or nodosities (false knots) due to localised excess of
mucoid tissue or to torsion-anomalies of the ves.sels (Thonia, E., Arcli.
/. Gynaek., Ixi. p. 36, 1900). Many so-called explanations have been
advanced to account for the twisting of the cord, l)ut none of them
has been generally accepted ; all that it seems safe to assert is that
the vessels grow faster than the cord as a whole, which, therefore, has
to l)e disposed in a spiral fashion. The cause of the unequal rate of
grcjwth is unknown. The foetal insertion of the cord (proximal end)
has been considered : at its placental or distal end the funis is
attached to the foetal surface of the placenta at a point not quite cor-
responding with the centre of that siirface, but lying a little eccentric
to it ; there the cord fuses with the ftetal part of the placenta, and its
sheath becomes continuous with the amnion, covering the foetal
surface. The cord may shnply lie beside the foetus, within the
maternal uterus (in the cavity of the amnion), or it may, especially if
it be of considerable length, lie disposed in the form of one or more
convolutions round the foetal body or limbs.
In the full-time fcetus the structure of the cord is comparatively
simple. The sheath consists of a stratified epithelium : the outer
layer of cells is corneous, and may show stomata ; there is a middle
layer of clear cells ; and beneath that a basal layer of granular cuboidal
cells (Minot). Before the fifth month the outer layer is made np of
dome-shaped cells, and probably corresponds to the epitrichium of
the skin. It may be said that the sheath of the cord is composed of
skin, but skin which has not passed the stage which it reaches at the
fourth month of intrauterine life. The fully developed epidermis of
the fatal abdomen extends for the distance of 1 cm. on to the cord,
where it becomes continuous with the sheath ; at the placental end
the latter merges with the amnion covering the placenta. Within
the sheath the vessels of the cord are held together by a mucoid or
embryonic connective tissue, Wharton's jelly, as it is called ; this
consists of anastomosing cells and a muciparous matrix with connective
tissue filjres (fcetal mesoblast) ; these parts (cells and fibres) tend to
arrange themselves in a concentric fashion round the three lilood
vessels, forming more or less marked systems ; and, where the systems
touch, the cells are triangular in shape, columns of these cells being
found in the funis. Embedded in the jelly of Wharton a group of
epithelioid cells with irregular granular contents can usually be
recognised ; this represents either the yolk-stalk or the allantoic
cavity of early intrauterine life, but which it is not quite safe to say.
The ves.sels of the full-time cord are three in number, two umbilical
arteries (allantoic in origin), and one umliilical vein (persistent left
allantoic vein). The structure of the umbilical vessels is peculiar ;
122 ANTKXATAL PATH()IX)(;V AND HYCilENE
they are coniposeil jilinost entirely of a middle or iiiii.seular cuat, being
therefore sinii)ly iini.scular tubes. There is indeed a tunica intinia,
but it is rudimentary in nature ; and of the tunica adventitia there is
no ti'ace at all, the outer surface of the muscular coat passing insen-
sibly into the surrounding Wharton's jelly. Tliere is no elastic tissue,
and the muscle fibres run in various directions, although the inner-
most layer shows a general longitudinal arrangement. Valves have
been described in both the vein and the arteries : they are more
constant in the latter than in the former, and are semi-lunar, or, more
rarely, diajihragmatic in shape. The calil)re of the vein is greater
than that of the arteries, but the walls are of almost the same thick-
ness : there are no vasa vasorum. There are no lymphatics in the
cord ; nerves have been described in it, but even if tiiey are present
they do not proceed far from the ftetal insertion. The funis will bear
a weight of from 5 to 10 kilos, without breaking ; rupture, when it
occurs, is near to the placental end.
The Placenta.
By means of the umljilical cord the corporeal part of the foetus is
connected with tiie great extra-corporeal organ, the pjlacenta. Tbc
placenta is in part fcctal and in part maternal in composition. Tin'
foetal portion consists of the vessels of the cord, which have suli-
divided over and over again, and are spread out in an umlirella-like
fashion over tlie mucous membrane of the uterus of the mother in
that part of its area which is called decidua serotina or utero-placental
decidua. On the one side (foetal aspect) of this expansion of the
funic blood vessels is the amniotic membrane, while on the other
side (maternal or uterine aspect) is the chorion. But while the
amnion forms a simple covering membrane for the placenta on the
side next to the fcjetus, the chorion is greatly expanded in a series of
more or less jjranched processes, the villi, some of which serve as
coverings for the suljdivisions of the funic vessels, and others simjily
pass across the intervening intra-] dacental space to attach the fa>tal
to the maternal p)art of the placenta. Further, from the decidua
serotina, processes or septa pass in the opposite direction across the
intra-placental space towards the fo'tal aspect and subdivide that
space into compartments. In this way the intra-placental space is
divided up into smaller cavities both by the attaching villi of the
chorion and by the septa arising from the decidua ; into these
cavities or intervillous spaces hang the vascular villi. The contents
of the intervillous space consist of maternal blood ; the blood in the
vessels of the villi is fiptal l)lood: and in this manner the maternal
and fuBtal blood are brought into close relationship liut do not actu-
ally mix.
The life-history of the placenta is a short one, for it is formed at
the third month and its existence ends with the birth of the fcetus ;
])ut in its short life it plays, as will be seen when the ]ihysiology of
the fuitus is considered, a very important part. The full-time human
placenta is a spongy mass, meta-discoidal in shape, measuring about
I'l.ACI'ATA 123
seven inches in diaineter, and from tvvo-tbiids of an inch to one incli
in thickness, and weighing about one pound. Tlie side of this dis-
cdidal mass, wliich is directed towards the fcctus and li(|Uor amnii,
has a smooth and glistening aspect, being covered liy the shining
anmiotic membrane ; to this side of the placenta the cord is attached
near to but usually not exactly at its centre, and under the amnion
the funic vessels can be seen ramifying in all directions. The other
side of the placenta (maternal aspect) has a very different appear-
ance : it has a dark red colour, is very irregular on the surface ; and
here and there there are grooves or sulci which correspond to the
decidual septa to which reference has been made, and which sub-
divide this side of the organ into lobules or cotyledons as they are
sometimes called. These cotyledons, it must be remembered, are
not primary but secondary formations in the case of the human
placenta. At its margin the placenta passes insensil)ly into the
memliranes, chorion, and amnion, which meet together at its margin
and form the rest of the bag of membranes which contains the fcctus
and the li(pior anmii. Near the periphery, but in the substance of
the organ, is a more or less circular vein, which is connected with the
maternal blood supply of the i:)lacenta. Before the l.iirth of the
infant the whole placental mass is attached usually to the anterior
wall of the uterus ; and the maternal aspect of the placenta after
birth represents the part which has separated therefrom and still
carries on it the torn through decidual tissue. Sometimes it is
situated on the posterior or lateral wall, rarely on the fundus, and
still more rarely on the lower jjart of the cavity of the uterus.
The blood supply of the placenta is a double one — fcctal and
maternal. The fcetal vessels consist of the two umbilical arteries and
the single umbilical vein which enter it at the insertion of the cord ;
they break up in its substance and pass deeply till their ultimate
ramifications and twigs, arterial and venous, are found in the villi
which hang in the intervillous spaces. The maternal vessels are
branches of the uterine arteries and veins which have grown into the
decidua serotina, and as it became changed into the maternal part of
the placenta have enormously enlarged and extended. The arteries,
which have been termed on account of their sinuous character the
" curling arteries," open into the intervillous spaces ; the veins arise
also from these spaces, which indeed connnunicate not only with
the veins of the muscular coat of the wall of the utei-us but also with
the circular vein of the placenta (coronary sinus, sinus of Meckel).
It is still a matter of dispute and discussion whetlier the intervillous
spaces are lined with maternal or fcetal tissue. According to one
view, the spaces are really gigantic maternal capillaries lined with
endothelium, into which the fcetal chorionic villi project and receive
a covering of endothelium which lies upon the epithelium of the villi
themselves ; according to the other view, the spaces are formed in a
tissue arising from a great jiroliferation of the fcetal epithelium
covering the villi, in these spaces the maternal Ijlood circulates, for
they connnunicate freely with both the maternal arteries and veins,
into them the villi hang covered by the chorionic epithelium, and
124 AXTKNATAI, I'A THOLOGY AND HYC.IKNK
they are in great ymi liiicil iK.t liy the luatenial vascular endn-
theiium but by the fa'tal epitlieliuni. If the former view be
accepted, there lie between the fn-tal and the maternal blood (1) tin-
endothelium of the fo-tal vessels, (2) the chorionic epitlielial cover-
ing of the villi, and {'■'>) the maternal vascular endntlidium <if tlic
intervillous space; if the latter lie the correct view, there lie between
the two liloods only (1) the endothelium of the fa>tal vessels and
(2) the epithelial covering of the villi. According to the researches
of Duval, there is in the placenta of the Rodents still less separating-
tissue between the maternal and the fcetal blood, for in it the villi
hang without epithelial covering into the maternal blood in i\u-
intervillous space: while in the iilacenta of the Ungulata (mare and
sow) there are three separating layers of tissue, fcetal entlothehum of
vessels, fcetal epithelium of villi, and maternal lining of intervillous
space. If the second view of the human placenta be accepted, il
follows that the organ in the human subject lies intermediate be-
tween that of the Ungulata and that of the Kodeutia in resjiect to
the amount of tissue which separates the maternal and ftetal blooil.
Under the microscope, the villi of the full-time jilacenta are seen
to be covered by a layer of plasmodium or protoplasm in which nuclei
are embedded at irregular distances from each other; this layer is
the syncytium. It is the fcetal epithelial covering to which reference
has been made above. In the placenta of early intrauterine life
there is a second layer of large nucleated cells with distinct walls
lying below the syncytium of the villi ; this has been called
Langhans' layer; and it is also in all probaliility foetal in origin.
Langhaus' layer disappears at an early stage in the life-history of
the placenta. The syncytium is at first very active, and from it
spring numerous buds of various shapes and sizes (jiroliferation-
islancls) ; in it also are to be seen clear or hyaline droplets which
may become separated from it and float free in the maternal l)lood,
ancl about the physiological significance of which there has been much
discussion {vide Chap. X.). Under the epithelium of the vilU is a very
delicate connective tissue stroma ; so delicate is this stroma in the
terminal villi, that the eai)illaries may lie said to lie immediately
iinder the epithelium, and as the capillaries have walls consisting of
little more than a single layer of endothelium, it follows that only a
layer of endothelium and one of epithelium intervene between the
blood in the fcetal capillaries and that of the mother in the inter-
villous spaces. During the three last months of pregnancy the
vessels in the villi, more especially of the marginal part of the
jDlacenta, begin to show obliterative changes; there is thickening of
the intima and also of the adventitia of the terminal and medium-
sized arterioles, and in them the circulation therefore slows and
ultimately stops, while the veins and capillaries are unatl'ected till
the changes in the arterioles are completed. In this way the blood
supply to certain groups of villi is diminished, and the syncytium
soon shows atrophic changes, often in patches. Round the villi
fibrinous infarcts form, and these are now regarded by some writers
not as pathological structures, bvit as the natural results of the fact
THE MEMBRANES 125
tliat the placenta lias learhed the term of its active existence
and is senile. In the maternal part of the placenta, senile changes
also occur of the nature of thrombosis in the sinuses, and are associ-
ated with the appearance of " giant cells," which may originate the
thrombotic conditions. In this manner, as has been pointed out in
Chapter lY., ji. M9, preparation is being matle for the physiological
readjustment uf fiuietions which takes place at birth.
The Membranes.
The umbilical cord and placenta are organs of the fcetus; they
are' functional necessities of fu'tal life. On the otlier hand, the
amnion in its whole extent, and the ch(jrion and decidual membranes
outside the placental area, are structures whose activities are largely
past ; they are carried on by means of the placenta into the foetal
period of antenatal existence, but their imiiortant part was played
before the fo?tal period began ; they constitute the " membranes " of
the full-term laliour. The amnion is the inner of the two fcctal
membranes, and forms a sac containing the fa?tus, cord, and liquor
amuii. It covers the foetal surface of the placenta, and at the margin
of that structure passes out on all sides to rest upon the chorion. It
consists of a single layer of low columnar epithelium with stomata
here and there, resting upon a stratum of wide-meshed young con-
nective tissue with stellate and spindle-shaped cells. The connective
tissue layer is the e.xternal of the two which go to make up the
amnion, and it is in contact with the inner surface of the chorion,
but is not firmly adherent to it. The chorion outside the jjlacenta is
no longer supplied with villi in the fu'tal period of antenatal life ; it
is the chorion heve or smooth chorion. Its inner layer is young
connective tissue with vessels ; its outer layer consists of epithelial
cells lying two or three deep and resting immediately upon the
I decidua (maternal), and this layer is probably continuous with
I Langhaus' cellular layer over the placental chorion (or chorion
[ frondosum). After the seventh month of fietal life it would seem
I that the epithelium of the chorion heve consists solely of this cellular
1 layer, there lieing nothing outside it corresjjonding to the sync^'tium
I or plasmodial tissue of the villi of the chorion frondosum or to its
j modification, the canalised tibrin.
I The decidual memljranes outside the placental area consist of the
j fused reilexa and vera of early intra-uterine existence ; but at the
i full term of pregnancy tliey are little more than shadows of tlieir
j former selves, in fact, it is doulitful if any recognisable trace of the
I retiexa exists. Through the disappearance of the retiexa tlie epithel-
I ium of the chorion heve comes into contact with the decidua vera.
1 Part of the vera comes awaj' with the foetal membrane at the time
I of delivery, and part (containing most of the glands) remains to line
j the cavity of the empty uterus and form the new mucous membrane
(post-partum regeneration).
The liquor amnii will be descrilied more appropriately in the
j succeeding chapters (Foetal Physiology).
CHAPTER IX
Physiology of the Fietus : General Statements; Sources of Information; Futal
Circulation, Extra-corporeal or Placental, Intra-corporeal with MainCurrL-nt
and Secondary Circulations ; Cardiac Activity, Peculiarities ; Pulse; PjIu"!
in the Fcutus, Characters ; Respiration in the Fcctus.
I HAVE already indicated some of the outstanding features of the
physiology of foetal life, and have referred to the lack of well-estaK-
lished facts in connection therewith; but it is necessary — at least '^n
it seems to me — to attempt a fuller exposition of the details of fo-tal
physiology, and at the same time still further to emphasise the
lamentable defects in our knowledge of this department of binlnuiial
study. In attempting to do the one, I shall doubtless succeed in
accomplishing the other. The value of an accurate acquaintance
with the facts of fretal physiology in arriving at sound cunclusinns
with regard to foetal pathology and antenatal hygiene, is incalculable:
but if it is at pre.seut unattainable, it is far better for the investigaldr
of this subject to know it, for nothing is more dangerous and in tiie
long run more disastrous than to draw deductions from data which
are uncertain and inexact. Let us then consider carefully this question
of Ftctal Piiysiology.
For all that was known of the physiology of the foetus before the
year 1885, we may turn with some confidence to the pages of Wilhelm
Preyer's work — Spccielle rhysiolo[iic dcs Emhryo: Untersnchungen
neber die Lehenserscheinungen vor der Gehirt — but since that book was
published an immense mass of observations has been accumulated
and is in great need of sifting. There is scarcely one of the scientific
medical jmirnals of France, Italy, and Germany which does not often
add directly or indirectly to the number of articles dealing with one
or other of the aspects of the physiology of antenatal life, and the
extensive bibliographical list of 552 references given in 1885 by
Preyer might now be more than doubled in length. Thei'e has lieen
no lack of writing, then, upon this subject ; but it may be confidently
predicted that there will be much mcu'e ere the theme is exhausted,
and the functions of intra-uterine life investigated and ascertained
with any degree of completeness and accuracy.
Our knowledge of tlie facts of ftetal physiology rests upon obser-
vations — (1) upon the full-time ftctus during labour and immediately
after liirth; (2) upon prematurely expelled but viable foetuses; (.''>) upon
immature and non-viable f(etuses in abortion-sacs; (4) upon ftetuses
of the lower animals, under {a) normal and (h) abnormal conditions;
f(etyvl physiology 127
and (5) upon infants affected with pathological states developed in
utero, in so far as their pathology may throw light upon tiieir
physiology. Further, something is to he learned from the nioditica-
tions in the physiology of the mother which occur during pregnancy,
and which are undoubtedly associated more or less nearly with the
changes going on in the fcetus ; some information also is obtainable
from a careful clinical examination of the contents of the maternal
uterus (viz. the foetus) during gestation. We must, further, be
ready to apply to the study of fcetal physiology all the discoveries
and advances made in connection with the physiology of the adult.
AVith all these means of acquiring knowledge at our command, it
might be expected that much would now be known of the functions
of iutra-uterine life ; Ijut the other side of the question must Ije
remembered — the impossibility of studying, of seeing even the fcetus
during its actual life in the uterus, the absence of exact information
regarding the modifications of maternal physiology during gestation,
and the still obscure and unsolved proljlems of the physiology of the
adult. When, after much patience and great care and research, one
problem of fcetal physiology has been in some degree cleared up, the
first result has visually been to bring forward two or three subsidiary
but equally difficult problems for solution. And so, as Preyer wrote
almost with a ring of despair in his words, " hier reiht die Physiologic
des Embryo Prolilem an Problem." Let us consider, first, the least
difficult problem, that of the fcetal circulation.
The FcEtal Circulation.
During practically the wliole of the foetal period of antenatal life
the circulation of the blood is the same. From the third to the
tenth month the circulation is known as placental, and during the
intervening months it undergoes no marked modifications. During
the neo-foetal period, it is true, the circulation is that of the chorion ;
but by the end of it there has been a specialisation of the circulatory
function, and the blood, instead of being sent to villi over a wide
expanse of chorionic surface, is now directed solely to those found
over one part of it, that, namely, which is in contact with the deciclua
serotina, the site of the de^'cloping placenta. From the end of the
neo-fcetal period onwards to the moment of birth, there is the
circulation of the placenta (Fig. 24).
The essential peculiarity of the placental circulation is the sending
of the foetal blood out of the foetal body to a specially prepared and
extra-corporeal organ (the placenta) for purposes of oxygenation and
other less understood chemical changes. This entails simply the
presence of an efferent vessel (or vessels) to carry the blood to the
extra-corporeal organ and of an afferent vessel to bring it back again.
We may roughly compare it to a coal-pit connected with a railway
system : to the pit there runs a line of rails along which trucks
carrying cinders and rulibish pass, and along another line come back
again the trucks filled with coal. But the presence of this accessory
extra-corporeal system of vessels entails some slight modifications of
128
ANTKNATAI. I*A THOLCKIY AM) HYdlKNK
the circiilatiiiii inside liie fci'tal Imdy, fur the bloml coming fmni the
placenta has to he distributed to the various parts of the body in
such a way that all shall share in it but, some to a greater extent
than others. To continue the comiJurison which has been instituted,
the coal from the coal-pit bus not only to be sent all over tlie railway
Scheme of I'd-tal eireulation (after Preyci'
system, but it has to be sent in special amount aud of a special
quality to the parts where the traffic is most and the speed of the
trains greatest ; in order to carry out this object, special lines have
to be laid and special depots built. It will be convenient to consider
first the extra-corporeal part of the fwtal circulation, and second the
intra-corporeal.
FCETAL CIKCULATIOX 129
The venous blood is carried from the f(etus to the i)lacenta by
the two umbilical arteries, each of which arises fnnii the internal
iliac artery of the same side. In the intra-abdominal part of their
course they are known as hypogastric arteries, and in the extra-
abdominal or funic part as umbilical arteries. Through tliem
impure fcetal l)lood is transmitted to their ultimate ramifications in
the capillaries of the villi, where it may be said to be brought, if not
into touch with, at any rate almost within sight of, the maternal blood
in the intervillous spaces. Having undergone arterialisation and
other chemical and bio-chemical changes, the blood is returned by
the ultimate branches of the umbilical vein to the vein itself, and
thence through the umbilical cord to the abdomen of the fietus. In
this way venous foetal blood passes to the placenta by means of two
arteries, and arterial blood returns from the placenta by means of
one vein. Why there should be two laterally originating arteries
and one mesially situated vein to carry out the transit of the blood,
is not clear ; but fcetuses in which there is only one artery are
generally malformed in various ways, and those in which the single
artery is mesial in position, and arises directly from the abdominal
aorta, are nearly always malformed in one special way, namely, show
fusion of the lower limbs or sympodia (102). In the extra-corporeal
part of the ftetal circulation, the venous and the arterialised bloods
are kept separate; the blood in the arteries is venous, that in the
vein is arterial.
The course of the intra-corporeal circulation of the foetus is much
more complicated than that of the extra-corporeal. It will be con-
venient to divide it, for purposes of description, into a main current
which passes from umbilical vein to umbilical arteries, and into four
secondary currents, which may be called hepatic, pulmonary, gastro-
intestinal, and inferior appendicular, or simply A, B, C, and D.
The main current of arterialised blood coming from the placenta
passes in the umliilical vein to the liver ; here the first secondary
current is given off, that, namely, which passes to the liver (hepatic
or secondary circulation A), being joined by the blood retiu-niug in
the portal vein from secondary circulation C (gastro-intestinal) ; the
main current, however, passes on directly through the special vessel,
: the ductus venosus Arantii, to join the venous blood in the inferior
I vena cava which is returning from secondary circulation D (inferior
I appendicular), and to be joined by the return How from secondary
circulation A (hepatic). The main current, which now consists of
, the pure blood from the placenta joined by the impure blood from
I secondary circulations A, C, and D (hepatic, intestinal, and inferior
I appendicular), pours through the opening of the inferior vena cava
1 into the right auricle of the heart, and is almost immediately directed
1 onwards by the mechanism of the Eustachian valve through the
; foramen ovale into the left auricle. A quantity of blood, which is
i small at the beginning of foetal life, but increases as the full term
j is approached, does not follow this course, but remains in the right
I auricle to join the main current again and pass into the right ven-
' tricle, of which more anon. The main current has now reached the
130 ANTKXA'I'AI. I'A'I'HOI.OflY AND IIYCIKNK
left auricle (jf tiie heiul, riiaii whirli it, is jjiii])elleil 1 >}• syslole throiiifh
the mitral valve into the left veiitiiele, hut ))rior to this it has heen
joine<l hy the hlood returning from secondary circulation B (pul-
mf)nary). The mass of hlood in .the left ventricle, consisting of tin-
main current with the return hlood from the four secondary currents,
is now, under the influence of ventricular systole, sent on into tlu'
aorta liy the aortic orifice, and distrihuted hy means of the innominate
and the left carotid antl suhclavian arteries to the head anil upper
limbs of the fcetus, a ])ortion, however, passing on through the de-
scending aorta to the rest of the body. From the head and upper
limbs the main current is brought back to the heart in the vena cava
superior, and enters the right auricle, where it is joined hy the blood
which did not pass through the foramen ovale, and they Ijoth jiass
by the tricuspid orifice into the right ventricle. From the right
ventricle at the time of systolic contraction, the current passes into
the first part of the pulmonary artery, and immediately gives offjiart
of its circulating blood to secondary circulation B (pulmonary) by
means of the right and left pulmonary arteries ; but the chief ]iart
flows onwards directly through the ductus arteriosus into the aiirta,
where it is joined by some of the blood which had entered the aorta
from the left ventricle. The main current, having l)een thus twice
through the heart, passes first liy the thoracic and then by the
abdominal aorta to the lower part of the trunk ; there part of it goes
through the cceliac axis, and the superior and inferior mesenteric
arteries to secondary circulation C ; the remainder passes on into the
two common iliac arteries, some of it (the now much diminished
main current) going by the hypogastric and lunbilical arteries ))ack
to the umbilicus, and so to the extra-corporeal (or placental) circula-
tion, while the rest is distributed to the lower limbs as secondary
circulation D (inferior appendicular).
Secondary circulation A may be descrilied in a few words. Part
of the arterialised lilood from the placenta in the timliilical vein
leaves the main cvirrent almost at once, and goes liy the afferent
hepatic veins (vente hepatis advehentes) along with the blood in the
portal vein to the sulistance of the liver ; from the liver the Ijlood
returns liy the efferent hepatic veins (vente hepatis revehentes) to
join the circulation in the vena cava inferior just before that vessel
opens into the heart. It is evident, therefore, wliy the name " hepatic "
has been given to this secondary current.
Secondary circulation B takes its origin from the trunk of the
pulmonary artery, while the main current passes on by the ductus
arteriosus to the descending aorta : it, however, passes to the lungs,
but in small quantity, and, having circulated in the i)ulmonary
capillaries, returns by the veins in a no less venous condition to the
left auricle. No aeration of the blood is going on in the lungs in foetal
life, and this current might almost be dispensed with: Juit at birth
pulmonary respiration begins and secondary circulation IS suddenly
increases in amount, and becomes of vital importance to the infant.
Secondary current C comes off' from the main current in the
abdomen, and passes by means of the cieliac axis and its branches.
F(1:TAI. CIRCLLATIOX 131
and by the supeiidr and inferior mesenteric arteries and tlieir branches,
to the stomach, pancreas, intestine, and spleen ; from these viscera
it is returned by the portal vein, vid secondary circulation A to the
main current in the upper part of the vena cava inferior. Like tlie
pulmonary circulation, this secondary current (gastro-intestinal, as it
may be termed) is of small importance in the ftetus, this being
explicable by the comparatively inactive state of the stomach and
intestines in antenatal life.
Secondary circulation J) (inferior appendicular) is that which
passes by the external iliac arteries and the continuations of the in-
ternal iliacs to the lower limbs and pelvis ; the return is by the veins
of the lower limbs and pelvis to the vena cava inferior, and so to the
right auricle and through the foramen ovale to the left auricle. The
blood in this circulation is of a markedly venous type.
It is evident, therefore, from what has been said, that the iutra-
corporeal foetal circulation does not show that separation of venous
from arterial blood which the extra-corporeal does, and which is
also met with in the postnatal circulation. As a matter of fact, it
is only in the main circulation, and in a very small part of it, that
pure blood is found ; no foetal organ is supplied with pure blood
fresh from the placenta. In the umbilical vein and in the ductus
venosus the blood is of the best quality ; but before it can reach the
liver by secondary circulation A, it has been joined by the altered
l)lood of secondary circulation C, and before it can reach the heart
it has been joined by the depreciated Ijlood of three secondary cir-
culations, A, C, and U. It is unnecessary to subdivide the blood of
the fa'tus, as Preyer does, into nine varieties, each having its own
degree of venosity ; but the following general facts are worth re-
membering. Although no foetal organ gets blood direct froiu the
placenta without admixture with depreciated blood, the liver is
privileged in receiving it nearly so, for its supply is mixed only with
the return current from the gastro-intestinal circulation, which
contains the results of the scanty digestive processes of antenatal
life. The heart itself, the brain, and the upper part of the body,
receive the next best blood ; but in this instance the next best
is much inferior to the best. The most venous blood is not that
which returns to the placenta in the umbilical arteries ; in fact
that is placed fourth in order of merit by Preyer, who points out
that it actually contains some of the blood of the umbilical' vein
which is unaltered, having passed through no capillary system. The
most venous lalood is that in the lower part of the vena cava inferior
which is returning from secondary circulation D ; and it is a striking
fact that some of it (the most venous blood) is sent back again to
the part from which it has come (lower limbs) without going to the
placenta. So some of the best blood goes back to the placenta un-
altered, while some of the most venous is sent round the circulation
again without going back to the placenta. These peculiarities of the
foetal cu-culation — disabilities almost they may be called — suggest the
conclusion that it is truly a temporary arrangement, so contrived as
to pass very easily into the permanent circulation of postnatal life.
132 ANTRNATAI, I'A THOLCKiV AND UYCilF.NK
'
The transition, then, lielweeii tlie eirculation of the foetus and
that of the infant is acconqilislied witli cimijiarative ease. It is
unnecessary in tliis \vork, which deals ])articularly with antenatal
pathology and physiology, to discuss fully the changes which take
place in the circulation at birth ; but some of the more important
parts of the readjustment may be referreil to. The essential change
is the elimination of the e.xtra-corporeal or placental circvilation, and
the introduction into the main current of the secondary circulations
E and I) (pulmonary and inferior appendicular). Through the
closure of the foramen ovale, the blood in the right side of the heart
can only reach the left side by passing through tlie lungs ; so the
secondary circulation B is taken into the main current. Through
the stoppage of the flow of blood through the umbilical arteries, the
main current in the lower part of the abdominal aorta can only
return to the heart by passing through the cjipillary system of the »
lower limbs and pelvis ; so the secondary circulation J) is taken in. :
Further, secondary circulation A (hepatic) unites with secondary ■
circulation C (gastro-intestinal) to form the single secondary cLrcula- I
tion which is known as the ])ortal system; in it, therefore, two sets
of capillaries are met with (hepatic and intestinal) as indications of
its original double character. The postnatal circulation, then, consists
of a main current and a secondary current. The course of the main
current is as follows: the l)lood in the inferior vena cava, as well
as that in the superior vena cava, is poured into the right
auricle ; thence it passes through the auriculo-ventricular opening
into the right ventricle; thence the current passes on l)y the pul-
monary artery to the lungs, and, having traversed the capillaries of
the lungs, is sent by the pulmonar}' veins to the left auricle ; then
the cii-culating fluid reaches the left ventricle, by whose systolic
contraction it is propelled by way of the aorta to all parts of the body,
returning from the various capillary systems by the superior and
inferior cavte. The single secondary circulation arises from the
descending aorta ; its current passes by the cceliac axis and its
branches, by the superior mesenteric artery and by its branches, and
by the inferior mesenteric artery and its branches, to the stomach,
pancreas, intestine, liver, and spleen ; it returns from the capillary!
systems of these viscera (with the exception of the liver) by means
of the portal vein, which carries it to the liver, where it circulate
through its second capillary system ; it then passes, with the blood
which has come to the liv'er by the hepatic artery, by means of the
hepatic \cins into the inferior vena cava, and so rejoins the main
circulation.
There are, then, many remarkable difterences between the circula-
tion before and that after birth ; and yet the ti'ansition from thf
one to the other is carried out with a strikingly small amount o!
structural change, strikingly small when the residts are considered
Through the aspiration of blood to the lungs from the right ventricle
the current ceases or markedly diminishes in the ductus arteriosus
while that in the pulmonary arteries and veins very greatly increases
a permanent character is given to this change by the closure of thi
Fa;TAI, CAHDIAC A( TION IHS
ductus arteriosus. Tlimugli tlie return cif a large ipuuitity of lilnod
from the lungs to the left auricle, the blood pressure in it is raised,
while there is a fall in the pressure in the right auricle througli a
dhuinished return of blood from the ])lacenta and the other parts
of the fa^al body ; the result is an equalisation of the pressure on
the two sides uf the foramen ovale, and the flow through it is
checked : the result is made permanent by the membranous closure
of the foramen. The physiological transition from the antenatal to
the postnatal form of circulation is no doubt very rapid, but the
anatomical transition may not be fully accomplished for some days
or even weeks. Physiological closure of the ductus and the foramen
happens first, aud anatonucal obliteration of their lumina follows later,
along with the conversion of the umbilical vein and ductus venosus
Arantii into the rounil ligament of the li\-er, and of the iimliilical
arteries into the vesical ligaments. It is therefore quite conceivable
that much ditlerence of medical and more particularly of medico-
legal opinion should exist with regard to the time after birth when
obliteration of these canals is normally completed, and should exist
in association with the well-known fact that in most cases the canals
are immediately closed in the physiological sense. Into the vexed
question of the modus operandi of the anatomical obliteration of the
ductus arteriosus, etc., I do not propose to enter ; the theories have
been many, and the facts as usual rather scanty, but they will all
be found well set forth in P. Strassmann's article {Arch. f. Gynack.,
xlv. 393, 1894), and in G. Gerard's contributions {Joiirn. de Vanat.
et de la physiol, xxxvi. 1, 323, 1900). It may be remarked that
Strassmann's valvular projection at the jioint of entrance of the
ductus into the aorta, referred to in the preceding chapter (p. 112),
has been regarded Ijy H. Scharfe {Hcgdvs Britr. z. Gcburtsh. u.
Gynak., iii. 368, 1900), as an artificial production. In the manage-
ment of the infant at birth it seems reasonable, from what is known
of the transition changes in the circulation, to allow the respiration to
be well established before placing a ligature upon the umbilical cord.
Cardiac Action in the Foetus.
The course of the circulating blood in the foetus has been described;
but the chief cause of its movement — the heart's action — has not yet
been considered. It is now that a commencement is made with that
part of the subject of fcetal physiology which abounds in problems —
" problem upon problem." I now begin to make frequent use of the
words " probably," " possibly," and " perhaps"; I lament the necessity,
but in the meantime the necessity is real ; ab(jut all the physiology
of the fretus, with perhaps the sole exception of the course of the
circulating blood, these indefinite words will best express the know-
ledge which we possess. Here and there are scattered facts — in a
wilderness of theories ; aliout some things even theories are absent,
none ha\-ing yet been evolved.
In the case of the human fretus, we can satisfy ourselves by
careful auscultation of the mother's abdomen, that the heart is
l:U ANTKNATAL i-ATlK )I,()(iY AM) llYdlKNF.
active, for I'ldin the end n{ the fmuth iiionlh of i)iegiianey its
beat can be heard. But, further, from the sixth week of ante-
natal life, tlie cardiac action may be observed by means of tlic
examination of early abortion-sacs. It may therefore be concluded
that during- the whole period of the fu>tal life (sixth week to end nl'
tentli montli), the heart of the unborn is functionally active. It
])erfeetly fulfils all the recjuirements of antenatal existence; at tin'
same time its action ditlers in certain jiarticulars from that met with
in postnatal life.
In the first place, its activity is much less dependent up<in thr
nervous system in fu?tal than in ])ostnatal life — its action is more
distinctly automa'tic. Tiiis peculiarity has Ijeen over and over again
demonstrated Iiy the birth of fcetuses without brain or spinal cmd
(anencephalic and amyelic), wlmse heart, beat had lieen heard befoie
birth, and seen at birth. Further, F. Nengebauer (Ccutrllil.f. Gynal:..
xxii. 1281, 1898) has shown how long this automatic activity may
continue. The case was a somewhat remarkable one : the fwtus, age
fourteen weeks, was removed, liy operation, from an extrauterine
gestation sac; in the process, its head, arms, a leg, and the whole ><i
its spinal cord were torn away, leaving only the trunk with one
lower liml) attached; yet the heart continued to beat in an automatii'.
rhythmical fashion for more tlian three hours ; at first the rate was
one beat every two seconds, but it gradually slowed until it was one
every five seconds; the contraction was noted to be antiperistaltic,
beginning with the ventricles and then extending to the auricles ;
and the movement of the cardiac apex was upwards, forwards, and
to the right. In a somewhat similar case reported by Wasten ami
referred to by Neugebauer {Cintrlhl. f. Gynal:., xxiii. 465, 1899), tbi'
heart beat for two and a quarter hours. In E. I'eiser's observatiim
{C'rntrlhl. f. Gyndk., xxiii. 10:jo, 1899), the ftetus was five months
old ; when its body was quite cold tlie thorax was opened, and I'eiser
was then startled to' see " tlie interesting spectacle of the beating
human heart " (" das interessante Schauspiel des schlagenden menscb-
lichen Herzeus"). The auricles contracted liefore the ventricles,
and the right scarcely preceded the left; the apex was raised and
turned towards the right. After twenty minutes the heart was
separated from the great vessels and placed in a warm saline solution,
where it continued to beat, Ijut with less marked movements. Its
activity continued for over an hour altogether. Observations of a
like kind were made by E. C)])itz (C'entrlbl. f. Gjpx'lk., xxiii. 6, 810,
1899). The fo'tal heart therefore has a very consideral)le degree of
automatic activity.
In the second place, the ftetal cardiac activity is not so im-
mediately dependent upon the oxygenation of the blood as is the
heart's action in jiostnatal life. The blood in tlie f(etus, with the
exception of that in secondary circulation A, is far from being well
oxygenated. Even in the infant at the moment of birth respiration
may not be established, and yet the heart may continue visibly to
beat for some time, for hours even ; cases in which an asphyxiated
infant was resuscitated after the lapse of hours, will recur to the
FCETAL CAKDIAC ACTION 135
iniiul of almost every obstetrician who has had a hnig obstetric
experience. I have met with a case in which cardiac activity
continued for five hours after birth without tlie huigs having come
into play ; the foetus in this instance was the subject of a number of
malformations. There is not, however, any evidence to show that
the foetal heart will continue to beat for anything like this time in
the uterus after the death of the mother ; as a matter of fact, there is
little chance of saving the infant if the post-mortem opening of the
maternal abdomen and uterus be delayed longer than five minutes.
The circumstances, however, differ widely, and the rapid death of the
fa?tus after the death of the mother is not to be ascribed solely to
defective oxygenation of its blood.
In the third place, it may be safely concluded that the events of
the cardiac cycle are not so clearly marked off and so unalterable in
their sequence in the fcetus as in the child or adult. For instance,
in the observation of Xeugebauer already referred to (loc. cit. siqyra),
the contractions were anti-peristaltic, beginning with the ventricles
and spreading to the auricles. Usually the auricles contract first,
the right slightly in advance of the left ; then there is a short pause ;
then the ventricles p)ass into systole, the right being immediately
followed by the left ; and then intervenes another pause, scarcely of
greater duration than the former. The pauses are of nearly equal
length ; and the whole cycle lasts from 0'3 to 0'6 of a second, of
which more than half is occupied with the ventricular systole. The
impulse and the mo-s'ements of the heart would seem to be the same
as in postnatal life, if it be permissible to draw conclusions from the
observation of the organ in ftetuses which have been expelled in
abortion sacs.
In the fourth place, the fcetal heart rate is much quicker than
the adult ; but there is a gradation from the one to the other
through the rate in the infant and in the child. In the early months
of fojtal existence it has been supposed that the rate is slower than
in the later months ; but the heart sounds are not audible in the
beginning of pregnancy, and therefore the estimation of the raj^idity
of action has had to be made from observations on ftetuses after their
expulsion from the uterus, manifestly a method not free from fallacy.
From the fifth month onwards to the full term, it seems well
estabhshed that the fcetal heart beats at the rate of 132 per minute,
or thereby, with, under certain circumstances, a slackening in rate
down to 100 or less, or an accelei-ation up to 180 or more.
Immediately after the birth of the infant there is, it is believed, a
transitory increase in the cardiac rate, followed by a slowing, ascribed
to the gradual development of the controlling influence of the vagus.
In the fifth place, the course of the blood through the heart is
not the same in the foetus as in the infant, and the quality of the
blood passing through the various chambers also differs. In no
chamber of the fcetal heart is there absolutely pure arterial blood,
and that of the right auricle is little belter (or worse) in this respect
than that of the left.
There are other details in which the action of the foetal heart
136 ANTKN'ATAI, I'A TllOLOCV AND HY(;iKNK
doubtless dilll'is from that of the circulatory or^aii in postnatal life,
l)ut over tliein and other e(|ually obscure matters we must not Iohli;
linger. For instance, it may very well be that variations in the rale
of the heart-beat do not depend ujiou just the same circumstances.
Little is known about the influences which quicken and those which
slow the fcctal heart; l)ut (1) activity of the fu^tal movements is
generally, if not always, followed by increased rate of fa'tal pulse ;
(2) increase in rate of the maternal pulse is sometimes associated
with increase and sometimes with decrease in rate of the fo'tal ])ulse;
(o) the greater the size and weight of the fcutus, the slower, in a
general sense, is its heart beat, but there is no constant relation
between the two ; and (4) the female fcetus has a quicker pulse than
the male, possibly because, as a rule, she is of smaller size and
weighs less. It is not known whether changes in the position of tln'
foetus in utero, eg. from cephalic to pelvic presentation, or from
cephalic to transverse, alter the rapidity of the heart's action ; and
very little is certain with regard to the effect of medicines or fooil
given to the mother upon the fcetal pulse ; and yet these are matters
into which in([uiry is practicable in maternity hospitals if not in
private practice.
It is generally stated and believed that in the pains of labour the
rapidity of the ftetal heart is diminished — to the extent of as much
as ten beats in the minute. Various theories have been advanced to
explain this supposed slowing of the heart; it has been ascribed to
compression of the placenta by the contracting uterus increasing tlie
pressure in the umbilical arteries, to the general compression of the
fcetus by the uterus, to the compression of the f fetal cranium (c.//. by
forceps) stimulating the vagi near tlieir origin, and to stimulation of
the vagi by the venous condition of the fcetal blood produced by the
uterine contractions. Objections may be urged against all these
theories, and with regard to the last, which is in some respects the
most probable, it has to be noted that the interference with the
supply of oxygen to the nerve centres in a labour pain nnist be of a
trifling nature. Indeed, Pestalozza {Rasaeijna d. $r. mnl., Modena, vi.
405, 473, 1891) has calculated how much oxygen would be required
by the fcetus during a labour pain, and has found it to be so small as
to give no support to the above view. There is, however, no need
for further discussion <if this matter, for it is admitted that the super-
vention of a uterine contraction may not in some cases be followed
by slowing, but by acceleration of the fcetal heart. In this relation
Pestalozza's cardiogram, obtained while the fcetus was still in utero,
deserves a paragraph to itself.
It has now and again lieen noted that the fcetal heart could not
only be heard but be actually felt tlirough the mother's abdominal
walls, by the obstetrician during labour. Some seven cases of this
kind, including two original ones, were published by D. F. Duval
{Johns Hopkins Hasp. Bull., viii. 207, 1897) four years ago, in all
of which, through the fietal presentation l>eing a brow, a face, or an
oceipito-posterior one, the chest of the infant was brought into close
contact with the anterior uterine wall, and through it witli the
Fa:TAI, CARDIOCIUAM 137
anterior abdoniiiial wall ; in these cases the filial lieart was felt by
the obstetrician's finger and its rate ascertained. Dnval, however,
does not refer to the important case reported by Pestalozza
{loc. cit. si'.jira), in which not only was the foetal heart-lieat felt
through the maternal abdominal wall, but a cardiographic tracing
of it olitained. The case was one of a twin laljour, and during
the expulsion of the first fcetus, the second one, which was lying
transversely with its back to the mother's back, was jiushed forward
against the anterior uterine wall to such an extent that its
heart-beat could be distinctly felt in the upper part of the
maternal abdominal wall on the right side. The rate was 140 per
minute. With the Dudgeon sphygmograph, the only instrument
available in the emergency, three tracings were obtained, two between
pains and one during a contraction ; of the two taken between the
pains, one was during ordinary respiration and the other was while
the patient held her In'eath. At the time when the cardiograms
were taken, the membranes of the second infant were still intact, but
there was not much liquor amnii ; the uterine and abdominal walls
wei'e thin, a circumstance which helped to make the observation
possible. The tracings sliowed a rapid rise of pressure to the apex
(opening of semilunar valves), followed not by a sudden decrease of
pressure, but by a continuance of it (" platform "), and then by a
descent to the base line, a fact which may be interpreted as proving
that the blood does not get very quickly or easily out of the
ventricles. It is noteworthy that in the cardiogram taken during a
uterine contraction there was no slowing of the rate of the heart's
action. Pestalozza was able to add greatly to the value of his unique
tracings, by taking cardiograiiis of a new-born infant which had not
respired, but which was not yet in a state of true asphyxia, of an
infant in a condition of true asphyxia neonatorum, and of an infant
in whom respiration had been fully established. In the state of
simple apnoea the cardiogram exactly resembled those obtained from
the fcetus in utero ; in that from the asphyxiated infant there was
slowing, irregularity, and a liroader " platform " in the tracing; while
in that from the infant in whom respiration had been established
there was a complete loss of the fcetal characters and an assumption
of the adult type. Too much reliance must not, of course, be placed
upon the evidence obtained from so few observations ; but it may in
the meantime be provisionally maintained that the human fcetus has
a cardiogram which differs from that of the new-born infant which
has respired, and that its characters are those shown in Pestalozza's
tracings.
It may here be noted that it has been generally believed that the
pulse in the new-born infant, and in the foetus also it is presumed,
is one of very low tension, and exhibits no proper apex or wavelets.
Indeed, it has been stated that no apex develops till the seventh year
and no dicrotic wavelet till the tenth, and this statement I accepted
and repeated in my work. An Introduction to the Diseases of Ivfancy
(1., p. 163). I now reproduce here two sphygmographic tracings which
my friend Dr. Oliphant Nicholson has recently obtained, one from
138
ANTKNATAL I'ATHOLOdY AND H V(;iF.NK
;ui iiifauL five luimites old (Fij^. 25) ami the dIIilt fnnu a child of six
days (Fig. 26), holli in puil'eet health; il will he noted that in both
there is relatively high tension, a well marked apex, and tidal and
dicrotic wavelets. It may therefore be conclnded that, with a delicate
sphygmograph and sufficient care in employing it, such tracing.? are ob-
tainable from the pulse of the normal new-born infant. No sphygnio-
graphic tracings have yet l)een olitained from the foetus in iitein
(membranes unruptured), and it is difficult to imagine conditions in
which they could lie taken ; Imt the sphygmogram of an infant born
lirematurely at the seventh month shows a more sloping line of
ascent to the apex.
In the chapter which deals with antenatal diagnosis, a further
reference will be made to the auscultation of the foetal heart, and
so-called funic souffle.
The Blood in the Foetus.
Our knowledge of the characters of the blood of the fiptus is in
great measure founded ujmn the examination of full-time infants at
or soon after birth : to a small extent only have observations of the
blood of prematurely expelled foetuses been utilised in the research —
a regrettable neglect. Let us consider, first, the histological and
chemical characters of the blood of the foetus, and second, its mode
of formation or luematopoie.sis.
The blood of the ftetus, just like the blood of the adult, is made up
of corpuscles and of plasma, and the corpuscular elements are of two
kinds, red and white cells.
During recent years a good many valualile observations have been
made upon the red cmpuscles of the fcftal blood, and I may cite
specially the work of Elder and Hutchison (Trans. Edinh. Ohst. ,^oc.,
XX. 154, 1895), of Bidone antl Gardini (Arch. ital. dc bioL, xxxii. 36,
BLOOD IX THI': l'(KTU.S 139
1899), i.f Fernini (Ann. di os/,V., xxi. 791, 1899), of iSI'iuiiLUii {llni!.,
xxi. 851, 1899), and uf Varaldo (Arch, di osf.et., vii. 72:!, 1900).
From these and from earlier investigations on tliis subject it may l)e
concluded that the red corpuscles are more numerous in the l)l(iod
of the tVetus than in that of the adult or child. ISut there is ni>
general agreement as to how much more numerous they are, although
it may be stated roughly that the infant at the moment of birth has
from one half to a million more red corpuscles per c.nnn. than an adult.
It is worthy of note, however, that the difference in this respect
l)etween the fcetal blood and that of the mother is usually much
greater than that lietween the former and the blood of a non-jiregnant
adult ; for tlie maternal Ijlood in pregnancy is poor in red cells, and
consequently the difference between the number of corpuscles in the
mother and her foetus may amount to as much as two or two and a
half millions per c.mm. in favour of the latter. The number of red
corpuscles in the foetal blo(3d may then be put at from six to six and
a half millions per c.mm. In premature fcetuses (seven to nine months)
the numlier of xanthocytes rises still higher and is connnonly above
seven millions per c.mm. ; and Bidone and Gardini {luc. cit.) have
met with a case, an eight months fcetus, in which there were no less
than 8,240,8:!;' per c.mm. As the number of red corpuscles in the
maternal blood is not greater in the early part of pregnancy, it
follows that the disproportion between the corpuscular richness is
more marked for premature than for full-term fo'tuses ; there is a
difference of more than three millions in favour of the fcetus (Ferroni).
It is a remarkable fact, that even when the mother is antemic in
excess of the ordinary amemia of pregnancy, the red cells of the
fietal blood, although diminished in their absolute amount, are
relatively little interfered with, so that in such cases the dispro-
portion lietween the two bloods is intensified (Ferroni). From all
these facts it may be safely concluded that ftftal Idood in the three
last months of antenatal life is peculiarly rich in erythrocytes, and
that this richness is not directly related to the state of the maternal
blood. What may be the significance of this persistent corpuscidar
richness of the ftetal blood, it is impossible to say with any degree
of assurance, but it is noteworthy that in cases of cyanosis from
congenital cardiac defects it is maintained long after birth.
In addition to the orilinary non-nucleated red corpuscles, the
blood of the ftetus contains a certain number of nucleated xantho-
cytes (ei-ythroblasts). They persist after birth, but only for a limited
time (three days or so), when they average from 1 to 20 to 1 to 8 of
the white corpuscles ; but in pseudo-leukremic amemia of children
and in athyria they may reappear in the blood. Some are mono-
nucleated and others contain two nuclei (Varaldo). In premature
fcetuses they are more numerous, and the younger the fcetus, the
more numerous they are ; this at any rate is probalile, for it has not
been definitely proved.
It may be added that in fcetal blood there are to be seen red
corpuscles which stain either in whole or in part with methylene blue
(young cells, probably), and others containing granules which stain
140 ANTKNATAI, I'AIHOI.OtiY AND HYGIFAE
with Ehrlic'h's neutral red. It has also lieeii stated that the xantho-
cytes ditl'er in size and slmpe from those of adult blood.
The ha-moglobin of the fo'tal lilood, like the red corpuscles, is in
e.Kcess of that in the adult, and greatly in e.xcess of that in the
maternal blood. As measured by Fleischl's luenioineter, it averages
about 120° (]5idone and Ferroni), but may, especially in jjremature
foetuses, rise aliove 125°; it is thus aliont fifty-two divisions of the
hfemouieter higher than with the maternal lilood. Further, as with the
red corpuscles so with the h;emoglobin, an aniemic condition of the
maternal blood does not affect the richness of the fa'tal blood in this
constituent to an appreciable extent, it simply exaggerates the dis-
proportion already existing. It does not appear that the sex of the
foetus has any effect upon the number of corpuscles or the amount
of hicmoglobin in the blood ; and it has not been observed that there
is any relation between the weight of the fietus and the characters of
its blood, an increase in weight not being accompanied by any in-
crease in the number of erythrocytes or in the quantity of haemo-
globin (Ferroni). It may be interpolated here that there is some
reason for supposing that a large quantity of erythrocytes and <if
haemoglobin in the maternal blood in pregnancy is likely to be more
often associated with male than with female foetuses : but there is
no evidence that the characters of the maternal blood in these re-
spects have any relation to the weight and length of the ftctus.
It is believed that foetal oxy-luemoglobin is more difficult to reduce
than maternal, possibly because it has a difi'erent molecular constitu-
tion. G. Zanier {Arch. ital. de hioL, xxv. 58, 1896) has made
observations on the resistance of tlie fa>tal as compared with the
maternal blood in the cow, and has found that it is distinctly greater
in the former : but there is need for further research upon this as
upon so many other points in the physiology of the fwtus. Some
attempts have been made to ascertain the respiratory capacity of the
foetal blood at different ages, and Nicloux (Compt.-rend. Soc. de hiol. de
Paris, liii.. p. 120, 1901) has found that from six months to the
full term the capacity is practically the same ; he estimated that the
hiemoglobin of the blood of a foetus of six and a half months,
weighing 1320 grms., was capable of fixing as much oxygen as that
of a fujtus at term weighing 37;'>0 grms. In this important and
fundamental property of tlie firtal blood, therefore, there is little
variation in the later months of antenatal life.
With regard, now, to the other corpuscular element in the fo-tal
blood, the white corpuscles, it has to be noted that they are also
increased in uumlter as compared with the adult state. According
to Elder and Hutchison {loc. cit.), the leucocytes nundter nearly
18,000 per c.nnu., or twice as many as are met with in adult blood:
the excess of the white is relatively nmch greater than the excess of
the red, there being in the infant at birth 1 white to 298 red, and
in the adult 1 white to 500 red. They are also increased in the
blood of the pregnant woman, l)ut not to anything like the same extent.
Tiiere is, therefore, marked ftetal leucocytosis. The white corpuscles
are of various kinds, ]iiilymoriilionuclear leucocytes, lymphocytes
BLOOD IX THK F(1:TUS 141
(small inono-iiuclear), large mouu-nuclears or transitional forms, and
eosino])hiles ; there are also cells with acidophilic and hasophilic
granules, although Elder and Hutchison saw none of the latter. Max
Carstanjen (Jahrh. f. Kindfrldlc, ?) F., ii. 1215, 1900) and others
liave attempted to estimate the relative proportion of the different
forms of white corpuscles in the fu^tus ; and it would seem that the
polymorphonuclears are more numerous than the lymphocytes, but
that within a few days after birth they are practically equal, and
that later still there is lymphocytosis; the transitional forms are
perhaps more numerous than in the adult, but the eosinophiles are
not relatively increased.
Such are some of the characters of the blood of the ftetus which
\m\& been established with a certain degree of probability ; some other
characters not so fully determined may be referred to. With regard,.
for instance, to urea, Cavazzani and Levi {Ann. di ostet., xvi. 456,
1894) have found that apparently there is no correspondence
between the quantity of this substance in the maternal and in the
fcetal blood ; further, the amount does not seem to be related to the
development or sex of the foetus, or to the age of the mother, but
there is more urea in the foetal blood, if the expulsive stage of labour
has been short; the average quantity is 0'215 per 1000. Cavazzani,
also, states that there is more glucose in the maternal than in the
foetal blood, a fact wliich would seem to show that even eminently
soluble substances do not pass through the placenta from mother ta
foetus or from fojtus to luother by the simple laws of osmosis. It may
be that the placenta has a power of selection ; in fact this is almost
certain. Nucleon, or phospho-carnic acid, is a substance which has-
been lately shown by Sfameni to exist in the fcetal blood {Ann. di
ostet., xxii. 1009, 1900) to the amount of 0'2106 per cent.; its
quantity does not seem to be influenced by the sex of the foetus, or
by conditions of the mother, but the greater the weight of the fcetus-
the smaller apparently is the quantity of nucleon in the blood.
There is twice as much in the blood as in the placenta. The density
of the fcetal blood (1060) is greater than of the adult, notwithstand-
ing the fact that the former fluid contains slightly more water than
the latter. The foetal blood, also, is said to contain less water than
the foetal tissues ; if this be true, it would seem to prove that the
water of the tissues must come from some other source than the
blood, possibly from the liquor amnii. As compared with adult
blood, that of the infant at birth contains rather less mineral matters.
The blood of the male fcetus contains more organic matters, but less
water and less soluble and insolulale salts, than that of the feiuale.
Sfameni {Ann. di ostet., xxi. 851, 1899), gives the average composi-
tion of foetal blood as follows : —
Water . . . . 78 '52 per cent.
Solids 21-47 „
Organic ..... 20'72 ,,
Inorganic .... 0'74 „
Soluble salts ... 0-62 „
Insoluble salts . . . 0'12 ,,
142 AN'II'.NAIAI, I'AlHOLCXiV AND HYGIENE
Fiiiin the researches of Hngounenq (Jonrn. dc physiol. ct de path, tj^ti.,
i. 703, 1899) it would seem that from 50 to GO per cent, of the total
amount of iron in tiie fcptal body is in the blood.
Manifestly there is much to be done before the characters and
composition of the fictal blood can be stated with any degree of
accuracy, and much more l)efore the meaning of these characters
and the bearing of the composition can lie satisfactorily deteriinned.
At the same time, as has been shown, a beginning has Iieen maile. An-
other subject around which it must lie confessed that much obscurity
exists, is the mode of origin of the corpuscular elements of the blo<id
in the ftctus. It would seem, however, that from the time of its
formation until the full term, the fo'tal liver j^lays a part in tiii'
formation of both the red and the white corpuscles; in this organ
the blood pressure is low, the cun-ent slow, and nourishment abund-
ant, conditions which favour its luematopoietic functions. 0. van
der Stricht {Arch, de hioloyic, xii. 199, 1892) has made a series of
elaborate investigations on the formation of both erythroblasts and
leucoblasts in the mammalian foetus, and has found in the liver
special haematopoietic capillaries in which ai-e formed the white
and red corpuscles. The white are not related in any way to the red ;
they have distinctive characters at all stages in their tlevelopment.
The red corpuscles originate from the erythroblasts by the expulsion
or disappearance of the nucleus. In the spleen, also, erythroblasts
and leucoblasts arise, the former in the splenic pulp, and the latter
in the Malpighian corpuscles. Possibly there is a production of
blood corpuscles in other tei'ritories in the foetal body in which the
blood pressure is low. J. Beard (Anaf. Ajiz., xviii., pp. 550, 561,
1900) is strongly of the belief that the thymus gland in its epithelial
portion is the first source of leucocytes, that it is in fact the parent
source of all the lymphoid structures in the body; according to (!.
L. Gulland, the white corpuscles already existing in the blood (ori-
ginal source luicertain) are caught in the reticular tissue of the ftctal
lymphatic glands, and then begin to multiply there (Journ. of Path,
and Baderiol., ii. 447, 1894). It is an interesting fact that Varaldo
{loc. cit.) has found more leucocytes in the umbilical vein than in
the umbilical arteries — there were on an average 4000 more leuco-
cytes per c.mm. in the vein. This excess of leucocytes in the
matrifugal as compared with the matripetal blood stream is ver}' im-
portant, for it supports the view that there is a physiological migration
of white corpuscles from the maternal to the faHal blooil. Varaldo also
found that while eosinophilic leucocytes were met with botli in the
arteries and vein, and that while the blood of both gave the io(lo|)hilic
reaction of Ehrlich, this reaction was more marked in the blood of
the vein, and the leucocytes which contained iodophilic granules
were more numerous in it. It would appear, therefore, that not
only do leucocytes pass from the mother's blood to that of her fcctus
to be retained in the fa?tal body, but that the.se white corpuscles
carry with them and in tliem certain substances whose precise nature
is yet to be determined. Again, it may be said that the physiology of
the frt'tus ]ireseuts problem u])on problem.
f
FffiTAL RESPIRATION 14:5
Respiration in the Foetus.
Respiration in the ftctus is a very ditterent function from
respiration in the infant and adult; it is carried out in the
placenta instead of in the lungs, and the gases pass from maternal
to foetal blood, and not from the atmospliere to the Ijlood. The red
blood corpuscles of the mother are the source of oxygen for the
foetus ; they represent its atmosphere. Eespiration by the placenta
has sometimes been compared to respiration by gills, Init the re-
semblance is incomplete and the comparison inexact. There is httle
need at the present time to enter into the reasons which can be
adduced to prove that the placenta acts as lungs for the fcetus, once
a greatly debated and uncertain question. Suffice it to keep in mind
that (1) the matrifugal blood in the umbilical vein is more arterial
in appearance (although the difference is often slight) than the
matripetal cun-ent in the umbilical arteries ; (2) re.spiratory move-
ments in the foetus are excited by interference with or stoppage of
the circulation in the placenta ; (3) oxy-hpemoglobin can be detected
by the spectroscope in the blood of the umbilical vein ; and (4) that
experiments upon animals have definitely proved the occurrence of
the placental gaseous interchanges in them which constitute respira-
tion. Further, it has been sliown that the current may occasionally
be reversed, and tliat oxygen may pass from the foetus to the mother;
this has been noted in asphyxia of the mother animal, in which
case the blood of the umbilical vein has been observed to become
more venous in appearance than that of the umbilical arteries ;
the commencement of artificial respiration of the mother restored
the colour of the blood as at the first. There are, however, many
other questions concerning foetal respiration about which little or
nothing is known ; some of these have been already referred to
mider the characters of the foetal blood {e.g. the respiratory capacity
of the fcetal blood), to others a few words may now be given.
There is, for instance, the question whether the foetus consumes
much oxygen in a short space of time, or whether it absorbs
little. Preyer (Joe. cit.) is of opinion that it does not consume
much, but that it is very dependent for its life upon what it
does consume. Then there is the i^roblem of the continuance of
the heart's action for a long time without the establishment of
pulmonary respiration, contrasting with its short continuance in
utero after the cessation of the placental circulation (e.g. in death of
the mother). Again, there is the great mystery of the mechanism
by which the oxygen of the maternal hemoglobin passes to the
fcetal haemoglobin, a mystery which is not greatly lessened by the
know-ledge that there is more ha?moglobin in the fietal than in the
maternal blood, or that the oxy-ha?moglobin of the foetal blood is a
more stable compound than that of the maternal. Some further
problems have been already referred to in Chapter IV., namely, the
cause of the first inspiration, and the meaning of the occurrence of
intrauterine respiration (vagitus uterinus) ; but a word must be said
144 ANTKNATAI. I'A THOLOCIV AND HYCilKNK
ill passiii.n' concerning' the (iliservaliniis of Fcrroni mi the ihytlniiical
movements of the fo'tus still in ntero. Ferroni {Ann. di ontrt., xxi.
897, 1899) has fcnuid tliat in additiDii to the rotatory or revolutionary
movements of the fu'tus, and those due to extension and tiexion of
the limhs and trunk, there are others of a rhythmical kind of which
tracings can be obtained liy means of a graphic apjiaratus. These
movements, which occur at any rate in the three last months of
fietal life, had been previously observed by Meiniann, Ahlfeld, Eeu-
bold, Weber, Bar, Pestalozza, Duci, and others; and various theories
had been advanced to explain their nature. Ferroni agrees witli
Pestalozza and Duci in their division of the movements into two
groups, in one of which the tracing shows sharj) elevations and de-
pressions, while in the other it exhibits nothing more than a series
of undulations. In the former tracings, the elevations, sometimes
with a sharp apex and sometimes with a blunt, are followed by
pauses, while in the latter the undulations are pi-actically continuous.
The frequency of the former is from 15 to 34 per minute, and of the
latter from 40 to 75 per minute. They are not pathological iihcno-
mena, for the mothers and also the foetuses were generally found to
be perfectly healthy. Both kinds of tracings are doubtless due to
rhythmical movements of the fa?tal thorax, and not to transmitted
pulsations of the maternal aorta ; the former are possiljly of the
nature of singultus (clonic contractions of the diaphragm), while the
latter are supjiosed to be intrauterine respiratory movements (super-
ficial and regular). Sometimes the two kinds have been found com-
bined in one tracing. From the present standpoint these movements
are of interest as proof that even before birth the fcetus makes respira-
tory movements, practises, as it were, thoracic gymnastics in ])re-
paration for the great extrauterine function of atmospheric respiration.
Whether these movements are powerful enough to draw liquor
amnii into the lungs or stomach, must be left for the mean time
imcertain ; but there can be no doubt that movements of a similar
kind are set up immediately after the expulsion of the foetus from
the maternal passages, and have as their result the drawing of air
into the lungs. There is here, then, further proof that nature makes
no leaps (" non facit saltus "), but prepares Ijeforehand for the transi-
tions of life and even for those of them which seem at first sight so
abrupt as does the establishment of pulmonary respiration in place
of placental. She makes the necessary transitions easy. Tiul\-,
birth marks not a beginning but a stage in life's journey.
CHAPTER X
Physiology of the Fa'tus {ront.) : Tempeiature of the Fu-tus ; Chemical Com-
position of Fiftus, Placenta, and Liquor Arauii ; Nutrition of the Fa'tus, Ijy
Liquor Amnii, Umbilical Vesicle, and Placenta ; Secretions of the Fu-tus,
Hepatic, Buccal, Gastric, Pancreatic, etc. ; Excretions of the Fcetus, In-
testinal, Renal, Placental ; Passage of Substances from Ftetus to llother ;
Internal Glandular Secretions in Fo-tus, of Thymus, Thyroid, Suprarenal
Capsule, and Pituitary Body ; Growth of the Fiutus, Determining Factors ;
Movements of the Fiutus ; Sensation in the Fietus.
The functions of circulation, blood-formation, and respiration in the
fcetus, have presented, as has been shown, many difficult C|uestions for
solution ; but yet more difficult ones are bound up with the phenomena
of antenatal tissue metabolism, secretion, excretion, and innervation.
There is, for instance, the nutrition of the fcetus, about which
Lobstein wrote that it was " less hypothetical than the suljject of
generation, but not perhaps in a much more satisfactory state " ; and
these words, which were penned nearly one hundred years ago (Dis-
sertation sur la nutrition du fietus, Strasbourg, 1802), might almost
be repeated at the present time, for although observations have been
multiplied, of actual facts there is no great abundance. A century
ago there were those who held that the nourishment of the fu?tus was
accomplished by means of the lic^uor amnii, but did not know whence
it came ; there were also those who believed that it was brought
al)0ut hj a communication between the placenta and the wall of the
uterus, Ijut did not know how the communication took place ; and
there were those who ascribed it to the lymphatic vessels of the um-
bilical cord, but were not sure that these vessels existed. Lobstein's
criticism might, with a slight change in terminology, be directed
against the teachers of obstetrics of to-day. Nevertheless, there ha.s
been progress. Let us see.
Temperature of the Foetus in Utero.
The observations which have been made, many of them with great
care, upon the temperature of the foetus in the uterus, or in the act
of expidsion from the uterus, throw a somewhat unexpected side light
upon the problem of tissue metabolism in the unborn infant. These
observations include the experimental work upon foetal rabbits and
guinea-pigs, carried out by Euuge and Preyer (op. cit), as well as the
estimation of the rectal and buccal temperature in the human subject
during and immediately after birth, made by Schaefer, Schroder,
14(3 ANTI'.NATAI, I' All l()I,( )(i^■ AM) 1 1 V( ilF.M',
Wui'.sti'f, 1111(1 iiKire recently by Vicarelli (Air/i. i/al. dc hio/., xxku.
65, 1899). Tliure are two aspects of this subject which may be con-
sidered : the first is tiie relation of the maternal temperature to that
of the fcctus ; and the second is wliat may be called the temperature
proper to the foetus itself. It is necessary to look at both these as])ects.
It has been found, cliieHy by experiments upon animals, that the
temiierature of tlie fo'tus falls and rises accordinfi as the nidtlier
animal loses or gains lieat. In the human subject the increased
rapidity of the fcetal heart in cases of fever in the mother pmliably
points to the same relation. Further, as it is not easy for tlie foetus
in its secluded position in utero to lose heat, it may be concluded
that its temperature will generally be above that of the mother. With
a maternal temperature of 42° C, or slightly more, the foetus will die;
and even 40° C. will become a danger to it, for the reason that it
doubtless means a higher figure for the infant in utero than for the
mother. Of cour.se the period of persistence of the high temperature
must be taken into account, and it has been found that fo'tal guinea-
pigs and rabbits are able to sujipurt a temperature of 41" C f<ir two
hours, and considerably higher temperatures for shorter intervals of
time. It has been shown experimentally, also, that foetal guinea-pigs
support chilling of the mother animal very well, a fall of as much as
6° C in half an hour not proving fatal. The fictus, then, loses and
gains heat easily and rajiidly, and the conclusidu drawn by Preyer is
that it does not, while in utero, possess a heat-regulating mechanism.
With regard, in the second place, to the proiluction of heat by
the fcetus itself, a large number of observations has been carried out
upon the human fcctus during labour — a thermometer being placed
in the anus in breech presentations and in the mouth in face cases,
while another (curved) thermometer was inserted into the uterus, oi-
simply put into the vaginal canal. The result, brietly stated, of the
experiments has been to prove that the living ftetus constantly possesses
a higher, but only a slightly higher temperature than the containing
uterus and than the vagina. The difference has not been found to be
great — on an average from one to two-tenths of a degree Centigrade ;
Ijut it was practically constant in favour of the foetus. The temjterature
of the liquor amnii has been found to be intermediate. In a dead
fictus, the thermometer in the cranial cavity (it was a case of
craniotomy) showed a lower temperature than that of the uterus
(Vicarelli, loc. cit.). Even the new-born infant, innnediately after its
expulsion, shows a temperature sliglitly higher than that of the
mother's uterus : but soon thereafter there is, as is well known, a
very striking loss of heat from exposure to the cold air, evaporation
of water from the skin, etc. It is interesting to note that it has been
found that there may be the difference of from two to three-tenths of
a degree between the temperature of twins ; further, well-developed
infants have shown a slightly higlier tem]ierature than weakly ones.
From all these observations it may lie concluded with some degree nf
assurance that the fcctus in utero not only receives heat fnnn the
maternal j>arts, but is also to some extent a source of heat itself. Tlir
high temperature of the foetus proves that metabolism is going on in
CHEMICAL COMPOSITION OF F(KTUS 147
it, that there is a certain amount of tissue respiration going tni, a
conchision which is strengthened by the fact that such products (if
oxidation as creatin, liypoxanthin, urea, uric acid, and carljonic acid,
are found in it. Proljably, as Preyer Ijelieves, fa>tal oxidation is
feeble ; but it is certainly present. Possibly foetal metabolism may
be found to have much in common with the tissue-changes of hiber-
nating animals. At any rate, there is, in this phenomenon of beat-
formatidu in tlie tVetus, a further example of the curious blending of
dependence upon the maternal processes and independence of them,
which is so characteristic of the life of the unborn infant.
Chemical Composition of the Foetus, Placenta, and
Liquor Amnii.
The consideration of the chemical composition of the foetus and
its anuexa, although not yet possible with completeness and accuracy,
is nevertheless calculated to throw further side lights upon this so
intricate subject of the nutrition of the unborn infant. In a matter
with this degree of complexity and obscurity, all side lights, even if
only rush-lights, are to be welcomed.
The foetus, according to Fehling's tables, contains at the full term
74-4 per cent, of water and 25'6 per cent, of fixed substances, while in
the adult body the proportions are 58'5 per cent, of water and 41 '5 per
cent, of fixed substances. As the steps of fcetal development are retraced,
the amount of water in the foetal organism increases, being 82-9 per
cent, at the eighth month, about 83 per cent, at the seventh, about
86 per cent, at the sixth, from 89 to 90 per cent, at the fifth, about
91 per cent, at the fourth month, and 97'o per cent, at the sixth
week. In fact, as has been pointed out by Fehling, the foetus at
the second month of antenatal life (neofoetal period) contains a
larger proportion of water than the blood, mucus, and milk, and indeed
resembles lymph in this particular. With regard to the mineral
constituents, there is an increase during ftetal life from 0-001 per
cent, of the total weight at the sixth week to 2'55 or 3 per cent, at
the full term. The fat increases from 0'57 per cent, at the fourth
niiinth to 2'44 per cent, at the eighth month, and 94 per cent, at the
full term : and the albuminous substances from 4-87 per cent, at the
fourth month to 11 '8 per cent, at the full term of pregnancy. These
figures cannot be taken as in any- sense final, as the number of
analyses made is still very small, and each chemical constituent
would require to be taken by itself and carefully investigated under
different conditions as to nutrition, etc. Some work of this kind has
lieen done ; for instance, Thiemich {CentrlU. f. Fln/sioL, xii. 850,
1809) has endeavoured, in the case of foetal dogs, to ascertain the
influence of the nourishment of the mother upon the fat of the foetus,
and has found that tlie kind of fat given in the food does not
apparently affect the fat of the foetus ; he concludes that the fat of
the foetus is not at all, or only in small part, derived from the fat of
■the food given to the mother-animal. L. Hugoimenq, also, has
specially carried out a series of researches on the mineral constituents
148
ANTKNAIAL I'ATHOl.OCi'i AND HVCIKNK
1
of the huiuuu I'n-tus am
g^n., i., p. 703, 1899:
uc\v-lMiru infant (Jonni. ih' physiol. ct dc path.
pji. 1, 509, 1900), and has elicited some
interesting facts. Tlie fcetnses cremated varied in age from four and
a lialf months to full term, and were eight in nunilier. It was found
from these analyses that tiie fixation of mineral elements was little
marked in the beginning of antenatal life, and very marked towards
the end of it: that, as a matter of fact, the global weight of stilts
fixed ill tlie three last months of pregnancy was about twice as great
as that in the six first mouths; and that at the time of birth the
f(Etus had subtracted about 100 grms. of minerals from the maternal
organism. In a fo-tus of four and a half months, weighing 522 grms.,
the ashes weighed 140024 grins., while in a full-time infant of 3300
grms. the weight of the ashes was 1061630 grms. ; in a fcetus of sLx
months, weighing 1105 grins., the mineral constituents weighed
30'7705 grms. The great fixation of minerals in the three last
months is therefore undoubted, if it is permissible to ilraw deductions
from one series of estimations. The iron is an important mineral
constituent, and was therefore specially investigated by Hugounenc|.
He found that its fixation-law was the same as that of the minerals
generally, viz. twice as much was fixed during the three last months
as during the whole preceding period of antenatal life. In the full-
term fcctus the total (juantitv of iron varied from 0'383 to 0'421 grm.
of FejOj, or from 0-268 to 0"-294 grm. of the metal (about 0-397 per
cent, of the ashes being FejOj). It was calculated that aljout 50 per
cent, or 60 per cent, of the iron was contained in the blood and the
rest in the tissues ; of the tissue-iron most would be in reserve ill
some organ, e.g. the liver or spleen. It is supposed that this reserve
iron is to make up for the lack of the metal in the mother's milk, for
it has been observed that human milk does not in its mineral con-
stituents exhibit the same parallelism with the ashes of the fa?tus as
does the milk of some of the lower animals, a parallelism which has
been sometimes termed Bunge's law. An interesting comparison in
tabular form of the mineral constituents of human milk and of a full-
time human ftetus is given by Ilugouueuq, and may be reproduced
here : —
Anhydrous phosphoiic acid (P.,0-, . So '28 per cent.
Lime(CaO) . . . ".' . 40-48
Magnesia (MgO) . . . . 1-51 ,,
Chlorine (CI) 4-26
Anhydrous sulplmric acid (SO.,). . 1-50 ,,
i Pero.xideofiron (Fe..O.,) . '. . 0-39 „
Potash (K.,0) . '. ■ . . . 6-20
Soda(Na.jO) 8-12
Anliydrous carbonic acid (CO.j) . . ' 1-89 „
21 -30 per cent.
14-79
2-87 ,,
19-73 ,,
0-18 ,,
1 35-15
10-43
The storing up of iron in the fiTtus during the third trimester of
pregnancy is at'compauied by a diminution in the maternal reserve of
that metal. This, at any rate, has been proved for the guinea-pig by
CHF.MISTRV OF PLACENTA
149
Charriii and Levaditi {Jonrn. dc j^hi/siol. et de jxifh. ghi., i., p. 772,
1899). These observers found no appreciable difference in the iron
constituents of the liver in the pregnant animal, but in the spleen
a diminution was demonstrable both chemically and histologically.
The foetal hypersiderosis is accompanied, therefore, by a maternal
hyposiderosis ; and it may lie remarked in jiasaing that it is possible
that this state of the mother in pregnancy may predispose her to
amiemia and greater liability to infection.
A few words must now be said regarding the other mineral con-
stituents of the foetus, and we still make use of the analyses of
Hugounenq {loc. cit.). The following table gives the percentage
amounts of the various substances for 100 grms. of ashes in fcetuses
I if difierent ages : —
.Sex .
F.
F.
F.
F.
F.
F.
M.
Age .
4-4i
4i-5
5-5A
6
6i
Term.
Term.
Weight in kgs. .
0-522
0-570
0-80'0
1-165
1-285
2-720
3-300
Ashes in grnis. .
14-0020
14-7154
18-3752
30-7705
32-9786
96-7556
106-163
CO.J .
—
1-50
0-96
0-90
0-32
1-89
1-16
CI . . .
8-99
9-91
8-59
7-75
8-53
4-26
4-54
P,05 .
34-74
.32-33
34-36
34-94
35 -.39
35-36
36-26
SO, .
T-46
1-27
1-80
1-78
1-46
1-53
1-23
CaO .
32-60
38-21
32-50
34-64
34-13
40-55
40-68
MgO . .
1-74
—
1-58
—
1-17
1-51
—
KoO . . .
9 •12
1-21
8-28
7-21
8-45
6-20
7-56
Na„0 .
12-23
13-75
12-62
10-62
10-95
S-12
5-96
FeA .
0-43
0-33
0-40
0-39
0-38
0-39
0-40
The predominance of the soda over the potash is to be accounted
fur by the relative abundance of cartilage in the foetus; and the
marked increase in the potash in the last weeks is due to its presence
in the red blood corpuscles and in striated muscle. In the second half
of pregnane}- the fixation of phosphoric acid shows inconsiderable
variations ; on the contrary, the proportion of lime increases greatly in
the last month, so that at the end of antenatal life the foetus assimilates
moi-e lime than phosphoric acid. Consequently, it follows that the
unborn infant does not assimilate all its phosphate of lime in that
form, but fixes first the phosphoric acid (as nuclein or lecithin), and
then the lime. If the alkaline bases, the phosphoric acid, and the
lime be left out of account (and their variations are due to the
development of the red blood corpuscles and the bone), the centesimal
composition of the ashes of the fa?tus remains fairly constant during
the second half of intrauterine existence, although, of course, the
total amount of the mineral constituents increases much in the last
weeks. This is a conclusion of some importance in approaching the
problem of fcetal nutrition.
It is a remarkable fact that the analysis of the placenta has been
almost entirely neglected ; it is only within recent years that any
attempt has been made to supply this defect in our knowledge of the
chemistry of generation. To V. Grandis (Arch. ital. de biol., xxxiii.,
pp. 429, 439, 1900) and P. Sfanieni (An7i. di ostet, xxi. 851, 1899, and
xxii. 1009, 1900) we are indebted for some careful estimations of the
150
ANIKNATAI. PA 11 lOI.OdV AND HVdlKNl-:
cuuipusiliuii 111' tliL' iilaceiila. There were ditlicullies iu the way of
an exact analysis, <v/. the imiHissibility of draining' oil' all the fcEtal
blood from the organ; hut Sfanieni believes that the figures in the
following table show not only the composition of the fietal blood
and the true placental tissue, but also the differences between
them : —
Placenta.
Fietal Blood.
■\Vater
83-67 lier cent.
78-52 per cent.
Solids
16-32
21-47
Organic
ir.-4.-)
20-72
luorganic .
0-86
0-74
Soluble salts
0-73 „
0-62
Insoluble salts .
0-13
0-12
The reaction of the placental tissue was neutral. It is noteworthy
that the amount of water contained in the placenta is very large (the
percentage given by Grandis, 83'S9, is practically the same as that of
Sfameni) : in this respect the organ stands midway between renal
tissue, with 82-7 per cent, of water, and the grey matter of the cerebral
cortex, with 85-8 per cent. Of the substances removed by extraction
(1-925 per cent., according to Grandis), most are albuminous in their
nature, and only a smiill jjart is true extractive. The conclusion
seems to be clear that the placenta contains easily ditl'usible album-
inous substances, which may be carried without difficulty from it by
a physiological solution circulating in the vessels ; Grandis, however,
does not attempt to decide whether these are elaliorated in the
placenta or come from the mother. Sfameni has shown tliat the
placenta contains nucleon (i)hospho-carnic acid), but not in such
amount as does the foetal blood. Grandis has made a sjiccial analysis
of the ashes of the after-birth, which amount to TOTo per cent. The
following table gives the percentage composition of the ashes : —
Placental .\shca.
Albuininous Ashes extracted
from unii-rigated Placenta.
Alhuminous Ashes from
irrigated Placenta.
CI
11-4
—
— 1
s.
0-204
-
-
Na
24-93
0-251
0-728
K.
6-57
-
-
POj .
33-46
55-18
14-5
CaO .
2-32
—
CHEMISTRY OF LIQUOR AMXII 151
The chief facts brought out by this analysis are — (1) the large
(luautity of phosphorus found ; (2) the extractibility of most of the
phiisphorus-containing matters with water, and the precipitation of
these with the albuminous substances ; (3) tlie preponderance of soda
over potash ; and (4) the large quantity of lime. An excess of lime
may show itself Ijy concretions on the maternal surface of the placenta,
and Sfameni points out that these concretions do not disturb the
growth of the fcetus, that in fact the more insoluble salts there are in
that organ the heavier the infant. I can support this observation,
for I met with a placenta with concretions some years ago, and the
fietus was markedly large and healthy.
It is possible that before these sheets have passed out from the
press further analyses of the placenta may have been made, supporting
or contro\'erting the conclusions which have been stated above ; in the
meantinre, it is to be noted that the chemical investigations, so far as
they have been carried, go to show that the placenta is something more
than a means of communication between mother and foetus, somethmg
more than a mechanical filter, — that it is in fact a special organ, con-
sisting in great part of highly diHerentiated tissue (epithelial in type).
Tlie liquor amnii, unlike the placenta, has often been the subject
of chemical analysis. The reason is not far to seek. The amniotic
fluid has been the central position, so to speak, around which the
great l)attle of the manner of fcetal nutrition has raged. Has this
tiuid or has it not a power of nourishing the fcptus ? Whence comes
it ? Is it of foetal or maternal origin ? Does it or does it not contain
the renal excretion of the foetal kidneys ? Is it swallowed by the
fo?tus ? These and many other allied questions have lieen asked and
variously answered, until the literature on this suliject has grown to
great dimensions. Further, the questions are of no recent origin, but are
almost as old as Obstetrics itself, for till the nature of the placenta was
to some extent understood the amniotic fluid seemed a probable enough
food for the unborn infant. There has always been much discussion
about the liquor amnii, " de aquis in cpiibus fcetus humanus quasi
natat," as the old writers used to put it. Manifestly the chemistry of
the fluid, if it were sufficiently known, will throw light upon all the
vexed questions ; man}' analyses have thei'efore been made, l:)ut have
not as yet thrown as much light as was expected, and are consequently
being continued, with what result time alone will tell.
In the meantime it may be stated that the liquor amnii is
chemically a serous fluid simply. It has a specific gravity of 1007 to
1013 or thereby, and a slightly alkaline reaction. It varies greatly
in quantity, as every obstetrician knows, but possibly it may be safe
to .say that usually at full term it amounts to a little less than a
litre ; it may also be said that it does not seem to bear any constant
relation to the weight of the mother or of the fcetus or of the placenta,
nor to the length of the umbilical cord. The water of the amniotic
fluid amounts to from 97 to 98 per cent., and may, in the second half
of pregnancy, even reach 99 per cent. ; alljumin and mucin have been
found in it to the extent of from 1 per cent, to 0-6 per cent. ;
extractives from 0-7 per cent, in the earlier months to 0'03 per cent.
152 ANTKNATAI, I'ATHOLOflY AND IIVCIKNK
ill the latter; and suits I'ruiii U'9 per cent, to O'.j ]>fV eeiit. The salts
have been iuvestiii;ated in the ease of the liquor ainnii of the cow, and
have been found to consist of NaCl, 0'58(J jier cent. : NaO, 0'l>67 per
cent.; KO, 0-060 per cent.; Ca, 0014 per cent.; Mg, 0-0038 per
cent. Urea is commonly but not constantly found, but apparently
not in greater quantity than is common in serous Huids (from 0030
per cent, to 0-045 per cent, at the close of pregnancy). In the case
of a diabetic mother, .sugar was met with in the liquor amnii
(H. Ludwig, Ccntrlhl.f. Gynak., xi.x. 281, 1895) to the amount of 0-30
per cent. Lockhart Gillespie {Trans. Edinh. Old. Sue, xi.\. 151, 1894)
has investigated the proteids and more particularly the albumoses of
the liquor amnii at the third and at the si.\th month of pregnancy,
and has found a trace of albumo.se in the former and -1685 per cent,
(proto, 0485 : hetero, -045 ; and deutero, -075) in the latter : the total
amount of proteids (including the albumoses) was -3819 ]ier cent, at
the third month and -9485 per cent, at the sixth. In the latter, also,
■09 per cent, of peptou was met with. (lillespie is of opiniim that the
presence of the lower forms of proteid bodies in the anniiotic Muid,
although difficult of explanation, may be due to the action upon the
albumin of digestive ferments similar to those described as being
present in pleuritic or ascitic effusions. Finally, it may be noted that
various substances given to the mother may be found in the liquor
amnii. c.f/. iodide of potassium.
It must be confessed that the chemistry of the liquor amnii, after
all, does not throw much light upon the question of fcetal nutrition —
it may be that we do not know how to interpret aright the meaning
of the analysis. It certainly .seems to be of inconsiderable value as a
food stuH' in the later months of antenatal life, unless partaken of in
relatively enormous quantities ; but it may play an important part as
a supply of water to the growing organism at all periods in foetal
existence. Although not food, it may very well be drink to the
unborn infant. It may also be .said in passing that its chemistry
does not clear up the vexed question of its maternal or fa-tal origin.
Some years ago, Krukenberg {Arch./. Gijna'l:, xxii. 43, 1884) wrote in
slightly hopeless fashion : " Die physikalisch-chemische Untersuchung
des Fruchtwassers giebt also keine Auskunft liber die Herkunft
desselben"; and the same judgment might be pronounced to-day —
" keine Auskunft iUier die Herkunft" — no information (or little) about
its origin, although for other reasons we are inclined to regard the
liquor amnii as of mixed origin, partly maternal, partly fu'tal.
Nutrition of the FcEtus.
The most diHicuIt prcibleni in fietal ]ihysioliigy is doubtless the
nutrition of the miborn infant. Xotwithstanding its exceeding diffi-
culty, it has from time inimemorial attracted investigators and ]ihilo-
sophers, and their work anil sjieculation, if they have accomplished
nothing else, have at least done this : they have demonstrated its
exceeding difficulty. Like the ]iroblem of the exact nature of repro-
ductinn and of the origin of sex, the iiuestion of how the infant grows
NUTRITION OF THE FCETUS 153
in the wumli lias fascinated and iierplexed generations of seekers after
truth, but has not discouraged them. Difficile est,fateor, sed tcndit in
ardna virtus.
In what has been already stated with regard to foetal circulation
and the chemistry of the blood, the ftctal tissues, the placenta, and
the liquor amnii, the way has been paved for the more intimate con-
sideration of the central problem of fcetal nutrition. The wideuess of
the problem and the great number of investigations to which it has
given rise forljid more than an indication of the salient points of the
theme. Let us in the first place endeavour to clear away some of the
difficulties, by discussing in order the liquor amnii, the umbilical
vesicle, and the placenta as a source of food-supply to the f(ctus.
Thereafter we may look at the matter of metabolism in the fcetns and
the question of tVctal secretion and excretion.
Whatever may be thought with regard to the nutritive properties
of the Uquvr amnii, there can be no doubt that it plays an important
part in antenatal life. It is an organ of protection to the fcetus,
saving it from shocks, injuries, changes in temperature, and excess-
ive pressure ; it gives freedom of mo\'ement with a minimum of
muscular effort to the unborn infant : and it is useful as a fluid
dilating wedge in the hours of partm-ition. Does it, however, serve
any other purpose or play any other part in intrauterine existence ?
That it receives excretions from the fietal skin and occasionally from
the fcetal kidneys is generally admitted — epithehal squames, vernix
caseosa, and hairs are met with in it as well as the products of renal
activity (urea, kreatinin), and when benzoic acid is given to the
pregnant mother-animal it is met with as hippuric aciil in the liquor
amnii (Gusserow). Further, it is the source of the chief water supply
of the tVetus ; this also cannot be doubted. No doubt it receives some
water from the mother by the placental route in the blood of the
umbilical vein ; but, as has been seen, the composition of the matri-
fugal blood (in the umbilical vein) when compared with that of the
foetal tissues (vide siqira) proves that all the water cannot be thus
obtained. Consequently, it follows that much of the li(]uor amnii
must lie absorbed through the fcetal skin (in the earlier months of
fcetal life), and swallowed by the mouth and taken into the stomach
and intestines (in the later months). Of the swallowing of the
liquor amnii there can be no doubt, for products of the activity of the
foetal skin (hairs, epidermis, vernix) could not in any other way find
entrance to the intestinal canal and be discovered as constituents of
the meconium. It may be granted, then, that there is a certain cir-
culation of liquor amnii through the fcetal tissues — a swallowing of it,
an absorption of it, and an excretion of it ; and it is probable that
there is a circulation of it through the maternal organism also, that
in fact the liquor amnii is being secreted and absorbed again by the
maternal tissues. It is, therefore, a water supply to the fcetus. Is it
also a food supply ? It must, I think, lie admitted that to a certain
extent it is. It can hardly circulate in the way that has been
described without losing some of its constituents to and taking up new
substances from the foetal tissues. It is true it does not contain much
154 ANTKNAI'AI. I'AIHOI.OCV AND HY(;IKNK,
nutriment, but it is LMnially true that it contains some; and if, as is
extremely ]irobablu, it is al)S(irbe(l and swallowed in relatively large
amount, tlie i|uautity of food that is thus conveyed to the fu'tus may
lie not incdMsiderable.
The part played by the uinhilical rexiclc or }•! ilk-sac in the nutri-
tion of the human fcctus is apparently not great. At any rate it can
only be of use to the fu-tus in the early weeks of fcetal life, for it soon
is left behind in development, and can scarcely be said to enlarge at
all after the neofictal ])eriod. Nevertheless there is evidence that in
tiiese early weeks it contains true yolk, and it is tlierefore more than
]irol)able that it is a source of food sujijily to the organism in the
transiticjn jieriod of neofcetal life, if not later. In other vertebrate
foetuses, the yolk-sac, as every student of Kmliryology knows, plays a
very important nutritive function ; but in mammals it is to all intents
of no consequence as a direct source of food supjily, although in some
mammals it takes part in the nutrition of the ftetus in another way, tn
be now referred to. In the Itodentia, Inseetivoia, and t'liiroptera the
umbilical vesicle becomes united by its vessels (vitelline or omphalo-
mesenteric) with the diplo-trophoblast (Hubrecht) or sub/.onal
membrane plus epililast, to form a temporary structure connecting
mother with ftetus, the vitelline or omphaloidean placenta. By and
by the vitelline is replaced by the allantoic placenta, but it is most
important to remember that for a time the nourishment of the fcetus
is carried on by a placenta the vessels of which are those of the um-
bilical vesicle. 1 have elsewhere (102) shown reason for supposing
that sometimes at least a vitelline placenta may intrude itself into
the embryological history of the human fietus, that in the sympodial
nKjnstrosity, and possibly in other terata as well, the allantoic vessels
do not develop, and yet a placenta is grown which carries the fo'tus
to the full term of gestation, and that this jilacenta is formed by the
vascularisation of the chorion by the vitelline vessels. Further, in
the non-placental mammals, such as the Marsupials, in which there is
no true placenta, either vitelline or allantoic, the organ which absorbs
nourishment for the t\etus from the mnther before the former is
transferred to the marsupium, is the umliilical vesicle. The young nf
the Marsupials is born in a very immature condition, but through the
medimn of the milk-nutrition of the marsupium is carried safely nn t"
full development. Through the formation of a vitelline and later ni
ail allantoic placenta, the })eriod of utero-gestatii m in the higher
mammals can be prolonged, the fo'tus can be more fully developed in
utero, and the mammary method of nutrition can be ]iost]Mined in
a later date. It may therefore be regarded as proliable, both on the
grounds of jihylogenesis and of ontogenesis, that the umliilical vesicle
and more particularly its ves.sels play a certain jiart in the nutrition
of the ftetus ; normally, however, vitelline nutrition is of short duration,
being limited by the close of the neofa^tal period, or very soon there-
after. With some forms of monstrosity it may be greatly prnlongcd,
and, even when no malformatidii exists in the infant, jicrsistcnt and
pervious vitelline vessels may be traced in the cord and full-time
lilaeenta, and these may ennlaiii blmid. An example of these per-
NUTRITION OF THP: F(KTL'S
155
manent vitelline vessels I met with some years ago ; the specimen is
here figured (Fig. 27). More recently Bovero has described a similar
case, in which he was able to inject the vessels {Intcrnat. Monatschr. f.
Anat. u. Physiol., xii. 31, 1895).
To summarise at this stage in our consideration of the subject in
hand : the liquor amnii is a certain but small source of food supply
to the fwtus, even in the later months ; the part played by the
nmbihcal vesicle and its vessels is under normal circumstances
finished in the early weeks of utero-gestation, but may be less
Fig. 27. — Placenta with persistent Umbilical Vesicle (a), and vitflline
vessels {h, h, b, h). Reduced by about one-tliird.
temporary under certain unusual conditions. IManifestly, there must
be some other organ of foetal nutrition which has not yet Ijeen referred
to, for it is impossible to accept the feebly nutritious liquor amnii and
tlie temporary yolk-sac as sufficient sources of food for the rapidly
growing unborn infant. That organ is universally admitted to be the
placenta.
The reader will be not unprepared for the conclusion that the
placenta is the chief organ of nutrition of the foetus ; for the side
lights upon the subject that have been got from the study of the
loG ANrKNATAI, I'AI'IlOLfXlY AND HY(;iKNE
tuiupeniluif of ihe t'ci'Hi.s, uf tlic chemical analyses iliat liavo lieen
made of its tissues and of the placental sul>stance, and of tlie histology
of the blood of the nnihilical vein and arteries, have all tended to
throw into jironiinence the iilacental factor in the ])robleni. At the
same time, it must he admitted that most of the evidence which we
possess is of the indirect kind ; and it is even now far from certain
to what extent the placenta acts simply as a transmitter of ])repared
nourishment, and to what extent it is also an organ which alters the
composition of the food-stufis coming to it and has a true secretion.
Much yet remains to be done Ijefore these problems are cleared up;
but let us take heart, much is being ilone — trniUt in nrdua virtus.
Let us consider some of the proofs which have l)een collected, indirect
although they may be.
There is, in the first place, evidence that in tlie human subject
certain substances pass from the maternal blood through the placenta
to the fcetus. It is difficult, however, to obtain proof of the passage
of the substances which go to liuild up the body of the foetus ; it may
be necessary to suppose that all the chemical constituents which
make up the structure of the body of the unborn infant have passed
to it in one form or another, and in one chemical combination or
another, from the mother's blood through the placenta, but exact
demonstration is really impracticable, for we cannot, as it were, ear-
mark any one sul)stauce in the maternal dietary and recognise it again
in the foetal body. Indirect proof, however, is forthcoming, and is
indubitable. Substances which do not normally exist in the fu'tal
organism can be administered to the mother, and their presence can
be afterwards demonstrated in the ])lacenta and fcetus. The sub-
stances which have been employed have nearly always been
medicinal; and chloroform, salicylic acid, iodide of potassium, alcohol,
mercury, and methvlene-blue may be mentioned as examples. The
chemical substance has not always been found to pass to the infant
(tluis, all ol}servers are not agi-eed as to the transmissibility nf
mercury), but its occasional passage is really all that is needed to
prove our present point, which is, that in the hunum subject soluble
and ditl'usible substances in the maternal blood may pass over to the
fcetus through tlie placenta. Eecently, Nicloux {L'Oh^tetriquc, Ann. v.,
p. 97, 1900), with the help of new methods and improvetl apparatus
for analysis, has given conchusive proof tliat alcohol administered to a
parturient woman one ho\ir or so before her delivery can lie found in
the blood of the umbilical cord. Further, the transmission of certain
diseases from mother to fcetus in utero, c.//. syiihilis, malaria, small-
pox, is evidence that the suljstances whicii are neither nutritive noi-
soluble may jjass through the placenta, and this fact may be lu^ld to
be indirect proof of fcetal nutrition liy the placental route; l)ut tliis
side of the subject is not at present em})hasised, for it will be referred
to again. The analyses of the blocxl of the umbilical vein and arteries
as carried out by Varaldo {loi\ cit. suprx) may also be advanced in
support of Ihc^ contention that the placenta is the great means of
transmitting nutrinu'ut to the fietus, and it may further be held to
give a hint as to the manner of its transmission ; for it was found that
NUTRITION OF THE F(ETUS 157
there were more white blood corpuscles in the bluod of the uiiiliilical
vein than in that of the arteries, and that more of them contained
iodophilic granules in the former than in the latter. It seems, there-
fore, to be reasonaljle to conclude that some of the leucocytes are
retained in the fcetus, and that they may, as was indeed supposed by
earlier observers, be carriers of nutriment.
In the second place, experiments upon the lower animals may be
adduced as giving :nore complete proof of the passage of certain
chemical substances through the placenta, from mother to fcetus via
the placenta ; and it is true that we can more scientifically regulate
and check such observations than we can the clinical researches upon
the human subject. On the other hand, it must not be forgotten that
there are considerable diH'erences between the structure of the human
placenta and that of the lower mammals, and it does not necessarily
follow that what is demonstrable in the case of the rabbit or guinea-
pig will be true for the infant. Nevertheless, these experiments have
been of service, and by their means it can be asserted that such sub-
stances as chlorate of potash, iodide of potassium, salicylate of soda,
bromide of potassium, lithium, mercury, antipyrine, quinine, arsenic,
alcohol, moi-phine, copper, lead, benzoate of soda, etc. etc., occasionally,
if not always, pass in the matrifugal blood stream to the fcetus.
Further, the fact that sometimes the substance experimented with could
be found in the fa?tus and in the placenta but not in the liquor amnii,
seems to exclude the possibility of the liquor amnii being more than a
most occasional means of conveyance of materials from mother to foetus.
Experiments upon animals have also shown that bacteria and their
toxines, substances which differ very markedly from the soluble
and diffusible chemical compounds to which we have referred, may
pass through the tissues intervening between the maternal and foetal
bloods in the placenta ; it is true that they do not always so pass, and
that it is not yet known what circumstances determine their passage
or non-passage, but their occasional transmission is further proof in
support of tlie belief that food substances may also reach the foetus
in this way.
In the third place, it may be with justice alleged that the placental
route is really the only one by which nourishment can pass to the
unborn infant in the later months of pregnancy. By exclusion we
come to this conclusion, for a well-nourished fcetus may be found with
almost entire absence of liquor amnii ; or, again, although there Ije a
sulScient quantity of amniotic fluid, the fcetus may suffer from an
imperforate condition of the cesophagus, an anomaly which of course
prevents the fluid l.>eing taken into the digestive tract, and yet the
nutrition may show no sign of having been interfered with. With
regard to nourishment by the umbilical vesicle, it is unnecessary to
point out that such a method is inconceivable in the later montlis of
antenatal life, as the food supply contained in it is quite inadequate.
Teratology furnishes a very strong argument in favour of the view-
that the placenta is not only the chief but practically the sole means
of the transmission of nourishment to the unborn infant ; for foetuses
so deformed as to possess scarcely any organ sa^'e the placenta, or a
158 ANTI'.NAIAI, I'A THOI.OdV AM) IIVCilHNF,
j)iirLiuii of the iiLu-eiitii nf iumllun- I'u'lus, may yet lie nt)urislie<l and
brouji;ht lliruiigli nine niontlis of intnuiterine existence to the full
term; the one oii;an which is essential to tiieir nourishment (1 say
iiotliing meanwhile rej^arding structural integrity) is the jdacenta.
It may be hazarded tliat, did the liuman fietus not ])ossess a jilaeenta,
it would 1)e imjHissible for it to 1)8 carried beyond tlie seeond month
of antenatal life ; it is the evolution of the placenta that has pro-
longed intrauterine existence, and made it possilile for the fo'tus to
be much further advanced in develoinuent wlien born. On this subject
and on some allied iinestions John Beard discourses most suggestively
in his Certain Problems of Vertebrate Emhrijology (Jena, 1890).
The ])lacenta, then, is at any rate a transnutter of nourishment
from mother to fcetus. But, is it something more ? Does it prepare,
elaborate, and otherwise alter the food-stuffs passing througli it ?
There is undoulitedly a consideral)le mass of evidence to show that it
does not simply permit materials to pass through from the one lilood
to the other by the plain and uncomplicated laws of osmosis : it
plays a more intricate and subtle part than that. It has a certain
selective power, as is shown by the fact to which reference has already
been made, that the ([uality of urea in the foetal and maternal lilood
is not the same. Further, it would seem that a larger quantity of
one chemical substance ])asses from nnjther to fcetus at one time in
pregnancy than at another, for in the later months there is a marked
increase in the amount of ir<m and of potash and lime in the infant ;
these materials are needed by the fu?tus then to form the bones, the
red corpuscles, and the striped muscles, and, perhaps, to make up for
the future deficiency in iron of the maternal milk ; and the jilacenta
apparently has the power of supplying them in the necessary abund-
ance. Again, the ])lacenta would seem to have the property of
storing up in its sulistance certain minerals, e.g. mercurj' ; this, at
any rate, is the finding of certain experiments upon guinea-pigs made
by Porak (Arch, de mid. e.vp. ct d'anat. path., vi. 192, 1894). In its
])ower of storing up mineral and possilily also microl)ic poisons and of
fixing glycogen, the ]ilacenta resembles the adult liver, and possibly
it may possess this faculty in order to set the fietal li\"er free for
other functions (h;eniatopoiesis ?). We must a\-oid " the guesser's
darkening of knowledge," but one is tempted to speculate upon many
matters concerned with the part played by the placenta in fcrtal
nutrition. Does it, for instance, yield a special secretion to the
foetus ? Does it also send to the mother an internal secretion, as has
jjeen suggested by Letulle and Xattan-L;irrier {lor. cit.), a secretion
which is neither glycogen nor fat nor mucin, but an albuminoid ? Does
it in any degree save the fcetus from the ett'ects of maternal mal-
nutrition ? Why is it that at first the placenta and the foetus seem
to grow almost pari paxgii. in wciglit, while later in antenatal life the
former scarcely gains at all, and tliT" lattci' continues to increase at
a wonderfully rapid rate ? Hier reiht wirklich die I'hysinlogie des
Embryo Problem an Problem !
The matters which we have l)een discussing, ditlicult and almost,
insoluble thougli they may well appear, must nevertheless yield in
SECRETIONS OF THE F(ETL'S 159
Cdiuple.xity to certain nther.s as yet liarely touched upon. I refer to
the problems of the metabolism of the fietus, its intracorporeal
as distuiguished front its placental or extracorporeal biochemistry.
That the fa>tus does not act simply as an absorber of prepared
nourishment, is certain ; that it acts to a certain extent inde-
pendently in the building up of its own tissues, is proved by its
temperature and l)y the chemistry of its excretions. The belief is also
strengthened by the study of its secretions. Let us consider, there-
fore, this aspect of the nutrition of the fa>tus.
Secretions of the Foetus.
The great size of the liver, and the fact that it receives the purified
and food-containing blood from the placenta before it can reach the
other organs of the fu?tus, lead us to expect that this gland plays a
large part in the metabolism of the body. There is good reason to
believe that this expectation is well founded. The presence, for in-
stance, of consideraljle quantities of glycogen in the ftetal liver at liirth
goes to show the activity of its glycogenic function ; at the same time
the detection of this material in most young I'cotal tissues {e.g. muscle,
heart), and its production in the placenta diminish, in theory at least
the part taken by the^ hepatic cells in this physiological act. Another
sign of hepatic functional activity is found in the presence of bile
in the gall bladder ; api)arently this secretion is poured out from the
third month of intrauterine life until the full term. It would seem
also that it is really bile, for it contains both bile acids and liile
Colouring matters, although bilirubin is proljably not produced in
appreciable quantity till the mid-term of pregnancy. It does not, at
the same time, appear clearly what purposes the bile serves in the
fu;tal economy, for it can hardly play a great part as an intestinal
antiseptic, and it is not much needed in digestion, and yet its early
presence indicates some functional importance. It gives to the
meconium its characteristic dark green colour ; so much we are
assured of ; what else it does in fcetal life is obscure, " bleibt nnklar."
It may be worth while to give here the chemical analysis of the foetal
liver, as determined by Doleris and Butte {Nouv. arch. d'obstH. et dc
(jynec., ii. 378, 1887) —
AVater ..... 70-70 . -*
Solids . . . . 29-30
Organic substances .... 27'981
Inorganic substances . . . 1'319
About the buccal secretions in the ftetus little is known, save the
fact that in the new-born infant the presence of ptyalin can usually
be detected ; but why there should be at the end of ftetal life a saliva
with an amylolytic power which will not apparently be needed (under
normal circumstances and while an exclusive milk diet is maintained)
till several months of postnatal existence have passed, is a hard pro-
Ijlem even among proljlems which are not easy. There is evidence
that the buccal secretions (salivary as well as mucous) are not free in
160 ANTFAA'IAI. l'AllI()I.()(iV AND HVCIKNK
thefd'tus; Imt it is, on tln'otliei hand, imt kunwii tcp what extent the
inoutli is ke]it lunist by the iiigeslinn of liquor anuiii. It is possible
that a small amount of gastric digestion may go f)ii in fujtal life ; for in
tiie case of the human fcetus, at any rate, it has heen noted by I)oleris
and Butte {loc. cit.) and others, that fibrin may be digested by a solution
made from a scra])ing of the mucous membrane of the stomach of an
infant that had jierished in l)irth (craniotomy). Tejisine, therefore,
is jireseiit in the stomach at liirth: and, according to tlic obsci'vations
of Kollikcr and Langendorti', it is there as early as the fourth month
of intrauterine existence. It is safe to state, in this connection, that
there is evidence that there is sutticieut digestive ferment in tin-
ftetal stomach to digest all the albuminous substances of the li(iU(ir
amnii which may be swallowed. On the (luestion of the nature and
source of the contents of the fcetal stomach, the communication of
George Iloliinson {Month. Journ. Med. Sc, vii. 506, 1846-47), although
written more than fifty years ago, may be j)rofitably studied.
With regard to the activity of the pancreas in ttetal life, there is
good reason to believe that paucreatin, the fat-emulsifying ferment, is
present to some extent. As to trypsin, the peptonising ferment, the
evidence is not so clear ; some observers have found it, althongh not
in all cases, while others have not noted it at all (c.i/. Dolcris and
Butte). The third or diastatic ferment of the pancreas does not seem
to be present either at birtli or earlier in antenatal life. Little is
known regarding the intestinal secretions in the ffrtus ; little, that is,
that is in any degree certain. There is no doulit some secreti(in (jf
succus entericus, but what its composition is and to what extent the
various intestinal glands take part in its production, must remain for
the present obscure. Some reason exists for supposing that the
glands of Brunner may act in a different manner in the foetus as com-
pared with the adult. But speculation can serve no useful end, when
so little is known.
Other secretory activities in the f(ctus are found in the seliaceous
glands and in the serous membranes. The vernix caseosa. with which
most fa?tuses are covered at the time of birth, is composed prineipallj'
of sebum from the skin glands and of desquamated ei»idermic scales ;
possibly the epitriehium may contribute to its formation. It contains
from 78 to 84 j)er cent, water, and from 9 to 10 per cent. fats. It is
doubtful if the sudoriparous glands are active in antenatal life : if they
are, their activity is in all probability restricted to the tcrniiiial weeks :
the purposes which these glands serve in the adult can hardly be said
to exist in the infant before birth. The manimar}' glands, however,
are functionally active, both in male and female fcetuses, as is demon-
strated by the presence in them of a milky secretion at the close of
intrauterine existence; the glands of the vagina also must be physio-
logically operative, fen- I have often had occasion to note the large
quantity of thick white mucus lying in that canal in female foetuses.
It is stated, on the other hand, that the lachrymal glands do not
secrete in the case of the fo'tus or infant at birth. The activity of the
serous membranes is shown by the presence of cerebro-spinal fluid,
and, under pathological conditions, by the occurrence of ascites, hydro-
i
TH]-: Fa-;Tra?4iiFCRjiii.-^6
P:XCRETI0NS of the FOiTUW^U^O^^^-^lQl
thorax, and hydiMi-jjerieardiuni. It is therefore quite clear from the
evidence of the secretions that not a little independent metaljolism is
carried on in the foetal tissues ; but further proof is forthcoming from
other sources.
Excretions of the Foetus.
The foetus has excretory as well as secretory activities. The
meconiimi with which the lower part of the intestine is distended is
made up of swallowed liquor amnii, lanugo hairs, vernix caseosa, and
epidermic squames, of bile, mucus, succus entericus, pancreatic secre-
tion, and of intestinal shed epithelium. One or more of these elements
may be alisent : when the bile is wanting, as in congenital obliteration
of tlie bile ducts, there is found the so-called meconiimi amnioticum,
which is of a yellowish brown or even of a grey colour ; when there
is imperforation of the oesophagus, the component parts which are
obtained from the liquor amnii will not be found. Special ovoid,
yellowish green corj^uscles (meconium corpuscles) have been descriljed.
Chemical analyses show that the meconium contains from 20 to .30
per cent, of dried solids, which consist of mucin, biliverdin, Ijilii-uljin,
bile acids, cholesterin, fats, fatty acids, and ashes (chloride of jiotassium
and sodium, phosphate of iron, lime and magnesium, and sulphate of
lime and soda). The absence of peptones, albumin, leucin, tjTosin,
lecithin, glucose, lactic acid, and lactates, and of the products of decom-
position (indol, phenol), lias been noted. According to B. Moore
(Schiifer's Textbook of Fhi/siolor/y, i. 474, 1898), the meconium also
contains a sulistance giving two absorption bauds, one to the red side
of the D line, and the other, broader and darker, l;>etween the D and
E lines of the spectrum. Under normal circumstances there are no
micro-organisms in the meconium during fffital life, and I have taken
meconium from the rectum of a still-born infant some hours after
birth, and found that it gave no growths on culture media. It does
not appear that intestinal peristalsis can be very active in antenatal
life, for it is very rare, save in cases of intrauterine asphyxia, to find
that any meconium has been voided into the liquor amnii ; but at the
same time it is necessary to bear in mind that the researches of E.
Eossa (Arch./. Gi/naek, xlvi. 303, 1894) go to prove that it may be
imperative to revise our ideas concerning the frequency of antenatal
defecation and its prognostic significance in connection with foetal
life. Certainly I have seen the membranes and cord stained green
with meconium when the infant was born alive, and when apparently
there had been no attempts at premature respiration. While few
writers have even suggested the possibility, of the occasional pas-
sage of meconium into the liquor amnii, many have strongly
maintained that there was a regular emptying of the contents of
the bladder during foetal life. That the kidneys may excrete a fluid
which is in all its characters urine, cannot in the present state of our
knowledge Ije doubted. The foetal bladder may be found distended
with this fluid at the time of birth, the foetus in breech presentations
may micturate during the act of birth, still-ljorn and premature
162 ANTKNATAI, I'ATHOLOdY AND HYCIKNK
foetuses may show on ijnst-morlem uxaiiiiiiitliou ;i Ijladilor lull of
urine, substances (c.fj. niethylene-blue) given to the mother in labour
may be discovei'ed in the urine jiassed by the new-born infant, and in
cases of valvular obstruction of the urethra an enormous dilatation of
the bladder and ureters may lie met with. I have repeatedly found
lu-ine in the bladder of still-born fo'tuses, lioth mature and premature ;
and recently 1 dissected the dead but fresh fo'tus of a woman who
died from eclampsia and jaun<lice with almost entire anuria — the
fatal bladder was over-distended with urine ; so that the fictal kidneys
may apparently be active when the maternal are not. From all these
facts it is clear that the secretion of a fluid by the kidneys in
antenatal life takes place. That the fluid is urine is also supported
by the evidence at our disposal. It is true that it is very pale in
colour, that it is very watery, and that its specific gravity is only
1010 or less : but it contains urea in small amount (O'lo per cent,
according to T. A. Helme, Uri/. Med. Joarn., i., for 1893, p. 1261),
uric acid in relatively large amount, chlorides, and kreatiuin. It not
infi-equently contains albumin, a fact which is explained by C.
Flensburg {Nurd. Med. Ark., n. ¥., iv., Hft. 2 and 3, pp. 1-38, 1894) as
due to the increase in the uric acid ; it occasionallj' contains liiliruljin
and indican ; and it may contain sul)stances such as metbylene-blue
administered to the mother (H. Eeusing, iTfecAr. /. Gchurtdi. a. Llyniik.,
xxxiv., ]). 40, 1896). The giving of benzoate of soda to the mother
with the detection of hippuric acid in the urine of the uew-ljorn
(Gusserow's experiment), has already been referred to. There is
therefore no room left for doubt that the foetal kidneys are at least
occa.sionally active during foetal life ; but it is quite reasonable to
suppose that their activity is not in any case very great or long-cou-
tinued. Like several other functions of the fcetus, that of urine
secretion can apparently be dispensed with if the placenta continues
to act in a normal fashion ; but there is the provision for the renal
function becoming more active in the presence of placental disability.
With regard to the emptying of the fcetal bladder into tlie liquor
amuii, there seems to be more than the usual difference of ojiinioii
among those who have studied the iihysiology of antenatal life. There
is nothing impossible in the supposition that the fwtus occasionally
micturates into the liquor amnii, for the passage of urine takes pdace
inmiediately after and even during birth, and the chemical com-
position of the liquor amuii and of the faHal urine is not unlike ; but
there is no sufficient evidence that this happens constantly or even
often during intrauterine existence, and in normal circumstances it
does not seem probable that the liquor amuii is mainly derived from
the fcrtal renal secretion. This seems to be a fair conclusion to draw
from the experiments of L. Schaller {Ccntrlhl. f. Gyniik., xxii., 321,
1898) ; he gave to the pregnant and parturient woman phloridziu (a
glucoside which jimduces glycosuria), and found sugar constantly in
the urine of the new-born infant and very rarely in the liquor anniii.
With regai'd to the origin of the licjuor amnii, when that fluid is in
excess (iiydramnios), it may not be possible to speak so emphatically:
the occurrence of cardial- and renal hyiiertrophy in the twin with the
1
TRANSMISSION FROM FCETUS TO MOTHER 163
hydramniotic sac (in uniovular twins) suggests a possible renal origin
of some of the amniotic fluid at least ( Vide, F. Schatz, Physiologic des
Fotus, Berlin, 1900 ; P. Strassmann, Arch. f. Physiol., Sup2^lcment-
Band, 218, 1899).
I have thus brought forward evidence to show that the foetus has
excretory as well as secretory activities, and have instanced the
intestines and the kidneys, but there can be little doubt that a much
more important and more constantly active excretory organ than
either of these exists in the placenta. The reverse current, that is to
say, the passage of substances, soluble and even formed, from the
fffitus to the mother through the placenta, has been practically
established by experimental and clinical evidence ; theoretically,
also, it seems necessary to regard the placenta as the great ex-
cretory organ of foetal life. Since the time when W. S. Savory
{Lancet, i., for 1858, pp. 362, 385) experimentally induced tetanus in
pregnant cats l)y injecting stryclanine into the kittens in utero, evi-
dence has been gradually and on the whole steadily accumulating
to demonstrate that this belief is well founded. Gusserow (Arch. f.
Gynael:, xiii. 56, 1878), for instance, obtained similar results to
Savory ; Preyer {op. cit., p. 219) also got positive evidence from the
use of hydrocyanic acid, nicotine, and curare, in the case of guinea-
pigs ; and it has been shown that, in asphyxia of the mother animal,
the blood of the umbilical vein of the fretus becomes markedly dark
in appearance, indicating that oxygen is being drawn from the frotus
to the maternal organism. Doubtless carbonates and other products
of normal fretal metabolism pass in this matripetal current through
the placenta, although it is difficult, in the human suliject at any rate,
to get direct evidence of it. It has been suggested that in eclampsia
the determining factor in producing the convulsions in the mother
may be the passage of toxines from the foetus into her circulation,
and in support of this Lannois and Brian {Lyon mid., Ixxxvii. 323,
1898) have found that salicylate of soda, iodide of potassium, and
methylene-blue injected into the foetus may be detected in the
maternal tissues and urine. Charrin {Ann. dc gyni'c. ct d'ohst., L., p.
197, 1898), from experiments upon the passage of toxines (of diph-
theria, of the Bacillus pyocyaneiis), has come to the conclusion that
such substances deposited in the foetus, either directly or through the
spermatic fluid of the father, can be transmitted to the mother; if
they do not pass easily or in great quantity tlirough the placenta, a
condition of maternal immunisation may be produced, as is seen in
Colles' law in syphilis. It is interesting to note that a similar view
was held by A. Harvey as long ago as 1848 {Month. Journ. Med. Sc,
ix., 1130, 1818-49 ; xi., 299, 387, 1850 ; Glasgow Med. Journ., vi. 385,
1858-59), although without the scientific proof now aflorded by
experimental fcetal pathology. L. Guinard and H. Hochwelker
{■Journ. de physiol. et de path, ghi., i. 456, 1899) have experimentally
shown that rose aniline trisulphonate of soda passes easily from fcetus
to mother, and can be found in the maternal urine and even in the
blood ; if, however, the fcetus be killed (as by strophanthus) and the
fcEto-maternal circulation stopped, it does not pass, and it is only
104 ANTENATAI. I'ATHOLOCiY AND HYCIIEN'R
f(iU!iil ill tlie fii'tal liswiu'S : the dealli nf the firtiis, llierefore, suspends
the fu'to-iilaceiital iiiterehaniies.
Friiiu all that lias l)een stated, it may, I think, be safely conchuleil
that, both on account of its secretory and its excretory processes, the
foetus must be regarded as the sphere of very considerable nietal)olic
activity. Before, however, I leave this aspect of the jihysiology of
the fcctus, it may be well to refer to the question of the jiart played in
antenatal vital processes by the thymus, thyroid, and suprarenal
glands, and liy the pituitary body. Tliis is an obscure corner of an
obscure department ; but we can at least benefit by realising how
obscure, for we may thereby lie stimulated to endea\'our to throw
some illumination upon it.
Function of the Foetal Thymus, Thyroid, Adrenal and
Pituitary Glands.
The possible htematopoietic function of the thymus as the parent
source of the white blood corpuscles, has been already alluded to, but
it may perform other functions diu-ing antenatal life and in the early
part of childhood. According to H. Ifoger and C. Ghika {Journ. de
2}hysiol. ct depath.gcn., ii. 712, 1900), the epithelial ])art of the thymus
has entirely disappeared at the third month of intrauterine life, and
its structure is clearly lymphoid ; there are no concentric corpuscles
of Hassall to be seen at this time, so that it is probable that they are
not derived from the primitive epithelial portion of the gland.
After the si.xth month, at which date there is a marked increase
in weight of the thymus, the corpuscles are ([uite easily seen. The
structure of the organ becomes more complicated in the presence of
infective agencies, so that it ]iossil)ly plays a part in the defence of
tlie organism ; but whether it does so or not before birth must be
regarded as uncertain. It is stated by K. Svehla (ArcJi. f.i'.rpcr. Path,
u. Pharm., xliii. 321, 1900) that the thymus of the human foetus
does not contain the active ingredient (which lowers the lilood
pressure and (quickens the pulse) that forms after birth. Another
interesting and perhaps suggestive fact has been brought out by the
investigations of Katz {Proyris med., 3 s., xi., p. 385, 1900), and by
Bourneville {ibid., p. 389), wlio have found that the thymus atro]ihies
and disappears earlier after birth in infants with little or no in-
tellectual development. This mav l)e taken in conjunction with tlie
belief of G. Gauthicr (Pn: dc wed., xx., pp. :19, 225, 410, 1900) tliat
tiie sole function of the thymus is to act as a regulator of growth
in the early part of life. As a matter of fact, the antenatal as
well as the postnatal function or functions of the thymus are
at present unknown. I have, however, lieen struck by the extra-
ordinary frequency with which I have met with a normal
thymus ill fictuses with various malformations and teratolngical
states.
The tlnjroid (ilaiid is a n-iiiarkaMc liudy,aiid the part it lias ]]laycd
in the history of I'hysiology is also remarkable. After having lieen
i'
FUNCTIONS OF THYROID IGo
for years regarded as a couiparatively uiiimpdrtaiit organ, as at iimst
a haematopoietic organ of not the first rank, it has recently come to
take a high and honourable place among the most important
structm'es of the body. The thyroid along with the parathyroids,
which are the link binding it to the thymus, is now known to be tlie
great regulator of body metabolism, and to be essential for growth in
at any rate the early years of life ; defects in it are the causes of
disease, and there is a thyroid theory of cretinism, of exophthalmic
goitre, of obesity, of infantilism, and of various skin diseases, besides
suggestions that the thyroid may be at least one of the causes of
eclampsia (in jDregnancj'), of adenoids, and of haemophilia. After
birth, at any rate, the thyroid has an internal secretion (iodo-thyrin),
which may he described as exercising an antitoxic, or, better, a
medicinal effect upon the toxic or pathological products of proteid
metabolism : these toxic principles are neutralised and stored up as
colloid or thyro-proteid in the thyroid gland. Possibly the iodine in
the iodo-thyrin has the most important action in maintaining the
nutritive equilibrium ; possibly, also, the parathyroids have a func-
tional association with the thyroid in preparing the iodine for the
iodo-thyrin. Diminished thyroid activity leads to slowing of the
nutritive processes, while increased leads to undue rapidity of metabolic
changes ; both these conditions may exist as purely fvmctional states
— hypothyroidism and hyperthyroidism. There is a great deal of
investigation yet to be imdertaken before we shall know all the
relations which exist between normal and aljnormal thyroid activity
and the pregnant state. The physiological hypertrojahy of the thyroid
of the pregnant woman was not unknown both to the medical
profession and to the laity of past ages ; and no doubt it plays a part
in safely carrying on the wonderful and exacting series of nutritive
and developmental changes which tests the maternal organism to its
utmost limits (M. Lange, Ztschr. f. Gcburtsh. u. Gyndk., xl., p. 34, 1899).
It is also known that there is thyroid hypertroph}' at the time of
commencing puberty, that ovulation is accompanied by hyper;emia of
the thyroid, and that the thyroid is active during lactation. Fiu'ther,
it is supposed that the vomiting of pregnancy, and possibly the thin-
ness of the face which then often is noticealjle, are due to increased
secretion from this gland. It is surmi.sed, also, that the marked flow
of the milk about the third day of the puerperiuin is due to the
sudden increase of thyroid secretion in the maternal blood caused l)y
the birth of the foetus. This statement Ijrings us then to the diffi-
cult question of the function of the fcetal thyroid. Has the thyroid
gland of the unborn infant the same regulating function in connection
with the metabolism of antenatal life as the thyroid of the mother has
over the metaliolism of the adult body, or as the thyroid of the infant
has over the metabolism of infancy and childhood ? Has the maternal
thyroid in pregnancy the double function of regulating both the
maternal and the ftetal metabolic processes ? When the thyroid of
the one is defective, can the thyroid of the other supplement it ?
These and a great many other questions cannot in the present state
of our knowledge lie satisfactorily answered ; but some things arc
16U ANTKN'ATAL I'A'IHOI.OdV AND HYGIENE
]iiiit.ly kuowu and others have l)eeii surmised : and to tliese we may
l)rieHy refer, always keei)ing in mind tlie imperfect nature of our
aci[uaintance with these problems. In tiie first ])lace, it is supposed
that the secretion of tlie thyroid cannot c(jntain iodine, for that
element is not to be found in the fVctus ; and if the iodine be c)f great
functional use, tiieu the ftetus must he dei)endent for it ujwn the
maternal and not upon its own thyroid. The goitrous cretin is bom,
it i,s surmised, with a healthy thyroid, but through absence of iodine
in his environment the thyroid degenerates some time after birth ; it
would be interesting to know exactly the state of the thyroid in the
oHs]iring of goitrous parents. In the fietal thyroid from the third
month onwards there is found a colloid material called thyro-
niucoin ; the reappearance of this substance in later life is regarded
as the cause of exophthalmic goitre ; as Gauthier {Jirv. de tni'il., xx.,
pp. 39, 225, 410, 1900) expresses it, this substance in the adult plays
tiie part of a noxious material, for it is "utilisable seulement dans
nil organisme fcctal ou tout est ii crcer, a transformer et a dctruire."
With regard to experiments upon animals, it has been stated that
the removal of the thyroid in a pregnant animal will cause the birtli
of a fietus with rickets (Gauthier). Further, it has lieeu found
experimentally that in cases where the thyroid of the l)itch was in
part removed, the ftetal puppy showed a hypertrophied thyroid con-
taining no colloid. W. Edmunds {Brit. Med. Jonrn., i., for 1900,
J). 1341) removed the lobe of the thyroid and the parathyroids on one
side, and on the other nearly the whole of the lobe, but left one para-
thyroid ; about four months later the animal (a latch) gave birth to a
puppy whose thyroid showed absence of colloid and a hyjiertrophic
state, which was regarded as compensatory to the maternal defect.
K. Svehla (lov. cit.) found for the thyroid as for the thymus, that in
the human fcetus the gland did not contain the material thatiiuickens
the pulse rate and lowers the blood pressure. From this confused
mass of facts and si^eculations it can only at present be gathered, that
it is improliable that the thyroid during ftetal life acts in the same
way or in the same degree as it begins to do after birth : the maternal
thyroid may have to secrete iodo-thyrin for both tlie maternal and
foetal organism ; but it is possible that in cases of maternal thyi-oidal
defect the fietal gland may to some extent take on its postnatal
function ; and these conclusions do not necessarily mean that the
thyroid is not acti\'e in intrauterine life, but only that it is not active
in the same way as after birth. Further, Svehla 's obsei'vations and
experiments seem to show that the thyroid of the fietus of the cow
possesses this power over the circulation licfore birth, which, as has
been stated, that of the human fictus does not.
Along with the thymus and the thyroid glands, it is convenient and
ajipropriate to refer to the suprarenal capsulc't of the foetus. There
is a hypertrophy of the maternal suprarenal capsules in pregnancy,
and in the foetus these organs are, as is well known, relatively large
in size; but the exact meaning, or even an approximation to the
meaning, of these conditions is not forthcoming. In the adult the
efi'ect of the internal secretion of the suprarenal capsules would
GROWTH OF FffiTUS 167
appear to be to raise the blood pressure, ami to slow the heart or to
quicken it if the vagi be cut. There is, therefore, a degree of physio-
logical antagonism between the thymus and thyroid and the supra-
renal capsules ; and it is interesting that in pregnancy all the three
are large, — the thyroid and suprarenals in the mother, and the
thymus and suprarenals in the fcetus. ^At the same time, it seems
to be clear from the experiments of iSvehla {loc. cit.) and others
that the adrenals in the human fcEtus do not contain the vaso-
constrictor principle, although those of the foetal calf apparently
do. Why there should be this difierence is not in any measure clear.
The effects of functional activity of the pituitary body in the
foetus are not yet known. In the adolescent and adult it appears to
control the growth of the body, and possibly does in later life what
the thymus and thyroid do in earlier postnatal life. Lesions of the
pituitary appai'ently cause acromegaly, which is a form of gigantism of
the adult. It has been thought that the thyroid and pituitary may
supplement each other in their physiological effects, and that the
pituitary may take on a vicaiious action, for enlargement of the
pituitary has been noticed after thyroidectomy ; but experiments
seem rather to show that the internal secretion of the pituitary has
an action more allied to that of the supi-arenal glands. At any rate,
extracts of the hypophysis increase the force of the heart's beat and
raise the blood pressure. As has Ijeen said, nothing is known aliout
the action of the pituitary before birth ; but it is interesting to note
tliat, while some ascribe acromegaly to a continuance of the antenatal
function of the gland in postnatal life, others (M. Collina, Arch. ital.
de hioL, xxxii., 1, 1899) find the cause in a perversion of its function,
toxic sul)stances increasing and setting up irritation in the tissues of
the limbs. That is to say, some consider that the pituitary secretion
does good during foetal life, l5ut harm if it continue to be poured
out later ; while others think that it must be altered after birth in
order that it may produce a pathological effect. About all the
internal secretions of the fcetus, it is permissible to suppose that
they have a different action in antenatal as compared with postnatal
life ; but it is simply a supposition.
From what has been said regarding the intracorporeal metabolism
of the fcetus, it must have become abundantly clear to the reader that
the problems which have been touched upon have taxed, and will yet
tax, the best efforts of the most skilled physiologists for some time
to come.
Growth of the Fcetus.
If the complexity of the problem of fa^tal nutrition has been
fully appreciated, it will be evident that it can be no easy task to
determine what conditions favour and what hinder the growth of
the unborn infant. Nevertheless some writers have attempted to
settle these points by very simple means, and have almost of neces-
sity failed. It is a matter of everyday experience that new-born
infants differ markedly from each other in size and weight, even
when there is good reason to Ijelieve that they have been liorn at
1G8 ANTJ'.NATAI. PATHOLOGY AND HYdlKNE
the full term of antenatal life, and even when the niotliers have
enjoyed uniformly good health. It has not yet )ieen found ])os.sible
t<i predict even approximately what the lengtli and weight of the
infant will he, and althougli attempts have been made to regulate
the growth of the fietus l)y controlling the diet of the mother, they
have not met with conspicuous success. The factors of fietal nutri-
tion are so numerous, and their relations are so intricate, that it is
impossible to arrive at the coefficient of mitrition, so to speak.
Many writers, however, have worked at this problem. While some
have held tliat the doveloi)m(>nt of the ftetus depends upon the age
(if the mother, her parity, the duration of lier menstrual How, and
the date of the commencement of her reproductive life, others have
seen a connection between the size of the infant and its sex, the
length of its cord, and the amount of its liquor amnii. Now, some
of these factors {e.g. the age of the mother and the sex of the foetus)
apparently have some intluence upon antenatal growth, althougli it
is often clear, in the light of the knowledge of fa^tal physiological
problems which we now possess, that the reasons gi\'en for a belief
in the efficiency of the factors are (juite inadmissible. But the chain
of factors which controls the rate of foetal nutritive processes is too
long to make it easily possible to pick out the separate links and
assign to each of them their relative importance. Among the pos-
sible factors may be named : the health of the mother, her food
supply (although it must not be concluded that a starved mother
will give birth to a puny infant), her employment (for there is some
reason to suppose that if the pregnant woman can rest in the last
montlis iif gestation the weight of her offs])ring will lie greater,
liacliinKint, Thi^c. dc Pari^i, 1898), the structural and ]>hysiological
integrity of the placenta, the activity of the fcetal organs of assimila-
tion, and the state of the growth-dominating glands lioth in mother
and fwtus. Furthermore, even if these factors were known, tliere
remains the unknown, and almost unknowable, intluence wliich the
fietus brings with it from its embryonic and germinal life into its
foetal existence — I mean the hereditary tendency to grow into a large
or a small infant. F. La Torre {Nouv. arch, d'obst. ct dc gynt'c, iii.,
l)p. 138, 185, etc., 1888), in his articles on this problem — "ce nteud
gordien," as he justly calls it — appreciated to some extent this diffi-
culty, for he abandoned such factors as the menstrual history and
state of parity of the mother, and gave great value to the state of
health of tlie fatlier, " le facteur ]icre." In apjiealing to this factor,
lie admitted that tlie size to lie attained by the fo-tus was to a large
extent determined before the commencement of truly fcetal life
(second month of antenatal existence). Tiiis intluence, certainly,
cannot be neglected ; neither can the state of the mother before
jiregnancy and her heredity be left out of accomit. Further discus-
sion of this Ciordiau knot of a problem is not in the ])resent state
of our knowledge ]irofitable. To have recognised tlie difficulties
whicli surround it, is, however, not willmut sduie small degree of
profit. We know that it is a CJordian knot, and tliat we have not
even the means nf cutting it, far less of untying it.
MOVEMENTS OF FCETUS 1C9
Movements of the FcEtus.
From the time, usually aljout the mid-tenn of pregnancy, when
the mother feels " life " or " quickening," until the birth of the infant,
there is no room for doulit that the fa-tus is capable of moving in the
liquor aninii. Women rely upon the occurrence of these " move-
ments " to enalile them to confirm the diagnosis of pregnancy which
was provisionally made when the menses ceased and the morning
sickness began ; the " stirrage " also brings to the maternal mind the
welcome intelligence that the infant is alive and not dead in the
womb. But there is aljundant evidence, Ijoth from the experiments
upon the lower animals and from the examination of abortions, that
the foetus moves before the mid-term of antenatal life ; in fact, it
may be reasonably concluded that during the whole of foetal exist-
ence and even in the neo-foetal period fcetal movements occur. I
have seen rigor mortis in a five months foetus (80), and J. Tissot
{Arch, de 2>liysiol. norm, et 2Mth; 5 s., vi. 860, 1894) has seen it
coustantlj' in fwtal kittens dying in utero ; and in these and similar
observations we Hnd evidence of an indirect kind as to the occurrence
of muscular movements before birth. Doubtless antenatal muscular
action is neither so powerful nor so prolonged as postnatal (and the
cadaveric rigidity is not so intense), but it is capable of being lirought
into action, and it is brought into action probably from the sixth
week onwards.
Foetal movements are independent of the supply of oxygen, and,
what is still more surprising, they appear to be independent also of
the cerelirum and medulla, for they occur in anencephalic and even
in acephalic fu?tuses, and may persist after craniotomy. For the
postnatal activity of the respiratory muscles, however, the medulla
oblongata is necessary, as was well shown in the case of anencephaly
reported by Onodi (Monatschr. /. Geburtsh. u. Gynaek.,x\. 718, 1900),
in which the monstrous foetus survived birth for two days and
breathed, the medulla and pons being present, although the cerebrum
and cerebellum were absent. This independence of the nervous
centres was, it will l^e remembered, manifested also by the muscular
activit}' of the fcetal heart {vide Chapter IX.).
Several varieties of foetal movements can be recognised both by
the obstetrician and by the mother : there are the movements of
revolution or rotation, by which the foetus changes his position or
presentation ; there are the extensions of the limbs and spine, by
which there is a temporary loss of the typical foetal attitude of
flexion ; and there are the rhythmical, heaving movements which
have been ascriljed to the diaphragm and intercostal muscles of
the unborn infant, and which have been compared to swallowing
movements, to hiccough (foetal singultus), or to intrauterine re-
spiration. As has already been stated, Pestalozza {loc. cit.) and
Ferroni {loc. cit.) have specially investigated the last-named move-
ments and have obtained graphic representations of them. From
another standpoint, fretal movements may be subdivided into passive,
170 ANTRNATAI. I'ATHOI.OCJY AND HYGIENE
irritative, retiex, iiii]mlsive, and instinctive; this is tlie suggestive
classification adopteil by Preyer (o]i. rit.), but ratlier from the study
of the muscular manifestations of the new-lioru than of the unborn
infant, so it niay l)e concluded. The passive movements of the human
fcetus are chieHy <if importance as aM'ording to the ol)stetrician the
valuable sign of pregnancy known as ballottement. Of the irritat-
I ive movements little is known, save that they are sometimes excited
^by poisons circulating in the mother's blood. The reilex movements
are very prominent in the new-born infant, and are probably well
marked also before l)irth (Fiuizio, Pcdmtria, viii. 2'A, 1900); the
tickling of the palms or soles causes flexion of the digits after the
infant is born, and possibly the pressure of the uterine walls or of the
other foetal parts may produce similar results in utero. The im-
pulsive movements have been compared by Preyer to those of half-
awakened hibernating animals, and are neither reflex nor instinctive ;
they are not caused by peripheral stimulation nor by cerebral initia-
tion ; jiurposeless movements of the limbs are instances of them.
Amijng the instinctive movements which probabh* the fcetus is
capable of making, are sucking and swallowing. Little is known
regarding the stimuli which excite foetal movements. Laying a cold
I hand upon the maternal aljdomen nearly always does so, a fact which
the obstetrician makes use of in difficult cases of diagnosis. So ap-
parently does a cold drink ; and indeed any shock or jar to the maternal
system may act as an excitant. Ch. Fere {Sensation ct hkhh-i-
mcnt, p. 94, Paris, 1900) has gathered together some other excitunis
or supposed excitants of foetal movements. They are loud siaimls
and strong smells, tlie red rays of light (as in the case of a hysterical
pregnant woman in a photographic saloon), maternal emotions (anger,
fear), and dreams, fatigue, and hunger. It has been noted that one
of the difficulties in obtaining a skiagram of the fcetus in utero is
the liability of the unl)orn infant to be thrown into violent move-
ments )jy the Piontgen rays (Bouchacourt, L'Ohstetrique, v., y\\. L'd.
l:>7, 1900). It is proljable that various medicines taken liy the
mother influence the frequency and force of the movements of the
unliorn infant; and it has Ijeen noticed that in women who have lieen
in the habit of taking morphia, abstinence from that drug has led to
spasmodic activity of the foetus in the uterus. Fere {loc. cit.) regards
all foetal movements as reflex in character ; the various excitants all
lead directly or indirectly to uterine contractions, and these, b}-
compressing the foetus, produce the muscular activity.
Sensation in the Foetus.
There can be no doubt that the fcetus possesses cutaneous
sensiliility before birth, and that pinching the skin of the limbs and
other parts sets up reflex movements ; but that there is sensibility
to temperature is doubtful, at least the liquor amnii ])revents
sudden changes in the heat of tlie surrounding iwrts, and so interferes
with the testing of this part of tiie nervous system. There may lie
some sensation of taste before birtli : but it is difficult to imagine tlie
SENSATION IN THE FCETUS 171
existence of any degree of hearing, sight, or smell. At tiie same time
the faculty of perceiving smells and sounds exists before birth, and
is manifest in prematurely born infants ; and the retina is sensitive
to light and the pupil reacts to mydriatics and myotics at the time
when the infant, premature or mature, is expelled from the womb.
Fere {loc. cit.) points out that the maternal sensations of sight,
hearing, smell, and taste are, as it were, reduced for the foetus
to the common elementary form of movement. All that need be said,
all that can be said, about mental processes in the unborn infant is
that there is much sleep.
The attempt has been made in the preceding pages to give the
reader some idea of what is known of the physiology of the foetus,
for upon it must be built up our views of the hygiene of antenatal
life, and upon it must be founded the explanation of the peculiarities
of fcetal maladies. How defective our knowledge is, will have l^een
very apparent ; but there is at least one hopeful eircunastance to
record — the number of earnest attempts that are every day being
made to supply the defects and to increase the sum total of what is
surely known of vital processes in the infant still within the uterus,
but already evincing a degree of independence in its life.
CHAPTER XI
r<ptal Pathology : General Principles. Scope of Fuftal Pathology ; Causes nf
Limited Knowledge ; FcL'tal Morbid States ; Classification : Causes of
Pecviliarities of Ffotal Diseases — (1) Influence of Intrauterine Environ-
ment ; (2) The Placental Factor ; (3) The Emljryonic Factor.
The fatal period of life is, as I have been trying to make eleav, lull
of wonders. There is the wonder of its anatomy, as revealed by tiie
study of the mechanism, which shows sucli accurate adaptation to
the varying needs of the various months of antenatal life. There is
the wonder of its physiology, the marvel of the mechanism in action,
with all its minor wonders of foetal circulation, respiration, nutrition,
e.Kcretion, motion, and sensation. There is the mystery of the inter-
relation with semi-independence of the maternal and fojtal economies,
the intertwining of two lives. There is the transition of birth, accom-
plished as a rule so smoothly and yet so complicated, so profound —
truly a wonder among wonders. There is the no less wonderful but
less evident transition from the embryonic to the fcetal state. Truly,
Nature is a past-mistress in the art of making transitions easy and
of utilising the materials and forces of one economy for the construc-
tion and working of another ; her secret, if we may guess it, is that
she makes careful preparations long before the transition actually
happens, and so tlie process is ipiick, safe, and smooth.
We are now in a position to study, with some hope of under-
standing its intricacies, the foetal mechanism thrown into disordered
action or thrown out of action fdtogether — I refer to firtal diseases
and intrauterine death. Here, also, we shall find much to marvel
at — the safeguards with which Nature has surrounded the delicate
foetus in utero, the protection of the fa^tal against the diseased
maternal organism and of the maternal against the diseased or dead
fo-tal organism, the tendency to ra]iid rejiair or recovery, and
the interesting peculiarities of morbid processes occurring in im-
mature structures. In this chapter fall to be considered the general
principles which seem to me to govern the manifestations of disease
in the fcetus, and to account for the characters which antenatal
maladies possess. ]5ut, first, what ai'c the morbid states of tlie
fcptus ?
Scope of Foetal Pathology.
Fu'tal pathology is cliafacterised liy diseases as distinguished from
embryonic jiatlmlogy, wliich has malfdrmations and monstiosities as
GENERAL PRINCIPLES 173
its peculiar possession. If the ([uestion be asked, " "What are the
diseases to which the foetus is liable ? " the reply must be that with
some inconsiderable exceptions it is liable to all the diseases to which
later life is liable. I made the discovery of the wide scope of ftetal
pathology some years ago, when engaged in writing my work,
The Diseases of the Feetus (2, -4) ; I found that in two volumes (the
only ones which have been published) I was able to discuss fully
no more than the congenital diseases of the subcutaneous tissue
and some of those of the skin ; and it soon became clear to me that
I was engaged in attempting to write a whole system of medicine
from the fcetal standpoint. When th-;etzer wrote his work. Die
Krankhciten des Fotus, he was able to put most of what was known
of ftttal pathology into 273 pages; but that was in 1837, and the
additions that have been made to our knowledge of the subject in
more than sixty years have been enormous. One had to comiuence
to attempt to wiite a book to realise how enormous the additions
had been. In a broad sense the pathology of the fa?tus is co-
extensive with that of the adult. The foetus enjoys a partial
immunity from the attacks of certain parasites which produce skin
diseases in post-natal life, and it is to some extent protected from
external violence by its environment ; with these exceptions it has
the same wide pathological possiliilities as has the child or adult.
Further, it is apt to be affected with certain maladies in a peculiarly
aggravated form. Foetal diseases, then, are, with few exceptions,
the diseases of postnatal life modified in certain ways.
Limited Knowledge of FcEtal Pathology.
While, liowever, the scope of fcetal pathology is wide, the
opportunities of studying it are few and our knowledge of it is
luuited. It has been urged that if it be true that the foetus is liable
to all the maladies of postnatal life, it is surprising that they are
not better known and more often met with ; and it has been added
that some diseases (their number is Ijeing rapidly reduced) have not
been seen even once in the foetus. These objections can be very
easily remo\'ed. The sick foetus, unlike the sick child or adult, is
not available for inspection save when he is expelled from the
uterus, an occurrence which may take place at any stage in his
malady — may not, indeed, take place at all till after the incidence of
intrauterine death or the supervention of intrauterine recovery.
If a physician's sole knowledge of his patient were limited to a
single peep at him once in a period of seven months, it is not to
lie ex^jected that his aec_[uaiutauce with his maladies would be either
extensive or accurate. Further, if he were unable, should his patient
chance to die, to make an examination of his corpse till some days
or weeks had elapsed, and lirought with them structural changes,
it is not likely that the conditions then found would throw much
hght upon the original malady. There are other reasons why the
pathology of the fo'tus is comparatively little known, such as the low
estimate of the value of fcetal life and the invasion of the subject
174 ANIKNATAL l>ATH()LO(iV AND HVdlKNK
by such uuxciL'iititic imaginings as those associated with maternal
impressions. I have already referred to the lack of knowledge of
the details of foetal physiology — a lamental)le defect, when it is
remembered tliat iiliysiology is the key to ])athology — and there is
the innate ditticulty of the subject. These reasons are suHicient to
explain the paucity of published observations of some of the diseases
of antenatal life. It may be added, however, that the peculiar
environmental conditions of the ftctus, and the prqjecti(ju of the
embryonic element into its life, in a large degree tend to mask the
resemblance between its diseases and those of the cliild or adult,
and even to make them appear essentially different.
Classification of FcEtal Morbid States.
Many systems of classiticatidii have l.icen used by writers on fcotal
pathology : some are catalogues and not really classifications at all ;
others are etiological, pathological, regional, or prognostic ; and yet
others combine all. " A true classification," it has been .said, " is a
compendious expression of perfect knowledge " : it need scarcely be
stated that such a classification of fcetal morbid conditions is not at
present possible. It is also clear that '" some provisional classification
is a necessary condition of increase of knowledge," and such a pro-
visional classification can be got for fcetal pathology.
The plan which I adopted in my work on the Diseases of the Fiettis,
and further elaborated in the index of Teratoloijia (16), may be
regarded as a combination of the regional and the etiological. It is
manifestly far from perfect ; it is purely provisional, and is intended
only as a convenient and suggestive method of grouping togetlier many
morbid states. It consists of seven primary divisions — (1) transmitted
diseases, (2) transmitted toxicological conditions, (3) idiopathic diseases,
(4) neoplasms, (5) traumatic morbid states, (G) diseases of the foetal
annexa, and (7) the pathology of foital death. The last-named
division is entirely for convenience, and will be dispensed with when
the pathologist is al)le clearly to difterentiate between the changes due
to disease and those that are post-mortem. The dimensions of the
third group (idiopathic diseases) must not be regarded as in any degree
fixed, for future investigations can hardly fail to enlarge the first
group (transmitted diseases) at its expense. One disease, namely-
congenital elephantiasis, may be said to be at present on its way from
the one group to the other ; at any rate the record sent to me by
Dr. MoncorV'O of Ilio de Janeiro {Trans. Edinh. Ohst. Soc, xxi., 2'), 189())
seems to suggest tiiis conclusion, for in it a woman who sutlercd
from lymphangitis in her pregnancy gave birth to an infant with
congenital elei)hantiasis, in whose Idood was the streptococcus of
Fehleisen, and the deduction was that the new formation was due tn
lymphangitis, set up by the streptococci coming from the maternal
circulation. With regard to the neoplasms, tiiere can be no doubt
that their origin in the fo'tal period is more tlian questionable: the
dermoids, the teratoids, the teratomata, and the included fu'tu.ses arc
certainly embryonic nr germinal ratlicr than fcrtal ; but, as has lieen
CLASSIFICATION 175
already insisted upon, the classification is intended for convenience
rather than for strict accuracy, and in the meantime the tumours may
be allowed to remain in it. An outUne of the sclieme of classification
is given below : —
Classification of Fcetal Morbid States.
I. Transmitted Diseases —
1. The Exanthemata, Malaria, etc.
2. Tuberculosis, Sepsis, Elephantiasis, etc.
3. Syphilis.
II. Transmitted Toxicological State.s —
1. Lead-poisoning,- etc.
2. Poisoning by Morphine, Mercury, Strychnine, etc.
3. Alcoliolism.
III. Idiopathic Diseases —
1. Subcutaneous Tissue and Skin, e.fj. General Dropsy,
Iclithyosis, etc.
2. Osseous System, e cj. Foetal Rickets, Achondroplasia, etc.
3. Alimentary System, e.g. Foetal Ascites, Peritonitis, etc.
4. Respiratory System, e.g. Pneumonia, Hydrothorax, etc.
.5. Circulatory System, e.g. Endocarditis, Hydropericardium,
etc.
6. Heemopoietic System, e.g. Thyroiditis, Thymitis, Hepatitis,
etc.
7. Genito-Urinary System, e.g. Nephritis, Distended Bladder,
etc.
8. Nervous System, e.g. Paralyses, Contractures, etc.
IV. Xeoplasms —
1. Of the Head and Face, e.g. Pre-auricular Appendages,
Cysts, etc.
2. Of the Neck, e.g. Cervical Cysts, Chondromata, etc.
3. Of the Trunk, e.g. Sacral and Coccygeal Cysts, Fibromata, etc.
4. (.)f the Extremities, e.g. Exostoses, Lymphangiomata, etc.
.5. Of the Internal Organs, e.g. Sarcomata, Rhabdomyomata, etc.
V. Traumatic Morbid States —
1. Fractures.
2. Dislocation.
3. Wounds.
4. Congenital "Amputations."
YI. Diseases and Morbid Conditions of the Fcetal Annexa —
1. Placenta, e.g. Tubercle, Qidema, etc.
2. Umbilical Cord, e.g. Knots, Rupture, etc.
3. Chorion, e.g. Abnormal Vascularity, etc.
4. Amnion and Liquor Amnii, e.g. Adhesions, Hydramnios, etc.
5. Decidual Membranes, e.g. Intiammation, etc.
176 ANTENATAL I>ATIK)I,()(iY AND IlVCilKNK
VII. Patuology of Fcetal Death —
1. Maceration, ^Mummification, etc.
2. Rigor Mortis.
3. Putrefaction.
It will be seen from a consideration of the scheme of classification,
that tlie niimljer of ftetal morbid states is large. Even if tlie neoplasms
be excluded, there still remain many interesting and important
maladies for investigation. It may yet Ije possible to .se])arate the
morbid states characteristic of foetal life from those cliaractcristic
of the neotVetal epoch, just as there is reason to regard munnnitication
as the special post-mortem change of the neoftetus and maceration
as the special alteration of the fcrtus ; but in the meantime our
knowledge is insufficient to permit generalisations of this kind.
Peculiarities of Foetal Morbid States.
A limited acquaintance with fa?tal diseases is sufficient to make it
plain tliat the maladies of the infant still in utero differ from those of
tlie child after birth in many ways ; but the causes of tliese differences
are not so plain. There must, however, be causes for the peculiarities
of foetal disease, and it has seemed to me that there ai-e at least three
factors which must be taken into account ; these factors may lie named
the environmental, the placental, and tlie emliryonic. They may be
best studied in that order.
Modifying Effect upon Foetal Morbid States of the
Intrauterine Environment.
Many of the peculiarities of f(etal morbid states find an explanation
in the altogether special conditions which characterise intrauterine
existence. This influence is evident, or is to be discovered if intelli-
gently looked for, in most fa;tal maladies ; but it is unnecessary here
to do more than draw attention to its presence in connection with the
exanthemata, with icthyosis, with fractures and wounds, and with
the phenomena of fietal death.
The modifying effect of environment is seen in the ciuuacters which
some of the exanthemata take on when they occur in utero. i'ffital
variola is a case in point. The eru]ition resembles that which occms
on mucous surfaces in later life, a fact which is due in all probability
to the inliuencc which the circumambient liquor anniii exerts u])on
the skin of the foetus. It keeps it moist ; and it is uncommon to find
a noteworthy formation of crusts, and the resulting cicatrices are very
little marked. The pustules do not appear to affect the face to the
same extent as they do in the .smallpox of later life; this may lie
ascribed to the fact that in utero the face is not more exposed to tlie
light than any other part of the body. The external manifestations
of erysipelas seem to be rare in the fwtus, and here also the licpioi-
amnii may be influential: ]irobalily, however, their place is taken by
ENVIRONMENTAL FACTOR 177
internal morbid clianges, such as endocarditis, an instance of which
lias been recorded by Bidone {Teratologia, i. 182, 1894).
The idiopathic maladies as well as the transmitted show the effects
of the antenatal environment ; in foetal ichthyosis, for instance, the
absence of friction may be regarded as one at least of the causes of
the enormous epidermic thickening which is so characteristic of the
disease. What the action of the liijuor amnii can be in cases of
ichthyosis is not clear. It is noteworthy, however, that this fluid,
which is usually protective, may under certain circumstances become
pathogenic ; for E. Opitz {Centrlhl. f. Gyncik., xxii. 553, 1898) found
that the liquor amnii in hydramnios, when injected into animals,
increased the formation of lymph and greatly irritated the kidneys,
while the normal liquor had no such effects.
Apart from the great traumatism of birth, the foetus is singularly
free from accidents. Now and again cases of severe maternal injuiy,
in which the foetus has participated, have been put on record, e.g. gun-
shot wounds of the abdomen and the so-called cow-horn Ca^sarean
sections ; Init such occurrences are the rarities of sui'gical literature,
a cu'cumstance which must be in great measure ascribed to the pro-
tection afforded to the unborn infant by its environment. Even the
records of foetal fractures and wounds, regarded usually as due to
contre-coiq] in falls or contusions of the mother, must be received with
some scepticism. Some time ago. Dr. W. Easby of Peterborough com-
municated to me the details of a case in which the left clavicle at
bu'th had the appearance of a badly united fracture. The child was
a healthy, well-formed girl, with no other deformities and no osseous
fragility ; there was nothing in the labour or the pregnancy to suggest
an explanation of the state of the clavicle. Such cases may, in the
absence of any more feasible theory, be ascribed to conire-cov/p, but
the evidence is slight. There have been observations in which a
cicatrix was found over the site of the united fracture, and the con-
clusion has been drawn that this represented an intrauterine com-
pound fracture. Further, in the case of the arm and leg bones, the
fracture has been met with in association with partial or complete
absence of one of the bones or other malformation, e.g. partial defect
of the fibula in cases of fracture of the tibia. To my mind these
observations rather support the idea that intrauterine fractures rarely
arise through external violence ; it would seem as if they had their
origin in what may be called amniotic traumatism. It is conceivable
that through the formation of an amniotic adhesion, the trace of
which is left in the cicatrix, the soft cartilage of the developing bone
is distorted, perhaps even broken, and the appearance of a healed
fracture produced. According to this view, the accompanying anoma-
lies, defect of a bone or of part of one, would be easily explicable by
amniotic pressure. The cases in which numerous fractures have been
found at birth do not come into this category; probably they are
always due to extraordinary fragility of the whole osseous system, a
fragility so great that slight traumatic causes, such as jolts, would be
sufficient to produce them. The intrauterine environment, therefore,
may have this double modifying effect upon foetal traumatic states :
178 ANTENAl'AL I'AIHOLOGY AND HYGIENE
il iiiiiy make fiacluies from external vi(jlence very rare except when
there is aljnormal brittleness of the bones ; and it may lead, through
the occasional occurrence of amniotic bands and pressure, to the
formation of so-called " badly united fractures."
With regard also to the cases of wounds on the skin of the fcctns
or areas of al)sence of the skin, there can l>e no doulit that these are
not commonly caused l)y maternal traumatism — indeed, the history
of accidents is usually wanting ; they find an explanation in the
tearing through of amniotic bands during the process of parturition.
Similarly, the so-called fa^tal or spontaneous amputations are scarcely
traumatic in the ordinary sense of the term, although they may be
due sometimes to funic or amniotic pressure acting in a somewhat
traumatic manner. These morbid states lie on the border-line between
fcetal pathology and teratology ; they afl'ect structures which retain
their embryonic characters wlien the other parts of the organism
have passed into tlie ftetal period.
When the foetus dies in the interior of the uterus, the post-mortem
changes which ensue are rarely of a jiutrefactive kind : and this
peculiarity finds its explanation in the fo?tal envii-onment. In its
intrauterine position the foetus is protected from putrefactive organ-
isms, save only in the cases in which ruptvu'C of the inendjranes has
taken place before the supervention of labour. Further, it is sur-
rounded by the warm liquor amnii, a medium which specially favours
the occurrence of the macerative changes which are the juithological
expression of foetal death. Maceration, then, is the process which the
foetal body undergoes when death occurs in utcro and when the mem-
In'anes remain unruptured. Occasionally, however, another non-
putrefactive change is met with, namely, mummification, the result
of which is the production of the fcetus compressus or papyraceus.
This occurs more especially when the dead fa'tus is not alone in the
uterus, but is in the presence of a living twhi, which in the process of (
growth pushes it to one side and compresses it. ^lummitication seems
specially to characterise earh' foetal or neofoetal death. In cases of
intrauterine death, therefore, the peculiarities of the environment not i!
(nily impress themselves upon the fcetal organism, but also have an
important and beneficial effect upon the mother, saving her in many
instances from blood-poisoning.
There is one point in connection with foetal death to which it is
necessary to allude because of its im])ortant medico-legal bearings —
namely, rigor mortis in the unborn infant. There is no evidence to show-
that the fcetal environment prevents the occurrence of rigor mortis,
yet it is commonly believed that if the new-born infant shows post-
mortem rigidity, it must of necessity have been alive at the time of ■
birth. This dictum, which has Caspar's weighty authority to support
it, has not seldona had an important liearing in cases of trial for I
suspected infanticide. I have elsewiiere (80) entered fully into this ■
cpiestion, and have proven, liotli from personal observations and from
]iublished arses, that the fcetus which dies in utero, even when it
is also premature, shows unmistakable rigor mortis, and that tliis
muscular rigidity may be the cause of difficulty in labour. The
PLACENTAL FACTOR 179
iiniuature coiulition of the muscular system and the peculiarities
of the environment may lead to a shorter and less intense rigidity ;
but that it occurs is certain.
The Placental Factor in FcEtal Pathology.
The modifying eftect upon foetal morbid states of what may be
called, for the sake of brevity, the placental factor, might have been
considered under the head of the Intrauterine Environment, for the
placental influence is really essentially environmental ; but it is so
important and so altogether special in its action, tliat it has seemed
best to me to discuss it separately.
The predominant part played by the placenta in the physiolog}'
of the foetus has been referred to ; its role in ftetal respiration,
secretion, excretion, and metabolism has been considered ; it has l^een
suggested that it is much more than a simple mechanical or biological
filter, through which materials pass by the laws of osmosis from one
economy to another ; and it has been hinted that it is an important
gland, with a secretion, with powers of independent metabolic activity,
and with physiological possibihties which are at present much under-
estimated. In the placenta the maternal and the f(etal blood come
into physiological, although not into anatomical contact ; they come
near enough to each other to exchange some of their constituent
parts, but they do not touch. It cannot be doubted that the placenta
has an equally important effect upon the pathological developments
of fffital life. What this effect is must, in the present state of our
knowledge of fcetal physiology and pathology, be left in some degree
uncertain : but there are several standpoints from which it may be
regarded, and from these points the reader is invited to survey it.
In the first place, the presence of the placenta makes it possible
for the fcetus to be diseased in structure to a very advanced degree
without the suspension of its vitality. An enormous amount of
morbid change may be present without the cutting short of intra-
uterine life. So long, for instance, as the foetal malady attacks
organs whose functions are performed in whole, or even in part, by
the placenta, the induced morbidity is only potential. The lungs
'. may be solid from pneumonia, and yet no inconvenience be caused
I to the foetus quA the state of its lungs so long as the placental
I economy is maintained. The kidneys may have their whole sub-
' stance converted into cysts without the foetus suffering to any
i appreciable extent, and the intestinal canal may be blocked in
I several places without symptomatological effects. The potential
! morbidity of intrauterine life becomes real at birth ; for instance,
i an imperforate condition of the liile-ducts which has not interfered
! with foetal health begins to set up marked sjniiptoms as soon as there
i is an organic severance from the maternal economy. The potential
I mortality of the foetus is another eftect of the placental predominance.
I An amount of structiu'al change quite incompatible with extra-
I uterine existence may be present in utero without causing fcetal
I death. A foetus with general dropsy may come to the full term
180 AXTFAATAI. l'Aril()L()(;V AND HYCilKNK
with its periliiueal, iicriL-anlial, and pleural cavilit's loailud with
Uiiid and witli advanced changes in its internal organs ; it may even
show signs (if life at birth ; yet it invarialily dies in a few minutes,
or at most hours, thereafter. Tlie general dropsy was compatible
with an intrauterine, but not with an extrauterine existence. With
the occurrence of birth the infant found itself in conditions in wiiich
its diseased organs were no longer alile to conserve life: the potential
mortality became real. I liave already referred tn the enormous
amount of teratological change which nught be present in the fa^tus
without causing its intrauterine death. It is thus possible for a
monstrous embryo to be l)orn into its neofretal pei'iod of existence and
to be carried through the whole of ftetal life without interruption.
The monstrosity is produced in the embryonic epoch; but the wrong
lines of development then laid down continue to he followed in the
ftctal period, and the ])roccss is imly brought to a conclusion by
death, when the organism is Y>i'o.jected into a non-jilacental environ-
ment. In this manner the placenta, by preventing intrauterine
death, no doubt often saves the mother from the risks of prema-
ture confinement ; liut for this effect the prolongation of the life
of a diseased or monstrous fu'tus would seem to be an unmixed
evil (44).
The placental factor in foetal pathology may lie looked at fmni
a second standpoint: the placenta may be regarded as a protection t"
the foetus, as a barrier preventing sometimes, if not always, the
passage of poisons and toxines from a diseased maternal organism to
the fcetus. Porak (Arch, dc mM. expir. et d'anat. path., vi. 192, 1894)
and others have experimentally demonstrated some of the ways in
which the placenta acts with regard to poisons in the maternal
circulation. It has been shown that it has a real affinity for some
toxic substances ; and in it accumulate copper aiul mercury, Init not
lead. In addition to its pulmonary, renal, and intestinal functions,
the placenta fixes glycogen and acts as an acciunulator of poisons,
and so resemliles in its action the liver in the adult. This has been
leferred to in the preceding chapter. But the storing up of poisons
in the placenta is not so general as the accumulation of them in the
liver of the mother. While the placenta stcu'es up poisons, it does
not on that account altogether prevent their passage into the fcetal
tissues ; it does not act as a complete liarrier. It otters, however, a
varying degree of obstruction to their passage; it allows cojiper ami
lead to pass easily, arsenic with greater difficulty, and mercury
apparently not at all, for Porak always found it in the placenta and
never in the fcrtal organs. These observations, it must be remem-
bered, were made on guinea-pigs, and do not of necessity apply to the
human subject; but in the absence of other evidence they have
n considerable value.
Willi regard to the action of the placenta as an accunnilatni-
(jf pathogenic microbes and their toxines, and as a barrier to their
passage to the foetus, a great deal has been learned during the last
fifteen or twenty years ; but the problems which yet remain for
solution are very numerous and the difficulties associateil with them
PLACENTAL FACTOR ISl
are exti'iuii'diuary. The idea that the placenta acts alwcu/s as a filter,
keeping back the bacilli and cocci which may be present in the
maternal circulation, and so saving the fa?tus from their evil eftects,
must be abandoned. That the placenta acts often as a prophylactic
filter is also open to grave doubt. Bacteriological researches have
shown that through it can pass the bacilli of anthrax, of fowl cholera,
and of typhoid fever, the pneumococcus, the streptococcus, the spiril-
lum Obermeieri, the bacillus of glanders, the pathogenic organism of
hydrophobia, and perhaps the ha^matozoon of malaria. Fuither, it is
not necessary to atlniit the existence of a placental lesion to explain
the passage of the micro-organism; for in the case of animals, at
any rate, the most rigorous examination of placentas through which
bacteria have been transmitted has sometimes shown neither macro-
scopic nor microscopic changes in them. For the infants of even
seriously tuljercular women to be found showing tuljercular changes
at birth is a rare occurrence, and it is only during recent years that
congenital tuberculosis has been definitely proven Ijy the discovery
of the tubercle bacillus in the foetal tissues and in the placenta. In
this disease, therefore, if in any, it might be expected that the bene-
ficent role of the placenta would be demonstrable. Georges Kiiss
(X*e I'herediU 2^(i'rasitairc de la tiibcrculosc humainc, Paris, 1898), who
has investigated the whole question of tubercular heredity in a very
complete fashion, is of opinion that even when the tubercle bacilli
make their way into the placenta, that structure has still the power
of protecting the fcetus from the microbic invasion. He adduces in
support of his statement the two cases of Lehmann, in which the
infants were free although the placentas were tuliercular, and those
of Schmorl and Kockel, in which, although there was placental tuber-
culosis and some bacilli were found in the vessels of the chorion, yet
neither the microscope nor experimental inoculations revealed the
presence of fcetal bacillosis. Kiiss also noted that the fa?tuses that
showed infection always had a much less marked bacillosis than
might have been expected from the intensity of the maternal blood-
infection and from the advanced state of the placental lesions. It
seems, therefore, fair to conclude that in tuberculosis, at any rate, the
number of germs that pass through the placenta is very small. It
must also be borne in mind, however, that even where the organs of
the fcetus of a tubercular mother appear healthy, inoculation of
animals with pieces of them sets up in some instances undoubtedly
tuberciUar processes. Possibly infective toxines may pass even when
the bacilli do not. The placenta cannot, therefore, be regarded as
a complete or certain barrier to microbic invasions even in the best
circumstances.
Third, it is now necessary to look at the placental factor from
quite the opposite standpoint, viz., as the chief, if not the only avenue
of access for germs to the foetus. Practically the only other way
possible from the mother to the fa?tus is by the liquor amnii. Cer-
tainly the researches of P. L. Ferrari {Lo Spcrimcntak, Ann. xlix., sez.
biologica, fasc. L, p. 62, 1895) on the structure of the amniotic mem-
brane seem to show that through its stomata materials may pass
lS-2 ANTKNATAI. I'AIHOI.OdV AND HYCIKNF,
fi(jiii the lymphatic system of the mother into tiie liquor amnii and
then to the fcctus by the mouth and intestinal tract (rule Chapter
X.) While, however, it is right to regard this as a possible mode of
entrance, it cannot be looked upon as a common one. I'robably
" water-liorne infection" is very rare in the foetus. It follows, there- .
fore, that the placental route is practically the only one from mother ■
to fietus ; and it is a matter of some importance to determine the
circumstances that increase or diminish placental permeability to
I)oisous and germs. Our knowledge of these circumstances i.s im-
perfect, but the following conclusions seem warranted. It is, for
instance, apparent from the study of the comparative anatomy of the
placenta, that its permeability must vary in different species, according
to the thickness of tissue intervening between tlie maternal and fo'tal
circulations. It would appear from the extensive researches of Duval,
that in this respect the himian placenta occupies an intermediaie
position between that of the rodents and that of the ruminants. In
the rodent the barrier is very slight ; in the ruminant there is a '
fourfold barrier, two capillary walls and two epithelial layers, between
the maternal and the ffctal Ijlood. There would seem to be no need
for a lesion in the former case, while in the latter some morbid change
would almost appear to be neces.sary, before germs or their toxinesi
could pass from mother to foetus. Again, there is reason to believe
that placental permeability varies at the different epochs of preg-'
nancy; this conclusion seems, at any rate, to be warranted in the
case of the rodents. The experiments of Charrin and Duclert {Ctrmpt.
rend. Soc. de hiol., p. 5G3, July 13, 1894) are, however, full of interest
in relation to the question of placental transmission, and deserve
notice. These observers found that certain conditions of the maternal,
blood favoured the passage of germs through the placenta ; ths'
presence in the blood of microl)ic toxines, c.ff. tuberculin, as well asi
of acetate of lead, alcohol, or lactic acid, seemed to increase in'
a marked manner the permeability of the placenta. Previous'
inoculation with corrosive sublimate, on the other hand, seemed
to make it more difficult for microbes to pass. It would almost
appear as if the prolonged presence of the microbes in the neigh-
bourhood of the barrier led to the breaking down of it l)y the
action of the toxinic products of microbic vitality. The experiments
it must be borne in mind, were performed on guinea-pigs ; never-
theless they have at least a suggestive value as regards the human
subject.
There can be no doulit, therefore, that although its ]iermealiilit}
varies, the placenta is the avenue by which germs and ])oisons read
the fictus. This circumstance has a very considerable bearing upoi'
the i)ositiou of primary lesi(ms in the foetus. The infection reaches
tiie body of the unborn through the blood, and traverses first th(
placenta and the umliilical cord, then the umbilical vein, then eithe
the liver or the ductus venosus, then the heart, and so is distributee
to the whole organism. It is no matter for wonder, therefore, tha
the primary jiathological changes are commonly found in the placenta
liver, or heart. In this way it is quite easy to understand how, ii
PLACENTAI> FACTOR 183
such a case as that reported liy Bidoiie (loc. cit.), erysipelas in the
mother does not produce skin lesions in the foetus, but streptococcic
endocarditis. The locality of the lesions is determined by the route
of invasion. Similarly, in congenital tuberculosis it is rare to find the
morbid process in the lungs, and in half the certain reported cases the
pulmonary tissue was devoid of lesions. It is true that the liver was
not invariably tubercular, but it is possible that in such cases the
infection passed outside the liver straight through the ductus venosus
to the heart and general circulation. If i^rimary lesions exist at all
in fffital syphilis, they are to be sought for not on the skin or the
mucous surfaces, but in the placenta or liver or heart. What has been
said of the distribution of diseases applies also to the invasion of the
foetal body by mineral or vegetaljle poisons, and Porak {loc. cit.)
has called special attention to this in his experimental work.
Thus a great many of the peculiarities of foetal diseases are to be
accounted for, and it becomes more and more apparent that the
pathology of the foetus is simply postnatal pathology modified by
the special phvsiological conditions which exist during this period
of life.
There is a fourth aspect in which the placental factor in foetal
pathology has to be considered, viz. the lethal effect iipon the foetus of
lesions of the placental substance. It has been pointed out that the
presence of the intact placenta preserves the life of the fcetus even when
its organs are most extensively diseased. The placenta is in this sense
the most vital organ that the foetus possesses ; but it is also the most
vulnerable. When it is itself the seat of lesions, the life of the unborn
infant is immediately in grave danger. All placental lesions are not,
of course, equally lethal to the fcetus, and I have noted cases of cysts
on the foetal aspect and of calcareous deposits on the uterine along
with perfectly healthy infants ; but, as a general r\de, disease of the
placenta means death of the fretus, or, what comes to the same thing,
premature expulsion of it from the uterus. It is of great importance,
in studying the causes of abortion and premature labour, to remember
that the placenta is an organ of the foetus. During the last few years
I have been frecjuently asked to state the cause of foetal death and of
premature delivery from the examination of the foetus alone. It is
scarcely ever possible to do so, for tlie cause of the fatal result is most
often in the very structure that is not available for examination I
cannot too strongly insist upon the fact that a foetus without the
placenta and membranes is an incomplete specimen. To attempt to
give an opinion from it alone resembles trying to find out the cause
of death in a case of head injury from the dissection of the thorax
and abdomen. A conclusion of some kind may be reached by a
process of exclusion, but its value cannot be very great. The
placental filter, then, may save the fcetus sometimes from disease,
but it may do so at the cost of foetal life. It may prove a barrier to
the disease germs, but, inasmuch as the barrier is the most essential
organ that the foetus possesses, this protective influence may be very
dearly bought. The placenta, in saving the fa>tus from disease,
becomes pathological itself, and so condemns it more certainly to
184 ANTKAATAL I'A'I'HOLOCY AND HYfHFA'E
death. Tliere may exist some doulit as to tlie exact nature of the
morbid cliauges in the foetus which alcoholism in the nu)ther tends to
produce (J. Matthews Duncan, Trans. Edinh. Ohatd. Soc, xiii. 105,
1888); but there can be no doubt at all about the frequency with
which abortion and premature labour from placental lesions occur
under these circumstances. When it is borne in mind that the
placenta is lungs, stomach, and kidneys to the foetus, it is easy to
understand how pathological changes in it soon lead to fatal results
in the latter.
From yet a fifth standpoint the placenta may be regarded in
connection with its effect upon foetal morbid processes. By reason
of its highly differentiated tissue and its active metabolism, it may
act upon pathogenic substances in other and more subtle ways than
by simply opposing a barrier to their passage from mother to fui'tus.
It is possible that it may secrete products which may act as anti-
toxiues ; it is also possible that under certain circumstances it may
liy a disordered metabolism produce materials which increase the
virulence of attacking germs or weaken the natural defences of the
placental tissues. Again, it is possible that too much speculation
may retard rather than advance our knowledge of this whole subject
of the influence of the placenta in fo-tal pathology.
There is, however, one other point to which some reference must
here be made, although it must be conceded that it also is largely
speculative. Thus far I have dealt only with the transmission of
disease from mother to fcetus ; but it may be asked whether the
current is not sometimes reversed or capable of being reversed, and
morbid influences pass from foetus to mother ? From what has been
stated in the preceding chapter regarding the excretory functions of
the placenta and the experimental evidence associated with them,
there is a presumption at any rate in favour of the reverse current
as regards disease. I have referred also to the fact that Charrin
(Compt. rend. held, dc I'Acad. des Sc, Paris, cxxvii. 332, 1898) has, in
the case of animals, succeeded in killing the mother by injecting the
toxine of Ltiffler's bacillus into the foetuses in utero ; it may be found
to be possible by making progressive injections, thus to render the
mother immune against the poison of diphtheria. We are tempted
to ask ourselves whether the fact that the ]>acillus, toxine, or poison
reaches the mother by the placental route will in any way modify
the results produced thereliy in the maternal organism ? Again, will
the physiological condition of the woman in pregnancy (anjemia,
hyposiderosis) increase or diminish her susceptibility to the morlml
intiuences coming to her from the fo'tus ? Does the i)lacenta liy its
metabolic activities or its internal secretion (not j'et demonstrated)
intensify or reduce the virulence of the germs or toxines ? The
whole question of the effect of foetal morbid processes upon maternal
predisposition and immunity can hardly Ije regarded as more than
toucheil at present, and much remains to be done before any con-
clusions can ))e drawn with security. Certainly the problem of a
mother with an acquired immunity against smallpox, scarlet fever,
measles, etc., carrying in her womb a fietus with an almost certain
EMBRYONIC FACTOR 185
predisposition to take any or all of these very diseases, is most
interesting and complicated. As complicated and as interesting is
the state of a mother who has not got syphilis and who is yet in
physiological contact throngh the placenta with a foetus who is
syphilitic because of the syphilis of the father. It seems necessary
to grant the existence of this reverse current of pathological influence
proceeding from foetus to mother, if we are to offer any explanation
of the occurrence of telegouy, the wii-eless telegraphy of antenatal
pathology ; without such a mechanism it is impossible to understand
how characters of a previous sire can be transmitted to the progeny
of a later one by the mother ; of course, in cases of telegony it would
also be necessary to predicate the possibility of the ova in the ovaries
becoming imbued with paternal characteristics apart from actual
impregnation. Many and difficult are the problems which present
themselves to those who are courageous enough to attempt to study
the laws of the phenomena of generation.
The Embryonic Factor in Fcetal Pathology.
While the placenta and the intrauterine environment serve to
account for some of the peculiarities of fcetal maladies, they leave
unexplained not a few. The occurrence which complicates fcetal
pathology so greatly is the projection into it of the results of
embryonic pathology. It is an error to suppose that every morbid
condition found in the infant at the moment of bu'th must have
arisen during parturition or in the foetal period. It is common to
speak of " foetal " monstrosities, but if by this it is meant that the
monstrosities in question are the result of foetal pathological processes
the notion is probably erroneous. There is good reason for believing
that malformations and monstrosities are the product of morbid
agents acting during the embryonic period. The foetus is born, as it
were, into fcetal life with all the results of embryonic pathology in it ;
so long as these are not incompatible with the continuance of fcetal
life, it goes on growing, and may reach the full term and be transferred
into extrauterine life, still bearing the evident traces of its embryonic
troubles. It is probable that the original malformations do not
during the fa3tal period greatly alter in their appearances ; they grow
witli the general growth of the body, and may, according to cir-
cumstances, become more or less marked, but they retain their
essential characters. They may, however, have a very important
bearing upon the development of fcetal diseases, and their coexist-
ence with them certainly makes their pathology very difficult to
understand. The difficulty is still further increased by the fact
to which allusion has already been made, that the whole organism
does not at once pass out of the embryonic into the fcietal period.
It comes about, therefore, that the foetal bone diseases are specially
difficult to understand, for they are really deformities originating
during the period which as a whole is characterised by the pro-
duction of diseases.
Some years ago it was a very commonly accepted theory that
186 ANTKNATAI. I'ATHOLOdY AND HVCUENE
monstrosities wcw. cmusimI hy ilie occurrt'iico of diseases in the foetus,
and Sir .lames Simjison (iimonj^ others) gave the weight of liis avitlior-
ity to the view. Modern research has not supported this theory.
Duval ("Pathogenic generale de Tenibryon," in Bouchard's TraiU de
patholor/ie gi'm'rale, i. 159, 1895), especially, decides against it, and
distinctly states that it is not to be thought that a malformation of •
any part i.s the result of a disease from which the malformed part has
suffered. With this I in part concur; but I tliink that just as a pre-
existing malformation may influence the progress of a fcetal disease,
so a fo-'tal disease supervening upon a malformation may, during the
seven months of foetal life, very considerably alter its manifestations
as seen at birth. Further, the cause of the malformation may not
cease to act with the close of the embryonic period ; it may continue
to act in the fcetal ; in this waj' it may be the cause of both the
deformity and the disease. For instance, a malformation of the
intestine and ftetal peritonitis often coexist ; both may be the result
of one and the same cause ; but it may also quite well be that the
existence of the disease has influenced the nature of the malformation,
and that the malformation has made the disease more or less active.
Exomphalos is a manifestly teratological condition, and there often
exists along with it a great amount of peritonitic fixation of the
abdominal viscera, a fact upon which stress has been laid Ijy
A. Eischpler (Archiv f. Entwickdurujs-mechnnik dcr Organismcn, vi.
556, 1898), but it seems to me that all this association shows
is that some common cause acting specially on the abdominal
region has Ijeen at work during the embryonic and the fcetal period.
Peritonitis coming on during the foetal epoch may exaggerate or
alter the appearance of the exomphalic condition, but it is doubtful
whether it is in any sense either the cause or the result of tlie
exomphalos. The consideration of the embryonic factor takes into
account, therefore, («) the modification of fcetal diseases liy pre-
existing malformations, and (6) the modification of malformations liy
coexisting diseases.
In the preceding pages I have attempted to describe three possible
factors which play a part in modifying the diseases which att'ect the
fcEtus and give to them their peculiar characters. Doubtless there
are other factors, but the existence of these three — environment, the
placental influence, and the embrj'onic complication — must be recog-
nised. In order to make the matter somewhat simpler, I may compare
the fu?tus to a tra\el]er coming from a tro])ical climate to our country.
He finds himself in a new environment wliich in many details difl'ers
much from that which he has left, and wliich gives new chai'acters to
the diseases which he now develops. Further, through his dress and
modes of life, he lays liimself open to taking certain maladies more
often and in more serious forms than ])reviously, while from others he
may perhaps be protected. In the third jJace, lie comes to our country
with the results of the diseases from wliich he has already sufl'ered in
his own land in him and part of him; and these earlier pathological
experiences also influence the course of the morbid states which he
ac(juires later.
PROBLEMS IN FCETAl, PATHOL()(;Y 187
Fcetal pathology, then, presents many difficult problems for solution.
It asks how pathological processes are altered by the presence of the
li(luor amnii and by the absence of atmospheric air and light; it calls
for a definition of the action of the placenta in the preservation of
health or the production of disease in the foetus ; and it places promi-
nently before us the extraordinarily complicated question of the
inter-action and inter-relation of emln-yonic malformations and foetal
diseases in the foetal period of the existence of the organism. Path-
ologists of the future have no light task before them in the solving of
these problems.
CHAPTER XII
Types of Traiisniilted Fcrtal Diseiises. Fcftal Variola: Patliofjenelic Possi-
bilities ; Clinical Peculiarities ; Diagnosis, Prognosis, and Treatment.
Fietal Vaccinia ; Antenatal Inununity. FcBtal Measles, Scarlet Fever,
Erysipelas, Parotitis, Influenza, Pertussis, Relapsing Fever, Yellow Fever,
and Cholera. Fcetal Typhoid; Pathogenetic Possibilities; Widal Test in the
FcEtus. Fcetal Malaria ; Observations ; Pathogenetic Possibilities.
The transmitted disease.s of the fcetu.s constitute the most interestuig
group of antenatal morbid states. Theii' interest dejiends, in the first
place, upon the varied and intricate relations which are or miLj be
established between the maternal and foetal organisms through them
and as a result of them : in no physiological or pathological labor-
atory could more elaliorate or instructive experiments be devised
and carried through than are to be witnessed in the utertis, when
the mother is the subject of a malady which is known to be trans-
missible. In the second place, their interest depends upon the
possibilities of successful therapeutics which they present ; when the
cause of a disease is known, and when the diagnosis of its occurrence
is not outside the bounds of possibility, the chances of successful
treatment, preventive and curative, are much increased. To some
extent it may be said that the etiology of the transmitted fct'tal
diseases is within our knowledge, and their diagnosis not altogether
outside our grasp ; with perseverance and skill their treatment will
yet be hopefully undertaken bj^ the well-informed pliysician. There
are other reasons why tlie transmitted ftetal diseases appeal more
directly to us than the idiopathic maladies ; some of these will
emerge, as the consideration of the suliject is proceeded with ; in the
meantime let us take, as the first type of this group, /(«<«/ variola.
Variola in the Foetus.
In the first separate work mi diseases of tlie tVetus (GG), tlio
author, Diittel, writes : " rrinmni, autem, deprehendimns morbuni
variolum, quo gravida corripitur saepius transire in ipsum ftetum."
and proceeds to gather together the cases of fretal variola which had
up ti) that time (1702) been reported. There were not many of
them ; Ijut in the nundjcr, it is interesting to note, were instances of
foetuses with smallpox, the ofl'spring of women who had themselves
escaped the malady, but had lieen in contact with cases of it. Thus
early was it observed that tlie infection might j)ass througli the
F(ETAL \'ARIOLA 180
maternal organism to the fetal withimt manifesting itself in tlie
former. Eeference was also made to the case of a variolous mother
whose infant was born with no signs of smallpox ; but in this
instance the infant died before the malady had time to develop. It
may be concluded that, prior to 1600, the occurrence of variola in
the foetus was hardly suspected, and was even denied, as is seen from
the statement, " Dum fretus est in utero, non ei accedere variolos
nee morbillos " ; but with the seventeentli century came the records
of undoubted cases, and, as has been seen, at the beginning of the
eighteenth, Diittel was able to enumerate quite a number of them.
As late, however, as the close of the eighteenth century, the birth of
such a ftetus was regarded as somewhat of the nature of a wonder, for
Lynn's paper read at the Eoyal Society (London) in 1786 was
entitled, " The singular case of a Lady who had the Smallpox during
pregnancy, and who communicated the same disease to the Foetus."
I have met with traces of a belief in the immunity of the foetus from
smallpox among the laity even at the itresent time. From the now
very large number of published cases of foetal variola it is easy to
obtain some idea of the pathogenetic possibilities, when a pregnant
woman develops smallpox or comes into contact with a case of it.
Let me state some of these possibilities.
When a pregnant woman is attacked by smallpox, it does not
necessarily follow that her infant will lie Ijorn showing the eruption
on its skin. It may be born alive with no sign of variola, and may
die soon afterwards, or may li^-e and not develop the disease ; in the
latter case, it would appear that it is possessed of an antenatal
immunity from variola, which persists in postnatal life. It may also
be born dead, having died in utero, from the high temperature or
some other cause, liefore the disease had time to show itself in the
form of the distinctive eruption. In fact, it must be regarded as the
exception and not as the rule to meet with variola in the stage of
eruption at the time of birth. There is great need for further and
more accurate investigation of the infants, alive and dead, that are
the offspring of variolous mothers, and yet show no external signs of
variola. It may be found that, although they have not the pustules
and other external indications of smallpox, yet they may have
suftered in other ways : for instance, there may be traces of the eruption
on mucous surfaces ; or the nutrition may have been interfered with,
and an atrophic state produced which persists after birth and pre-
disposes to infantile diarrhoea, etc. ; or there may have been secondary
infection with streptococci and staphylococci (Auche, Bull. Soc.
d'anat. et physiol. de Bordeaux, xiii. 278, 1892) ; or the placental
tissues may have become diseased, and foetal death occurred. From
our knowledge of other transmissible maladies, we are justified in
lielieving that the poison of variola, entering the ftctus by the
umlnlicus, may cause lesions in the organs along the placental route
of invasion without affecting the skin.
When, however, tlie foetus shows marked external signs of small-
pox, several clinical types may be met with. Thus, the mother may
pass through a slight attack of modified variola, her pregnancy may
190 AN ri-.NAr.U, l'.\ril()I.()(iV and ll^(iIKNK
go on to the full leiiii, uiul :i living iufaut be born eoveied with a
great or a small number of pustules, or with scars, or with simple
papules which have not yet suppurated. Again, the pregnancy may
be interrupted, and the fu'tus l)e liorn prematurely, showing the
eruption in one or other of its stages, or developing the exanthem
within a few hours or days of liirtli. Yet again, the mother may die
from confluent or hiemorrhagic smallpox, and the tVetus be removed
post-mortem from her uterus and be found bearing the evident signs of
the malady. Apparently the f(ptus is susceptible to variola at any
stage, for a case at the third month has been reported, and there are
observations at almost all ages after that up to the fidl term. An
interesting complication is introduced into the clinical types, when
the uterus contains not one but two ftctuses ; in one of the recorded
cases both the twins suffered from variola ; in another case, one was
affected while the other had evidently escaped ; and in a third case,
although both fcetuses showed the eruption, one exhibited many
pustules (sixty-five in all) while the other had only a few (six). In
these plural pregnancies Iwth the ftetal membranes and the placenta
were generally double, but in one remarkable instance, reported by
Chantreuil {Gaz. d'lwp., xliii. 173, 1870) the placenta was composed
of a single mass, although there were two chorions and amnions.
Chantreuil's case was also noteworthy, for the reason that, while one
twin evidently had variola, neither the other twin nor the mother
suffered from it, a striking example of the pathological independence
of the unborn infant, both as regards his mother and his brother
or sister in utero. It is possible to account for such a case as that
just referred to ; but what is to be said about the explanation which
Legros {Gaz. mcd. dc Far., 3. s., xx. 493, 1865) offers in connection
with the following record ? A woman gave birth to a five months
foetus showing the eruption of smallpox; she had not herself had
smallpox ; but the father of the child was in the stage of con-
valescence from variola when conception took place. Could the
infection have remained latent in the embryo and then in the fo'tus
until nearly five months of intrauterine life had elapsed ? This
possibility has been affirmed for syphilis and malaria, but in this
case one is tempted to ask whether the fectus was really suttering
from variola ? At the same time, it may be that the incubation
period in the fietus is different from that in the adult, for in the case
reported by Laurens {Bull. Soc. anat. de Par., xliii. 184, 1868) tlie
mother had smallpox early in her pregnancy, and two and a half
months later aborted of a fietus with the eruption well marked. In
order to complete this survey of the chief clinical po.ssibilities of
ftetal variola, it may be added that the disease may perhaps be
acquired by the infant during his transit through the maternal
passages, or very soon thereafter; but this can hardly be described as
ivvLQ fatal smallpox.
Eeference has already been made in the previous chapter to the
symptomatological i)eculiarities of variola as it occurs in the unborn
infant ; but certain details may profitably be repeated here, and some
new points added.
Fig. 28. — Laurens' Case of Smallpox in tlie Fcetus
larcot.
Laurens
15
1
23
22
19
30
8
—
16
15
12
20
192 ANTF.NATAI. I'A THOLCXiV AM) HYCUKNE
Tlie eruption has a distriluition wliicli may best be desciilied as
irregular ; tlie order of aiipearance is also irregular. Tlie spots are
usually few in num1)er (12-100), and the variola is therefore of the
discrete type; rarely they are many, and the confluent type is
produced ; even the lucmorrliagic form of eruption has been met with
(Cless, JA'rf. C'or.-Bl. <1. wiirt/cmh. drztl. Ver., xxxvi. '2'i, 18GG). Below
will be found in a tabular form the number of s])ots and their dis-
tribution in two cases of fu'tal variola, one reported by Charcot {Cumpt.
rend. Soc. de hioL, v. 88, 1853) and the other (Fig. 28) by Laurens
(These, Paris, 1870):—
Face ....
Scalp and back of neck
Thorax and abdomen
Scrotum and buttocks
Upper limbs
Lower liml)S
93 88
The pustules vary in size from 1 to 9 mm. in diameter ; they have
the same shape as in the adult, and show umbilication, and they run
through the same stages of macules, papules, vesicles, and pustules.
They have a white or pale yellow colom', and contain clear yellow or
slightly opaque fluid, and sometimes pus. Suppuration, however,
is not a common feature, and there is little or no crust formation ;
the eruption resembles that seen on mucous surfaces in the adult.
The pustules are surrounded by a red areola ; they are not limited to
the skin, but have been found on the mucous membranes of the mouth,
pharynx, and stomach, and even on the visceral pleura (E. Hue, 7'hese,
Paris, 1862). The microscopical appearances of the eruption have
been described by Charcot {Compt. rend. Soc. dc hioL, iii. 39, 1851) :
" Une alteration eavitaire du corps muqueux de Malpighi."
With regard to the stages of the fever iu utero, it seems to I)e
generally believed that the incubation period varies within wide
limits (Margoulieff, TVft'sc, Paris, 1889); there is some evidence that
it may occupy the same time in mother and fcptus and run simul-
taneously, but there is also evidence that it may begin in the fcetus
only when the stage of eruption has been reacheil in the mother, and
there is even reason to suppose that the incubation may be lengthened
to four or five weeks. The stage of invasion is marked, sometimes at
least, by exaggerated fcetal movements, and possibly by maternal
malaise ; the stage of suppuration, when it occurs, is no doubt
signalised by an aggravation of the mother's symptoms : and the
stage of desiccation possibly follows a course ditlering in some details
from that seen when the pustules are under the influence of the air.
In fcrtal as in adult variola complications are met with, and cases
have been reported of periostitis and necrosis of the tibia and of
staphylomatic exophtlialmia iu infants who have suttered from
exanthem in utcvo (T. Mejan, Joxirn. dc mi'd., chir., et i^harm., i. 145,
1803).
FCETAL VARIOLA 103
It need hardly be added that smallpox as it occurs in the fwtus
is the same disease as that met with in the adult ; but, as a matter
of fact, it has been proved to be so by the occurrence of infection, and
by the possibility of inoculating another individual with the malady
by means of the matter from the pustules of the new-born infant
(E. Jenner, Med.-Cliir. Trans. Lond., i. 271, 1815). Further, infants
who have suffered from the disease in utero have been found to he
refractory Ijoth to inoculation and to vaccination.
The antenatal diagnosis of fcetal variola has not been made ; but
there is no reason why it should not be provisionally made when
smallpox is met with in a pregnant woman, and when there is the
distinct history of exaggerated fcetal movements corresponding in
time with the stage of invasion in the mother. After the infant is
born there ought to be no difficulty in recognising the disease, save
perhaps in the cases in which the mother has escaped, but even in
these the history of exposure to infection and the nmljilication of the
pustules ought to suffice. Neonatal pemphigus and ecthjinatous
syphilis neonatorum present resemblances, but not so great as to
mislead the careful observer who is aware of the possibility of
smallpox attacking the fcctus in utero without at the same time
affecting the mother. It is impossible to state what is the intra-
uterine death-rate for foetal variola. Possibly the fate of the foetus
is determined chiefly hj the degree of severity of the maternal
malady, and by the occurrence or non-occurrence of premature
labour, and not so much by the type of the fever by which it is
affected. Mauriceau, who by his writings made conspicuous addi-
tions to the knowledge of fcetal pathology, was himself an instance
of a good recovery from foetal smallpox. That the foetus recovers
from intrauterine A'ariola need not cause much surprise, when
it is remembered that its surroundings are the very ones that the
physician would choose for his variolous patients, including as they
do, protection from light and the continual bathing of the whole body
in a warm fluid medium of practically constant temperature. But,
on the other hand, the presence of smallpox in the unborn infant
may increase the gravity of the maternal prognosis, for it is probable
that the mother's organs, and especially her kidneys, may receive
from the morbid foetus such a flood of pathological products as to be
most prejudicially affected thereby.
The treatment of variola in postnatal life is or ought to be
prevention, and nothing else ought to Ije necessary. In vaccination
we have a sure means of preventing this malady, and this means
ought always to be used. Is there any reason why a different
standard of treatment should be applied to the unborn infant ? It
has been stated that, supposing the foetus has taken smallpox in
utero, we may with some degree of confidence leave it to Nature to
eftect a cure, our chief duty being to prevent premature expulsion of
the little patient from his hospital : but are there any means that
can be adopted to lessen the risk of his developing variola in utero ?
In other words, is intrauterine vaccination possible ? The answer
to this question demands a separate paragraph.
13
194 ANTENATAL I'ATlIOI.OCiV AND HYGIENE
Vaccinia in the Fcetus.
The infant of a woman who has had smallpox in her pregnancy
may be insusceptible to vaccination. A case of this kind occurred
in my dispensary practice some years ago : a woman who liad during
her gestation a mild attack of ^'ariola, gave jjirth ten weeks after
lier recovery to a child, who was vaccinated on several occasions
but always without success ; she herself had good vaccination
marks, which no doubt accounted for the mildness of her attack.
There seemed to be no evidence that the child had had variola in
utero ; if he had, the recovery must have been absolutely perfect, for
no traces were visible. It may be supposed, perhaps, that lie was
immune against both smallpox and vaccination as an idiosyncrasy.
It seems, however, to be more reasonalile tn believe that he had been
protected by the placental barrier, or some other means, from the
maternal disease, but had at the same time got minimum doses of
the toxine and been rendered immune against variola, and therefore
refractory to vaccination. Whether this be the correct explanation
of the occurrence or not, the case raises the question of the possibility
of protecting the fcetus by vaccinating the mother. If a mother
suffering from smallpox can confer immunity on her infant in
utero, without the latter showing any external signs of variola, can
she by undergoing vaccination also give this immunity without the
child exhibiting vaccination marks ? In a sentence, can we give
the unborn infant immunity against smallpox l)y vaccinating the
mother during her pregnancy, and if so, is the result brought about
by the vaccination of the ftetus or by the transmission to it of
an acijuired property l;iy the mother ?
Many observations have been made upon tlie vaccination of the
pregnant woman. During an epidemic of smallpox, pregnant women,
like the other members of the connnunity, are revaccinated, to save
tliem from the disease ; and there are therefore many opportunities
of testing whether their infants are afterwards refractory to vaccina-
tion or not. It must at once be admitted that they are not invari-
ably refractory to subsequent vaccination ; but it may also be
claimed as clearly proven by statistics, that many of them are
insusceptible, and that the immune percentage, so to speak, is larger
than can he accounted for Ijy idiosyncrasy or accidental causes.
According to some observers, the percentage of refractory infants
is 32 ; according to others it is as high as 80 per cent. ; and among
recent authorities, Piery (Lyon niM., xciv. p. 37, 1900), from his
own results and those of others, gives 58 per cent, as the average.
Hermann Palm (Arch. f. Gynack, Ixii. 348, 1901), however, giv( ^
a mucli lower pro])ortion of refractories. It will, I think, ln'
safe to accept one t'lctus in three as the proportion protected by
vaccination of the mother in the second half of pregnancy. From
what we know of the laws of placental transmission, this is what
was to be expected. If we compare the transmission of smallpox
with that of vaccinia, we are not entitled to expect that the latter
VACCINIA IX THE FGETUS 195
will pass from mother to fcetus oftener than the former. But, it
may be asked, are they comparable ? I think they are : but it is
necessary to remember that there are details in which they differ.
An infant lias never lieen liorn carrying a vaccination pustule upon
its skin, as the result of the vaccination of the mother ; but, similarly,
an infant has never been born with the primary sore of syphilis
upon its genital organs. The point of contact of mother and foetus
is in the placenta and not on the foetal cutaneous surface. If
a vaccination mark or a primary sore occur in antenatal life at all,
it is to be looked for in all probability in the placenta. To return,
now, to the original question with which this paragraph began,
How does maternal vaccination in pregnancy protect the fcetus ?
It may be that there is a direct transmission of the antitoxine
which is elaborated in the maternal tissues to the foetus; but
it is more prolialjle that the immimising agent, whatever it may
be, passes to the foetus and acts upon its tissues and fluids, and
that these then elaborate the antitoxine. This, at any rate, is the
view advanced by Lop {TMsc, Paris, 189r>), and it has much to
commend it.
There is reason to believe that the protection against smallpox
which a fcetus gets from the vaccination of the mother during her
pregnancy does not last long; six months has been stated as the
probable period of protection. In this respect it is comparable, as
has been pointed out by Bar, Beclere, and others, to the immunitj^
given hy immunising serums rather than to that conferred upon
the infant after birth by arm vaccination. The practical consequence
of this conclusion is, that it is necessary to vaccinate all new-born
infants whether their mothers have been vaccinated in pregnancy
or not.
It must, in conclusion, be pointed out that it is possible that an
infant may obtain immunity against smallpox (as shown by
refractoriness to vaccination), in another way than that referred to
above : it may he rendered immune while still in the mother's
ovary. Thus, there is reason to believe that sometimes the vaccina-
tion of the mother during her childhood may confer immunity npon
her future infants: Piery {loc. cit.) found that of forty-four women
who were vaccinated without success in their pregnancies, presum-
ably on account of earlier successful vaccination, thirty-one gave
bii'th to infants that were refractory to vaccination; while of five
women vaccinated successfully in the last month of pregnancy, on
account of absence of pre-existing immunity, only one transmitted
immunity to her infant. This " hereditary " mode of transmission
of immunity from mother to infant is more closely related to the
experimentally induced immunity against such microbic conditions
as the pyocyanic disease {vide Charrin and Gley, Arch, de fhydol.
norm, et path., 5 s., viii. 225, 1896) than to the matters at present
under discussion ; it will be referred to later. The practical
conclusion is, that it is wise in the presence of an epidemic of
smallpox to revaccinate a pregnant w-oman for the sake of her
unborn infant, even if not for her own.
196 ANTENATAL I'ATIIOLOCY AND HYGIENE
Foetal Measles, Scarlet Fever, Erysipelas, etc.
I have chosen f«>tal variola as the type of tlie exanthemata that
may be met with in intrauterine life, for many cases have been
recorded, and therefore most of the clinical and pathological
varieties have Ijeen observed. The otlier eruptive fevers, however, if
not so well known, are at any rate not unknown in the foetus ; and the
investigation of some of them has brought out new facts with regard
to the jiathological intertwining of the maternal and fo'tal lives.
Of foital measles I have met with and pnbli.shed a case (56).
The mother developed an attack of measles for the first time at
the sixth month of her first pregnancy ; the disease ran its ordinary
course, but during the stage of decline of the eruption the fcptus
was prematurely expelled and soon died ; and the mother made a
good recovery. The fwtus, a male, showed a large number of spots
of morbilli on the back, a few on the lower limbs near the ankles,
and one or two on the face ; some stringy mucus was adherent to
the nose and mouth. He was somewhat poorly nourished. At the
time when I published this case (189.3), I gathered together from
literature some twenty recorded examjdes of fa'tal measles. Among
these was the case quoted by Squire {Trans. Obsf. Soc. Loud., xvii.
146, 1876) from the "Sydney Pa^^ers": "Lady Sydney was sickening
for measles, when, on third day, with severe cough and full rash,
she was brought to bed of a goodly fat son ; the child was also full
of the measles, mostly in the face, yet it sucked the nurse as well as
any child could." So far as could be judged from the chuical
details given in the twenty cases, it seemed that the infection of
mother and foetus must have been simultaneous, for the eruption
on the latter at the time of birth corresponded in character with
that then exhibited liy the mother. No instance has been placed
on record of a f(Ptus sutfering from measles, the mother escaping,
although having been subject to infection ; but the small number of
known cases does not permit us to draw conclusions regarding this
and other pathogenetic possibilities.
Of fcetal scarlet fever I have also met with one case, tliat reported
by Dr. Milligan and myself (59). The mother was a primipara, 21
years of age, who began to suffer from symptoms suggesting scarlet
fever about the seventh month of her pregnancy ; from the state of
the tongue, the appearance of the rash, and the high temperature, as
well as from the distinct history of exposure to contagion, the
diagnosis was fully made; the infant was born prematurely and with
considerable hicmorrhage in the third stage. Within twenty-four
hours of its birth it was noticed that the child was covered with a
red rash and that some of the glands of the neck were enlarged;
the skin was hot to the touch, and the tongue was bright red, although
not coated as in .scarlet fever in later childhood. The diagnosis of
scarlet fever developed in intrauterine life was made, and in about
a week afterwards both mother and infant passed through the stage
of desquamation. Not more than twenty well-authenticated cases
FCETAL ERYSIPELAS 197
of scarlet fever in the fretns have been recorded ; but it may occur
oftener than is supposed, for the diagnosis is uot easy, and the
eruption is apt to Ije confounded with the physiological erythema
and desquamation of the new-born. In the instances which have
been noted, the infection in mother and foetus would seem to have
been practically simultaneous. Leale's case was a very clearly
established and typical one {Med. News, xliv. 635, 1884).
Although the intrauterine transmission of erysipelas is to be
regarded as possible and even probal^le. it is a striking fact that so
few cases have been reported in which that malady was noted in the
Fig. 29. — Section of Tricuspid Valve of Heart : a, vegetation upon valve ; h, tri-
cuspid valve ; c, newly formed vessel, indicated by micro-organism ; d, mycotic
thrombi ; e, infiltration of leucocytes.
infant at liirth. Even inE. Kaltenbach's ol^servation {CcntrlU.f.Gyndk.,
viii. 689, 1884) and in Stratz's {ibid., ix. 213, 1885) the diagnosis
could not be regarded as certain, for the bacteriological confirmation
was wanting. Lebedeff's case {Ejcncd. Uin. fjaz., St^Petersb., vi. 285,
1886) was more completely demonstrated. It may be, however,
that the foetal environment and the peculiarities of fa?tal physiology
prevent the development of the characteristic cutaneous and sub-
cutaneous manifestations of erysipelas ; it may also be that foetal
erysipelas, when it has occurred, has been classified simply as a
well-marked instance of neonatal erythema and desquamation.
198 ANTENATAL PATHOLOGY AND HYGIENE
Kecent iiivestinatinns on tliis subject seem to show that erysipelas
can be and pnibitbly often is transmitted from mothei' to fn'tiis, but
takes on pathological characters in the latter which ditl'er from tlmsc
seen in the former. The streptococci apparently sometimes pass the
placental barrier and invade the foetal tissues l)y the umbilical
avenue of entrance ; they nuist then reach first the organs, such as
the liver and heart, which lie directly in tlieir path ; and there is
evidence to show that they may set up morliid changes in these parts
without att'ectin.!;' the skin or sulicutaneous tissue at all. The
interesting and important observation made by E. IJidone (Tcratolfyin,
i. 182, 1894) has been incidentally referred to in the preceding
chapter. It was that of a pregnant woman, a primipara, who was
attacked by facial erysipelas about the beginning of the ninth moutli :
after having given birth to a male infant, she died in the ])uerperium
from septic peritonitis and endometritis. The infant died about
nineteen hours after birth, and at the autopsy vegetations were found
on both the tricuspid and mitral valves, but specially on the former,
along with incipient glomerulo-nephritis ; numerous streptococci were
found iu the spleen, lungs, kidneys, but more particularly in the
vegetations on the cardiac valves (Fig. 29); and cultures and in-
oculations showed that the micro-organism was the streptococcus nf
erysipelas. In this case the streptococcic endocarditis on the auriculn-
ventricular valves seems to have taken the place of the skin lesinus
of erysipelas, for it is apparently clear that the infection ])asseil
through the placenta from mother to fcetus. The maternal disease,
then, led to the develo]iment of a pathological condition in the fo'tus,
which was the same in its microbic nature but differed in its manifesta-
tions. It may be that what has been found in relation to erysi]jelas
may apply to other transmissible diseases; the mother may show the
typical manifestations, while the foetus suffers from a modified malady.
Moncorvo's suggestion relating to congenital elephantiasis and the
streptococcus will he considered later.
Along with ftetal measles, scarlatina, and erysipelas, I may place
foetal parotitis, influenza, and pertussis. There are scanty records of
cases in which mumps and whooping-cough seem to have been present
at birth ; and of congenital infliienza there are several instances, and
I have myself noted at least three (20). Cases of relapsing fever
(E. Albrecht, IFiai. mrcl. BL, vii. 738, 1884 ; ,SY. Pder^h. mcd. JVclnischr.,
i. 129, 1894; Mamuroffski, ihid., Bdla(ic,\\ 10, 1896); and of yellow
fever (J. Jones, Mcd. Times and Gaz., i. for 1874, p. 5; C. Fiulay,
£din. Mcd. Journ., xl. 416, 1894), have lieen reported; and cholera
in the new-born infant has been met with (J. C. Lucas, Trans. Obst.
Soc. Lond., xxi. 250, 1880 : Tizzoni and Cattani, Ccntrlhl. f. d. med.
Wisscnsch., xxv. 131, 1887; E. Yitanza, Eiforma med., vi. 272, 278,
284, 290, 1890). Varicella in utero is not unknown ; J. Grindon
(Journ. Cutan. and Gcn.-Urin. Dis., xix. 237, 1901) has recorded an
apparent case, although the cutaneous lesions in the infant were not
typically vesicular. Foetal typhoid is a morbid entity which has
only recently lieen recognised ; and, since it presents several features
of special interest, deserves a more detailed description.
FCETAL TYPHOID 199
FcEtal Typhoid Fever.
]^>efore the recoguitiou of the baciUus of typhoid fever, few cases had
been met with iu the foetus ; the reasons were obvious, for the
external appearances of the disease were such as might easily pass
unobserved, and the internal pathological conditions were seldom
looked for. Fnrtlier, it was almost to be expected that the intestinal
appearances which are so diagnostic in typhoid in the adult, would l)e
little if at all marked in the fetus. Nevertheless, two or three cases
of foetal typhoid ending fatally soon after birth were reported prior
to the discovery of the causal bacillus (Charcellay, Arch. gi^n. clc mM.,
3 s., ix. 05, 1840) ; in these the ulceration of the Peyerian patches
in the intestine was observed, as was enlargement of Brunner's glands.
"VMien we remember the characters of the distribution of pathological
lesions iu the firtus, due to physiological peculiarities and the avenue
of entrance of the infection, it need not be a source of wonder that so
few cases of typhoid fever with intestinal lesions have been met with ;
such cases must be very rare. There is good reason to believe that
foetal typhoid is commonly unaccompanied by intestinal ulceration ;
and it must not be forgotten that even adult typihoid sometimes shows
the same peculiarity. The discovery of the pathogenic organism of
typhoid made it possible to diagnose with some degree of confidence
cases of enteritis without intestinal lesions ; and the result of this
bacteriological discovery was immediately manifest in the publication
of a considerable numljer of instances of fcctal typhoid fever. One
of the first, if not the very first certain case, was that reported by
C. J. Eberth (Fortschr. d. Med., vii. 161, 1889), for the evidence in
the observations of H. Eeher (Arch. f. cxpcr. Path. u. PharmalvL, xix.
420, 1885), of E. Neuhauss (JBcrl. Idin. Wchnschr., xxiii. 389, 1886),
and of A. Chantemesse and F. Widal {Arch, de jjhysiol. norm, et jMth.,
3 s., ix. 217, 1887) was not conclusive. In Eberth's case the bacillus
was found in the blood, the spleen, and the placenta; the foetus,
hmvever, was born dead, as it was also in Hildebrandt's case {Fortschr.
d. Med., vii. 889, 1889). The bacteriological recognition of typhoid
fever in the living foetus was carried out by P. Ernst {Beitr. z. path.
Anat. u. z. allg. Path., viii. 188, 1890) ; in the instance reported by
him the infant lived for over ninety-three hours, and the bacillus was
found in the spleen, the brain, and the marrow of the femur; the mother,
in addition to her typhoid fever, had suffered from a traumatism, which
it was thought may have caused haemorrhages into the placenta and
facilitated the passage of the micro-organism. J. Giglio's observa-
tion {C'entrlbl. f. Gi/ntlk., xiv. 819, 1890) was interesting on account
of the early period in antenatal life that the foetus had reached — three
months. V. Frascani {Biv. (jen. ital. cli din. med., iv. 282, 348, 1892)
made careful microscopic examinations of three foetuses from women
suflering from typhoid ; iu one of these it is interesting to take note
that the bacilli" were found in the placenta but not in the foetal
organs. Tlie infant with congenital typhoid seen Ijy T. Janiszewski
{Miinchcn. med. Wchnschr., xL 705, 1893) lived for fifteen days. In
200 ANTENATAL PATHOLOGY AND HYCilF.NF,
these cases, as also in that ie]"tited by Freuiul and Levy {ISerl. l-l'ni.
Wchnschr., xxxii. 539, IS!),")), there was no special localisation of ]iatho-
logical processes, but rather a general blood infection with tlie typhoid
bacilli. Negative bacteriological results were obtained by G. Uesinelli
(Ann. di ostet. e gincc, xviii. G95, 1896), all the cultures from the
tVctus of a mother with typhoid remaining sterile. It should lie
noted that souietrmes there seems to have been a mixed infection as
in H. Diirk's observation {Miinchcn. inecl. Wchrii^chr., xliii. 8-42, 1896),
in which Eberth's bacillus of typhoid as well as the Striphi/loroccvs
pyogenes albiis were discovered in the spleen ; further, in Fraenkel
and Kiderlen's report {Fortschr. d. Med., vii. 641, 1889) the typical
bacilli of typhoid were not found at all but only the y^tajihylococcvs
pyogenes albits ct Jfavus. Mixed infection and infection with
secondarily developed microbes are pathological possibilities which
have to be kept in mind in the consideration of all the maladies
that may be transmitted from mother to tVctus.
With the year 1896 came the discovery of the Widal serum test
for typhoid fever, and it was not long before this new diagnostic
means was applied to the recognition of foetal typhoid, with most
interesting developments. G. Etienne (Pressc mdd., p. 465, 1896)
noted the aljsence of any agglutinative action on the part of the blood
of the foetus from a mother who had died from a severe attack of
typhoid fever ; and negative residts have also been obtained )jy A.
Dogliotti {Gazs. mcd. di Torino, xlviii. 801, 821, 1897), Charrier and
Apert (Prcsse mM., p. cii., 1896), and Plauchu and Gallavardin {Lyon
med., Ixxxviii. 479, 1898). On the other hand, the five months fa'tus
which I saw in 1897, and which was examined and fully described by
W. Fordyce (Trans. Edinh. Obst. Soc, xxiii. 90, 1898), gave very
marked positive results. It was the offspring of a woman who died
from typhoid fever soon after delivery, and serum taken from the
jDeritoneal cavity of the foetus, as well as blood from the heart, showed
very distinctly the agglutinative action ; growths of the typhoid
bacillus were obtained from the kidney, spleen, and intestinal
contents, but not from the blood. The Widal reaction was also gi it
by Chambrelent (Journ. d. viM. de Bordeaux, xxvii. 245, 257, 1897),
J. V. Crozer Griffith (Med. News, Ixx. 626, 1897), and A. Mosse and
Dannie (Compt. rend. Soc. de bioL, 10 s., iv. 2:58, 1897). In Crozer
Griffith's case the infant was, save for slight jaundice, healthy at birth,
and continued to be so ; nevertheless, when seven weeks old, its blood
gave the Widal reaction. Griffith thinks that the child may have
had typhoid fever in utero and recovered after a very short attack, or
that the agglutinating principle may have passed through the placenta
from mother to fretus without the latter contracting the disease at
all. Ziingerle's observation svqiports the second supposition (Milnchen.
mcd. Wchnschr., xlvii. 890, 1900), although Crozer Griffith is him-
self inclined to favour the first. The whole ([uestion of the meUmd
and meaning of the transmis.sion of the agglutinating jirinciple
without the passage of the disease itself must still be regarded as
unsettled (C. Achard, Compt. rend. Soc. de bioL, 10 s., iv. 255, 1897 :
Mossc and Krenkel, L'i'/l. et mini. Soc. nu'd. d. hop. de Par., 3 s.,
FCETAL TYPHOID 201
xvi. 49, 1S99 ; G. Etienne, Covqit. void. Soc. dc hioL, 11 s., i. 860,
1899).
Maternal typhoid fever, in addition to tlie effects that have been
referretl to above, may liave yet anotlier intiuence upon the fcetns in
utero. Xot only may the unborn infant talce the fever and show the
typical manifestations of it, not only may the pathogenic bacteria of
typhoid be found in the fretal tissues or be grown in cultures from
the foetal organs, not only may the agglutinating principle be trans-
mitted through the placenta and be discovered in the serum of the foetus,
l>ut there may be also met with certain little understood but vastly
important pathological changes in the fwtal viscera, more particularly
in tlie liver, thyroid, brain, and suprarenal capsules, which have a
far-reaching effect upon the postnatal life of the offspring. To these
changes the attention of the profession has been specially directed liy
A. Charrin (C'onqif. rend. Soc. de hioL, 2 s., i. 550, 1899), by Charrrn
and Xattan-Larrier (Journ. dc jjhysiol. et de imth. ghi., i. 292, 1899),
and by Charrin, Guillemonat, antl Levaditi {Soe. de hioL, January 6,
1900); they consist in degenerative and sclerotic alterations un-
accompanied by the presence of microbes, but productive of a slacken-
ing of body metabolism and lowering of body temperature, along
with a tendency to develop broncho-pneumonia, gastro-enteritis, and
infantile atrophy. The same results are produced, as we shall see, by
other infectious maternal conditions, and are probably due to the
transmission of toxic principles through the placenta. It would seem
also, from some oliservations that have been made, that these trans-
mitted toxines may produce still more profound alterations in ante-
natal health, taking the form of malformations and structural
anomalies ; to this matter, however, I shall again return. Finally, it
has been thought that typhoid fever of the mother iu pregnancy may
lie the cause of intellectual peculiarities in her offspring, developed
many years afterwards (J. E. Corbin, Thesf, Paris, 1890). In this
connection, the case reported by W. Osier {Teratolorjia, ii. 13, 1895) is
peculiarly suggestive : the foetus of a woman who died from typhoid
fever in its late stage was removed from the uterus post-mortem : in
the left cerebral hemisphere there was a large recent clot wdiich had
broken through the ganglia into the lateral ventricle ; the mother was
also the subject of inherited syphilis. It is possible that the foetal
cerebral hiemorrhage was due to the maternal typhoid ; and, had the
infant lived, it would undouljtedly have shown phenomena caused by
the intracranial condition.
FcEtal Malaria.
Typhoid fever in the foetus is a discovery of modern medicine ;
the existence of foetal malaria was known to Hippocrates. There is
at any rate an obscure reference to it in the treatise on Airs, Waters,
and Places, in which it is stated that women who drink unwholesome
water from marshes have difficult labours, that their infants are large
and swelled, and that during nursing they become wasted and sickly
(83). Several reported instances are to be found in medical literature
202 ANTENATAL l'ATll()I.()(;V AND HVCIKNK
prior to the iiiuetoentli century. Thus U. F. l';iulliiii in liis ithscr-
vationes mcdico-physkcv selectee et curiosce (published us an appendix to
the .Mlsnllanra curiosa, Dec. ii., Ann. v., 1(J87), under the title " (^)uar-
taua infantis in utero," relates, without the professional secrecy of the
present day, how Anna Dorothea Meisenthurm, a soldier's wife,
sud'ered from a tpiartau a;,fue in whicli her fcctus participated. . Here
is the description : " Ultiniis luensilius in et ante paro.xysnnnu eni-
bryoueni niaxinie inquietuni, treniuluni, et ab uno in aliud latns sese
volutantem nianifeste sensit, ut tristem siljimetipsa pnediceret
eventuiu. Tandem, superato eodem die terribili paro.xysmo, circa
decimam vespertinam peperit tiliolam, ([ua? una eadeuKpie hora, una
cum matre, febri ista misere alHigebatur." The infant, he j^oes on to
tell us, succumbed in about .seven weeks. " Mater tandem, Dei
misericordia, convaluit." That in those days as now was something
to be thankful for. A good many other cases of a similar nature are
to be found in the older authors, and most of these were gathered
together by Gr.'etzer {Die KrankhcHcn dcs Fotus, p. 22, 1837). One of
them I reproduce here in full, as a type of antenatal pathology and
diagnosis in the close of the eighteenth centm-y, for it is well worth
reproducing. It is " The Account of a Case of Ague in a Child in
Utero," by Dr. 1*. Russel (Trans. Soc. Improve. Med. and Chir. KnoivL,
ii. 96, 1800). Here it is in Dr. Eussel's own words: —
" In the mouth of June, 17(J7, a young healthy woman, at Aleppo,
already the mother of two children, and then in the seventh month
of her third pregnancy, was attacked with a tertian fever. The fits
returned regularly about noon, and terminated in less than ten hours
by a profuse sweat ; Init it was remarkable in this case, that the fo'tus
seemed to suffer a paroxysm perceptibly distinct from that of the
mother. About eight in the morning of the odd days, the woman
felt the child (as she expressed it) tremble with great violence ; and
she was sensible at the same time of a sudden weight and coldness in
the womb. The coldness went off' in less than fifteen minutes, and
was succeeded for more than an hour by a glowing heat, duririg which
the child was at intervals somewhat restless, though its motions then,
she .said, were not tremulous, but like what she had felt at other times
when in health. While this happened to the child, the mother to all
appearance remained well : her pulse was not altered, and she only
complained of lassitude and a dull pain in the forehead, the usual
forerunners of the paroxysm. On the access of the fever at noon the
child again became unquiet. It stirred but little while the cold fit
lasted, and throughout the hot fit was alternately quiet and restless.
The mother constantly insisted that the struggles of the child at noon
were totally of a dillcrent kind from the tremulous motion of which
she was sensible in the morning. The same circumstances invariably
attended every fit until the eleventh day of the disease. The pcruvian
bark was administered on the termination of the fifth paroxysm. On
the eleventh day, tlie child remained quiet all the morning, and the
mother, feeling less of her usual headache and lassitude, was in hopes
of being cured as well as the child. Her tit, however, returned at
noon as violent as ever, and the child, who till that time had lieen
FQa'AL MALARIA 203
perfectly ijiiiet, became disturbed as usual during the mother's
paroxysm. The bark was repeated in the succeeding intermission,
and the fever did not return. I have met with a few instances some-
what similar," adds Dr. Ilussel, " but in all of them more might be
ascribed to the power of the mother's imagination than in the present
case, the patient being a woman of remarkable good sense, of a
chearful (m-) disposition, and who had never been subject to hysteric
ailments."
Unfortunately, the author does not record the state of the infant
at bii'th, but even in the absence of information on this point the case
is both curious and interesting. If we accept the conclusion that the
fcetus sutiered from malaria in uterci, then it would appear that its
seizures did not occur simultaneously with those of the mother. The
occurrence of foetal malaria of a different type from that of the mother
has, however, been noted by other writers. Further, the diagnosis of
the fcetal malady is an interesting feature of the case, and a still more
interesting one is the success of antenatal treatment, a success gained
apparently more quickly for the fcetus than for the mother.
Xotwithstanding the publication of Eussel's case, and others of a
somewhat similar kind, Leroux found it necessary in 1882 (Eev. dc
mcd., ii. 561, 1882) to collect together all the available evidence in
order to establish the probability even of the occurrence of fcetal
malaria. He put on one side the evidence founded solely upon the
history of intrauterine shivering fits noted by the mother as un-
reliable, and gave more weight to the discovery of hypertrophy of
the spleen discovered at birth. The cases of G-. E. Playfair {MM.
Med. Journ., ii. 901, 1856-7), of Bouchut (Gaz. d. hop., xxxi. 221,
1858 ; XXXV. 245, 1862), of Brunzlow {Mcd. Ztg., x. 57, 1841), of
Schupmann {Journ. f. Gchurtsh., xvii. 318, 1838), of P. Aubinais {Journ.
dc la Sect, de med. Sac. acad. Loire-inf., xxvi. 15, 1850), of Lepidi
{Morgar/ni, xii. 923, 1870), of Bohu {JaJirb. d. Kindcrh., n. F., vi. 115,
1873), of Bazin {Gaz. d. hop., xliv. 286, 1871), and of Bureau {Rev.
mens, de mi'd. el chir., iv. 214, 1880) have all some value ; but in the
end Leroux comes to the conclusion that " les observations ne sout ni
assez nombreuses ni assez probantes." His sceptical position would
seem to be largely due to the discovery, made about the time his
communication was published, of the ha-matozoon malarife of Laveran,
and to the belief then current that formed bodies, such as h;ematozoa,
could not pass the placental barrier.
Since the time of the recognition of the causal haematozoon or
Plasmodium of malaria, the number of reported cases of foetal malaria
has increased, as is shown by tlie publication of observations by
Yerneuil {Bcr. de med., ii. 641, 1882), by W. T. Taylor {Amcr. Journ.
out., xvii. 538, 1884), bv F. Cima {Pcdiatria, i. 231, 1893), by F. M.
Crandall {N. Yorh Polyclin., i. 38, 1893), by Moncorvo {Med. inf., ii.
363, 1895), and by K. Winslow {Boston Mcd. and Surg. Journ., cxxxvi.
514, 1897). Felkin's two cases {Trans. Edinh. Gist. Soc, xiv. 71,
1889) are chiefly noteworthy for the reason that in both instances
the mothers were free from malaria, and that apparently tlie disease
had been transmitted from the fathers to the foetuses without the
204 ANTENATAL I'ATHOIXXiY AND HYGIENE
mothers being uH'ected. ^Vtteiuiits lo discover the ha-niiitozoou in the
fcetal tissues have not been crowned with success, for V. Cacciui
{Bull. d. Soc. Lancisiana d. osp. di Homa, xvi. 12, 1895-6) and
Bastianelli {ibid., xii. 48, 1892) botii obtained negative results. This
failure, liowever, cannot be used as conclusive evidence against the
possibility of transmission of malaria from mother to fcntus, for in
typhoid as we have seen, and in tubercle as we shall see, it is exce])-
tional to find the causative organism in the fuHal tissues. It may
also be urged that the peculiarities of malarial infection and tlic
necessity of the presence of the mosquito, Anophcloi, may prevent or
make very difficult the intrauterine transmission of the disease ; but
it must be remembered that the passage of malaria from mother to
foetus is not to be compared to the infection of one individual by
another; there may be no need for the intermediate devclojiniental
phases of the malaria parasite when the fcetus is to lie tlie host, the
mother and foetus being co-hosts as it were. At any rate, there is
good reason to believe that tlie parasite {H(emam<xha, Hccmatozoon)
can pass the placental barrier, more especially if , as Varaldo {loc. cit.)
maintains, white blood corpuscles habitually do so. There may be
some doubt whether the red corpuscles of the foetal Ijlood may be so
easily invaded by the parasite as are those of adult blood. The
question must l)e left unsettled.
To summarise : It would appear that the foetus may lie attected
with malaria in utero and be born with the hypertrophied sjileen of
that malady ; it may receive from the maternal organism toxic-
products which interfere with its nutrition and cause it to be bom
delicate and little able to resist postnatal infections ; and it may
possiblj' sometimes be expelled from the uterus with a partial im-
munity against malaria (P. Pennato, Eiforina mcd., xiii. 1, 4, 206,
1897). Tiie fear of inducing abortion or premature labour by
administering quinine to a pregnant woman who is suH'ering from
ague seems to l)e largely imaginary; to give that drug would rather
appear to be good treatment both for mother and foetus.
The types of transmitted foetal disease which have Ijeen chosen
for description in the present chapter offer some interesting contrasts
as well as some evident resemblances. Their consideration leads us
to the inevitable conclusion that the manifestations and mechanism
of intrauterine transmission are much more complicated than miglit
at first thought have been anticipated. It is evident that a disease
such as measles or smallpox may pass from mother to f<ptus, and
show itself in the latter in the same form, or in nearl)- the same form,
as in the former. It is evident also, from what is known of foetal
typhoid and erysipelas, that in the unborn infant the disease may
take on characters which are unknown or at least seldom met witli in
the adult ; these characters are in great measure due to the route by
whicli the infection reaches the ftctus, and to the ]ieculiarities of
fd'tal physiology. Further, it is clear that the fiotus in utero may
suffer not only from the attacks of the causative micro-organism of
the maternal disease, hut also from those of secondary infections
(streptococcic or staphylococcic): in some instances the effect of tlie
I
TRANSMISSION OF DISEASES IN UTERO 205
latter may be more prejudicial than that of the former. Apparently
the fd'tus is sometimes immunised in utero by a process other than liy
suflering from the disease itself. This is a complicated and involved
c[uestion, but may possibly be explained by the action of the placental
tissixes upon the toxiues or antitoxines. There is some evidence
that a disease may pass from the paternal to the foetal organism vid
the maternal body without the last-named showing signs of infection.
These are some of the considerations suggested by the foetal maladies
above reviewed. They throw light upon some problems of intra-
uterine transmission, but they appai-ently darken others — apparently
only, for it cannot be doubted that in time and with further know-
ledge will come elucidation. There I'emains misolved the large
problem stated thus by Mademoiselle Margoulieff, " Par quel caprice
pathologique le placenta laisse-t-il passer le meme micro-organisme
qu'il arretera dans un autre cas ? " (These, Paris, 1889). At present
we can only repeat, " par quel caprice ? " hut we Icnoio that it is no
caprice.
CHAPTER XllJ
Types of Tiansinitted Fictal Diseases; Fietal Tubercle; Evidence of its Exist-
ence ; Causes of its Karity ; C-'liaraotcrs ; Baunigarteu's Theory of Latency :
Non-tubercular Manifestations of Antenatal Tuljercle ; Projiliylaxis ; Firtal
Sejisis ; Fcetal Epidemic Cerebro-spinal Meningitis ; Futal Purpura ; Fietal
Pneumonia ; Fatal Anthrax ; Fo'tal Rheumalii- Fever.
FtETAL TunERCULOSis, which is the subject to the consideratiuu of
which I shall devote the greater part of this chapter, is a inorlm!
entity whose existence has been insisted upon by one school of
pathologists and as stoutly denied by another. It has given rise tn
numberless discussions, which have served this useful purpose, if nu
other : — they have for a while focussed the minds of pathologists and
physicians upon the vexed question of intrauterine and iiitrao\'ular
transmission of disease, of the paternal influence in heredity, and of
the dilierenee between hereditary predisposition to tubercle and foRtal
infection with tuliercle. Tliese are questions which the profession
cannot afford to pass by. At this time, when a campaign is going on
against tuberculosis, it is manifestly a matter of no little importance
to consider well all the aspects of the subject. It would be bad
generalship in such a campaign not to reconnoitre every part of the
enemy's position ; were precautions of this kind neglected, masked
Imtteries might open fire at a critical stage in the great battle, and
lead to irretrievable disaster. It is therefore incumbent upon us, in
our struggle against tubercidosis, to make a reconnaissance in force
with a view to discover what may be the strength of the antenatal
section of the hostile attacking forces. In other words, it is neces-
sary to take into account antenatal as well as postnatal tuberculosis.
Tubercle, " cette maladie de tons les peuples, de tons Ics milieux, on
poiuTait presque dire de toutes les families," is, in a certain sense and
to a certain extent, a preventable disea.se ; for it may be possible
greatly to diminish the risks of the entrance of tubercle bacilli into
the human body, even if it can scarcely be hoped that the chances of
such a microbic invasion will be altogether abolished. If it were
found possible to exterminate absolutely the immediate cause
(microbic or toxinic) of tubercle, it might then be permissible,
perhai)s, to neglect the question of the receptivity or unreceptivity of
the body-cells with regard to that microbic or toxinic cause. If
there were no seed being sown, it would not matter much about the
soil ; but there is seed in abundance, and heuce it does matter
about the soil. Therefore, in any attempt to prevent tubercle, the
F(ETAL TUI5RRCLK 207
problem resolves itself into the prevention of the incidence of tnbercle
bacilli upon the tissues of the body, and (since this cannot be carried
out with absolute success) into the preparation of the tissues to
resist the morbid action of the bacillary invaders. Now, this is not
a problem of postnatal life only : it is also a proljleni of antenatal
life, for the organism before birth is liable to the attacks of tubercle
bacilli and toxines, and its tissues may likewise be more or less able
to repel such attacks. Further, the antenatal side of the problem
has an important bearing upon the postnatal. For this reason, there-
fore, if for no other, the suliject is well worthy of study.
In the present chapter I am concerned with fo'tal tuberculosis,
l)ut it must not lie forgotten that possilily the organism may fall
under the influence of the tubercular poison during one or other of
the two earlier epochs of antenatal life. It may be infecte.d during
the embryonic or during the germinal period as well as during the
fcetal. Of the possibility of the ovum being invaded by a tubercle
bacillus when in the ovary, or when passing down the Fallopian tube,
and of the possibility of it Ijeing penetrated by a spermatozoon whicli
has a bacillus in its interior, I shall have something to say iinder the
head of Germinal Pathology. The effect of the tubercular poison
upon the organism in the embryonic or developmental period of its
antenatal existence will, as I shall afterwards show, probably take
the form of interference with development, i.e. of malformation. In
the meantime, however, let us focus our attention upon foetal tuber-
culosis, upon the cases in which there is reason to believe that the
niorliid processes in the foetus are set up between the second and the
ninth months of intrauterine life.
Evidence of the Existence of Foetal Tuberculosis.
The evidence which may Ije and has been adduced in support of a
lielief in the existence of foetal tuberculosis may lie direct or indirect.
The direct evidence is founded upon the discovery of tubercular
lesions in the foetus, upon the recognition of the tubercle bacillus in
its tissues, and upon the fact that its lilood and organs when injected
into animals lead to the development of tuljercular processes. The
indirect evidence, of much less value, rests upon the discovery of signs
of tubercle in the placenta, umljilical cord, and liquor amnii, and upon
the tulierculinisation of the new-born infant of a tubercular mother.
I shall here descrilje three typical cases of foetal tuberculosis : the
first of them occurred before the discovery of the tubercle bacillus,
and its diagnosis rests, therefore, upon the lesions present in the
fcEtus ; the second is a fully estalilished case according to the exacting
requirements of the modern definition of tuberculosis ; and the third
is an instance of tubercle without evident lesions, in which the proof
depended upon experimental inoculations.
The first case of foetal tuberculosis which I select as a type is that
reported in 1873 by Charrin {Mem. et Compt. rend. Sue. de sc. mkl. de
Lyon (for 1873), xiii., pt. 2, 65, 1874). There were cases put on
record before this date, but most of them were incompletely stated
208 ANTENATAL I'ATHOLOCV AND HYGIENE
mill unconvincing; ChaiTin's case was fairly complete in its clinical
and pathological details, and as convincing as it could be in the
absence of modern bacteriological tests. The mother was a tripara,
29 years of age, who, at the fourth month of her pregnancy, developed
a pleurisy ; at the seventh she had all the signs and symptoms of
phthisis. At this time labour came on prematurely, and she died ten
ilays later; at the autopsy, tubercles were found in the lungs and
pleura and in the spleen and kidneys, the bronchial glands were
caseous, and the liver was much enlarged and fatty. The genital
organs were normal. The placenta, unfortunately, was not availalilc
for examination. The foetus, a female, weighed only 1100 grms. at
birth, and had a greatly distended abdomen ; it was very feeble, and
died in three days, after having developed a general cedema. At the
necropsy, miliary tubercles were found in the kidneys, suprarenal
capsules, great omentum, spleen, and liver; the abdominal cavity
contained much clear yellow serum with tiakes of lymph in it ; the
mesenteric glands were much enlarged, and were nearly all caseous ;
the bronchial glands, also, were caseous; and there were some scat-
tered grey granulations in the lungs. Charrin draws attention to the
localisation of the lesions in the fcetus as compared with the mother,
abdominal in the former, thoracic in the latter; and he rightly
emphasises the apparent rapidity of transmission of the tubercular
process from mother to fa3tus. Several of the circumstances wliich
struck the author as peculiar and difficult to explain are now well
known and easily understood by all who have studied Antenatal
Pathology : there is nothing in this recorded case to make us doulit thai
it was really tubei'cle of the foetus ; no doubt it was a very rare instance
of it (for it will be shown that it is extremely rare to meet with such
marked and widespread lesions), but yet indubitably fietal tubercle.
The recently observed case of Auche and Chambrelent (Arch, di'
mM. exper. d d'anaf. path., xi. 521, 1899) will serve excellently as a
type of a fully established instance of fcetal tuberculosis. It was that of
a prematurely Ijorn but living female infant, the product of the fourth
pregnancy of a tubercular woman, forty years of age, who died three
days after her confiuement. It was found at the autopsy that she
(the mother) had been the subject, not only of far advanced pul-
monary phthisis, but also of tubercular disease of the liver, spleen,
intestines, mesenteric glands, and kidneys. The ovaries, Fallojiian
tubes, and uterus were healthy, and there were no signs of peritonitis.
The other children of this woman were alive and well, but in her
family history there was the record of the death of one sister from
phthisis. There was no history of alcoholism. The infant, which was
born between the sixth and seventh months of intrauterine life, sur-
vived in the couveuse for twenty-six days, and then died without
having exhibited any marked symptoms. It had, however, lost
weight continuously. At the autopsy no peritonitis was found, and
the intestinal canal showed no tubercular lesions. In the liver, how-
ever', were numerous yellow granulatitms ; in the spleen there were
crowds of the same coniluent, punctiform granulations ; while in the
lungs were grey, transparent, round granulations in much smaller
FCETAL TUBERCLE 209
numbers. The bronchial glands were tubercular, but the other
organs had a normal appearance as seen by the naked eye. Micro-
scopic examination revealed an excessive number of tubercles in the
liver, some caseated in the centre, along with an enormous quantity
of Koch's bacilli. The same condition was found in the spleen.
Tliere were no giant cells. Many bacilli were fovmd in the pul-
monary alveoli. Further, tubercular endocarditis in the right
ventricle was discovered by means of the microscope. It remains to
be noted that the placenta showed many tubercular granulations,
some caseous at the centre and others not ; the chorionic villi were
in some places little altered, in others they were lost in the caseous
portions ; some giant cells were seen, and bacilli were present,
although they were not so enormously numerous as in the fojtal
organs. Three rabbits were inoculated with fragments of the liver,
spleen, and lung from the infant, and these all died of generalised
tubercle, with numerous bacilli in the lesions. A piece of placenta
was inserted under the skin of a guinea-pig ; two months later the
animal was examined, when it was found that tubercular infection
had occurred. Finally, two cubic centimetres of blood from the
imibilical cord were injected into the peritoneal cavity of another
guinea-pig without any apparent results ; but the animal died nearly
a year later, when it was discovered that there was tubercle of the
peritoneum, mesenteric glands, liver, spleen, and lungs, with bacilli
in all the lesions.
Some five or six further cases, in which the evidence in favour
of the existence of foetal tuberculosis was as clearly or nearly as
clearly estabhshed, have been reported during the past ten or twelve
years; but it is freely confessed by all who have investigated the
subject, that such instances are extremely rare. It would seem, also,
from G. Kiiss's masterly exposition of the whole question of antenatal
tuberculosis {De I'hMdiU ixcrasitairc de la tuherculose humaine, Paris,
1898), that well-established cases in the fcetal calf are almost as
uncommon as in the human subject. The reasons which have been
advanced to explain this great rarity will be referred to later; in
the meantime, the fact that at birth evident tubercular lesions are
I most exceptional in the offspring of tubercular mothers, must be
I accepted as fully proven. In order, however, that the case for
j congenital tuberculosis may be quite fairly stated, some reference
I must be made to the third type of the malady, that in which,
I although evident tubercular lesions were not met with, yet the
i bacilli were found in the fcetal tissues, and inoculation of animals
I with pieces of organs or blood from the fetus led to the development
I of tubercle. About twelve instances of tuberculosis without lesions
I have been put on record, including those of Schmorl and Birch-
\ Hirschfeld (Beitr. z. path. Anat. u. z. allg. Path., ix. 428, 1890), of
i Aviragnet {These, Paris, 1892), of Londe and Thiercelin {Gaz. d. hd}).,
I Ixvi. 189, 1893), of Schmorl and Kockel {Bcitr. z. jMth. Anat. n. z.
j allff. Path., xvi. 312, 1894), of Bar and Eenon {Compt. mid. Soc. dc
I hioL, 10 s., ii. 505, 1895), and of Jens Bugge (Bcitr. s. jtath. Anat.
I u. z. allg. Path., xix. 433, 1896). The case described by Bugge may
14
210 ANTENATAL PATHOLOCJY AND HYGIRNK
1)6 given as a good exiunple of this tyjie of antenatal tuberculosis.
It was that of a woman, ?>9 years of age, the daughter of a plitliisical
mother, who had had thirteen children, of whom ten liad died of
tubercle and one was ill with the disease. Two years previous to
the birth of her fifteenth infant, she began to show signs of i)hthisis,
and she died four days after being delivered of a female infant. The
necropsy discovered tubercular changes in tlie lungs, liver, lironcliial
glands, kidneys, and intestinal canal. The placenta was not ex-
amined. The infant lived for thirty hours ; it was prematurely
born (second half of the eighth month), and weighed 1820 grms.
With the naked eye no tubercular lesions were discoverable in the
organs of the infant ; liut microscopically, bacilli were found in the
blood of the umbilical vein, aud, to the number of four, in the lumeu
of one of the small vessels of the liver. Further, blood from the
umbilical vein, and a piece of the liver, were inoculated into three
guinea-pigs, all of which succumbed from tubercle in two and a hall',
four and a half, and five and a half mouths respectively. In this
case it is larobable that foetal infection occurred late in pregnam y,
possibly even in the course of laljour.
Of indirect evidence bearing upon the occurrence of fcetal tuber-
culosis it is unnecessary to saj- much. The histological and bacterin-
logical examination of the placenta and membranes in all cases, but
especially in those in which the infant survives birtli, ought to 1 ii'
carried out; but the discovery of tubercular lesions or bacilli in Uie
foetal annexa does not of necessity indicate tuberculosis of the fo'tus
itself, as was shown some years ago by Schmorl and Kockel {Beitr.
z.path. Anat. v.. z. allcj. Path., xvi. 312, 1894). With regard to the
examination of the blood of the umbilical cord, and the inoculation
of animals with it, Kiiss {op. cit.) has pointed out that, while positi\ e
results may have a certain value, negative ones have very little, fur
the bacilli of tubei-cle are rarely found in the blood. InoculatiDus
of animals with liquor amnii from cases in which the mother was
tubercular have been little practised ; Herrgott {Ann. dc ijyna-. d
d'ohsf., xxxvi. 1, 100, 1891) obtained positive results in one case;
but tubercle bacilli in the liquor amnii do not necessaril}' mean
tubercle of the fcetus. A more useful means of investigation may
be found to be the testing of new-born infants, the offspring ni
tubercular mothers, with tuberculin ; but in the meantime it is
doubtful whether the medical man would be justified in using this
method, even if the parents were ready to give their consent. After
all, it is unnecessary to have recoiu'se to indirect evidence to prnve
the occasional but rare occurrence of foetal tuberculosis ; that fad
is sufficiently proved by the direct evidence. Foetal tubercle occurs,
Ijut it occurs with almost extraordinary rarity. Let us inquire .
whether there is any explanation of this great rarity.
Causes of Rarity of Fcetal Tuberculosis.
It must, in the first place, be borne in mind that tlie irans-
jilacental passage of diseases, and even of the most transmissible
Fa:TAL TUBERCLE 211
diseases, is far from constant. Already, in describing fictal smallpox,
measles, scarlet fever, etc., I have pointed ont the rarity of tliese
maladies. Not every woman wlio sutlers from one or other of the
infectious fevers transmits the same to her unborn infant ; she may
transmit some morbid influence which may show itself in weakened
foetal metabolism of one kind or another, but it is exceptional for
her to pass on the disease itself. The reasons for this rarity of
transmission have been considered under the head of the Placental
Factor in Fwtal Pathology, and need not be reconsidered ; suffice it
that the placenta sometimes acts as a prophylactic barrier. In the
case of tubercle, however, there are also special reasons why the
foetus is so rarely afiected. In order that the tubercle bacilli may
reach the foetus in utero, they must be present in the blood of the
mother and pass through the placenta, for there is practically no
other avenue of entrance. The ordinary mode of infection (viz.
pulmonary and aerial) is out of the question for the fcetus. Now,
it is an unconnnon occurrence for the Ijacilli of tubercle to be present
in the blood-stream ; they can live in it, and do so in advanced cases
of general tuberculosis, but they constantly show a tendency to
escape from it and to become localised in special organs. In a
sentence, an intense blood-infection is quite rare in tubercle. It is
not often that women showing marked and generalised tuberculosis,
with numerous bacilli in the blood-stream, come to the full term, or
even to the seventh month, of pregnancy ; therefore it is rare for
tubercle bacilli to arrive in the placenta. Even in ordinary phthisis,
howe\'er, it is possible that bacilli reach the placenta ; Ijut then there
is some evidence that the placenta is not a good culture medium for
them, and even if that be not so, there is the natural tendency of
the organ to act as a barrier to microbic invasion. So that it is easy
enough to believe that few germs actually arrive in the fcetal tissues.
Further, it may be hazarded that the twtal liver may act as a second
barrier in the way of a successful Ijacillary invasion ; and that, being
the potent organ in fietal life, which it undoubtedly is, it may act in
concert with or as a substitute for the placenta, and thus save many
a fcetus from tubercular contamination. Some additional causes of
the rarity of ftetal tubercle may be referred to briefly. There is the
rarity of primary tubercular lesions of the genital organs (uterus,
ovaries, and Fallopian tubes) of the mother. J. D. Williams and I
met with and reported a case of primary tulierculosis of the
Fallopian tubes .some years ago (19), but such cases, as also
examples of primary tubercle of the ovaries (Loeffler, Wien. med.
1 Wchnschr., August 26, 1899), are exceedingly rincommon. No doubt,
I if tubercular changes in the tubes, ovaries, and mucous membrane of
the litems were more often met with, placental tubercle would be
; more common, and cases of fcetal infection would he less rare than
I they are. Finally, it is possible that if fwtal tubercle were more
j often and more carefully looked for in the still-born foetuses of
I tubercular women, it would be more often found. At any rate,
[ enough evidence has been led to demonstrate the causation of its
■ apparent rarity.
212 ANTKNA'I'AI, I'AI'IIOLOCY AND IIYCHEN'K
Characters of FcEtal Tubercle.
Fcetal tuberele differs from iufiiiitilc iiiiil ndiilt ttilierele in its
characters; but the difl'erences are .such as can he cxjilained hy the
geueral laws of antenatal as distinguished from ])()stnatal pathology.
In otlier words, f fetal tuberculosis has peculiarities, not l)ecause it is
tuberculosis, but because it is fcetal. It is unnecessary to do more
than enumerate the peculiarities. In the Jirst place, fcetal tubercle
is not pulmonary tuliercle. In the cases in which definite tubercular
lesions are i)resent they are rarely found in the huigs, and even when
they are met with in these organs they are ipiite discrete. Evidentlj'
this is just what was to be expected, for the lungs are not in the
direct line of bacillary invasion of the fcetal body, neither is the
circulation in the lungs at all active. On tlie other hand, the liver
is in direct communication with the mnbilical avenue of approach,
and therefore it is to be expected that in it and in the neighljouring
glands there will be tubercular lesions. As a matter of fact, the
liver is frecpiently affected; but it has to be noted that there are not
a few exceptions. Possibly this is to lie explained by the fact that
the invading germs may pass direct to the iieart by the ductus
venosus without traversing the liver. From a study of the reconlcd
cases, it would appear that tuljercle germs may reach the fcetus iu
large numbers ; when they do so the lesions are generally wide-
spread : they may, on the other hand, be few in number, and then
the lesions are commonly localised, iu the suprarenals, in the cere-
bellum, in the liver, spleen, and indeed in all the glands, and rarely
in the bones and serous membranes. In the second place, such cases
as that of Auche and Chambrelent {loe. cit.) seem to prove that ■
the foetal tissues, far from being unsuitable soil for the growth of
tubercle bacilli, are peculiarly fitted for their reception and develo))-
ment. In the liver and spleen they have been found in such nundicrs
as to rival the lesions of "avian tuberculo.sis." This conclusion, if
warranted Ijy further research, has a most important liearing u]iiin
the theory of Baumgarten. In the third place, it may turn out that
iu fcetal tubercular lesions giant cells are wanting; Imt, iu the
absence of a large nund^er of observations, it is not safe to make this
generalisation. In the fourth place, tubercle bacilli may be ]n'esent'
in the foetal organs in large numbers without the development of the'
characteristic lesions of postnatal tubercle ; this is the .so-called'
bacillosis without lesions, and it may be due to the termination ol
antenatal life liefore the lesions have had time to form. Inf'antf
who show bacillosis may be apparently perfectly viable and well
developed ; on the other hand, the exiierimental work of A. Charrir
(Joitrn. de phijsiol. ct dc path, gen., i. 82, 1899) and others would seen
to prove that the offspring of guinea-pigs which have lieen inoculatec
with tubercle grow slowly, have a low temperature, and suffer fron
lesions in the liver, thyroid, and sometimes in the kidneys. In thi
latter case, however, the foetuses do not necessarily contain tnbercl'
bacilli. It is quite possible that these hepatic, renal, and othe
BAUMGARTEN'S THEORY 213
clianges are the result nf the transmission of toxines, and not of the
bacilli themselves ; a similar supposition has been made with regard
to typhoid fever occurring in pregnancy. It may therefore be said
that, in the fifth place, foetal tubercle may take on characters not at
first recognisable as in any way tubercular.
Baumgarten's Theory.
Any discussion of fcetal tubercle would manifest!}^ be incomplete
without a reference to the views advanced by Baumgarten {Ccntrlhl.
f. d. mcd. Wissensch., xix. 274, 1881 ; Samml. Min. Vortr., No. 218,
"l882 ; Ztschr.f. klin. Mcd., vi. 61, 1883). This author was struck by
tlie fact, which has engaged many other workers in this field of study,
that while tuberculosis is evidently and very frequently transmitted
from parents to children, it is couimouly not till late childhood or
early adult life tliat distinct signs and symptoms begin to appear.
In order to retain the idea that the tulsercle of the ascendants was
transmitted to theii- descendants, and to bring it into harmony with
the long period of apparent immunity which intervenes between birth
and the appearance of the disease, Baumgarten was led to formulate
the theory of the latency of the germ. He believed that germs are
carried to the unborn infant either through the placenta or by the
ovum or spermatozoon (at the time of conception) ; that these some-
times, possibly when very numerous, set up distinct tubercular
lesions in the foetus, or lead to the develojiment of the rare infantile
form of tuberculosis ; that most often they are few in number, and
remain in the foetal tissues and organs in a sort of larval state till
birtli, and for a short time thereafter ; that the larval stage is
succeeded liy one of semi-activity, in which tubercular foci . are
formed ; and that these foci may long remain latent, existing simply
in the anatomical and not in the clinical sense, but may at some
time or another give rise to active tubercular manifestations. It was
thought that the tubercular foci were most often to be found, if
looked for, in the bones and glandular system. Now, modern research
has revealed some facts which lend support and some which go to
discredit this theory of latency of the germ as stated by Baumgarten.
For instance, it is now known that tubercle bacilli may, in small
numbers at any rate, gain access to the fretus through the placenta,
and that at the time of birth they may have produced no recognisable
tubercular lesions. On the other hand, there is little or no evidence
to support the conclusion to which Baumgarten was driven, that the
tissues of the fa?tus, on account of their great vitality, restrain or
altogether prevent the growth of the germs of tubercle. Such cases
as that reported by Auche and Chambrelent {loc. cit.), and such
experiments as those of Sanchez-Toleilo (Arch, dc niM. exp^r. et d'anat.
path., i. 503, 1889) and A. Gartner {Ztschr. f. Hyy. ti. Infedions-
krankh., xiii. 101, 1893), show no special resistance of the foetal
tissues; indeed, it has already been stated that, when tubercle bacilli
reach the fa?tal organs, they apparently have found a soil very
suitable for their growth, and may soon be as numerous as they are
214 ANTKNATAI. I'ATHOI.OdV AM) llYCilKNE
in '•avian tuliuic-ulosis." There are oLlier dittieullie.s in the way of an
acceptance of Baumgarteu's theory ; and it nnist, I think, be fully
conceded that the great number of cases of tuberculosis, both in
children and adults, are caused by the invasion of the organism by
germs in postnatal and not in antenatal life. The cases of true
congenital tubercle, with or without lesions, are rare ; and there is no
good reason to believe that germs entei- tlie foRtus, and after a ]ieriod
of latency lead to antn-infection in adult life.
Non-Tubercular Manifestations of Antenatal Tubercle.
I have already referred to the occurrence of pathological ccm-
ditions in the ofl'spring of tubercular women, conditions which are
not tubercular in the usual sense of the word ; these I have, for
want of a better name, called the non-tubercular manifestations of
antenatal tubercle. I do not defend the nomenclature; but I draw
the reader's attention to the phenomena, fur they are, to my mind,
of a very special importance.
I have at various times met with the following cases. There was
the instance of foetal ascites and distension of the bladder in the
offspring of a tubercular woman, which I recorded (197) in the Edin-
hurrjh Obstetrical Society's Transactions in 1897. Into tliis case and its
meaning I do not propose to enter, f(.)r unfortunately no examination
for the tubercle bacillus was made. It, however, directed my atten-
tion towards the occurrence of ftetal diseases, not necessarily of a
tubercular type, in the offspring of tuliercular parents. The second
case was more immediately important and striking. It was as
follows : —
On January 2, 1899, I saw with my friend. Dr. John Stevens, an
interesting case of congenital anonuily of the knee-joint. The patient
was a male child, eleven months old, the offspring of the third
pregnauey of a woman whose two earlier gestations had also ended in
the birth of males, but well-formed anil healthy males. There was
one fact, however, about the third pregnancy which calls for
immediate notice ; it was that the mother during it was in an
advanced stage of pulmonary tuberculosis. Obstetrically, it ]nu'sued
a normal course ; the infant was carried to the full term and born
without artificial assistance. Soon after liirth it was noticed tliat tlie
uifaut, who was healthy in appearance and not malformed, had tlie
power of causing a curious change in his right knee-joint. "When the
right foot was pressed against the left leg, and more particularly
during struggling and crying, a slight creaking sound was heard, and
it was then evident that a dislocation outwards of the right knee had
occurred. This phenomenon happened frequently, .sometimes very
many times in succession, and as the infant grew older it seemed as
if he derived a certain amount of satisfaction from this voluntary and
transitory dislocation. When I saw him he was eleven months old,
and was beginning to stand, and could bear his whole weight upon
the right foot. Notwithstanding this, he was still able to dislocate
the knee, without a]ipareiitly causing any inconvenience to himself.
ANTENATAL TUBERCLE 215
By seizing the right leg and pressing the head of the tibia outwards,
I found I could cause the luxation, and reduce it again quite easily and
without distressing the child. The two knees did not appear to be
dissimilar, but the dimple over the external condyle of the femur in
extension of the joint seemed to be more marked on the right side.
All the movements of the knee took place quite naturally. Careful
palpation during the production of the dislocation discovered that
the head of the tibia passed outwards to a slight extent at the same
time as the distinct click was heard. There was no clubfoot ; indeed,
the boy was normal in every way, save for the recurrent dislocation
of the knee. This was the state of things in January, and it was my
wish that as soon as he was able to walk the child should be fitted
with a retentive apparatus to fix the joint and allow of retraction of
the ligaments, for it was evident that there was some relaxation of
the ligamentous structures, and especially of the crucial ligaments.
But as the weeks passed it was noticed that as he began to stand and
walk the dislocation occurred with diminishing fre(piency. At the
age of sixteen months there was power of walking, and the dislocation
no longer happened, and even considerable pressure did not produce it,
and manifestly there was no need to make excessive pressure. The
mother, however, had succumbed to the phthisical condition from
which she was suffering, her infant remaining well and healthy.
This case suggests the question whether the state of the infant's
knee-joint was iu any way the result of the mother's tuberculosis.
Unfortunately the placenta was not available for microscopic
examination. It is only right to state tliat the father of tlie child
was the subject of n;evoid swellings of the eyelids and of mevi upon
the scalp and back ; these were congenital in their nature. The case
was fully reported in 1899 (105-107).
So much was I impressed with the association of foetal malforma-
tion and disease with tubercle in the parents, that when, in the
Septemlier of 1900, I had charge of the Eoyal Maternity Hospital,
Edinljurgh, I had under my care a parturient woman with phthisis
of both lungs, I caused careful search to lie made for malformations
or anomalies in the infant to which she gave birth. It was found
that the child had webbed toes.
These observations do not of course stand alone. The occurrence
of malformations and strixctural peculiarities iu the children of
phthisical parents has lieen known for years, and V. Hauot {Gaz.
hchd. dc med. ct chir., xliii. 265, 1896) has called it heteromorphic
tubercular heredity. Various dystrophies have been noted, such as
minor malformations of the cranium, hernias, ectopia of the testicle,
malformations of the heart and great vessels, lobulation of the liver,
congenital dilatation of the oesophagus, infantilism, congenital
dislocation of the hip, hare-lip and palatal defects, deaf-mntism, and
even actual monstrosities (pseudencephaly, anencephaly). In these
cases it would ahnost seem as if the malformation or anomaly had
taken the place of the truly tubercular lesion. Hanot {loc. cit.), for
instance, suggests that congenital atresia of the pulmonary artery,
which he has noted in the descendants of tubercular parents, may
216 ANTKNATAL I'ATHOLOCIY AND HYGIEXE
represent tlie whole ol' the transmitted tendency ; the cardiac mal-
formation of the oilsjirinj^ of tubercular parents may then indicate
not a proneness to become tubercular, but an innuunity against
tuberculosis 1 Without going so far as Hanot does, it may be
conceded that there is in all probability the relation of cause and
elfect between the tubercle in the parents and the malformations and
dystrophies in the children. It may also be said, and in this respect
the evidence is against Hanot's view, that sometimes foetal tuliercle
may co-exist with a malformation; Sarwey's case (-4?-c/;./. Gijnack.,
xliii. 162, 1892), was that of a foetus which had a large meningocele
and cleft palate, and at the same time showed distinct tuliercular
lesions in the liodies of the cervical vertebra'. Too much must not,
however, be concluded from Sarwey's observation, for in it the father
alone was tubercular, and the tuliercular nature of the fcetal lesions
was not estaljlished beyond all doubt. G. Keim {I'Ohdi'triqv.c, iv.
4-73, 1899), has recently reported a remarkable case in which the
twins of a tubercular mother were of the same sex, and yet, while one
was normal in appearance, the other showed malformations of the
lower limbs. This whole question of the non-tubercular manifesta-
tions of antenatal tubercle must be for the meantime left in a chaotic
state. Its meaning is not clear (" bleibt unklar "), although it may
be conjectured that the malformations are due to tuliercular toxinic
products reaching the embryo (bacillary toxa-mia), and disturliing
normal embryogenesis. Possibly such experiments as those made by
G. Carriere (Arch, de mid. exper. et d'anat. 2)ath., xii. 782, 1900), in
which the young of tubercular guinea-pigs showed various morbid
states, and were more easily tuberculisable, may j^et throw light
upon the matter. They show, apparently, that when the disease
itself is not transmitted from parent to child, a sort of weakened
state may be passed on, which both before and after birth may
lead to morbid developments, arrests of formation, and arrests of
function.
The Antenatal Factor in the Prophylaxis of Tubercle.
From what has been written, it is evident that the antenatal side
of the problem of the prevention of tubercle cannot be neglecte<l.
While it is clear that foetal tul)ercle with lesions is very rare, and
while, therefore, the danger of an infant being born already att'ected
with tubercle is slight, yet there are associated dangers which
are not slight, and which we cannot afford to neglect. There is
evidence that the offspring of tubercular women are born not in-
frequently with dimuiished powers of resistance, and even with
various malformations, some of which, such as cardiac anomalies, act
as veritable disalulities. These may be due to the transmission to
the ftetus in utero, of bacilli or of their toxinic products. Xo doubt,
in such weakened organisms the advent of tubercle bacilli from the
outside in postnatal life will be less likely to be eflectually resisted ;
in this sense it may be said that the tendency to become tubercular
is transmitted; it is not, however, a tendency specially to liecome
FCETAL SEPSIS 217
tubercular, hut a teiuleiicy to yield to the onslaughts of all forms of
pathogenic organisms and their associated toxines. It may then be
concluded that it is a danger to the unborn to have a tubercular
mother ; but the danger is much lessened if there be a healthy
placenta.
Foetal Sepsis.
As yet comparatively little is known of the transmission from
mother to foetus of the specific organisms of sepsis ; but it cannot he
doubted that a most important part of antenatal pathology, that
dealing with fcetal sepsis, yet remains to Ije investigated. Reference
has already been made to the discovery of streptococci in the fcetus
of a woman suffering from erysipelas (Bidoue's case), and indications
are not wanting of other instances of a similar or allied kind. Thus
G. Eicker {Centrlhl.f. allg. Path. u. path. Anat., vi. 49, 1895) records
two cases in which the streptococcus pyogenes was found in the
human fojtus ; in one, the mother died of diphtheria at the sixth
mouth of pregnancy, and the micro-organism was found in her body,
in the placenta, and in the liver of the fcetus, although the foetus and
placenta showed nothing abnormal otherwise ; in the second caise the
mother suffered from an abscess of the arm, which proved fatal after
the deliver}' of a dead-born infant, which showed the streptococcus in
the blood of the umliilical vein. Cases of true fcetal sepsis must not
of course be confounded with the comparatively much commoner
instances of intranatal infection of the foetus ; when septic germs are
present in the mother's vagina, they may, during labour, and especially
dm-ing prolonged labour, gain access to skin wounds, or to the eyes, or
to the mouth and lungs of the infant passing through the canals ; they
may set up ophthalmia, or pneumonia, or septic cutaneous conditions,
but these are not truly fcetal in origin. Even the cases in which, on
account of premature rupture of the mend^ranes, germs gain access
to the fcetus while it is in the uterus (Queirel, Marscille-mtkl., p. 124,
July 15, 1895), ought to be separated from those in which the
infection takes place Ijy the placental route, the uterus being still
a closed cavity. In addition to Eicker's cases, which have been
referred to above, Bonnaire {I'Olstctrique, iv. 473, 1899) has recorded
three instances in which streptococci seem to have passed from
mother to foetus by the placental route ; in one of these the mother
died of eclampsia after ha^'ing expelled a dead fcetus ; the maternal
blood and meningeal pus gave a pure culture of streptococcus
pyogenes, and the cerebro-spinal fluid of the infant gave a culture
rich in streptococci. The article by AVidal and Wallich {Compt.
rend. Soc. dc bioL, 10 s., v. 266, 1898) is also of interest in this
connection. The staphylococcus also sometimes passes to the foetus,
as has been shown by Fraenkel and Kiderlen in their case already
referred to (vide p. 200) ; and two or three cases are on record in which
the bacteriimi coli seems to have been transmitted. The passage
of the diplococcus of pneumonia will be considered in a separate
paragraph.
It must be freely admitted that true foetal sepsis occurs ; but it is
218 ANTKNA'IAL I'ATHOLOCJY AND IIVdIKNi:
jiroljably C(Jiiiparativcly rare. It luay, as has Ijcuii staled in tiie
description of tVrtal typlioid, be met with as a secondary and
associated infection in antenatal life. An interesting part of this
subject has yet been liardly at all investigated, namely, the character
of septic lesions in the ftetus. In some of the older works we read
of purulent collections in the foetal tissues (P. Ollivier, Arch, i/i'n. de
mM., 2 s., V. 70, 1834), and it is possible that these may liave been
the result of ftetal sepsis. IVIore recently Palazzi (Ann. di osfct. r
r/incc, xxiii. 558, 1901) has met with two cases of abscess in the
foetus, but in each instance the mother was quite healthy. Foetal
endocarditis, also, and hepatitis may be consequences of the invasion
of the foetal body by the umbilical avenue. It may be surmised, in
addition, that septic conditions of the mother may produce morbid
states in the fa;tus which are not themselves evidently septic, such as
delayed develoj^ments, congenital weakness, and tendencies to defect-
ive body metaliolism of various kinds. At any rate, the experience
which has been gained from the study of the dystrophies of fcetal
tuberculosis and syphilis would almost warrant us in concluding that
sepsis also has similar effects. It must be freely confessed, how-
ever, that much remains to be done to elucidate the problems of foetal
sepsis. It may be hazarded, from what is known of allied conditions
in the new-born infant, that suppuration is a comparatively rave
result of the entrance of septic bacilli into the f<etus.
I may close this chapter with a few notes of some diseases which
have only rarely lieen observed in the fojtus, namely, epidemic
cereln'o-spinal meningitis, purpura, pneumonia, anthrax, and rheumatic
fever.
Epidemic Cerebro-spinal Meningitis in the Foetus.
In October 1899, I received a letter from Dr. 11. B. H. Gradwdhl,
bacteriologist to the St. Louis City Hospital, U.S.A., containing a
reference to " a case of epidemic cereln'o-spinal meningitis trans-
mitted in utero." As the case is probal)ly uni(pie, 1 give the details
somewhat fully.
The patient was a woman, aged 31, seven months pregnant, wlio
two days before coming into hospital had begun to suffer from pain
in the left ear. Some drug had Ijeen injected into the ear by a
medical man but witliout relief, and she soon became comatose. Ko
foetal heart sounds could be heard, and the fa^tus could easily lie
pushed from side to side. Vaginal examination revealed a soft
undilated os. Eespirations were somewhat laborious, and the pulse
was rapid (120) and weak; temperature 102° F., pupils unequal,
Kernig's sign present. The head was drawn back, there was hyi'cr-
a'sthesia and photcq)hobia, and on touching the spine or back of the
neck the patient Wduld come out of her coma for a moment or two
and nnitter deliriously. Tachc a'n'bralc was manifest, and there was
instability of the pni)il. She died undelivered, and at the necropsy
the kidneys showed acute parenchymatous nephritis, and inside the
cranium was a typical meningitis (an abundant purulent exudation
F(ETAL PURPURA 219
was scattered here and there over the entire meningeal surface,
especially at the liase), while the same condition was found upon
the cord. A seven months fa-tus was removed from the uterus, and
in it there was an exact counterpart of the condition of the maternal
meninges, with perhaps more of a sero-purulent exudation than a
purely purulent one. Bacteriological examination of fluid from l^oth
the maternal and fcetal meninges revealed the presence of the diplo-
coccus intracellularis meningitidis. The same micro-organism was
also separated in piu'e culture from the left ear of the mother. Dogs
inoculated with cultures from the maternal and foetal meninges died
in convulsions.
This case occurred during an epidemic in which thirty-four
persons were affected, and details both of the epidemic and of the
special case were communicated by Dr. Gradw-ohl to the Philaddphia
Monthly Medical Journal (vol. i., July and September, 1899). In the
absence of further mformation about epidemic cerebro-spinal men-
ingitis in the fa;tus, the case must stand alone, and it would be rash
in tlie extreme to draw anj' deductions from it.
Fcetal Purpura.
Fcetal purpura, like foetal cerebro-spinal meningitis, would seem
to be one of the rarest of the diseases which may be transmitted
from the mother to her unborn infant. Some of the cases which
have lieen repoi'ted would seem to have been the results of the
traumatism of labour, and not true instances of the purpuric disease ;
others appear to have been examples of haemorrhages into the skin
developed after birth, as in Dr. Elizalieth Stow Brown's case {Amer.
Journ. Ohst.,x.\u\. 1048, 1885), in which there was melajna neonatonmi
and omphalorrhagia, and in which, also, there was a family history
of hemophilia. I have recently met with a case, which occurred in
the practice of Dr. W. H. Miller of Edinburgh, in which the fcetus
sliowed numerous purpuric spots over the head, chest, and abdomen.
There was, however, no history of any aljnormality in pregnancy,
and the mother was quite healthy ; there was no reason to regard
it as true purpura hiemorrhagica. It may be added that the foetus
showed also complete hypospadias, with non-descent of the testicles,
niaking the diagnosis of the sex douljtful ; and there were various
internal anomalies. Some reported instances of purpura neonatorum,
such as that described by J. H. Glenn at a meeting of the Eoyal
Academy of Medicine in Ireland {Med. Press and Circ, i., for 1893,
p. 587), are evidently cases of congenital syphilis. If the above-
named morbid states be excluded, very few genuine examples of foetal
purpura remain in medical literature. Possibly the cases of Petit
{Bidl mid. du nord, 2 s., xii. 363, 1872) and of Dalziel {Glasgow
Med. Journ., 5 s., xxxii., 65, 1889) may be regarded as such; cer-
tainly the instances reported by Dohrn {Arch. f. Gynaek., vi. 486,
1873-4) and by J. C. Diehl {Ztschr. f. Geburfsh. u. GynciL, xli. 218,
1899) have strong claims to be accepted as true instances of the
transmission of purpura hemorrhagica from mother to foetus.
220 ANTENATAL PATHOLOGY AND IIYGIENK
Diehl's case is ruiMirted with coiisiileiiilile I'ulue.s.s. The mother
was 36 years of age, and had six normal confinements, but no
abortions, and was pregnant for the seventli time. Having reached
the fifth month, she was attacked by pains and stiffness in the lower
limbs, and had to keep her bed. Slie gave birth to a male fu'tus,
the confinement not being accompanied liy marked bleeding. Soon
afterwards she was found to lie suffering from pur])ura in the skin of
the chest and abdomen, arranged in a somewhat symmetrical manner.
The urine contained blood, and the pulse was small, soft, and (|uick.
She died on tlie third day of the puerperium. The fcetus, like
the mother, showed cutaneous hicmorrhages, with a symmetrical
distribution, but affecting only the head and back; they were
punctiform. Post-mortem examination revealed, in the case of the
mother, numerous internal ha-morrhages in the dura mater, under
the periosteum of the anterior wall of the spinal canal, in the peri-
aortic tissues, in the left crus of the diai)hragm, in the tissue round
the urethra, and in the bladder wall, and elsewhere. The ftetus
showed irregularly distributed hfcmorrhages iii the dura mater, in
the spinal canal, in the visceral layer of the pericardium, in the '
peritoneum, and on the palate; there were no signs of syphilis.
It is unnecessary to refer to the microscopical appearances of the
maternal and fcetal organs ; Ijut it may 1 le noted that in none of
the organs (maternal or fretal) were micro-organisms discovered,
although they were very carefully looked for. Dohrn'.s case {loc.
cit.) resembled the above in certain details, but differed in the fact
that both mother and infant recovered ; the evidence, tlierefore, in
favour of the diagnosis of ftetal purpura rested entirely upon clinical
observation.
The case reported liy V. Hanot and Ch. Luzet {Arch, de mcd. <
expir. ct d'anat. imtli., 1 s., ii. 772, 1890) may be referred to here, as
it is apparently related to purpura, to cerebro-spinal meningitis, and
to sepsis. Briefly stated, the case was as follows : — The mother had
had a normal pregnancy, which ended in the expulsion of a dead ■
full-time foetus. On the day before labour supei'veued, however, she
had become comatose, and a number of purpuric spots had appeared ■
upon the abdomen and on the upper and lower limbs. She died
two days after her confinement, and at the post-mortem examination
a state of sub-acute purulent cerebro-spinal meningitis was dis-
covered, with the streptococcus pyogenes in the meningeal exudation,
in the spleen, liver, and uterus. Tlie foetus, whicli liad evidently not
been long dead, showed iro purpuric spots on the skin, but there were
some hitmorrhages in the pericardial and pleural membranes. In
these petechia^ on the pericardium and in the liver, the streptococcus
pyogenes was found. The authors are of opinion that the maternal
cerebro-spinal meningitis was the ])rimary source of the bacterial
infection, wlience it sjiread to the rest of the bodj' and through the
placenta to the ftetus, causing its infection and death in utero. It
would seem that the case is more nearly allied to fcetal sepsis than'
to foetal purpura ; but, after all, the question may be reasonably
asked, "What is purpura ?
FtETAL PNEUMONIA 221
Fcetal Pneumonia.
Scattered throughout inedical literature are reports of cases in
which the fcetus in utero apparently sutlered from pneumonia. Thus,
in B. C. Hirst's observation (Amcr. Journ. Ohst. xx. 1195, 1887), a
prematurely born infant, who only lived twenty-two hours, showed
marked double catarrhal pneumonia, which the author was inclined
to regard as due to the drawing of meconium into the lungs by the
making of intrauterine inspiratory elforts; the mother in this
instance did not suffer from pneumonia, but from a large lumbar
abscess, so that it is probable that the foetal pneumonia was truly
septic in origin. In two cases of epidemic cerebro-spinal meningitis
in pregnancy observed by P. Foa and G. Bordoni-Ufireduzzi {Deutsche
mcd. Wchmchr., xii. 249, 1886), the mothers suffered from pneumonia
in the stage of red hepatisation, and the foetuses, expelled at tlie
fourth and sixth month respectively, showed in their l)lood and in
the liver the characteristic diplococcus of pneumonia; the micro-
organism was discovered also in the uterine sinuses and in the foetal
portion of the placenta. These authors also demonstrated the passage
of the diplococcus pneumonite iir animals. As was noted with other
transmissible diseases, so with this, it occurs now and again that the
causal microbe is not found in the foetus: thus, in one of E. Levy's
cases {Arch. f. cxpcr. Path. v. Pharmakol., xxvi. 155, 1889), there
was croupous pneumonia in the mother, but the diijlococcus was not
found either in the blood or in the spleen of the fa^tus expelled at
the fifth month of antenatal life. Several cases are on record in
which l>oth mother and infant developed pneumonia (M. Thorner,
Diss. Muiichcn, 1884; Netter, Compt. rend. Soc. de bioL, 9 s., i. 187,
1889; A. Yiti, Bifor/na med., vi. 578, 584, 1890; and M. Delestre,
Comiri. rend. Soc. de hioL, 10 s., v. 150, 1898); but the fostus some-
times had lesions of other pai-ts as well as the lungs, c.ff. of the pleura,
pericardium, and peritoneum. G. Carljonelli's case {liiv. di ostet. e
f/inec, ii. 281, 1891) was peculiar in that, while the foetus showed the
diplococcus of pneumonia in the peritoneal exudation, in the sisleen
and in the blood, the mother had suffered from no infectious disease
during her pregnancy.
It is evident that these cases of ftetal pneumonia have close con-
nections with septic conditions ; indeed, it may be found desiralile in
the future to group them with fcetal sepsis rather than in a division
by themselves. A reference to the geneicil principles which have
been laid down with regard to foetal diseases will make it plain wliy
the lungs are neither often nor exclusively affected in these cases ; the
organs are not in the direct line of the circulation, and are not
supplied with a large amount of blood. Of course, it is not always
possible to exclude infection of the foetal lungs, which has occurred
during the progress of labour, for, when early rupture of the mem-
branes takes place, infected liquor amnii or vaginal secretion may be
sucked into the mouth of the infant, and reach the pulmonary tissues,
setting up inilammatory processes in them. Instances of this intranatal
222 ANTKNATAl. I'ATHOLOCIY AND HY(;1KNK
mode ol' iiifectiiiii have 1pl'(.'ii recorded Ijy Legry and Duljri.sav {An-h
de focoL, xxi. 599, 1894).
Foetal Anthrax.
Although the liacillus aiithraeis v.a.s one of the tir.st microbes
whose passage through the placenta from mother to fcetvis was e.\i)eri-
mentally determined in animals, clinical proof of its transmission in
the case of the human subject has only been forthcoming during
recent years. D. Morisani {Morgagni, xxviii. 523, 188G) recorded an
instance of anthrax in a jiregnant woman, but the fcptus was dead-
born, and no cultures of the liacillus anthracis could be got from
its tissues ; on the other hand, the pregnant woman suHering from
malignant pustule who was seen by S. Eomano {Mdrgwjni, xxx. 458,
1888) gave birth to a living and healthy infant. With regard to the
case observed by F. Marchand {Arch. f. jtath. Anat., cix. 86, 1887),
the mother was found at the autopsj- to have lieen suffering from
anthrax, and the infant developed the same malady ; but the evidence
of intrauterine transmission was defective, for the infection might
have occurred in the act of birth, and, further, the avenue of entrance
of the maternal infection could not be deteriuined. In the placenta,
bacilli were found only in the intervillous spaces. Over against these
negative or practically negative results must be placed, the three
remarkable cases reported by M. J. Eostowzew {Ziachr. f. Grhiirtsh.
u. Gynak., xxxvii. 542, 1897). These were instances of malignant
pustule attacking pregnant women at the eighth, seventli, and fourtii
months respectively, and proving fatal a few days after the expulsion
of the uterine contents. The bacilli of anthrax were found not only
in the placental intervillous sjaaces, liut also in the facial villi ; and
in one case there were luemorrhages into the placental substance,
while in another there was some necrosis either of the sj'ncytium
alone or affecting all the component parts of the villus ; and in the
necrotic areas were the bacilli, Eostowzew also found the characteristic
microbes in the licpior amnii. With regard to the fu>tal tissues (apart
from the chorionic villi), it was noted that some bacilli of anthrax
were to be recognised in the blood and organs, but they were few in
number, and did not stain well with reagents ; possibly they were in
a more or less inactive state, although, as we have seen in respect
to fcetal tuberculosis, there is no reason to believe that the fu'tal
structures have any bactericidal etTect upon germs. From the study
of Eostowzew's cases, it may be considered that, while the germs of
anthrax had made their way to the foetus, tliey had not yet produced
the disease in it ; possibly they had not had sufhcient time. There
is a considerable literature dealing with the transmission of anthrax
from mother to fcetus in the case of animals (E. Perroncito, Arch. itcd.
de hiol., iii. 58, 188:-.: G. Sangalli, E. Isf. Lomh. d. ,sc c Ictt. Rcndic,
Milan, 2 s., xv. 668, 1882 ; I. Straus and C. Ohamberlaud, Gaz. held,
de inM., 2 s., xx. 167, 1883 ; V. Carita, Gior. d. r. Accad. di mcd. di
Torino, 3 s., xxxi. 349, 1883 ; ]\I. Simon, Ztschr. f. Gehiirtsh.u. Gyncik.,
xvii. 12G, 1889: W. Eo.senblath, Arch. f. path. Anat., cxv. 371. 1889;
\
FCETAL ACUTE RHEUMATISM 223
M. E. Latis, Eiforma vml, v. 842, 1889 ; il. E. Latis, L'cHr. z. imth.
Anat. u. z. allij. Path., x. 148, 1891 ; and C. Massa, lil/urma iiicd., xii.,
pt. 2, 531, 1896); but, as has been stated, the cases in wliicli a
pregnant woman has transmitted the malady to her unborn mfant
are few in number.
No instance has yet Ijeen reported in the human subject in which
a mother has transmitted hydrophobia to her foetus ; but in the pre-
sence of the necessary conditions the occurrence is not to be regarded
as impossible. Further, the transmission has actually occurred in the
lower animals; E. Perroncito and Carita (Gior. d. r. Accad. di med. di
Torino, 3 s., xxxv. 122, 1887) inoculated a pregnant rabbit with
rabies in the neighbourhood of the fourth ventricle ; some days later
the contents of the uterus were expelled, and the animal died of
rabies; with the medulla oblongata of two of the living foetuses
which had been expelled, two guinea-pigs were inoculated; one of
these remained healthy, but the other died, and two other guinea-pigs
and a rabbit were inoculated from its medulla ; all the three died with
the symptoms of rabies. The disease had therefore Ijeen transmitted
in the case of some but not of all the foetuses. G. Zagari's experi-
ments {Gior. internaz. d. sc. med., n.s., x. 54, 1888), however, gave
negative results; but Palazzi {Ann. di ostet. e. ginec. xxiii. 570, 1901)
refers to Lisi's possible case of the placental transmission of hydro-
phobia in a bitch, and gives details of a somewhat doubtful instance
in a. cow which had been under his own oljservation. Tiiere seems
to be no reason to doubt that, as with other transmissiljle maladies, so
with hydrophobia, its intrauterine and transplacental transference
from mother to foetus may occasionally occur.
In a case of maternal diabetes mellitus, H. Ludwig {Ccntrlhl. f.
Gijndk., xix. 281, 1895) found an excessive quantity of liquor amnii,
and in that amniotic fluid were very distinct traces of sugar ; he
hazarded the suggestion that possibly this might be an instance of
foetal diabetes. As, however, the infant was born dead, there was no
opportunity of testing the suggestion by the results. Further, E.
Eossa {Centrlbl. f. Gynuk., xx. 657, 1896), in the following year met
with a somewhat similar case ; in it the infant survived birth long
enough to give an opportunity of m-ine analysis ; the nrine contained
no sugar, although the liquor amnii and the maternal urine did.
FcEtal Rheumatic Fever.
Sometimes, although ^'ery rarely, a pregnant woman suffering
from acute rheumatism give.s birth to an infant whose joints are
enlarged and tender ; the presumption then is that rheumatic fever
has been transmitted from mother to foetus in ntero. The case
reported by J. Haig Ferguson {Edinh. Hosj). Eep., i. 608, 1893) was
apparently a well-estaldished example of this transmission. The
mother had twice suffered from rheumatic fever, and was attacked
for the third time at the second month of pregnancy; she was ill
224 ANTENATAI. PATH()L()(iV AND HYdlKNK
tor four iiiontlis, anil tliereafter had rheumatic pains till the full
term; the child at hirth was plump, but ciied when handled, ami
the knees and wrists and fingers were swollen; after hirth it rajiidlv
became emaciated, the swelling of the joints increased, and redness
and tenderness develoiied ; the infant died when ten days old. At
the autopsy the elbows, wrists, and knees were found enlarged, there
was iluid in the knee-joint and in the pericardium ; the bones were
not, however, diseased. A somewhat similar case was that seen liy
F. E. Tocock (ZftHCf^, ii., for 1882, j*. 804): less than twelve hours
after birth the child's temperature was found to be raised, the right
shoulder and elbow were swollen, and the skin covering them was
red ; since, also, these parts were evidently tender to touch, the
diagnosis of congenital rheumatism was made, and salicylate of soda
was administered : the infant made a good recovery. Schicfer's
observation {Berl. kiln. Wcltnschr., xxiii. 79, 188G) closelj' resembles
the foregoing; in it, also, the infant reco\-ered under salicylate nf
soda. Possibly some of the cases which have been reported as
instances of rheumatism in the new-born have been truly antenatal
in their origin ; l^ut even if they be admitted, the total numljer of
observations remains very small. It must also lie l)orne in mind
that septic and gonorrhoeal conditions in the new-liorn may closely
simulate acute rheumatism. It remains as an undouljted fact that,
for some reason, acvite rheumatism is rarely present at birth.
The types of fo;tal disease which have been considered in this
chapter, and more especially tuberculosis, will have suggested and
illustrated several new pathological jiossibilities which arise when
a pregnant woman is the subject of a malady which may be trans-
mitted to her unborn infant. In particular, the reader will have
learned that sometimes the disease itself may not be transmitted,
and yet the pathological state of the mother may produce its effect
upon the foetus, and set up in it morbid conditions which, for want
of a better word, we call dystrophies. This special peculiarity of
foetal pathology will be more fully dealt with in the following
chapter, for it is well demonstrated in connection with fcetal syphilis,
and with that important malady the chapter has to do.
CHAPTER XIV
Types of Transmitted Fu-tal Diseases : FtLtal Syphilis ; Limitation of the
Suliject ; Definitions of Infantile, Keonatal, and Fa'tal Syphilis ; Morbid
Anatomy, General and Special ; Dystrophies of Antenatal Syphilis ; Patho-
genesis ; Nature of the Morbid Agent ; Modes of Transmission of the
Syphilitic A'irus ; Eft'ects of F(jetal Syphilis ; Modifying Influences ; Treat-
ment.
F(ETAL syphilis is the malady that most medical men think of when
reference is made to fcetal disease. It has been studied in all its
aspects and at very considerable length by a multitude of careful
observers. It has been taken as the type of antenatal maladies, as
the typical disease of the foetus ; it may almost be said that, to some
investigators, foetal pathology and foetal syphilis have been synony-
mous terms. It has comparatively seldom been contrasted with the
other known transmitted maladies of the unborn infant ; and it has
scarcely at all been studied in the light of recent generalisations
regarding the phenomena and laws of Antenatal Pathology. The
description of foetal syphilis given in this chapter is not to be looked
upon as in any sense an attempt to equal, far less to surpass, the many
accurate and exhausti\-e accounts of the morbid anatomy and patho-
genesis of the disease which have been set forth by such noted
specialists as Colles, Diday, Hutchinson, F. von Baerensprung, Fiirth,
Fournier, Kassowitz, Heubner, Parrot, and Hochsinger. I intend
simply to consider syphilis as one of the many morbid states which may
be transmitted to the foetus in utero, albeit one of the most important
of these ; to point out in what resi^ects it agrees with or differs from
these other transmitted states ; and to essay to show and illustrate
the manner in which the malady obeys the laws which govern
Antenatal Pathology. To do more than this would be to expand
this chapter into a volume, and so destroy the symmetry of this
Manual of Antenatal Pathology ; to do less, would be to give in-
adequate consideration to a foetal disease of great importance and
with far-reaching consequences.
Limitation of the Subject.
I do not intend, save in an indirect fashion, to describe the
syphihtic manifestations which first appear during the second month
of life. To them the name of infantile syphilis is correctly enough
given. They are due in the great majority of cases to infection whicli
has occurred before birtli ; but in a small minority of instances they
15
22G ANTl-.NATAI. I'ATHOI.OC.Y AND HYGIENE
take tlieir origin in tlit^ iiiUaiialal or in tlio neonatal j)eiiod, and are,
therefore, sometimes of the nature of "ac<niired" syphilis, albeit tlie
acquirement is entirely involuntary and "innocent." Tlie possiliility
of the acquirement of syphilis during the act of parturition has been
doubted; Ijut some few cases have been put upon record {vide,
L. D. Bulkley's Si/phUis in the Innocent, p. 170, 1894), in which a
chancre (" at the root of the nose," " at the inner angle of the eye," ,
etc.) appeared four weeks after birth, and could apparently l)e traced
to recently developed syphilitic lesions of the mother's genitals
(Thiry, Prcssc inhl. hcljjc, xxxvi. 241, 1884). Cases, also, have been
reported in whicli syi)hilis was acquired during the neonatal period,
either from the nurse in lactation or from an infected infant. As a
rule, however, syphilis showing itself for the first time in the second,
month of life has been transmitted to the infant before birth ; in its
clinical manifestations it differs from the acquired ftnins in the
absence of the primary sore and initial glandular enhirgement, and
in other minor details such as the rarity of roseola. It is syphilis
occurring in and being modified by the infantile organism ; it has
characters which are impressed upon it by the peculiarities of the
physiology of the infant {e.g. its fatality, the nature of the cutaneous
lesions) ; and for it, in my opinion, the name infantile sy2}hilis ought
to be rigidly reserved. Like syjihilis in the adult it has the power, iu
a very remarkable degree, of simulating or imitating many non-
syphilitic morbid processes ; there is scarcely a cutaneous malady
that may not thus be simulated, and even affections of the respiratory
circulatory, gastro-intestinal, and nervous systems may be copied
more or less closely by sypliilis. The well-known symptoms and
signs of the disease, as it occurs in infants, it is not my purjiose tc'
consider, they are fully descriljed in countless text-books and mono-
graphs ; l)Ut I may draw the attention of the reader to the striking'
fact that, although the infant is undoubtedly .syphilitic at birth, thi
clinical manifestations of the taint have their appearance delayei
until six weeks or two months liave elapsed. What may be th(.
meaning of this period of freedom from the external signs of thi
disease it is iiot yet possible to determine ; all explanations must bi
more or less of the nature of guesses. It is possible, of course, tha
the extrauterine environment differs so essentially from the intra
uterine that it takes some time for the disease to become eviden
along tlie new lines of development wliicli are imposed upon it b;
the new conditions which surround it. It may be that fa?tal con
ditions favour the occurrence of visceral lesions, while the infantil'
environment predisposes to cutaneous and respiratory changes ; som
time is necessary before the new jiathological departure makes itsel
felt. It is possible, also, that anti-syphilitic treatment of the niothc
before her confinement may have lieneficially affected her fcetus i
utero, and tlial this good effect jiersists for four or five weeks aftc
birth ; but this explanation utterly fails to meet the cases in whic
no uiercmy has Ijeen given to the mother in her pregnancy.
Xeithcr do I intend to discuss fully the syphilitic manifestatior
wliicli occasionallv occur durintr the first month of life. For them tli
NEONATAL SYPHILIS 227
teriu neonatal si/phi/is ought to be reserved, and tliey ought to be dis-
tinguislied from the signs which are actually present at birth and to
which alone the name fivtal si/philis should be applied. Xeonatal
syphilis is comparatively rare, that is to say, the offspring of
syphilitic parents, showing no external indications of the taint
at birth, do not often develop unmistakable manifestations of it
during the first two or three weeks of life. When, however, the
disease is met with at this period of infancy, it has characters which
are to some extent peculiar to it and which are possibly the result of
the peculiar physiological conditions which then pievail. I have
already in Chapter IV. dealt in some detail with the physiology of the
neonatal period, and have emphasised and exemplified the fact that
it is essentially a period of transition, of readjustment, and alteration
of structure and more especially of function to suit the new environ-
ment ; there is no need for me to enter again into details at this
stage. Syphilis, like other maladies which may attack the new-born
infant, has characters impressed upon it which are the result of the
special physiology of the neonatal period of life. For instance, it is
very fatal and very rapidly fatal, a fact which is no doubt partly to be
explained by the transitional nature of the neonatal economy. Death
is then due in all probability to visceral lesions, for such infants come
into the world already carrying in their internal organs the structural
changes due to foetal syphilis ; these changes were to some extent
compatible with intrauterine life, but they seriously interfere with
prolonged extrauterine existence. The only sign of neonatal syphilis
may therefore be rapid death, apparently brought al:iout by a trifling
cause but really due to antenatal vi.sceral lesions which become lethal
under the changed circumstances which follow birth. There may
also, however, be special signs of the syphilis of the new-born. Of
these perhaps the most distinctive is pemjihigus. The bulla; of this
cutaneous affection may be present at birth and the disease be there-
fore truly fojtal ; but very often they do not appear until a few days
liave elapsed. It is a striking fact that the most marked cutaneous
manifestation of neonatal syphilis should be pemjihigus, but it finds
an explanation in the loose attachment of the epidermis to the under-
lying skin at this period of life and in the resulting tendency to
desipiamation. Pemphigus occurs also in the new-born as a sign of
diseases other than syphilis (e.g. sepsis), and is then no doubt due to
the same keratolytic state of the integument ; but the form to which
I now specially refer has peculiarities of its own due to its syphilitic
nature. The bulke contain a blood-stained or purulent fluid ; they
are large and numerous ; they have a special tendency to affect the
palms and soles ; and after rupture they tend to leave irregular ulcers
covered sometimes with a brownish or blood-stained crust. In
syphilis neonatorum, then, pemphigus is apt to occur because the
subject affected is the neio-horn infant, and syphilitic pemphigus of
the new-born has special characters which distinguish it from the
non-syphilitic variety. Another peculiarity of neonatal syphilis is
its hsemorrhagic tendency. So marked is this tendency in some cases,
that the name Si/iihilis hcemorrhagica neonatorum has been introduced
1
228 ANTKNATAL I'ATHOLOGV AND HYGIKNK
(G. IJelaeiKl, Deutsche Zlschr. f. prcdt. Med., v. 28'), :'.01, 1878;
E. Petersen, Vrtljschr. f. Dcrmat., x. 509, 1883 li Fischl, Arch. f.
Kinderl:, viii. 10, 1886-7 ; F. Mracek, Vrtljschr. f. Dcrmat., xiv. 117,
1887 ; etc.), to give expression to it. It would seem (from Mracek's
statistics) that the bleeding most commonly occurs in the skin,
subcutaneous tissue, lungs, and pleura, and less frequently in the
heart and vessels (adventitia), brain, kidneys, scalp, liver, etc. ; but it
may apparently take place in any organ or tissue in the body. It
may be ascribed in part to the direct effect of .syphilis upon the
tissues, and in part to the transitional state of the blood and circula-
tion immediately after birth. Syphilis attacking the new-born child
may also, like that malady in infancy and later life, .simulate or imitate
the diseases which are to some extent peculiar to the neonatal state.
Thus, there is a syphilitic neonatal omplialorrhagia, a syphilitic oedema
neonatorum, a syphilitic jaundice of the new-born, a syphilitic mehena
neonatorum, and sri on. These morbid states are all full of interest,
and they are, moreover, in a sense congenital, being due to a specific
infection which has occiu'red before birth ; Init, as has lieen staled
above, they do not fall to be considered under the heading of fotui
syphilis properly so called.
The name fcetal syphilis ought, in my opinion, to be limited to
the pathological changes which are produced in the organs and
tissues of the unborn infant during the foetal period of antenatal life,
a period wiiich lasts, as will be remembered, from the sixth to the
fortieth week. As will be seen immediately, most of these change-^
are of the nature of diseases, but some few of them are more correctly
to be regarded as deformities. The latter find an explanation in the
fact, to which reference has already been made elsewhere (p. 10), that
all the foetal organs have not completed their development when
they reach the beginning of the foetal period : the syphilitic virus
acting ujion them in their embryonic state will, it may lie supposed,
produce in them malformations rather than diseases. It is in this
way that some of the so-called dystrophies of foetal syphilis are
produced. Theoretically, foetal syjihilis ought to lie sepai-ated from
what may be called emlnyonic and germinal syphilis. It is very
probable that syphilis acting upon the organism in its embryonic
period of antenatal life produces changes of a very different kind
from those met with in the fcetal period. It may ultimately he
found that the former are of the nature of monstrosities and malforma-
tions rather than of diseases in the strict sense of the word. It is
not, however, in the meantime possible to carry out in practice this
separation of the phenomena of fcetal from the phenomena of
embryonic and germinal syphilis ; with fuller knowledge it may yet
be accomplished.
I have thus indicated certain Umitations of the suliject to be
considered in this chapter; Imt it must not be forgotten that there
is another aspect of the matter. It is necessary to bear in mind that
when sypliilis attacks the organism in the fcetal perioil,it attacks not
only the foetus but also the so-called foetal appendages, namely, the
placenta, membranes, cord, and liijuor amnii. There is, therefore, in
PATHOLOGY OF FCKTAL SYl'UlLIS 229
this direction an expansion of the meaning of the term fcctal syphilis.
Although, in my classification of fa'tal morbid states (p. 175), I
have placed diseases and morbid conditions of the fcetal annexa in a
group by themselves, it is not wise to insist too strictly upon this
separation ; and, as a matter of expedience, it will be best in the case
of foetal syphilis to neglect it altogether.
Morbid Anatomy of Foetal Syphilis.
Of the vexed question of the channels by which the syphilitic
virus reaches the ftetus in utero something will be said ere long ; but,
in the meantime, I proceed upon the assumption that fcetal infection
with syphilis is generallj' transplacental. I do not doubt that
syphilis in the father may produce certain effects upon the fcetus
through the fertilising spermatozoon and that syphilis in the mother
may act upon the ovum in the ovary and the emliryo in the uterus ;
I do not deny the possibility of sperminal and germinal infection
leading to syphilitic manifestations in the fcetus, liut, on theoretical
grounds, I regard it as unlikely ; the consideration of these matters,
however, can be more properly taken up after the morbid changes
met with in the f(etus have l>een dealt with. It is provisionally
imderstood, then, that the fa?tus takes syphilis from the mother
through its vascular placental connections, and rarelj', perhaps,
through the medium of the liquor amnii. What, now, are the
pathological changes which may be found in the fcetus at the time
when it is expelled from the uterus ?
General statement. — Fcetal syphilis, being a fcetal disease, will be
subject to the laws that govern fcetal pathology. What these laws
are, a reference to Chapter XI. will show. For instance, the intra-
uterine environment will modify the morbid changes which occur as
the result of syphilitic infection; the cutaneous changes will be
slightly marked or al)sent altogether, and the post-mortem alterations
(when fcetal death occurs) will l)e those due to syphilis associated
with those due to the aseptic surroundings. Again, the placental
factor will have its influence ; if we may judge by analogy, it may be
said that the placenta will in some instances keep back the syphilitic
poison (microbic or toxinic) and so save the fcetus from syphilis ; in
other cases, possibly on account of placental lesions, it will allow it to
pass, and then the fcetal tissues will lie attached in the manner and
order which are peculiar to infections arriving by the umbilical avenue ;
in yet other cases, the placenta will itself become seriously pathological,
and this will entail not fcetal disease so much as fcEtal death ; and
finally, the foetus may become infected through the placenta and then
die on account of lesions in the placenta. From the great frequency
of intrauterine death in cases of maternal syphilis, it may lie con-
cluded that the placenta acts most often in the two last-named ways.
It must, also, be borne in mind, in considering the morljid anatomy
of fcetal syphilis, that some of the changes present may be the results
of the action of syphilis upon the organism in the embryonic or
germinal epochs of antenatal life ; all that is seen in the fcetus at
230 ANTRXATAI, PATHOI.OCIY AND HYGIENE
liirtli is nut necessarily the result of causes acting in the fietal
period; this statement applies with special force to what are called
the syphilitic dystrojihies.
Special morbid anatomy. — Our knowledge of the morbid anatomy
of the various organs and tissues in fcetal syphilis has heen derived
from the study of foetuses born either dead or alive, at or (more
frequently) before the full term of intrauterine existence. In many
details it is unsatisfactory, fur next to nothing is known of the initial
stages, and the changes due solely to intrauterine death have been
persistently confounded with those caused purely by the disease.
Nay more, histological conditions of the organs which are normal in
the ftetus have been described as due to the syphilitic poison. I shall
liegin my consideration of these changes with the description of them
as they are found in the placenta and umbilical cord, for the former
is the most important organ that the fcctus has, and by its pathological
state no doubt much is determined.
The 2^l(<'Ci'nfa. — Alterations in the structure of the ])lacenta in
.syphilis are very frequent although not constant: when they occur
they are very often of the kind to be now described, Imt they are
not invariably so. If, therefore, we give the name "syphilis of the
placenta " to these morbid changes, it must be with the reservation
that, while they are highly suggestive of syphilitic infection, they
are not absolutely jiathognomonic thereof. The pathology of the
syphilitic placenta has been carefully investigated by a consider-
able numlier of workers, including E. Friinkel {Areh. f. Gi/naeh:,
V. 1, 1873); C. Hennig (Ibid., 'vi. Ul, 1873-4): K Hervieux
Arch, de tocoL, vi. 513, 1879); G. B. Ercolani (Bull. d. sc. med. di
Bologna, 6 s., xi. 217, 1883); E. Zilles (Mittli. a. d. rjeburtsh.-gynak.
Klin., zu Tiibimj., i. Hft. 2, p. 1, 1884); A. Gascard (Thhc, Paris,
1885) ; M. Pediciui (Progresso med., Naples, i. 67, etc., 1887) : Thiel
(Dinmi., Wtirzburg, 1889); Piosinski (Dis.'iert., Koni-sber--, 1889);
Vt. E. d'Aulnay (Arch, de tocoL, xxi. 910, 1894); Eckardt (Verhandl.
d. dcutsch. Gcscllschf. Gyniik., vi. 627, 1895); Schwab (Prcsse mM., ]•.
494, 1895); J. D. Bissell (Amer. J. Gyn. and Obst., xi. 147, 1897):
Audebert (Journ. de med. de Bordeaux, xxviii. 82, 1898): and \'.
Wallich (Rev. 2'>rat. d'obst. et de 23a;diat., xi. 33, 1898). By the naked
eye the jilacenta is seen to be larger than normal and ]>aler in colour
— it is of a pale red with yellowish-white patches. When handled it
is to be noted that it is softer than usual and may even be frialile.
In the case of a dead syphilitic fcetus the weight of the ])lacenta is
to that of the body as 1 : 4, whereas in the absence of syphilis it is as
1 : 6 (C. Euge, Ztschr.f. Gehurtsh. u. Gyndl:, i. ."i7, 1877). Under the
microscope the most important change is found to be a diffuse and
gradual inflammation affecting specially tlie blood vessels. There is
well-marked endarteritis and very often a thrombus is to lie seen
in the lumen of the vessel along with indications of periarteritis
outside. These changes are specially developed in the vessels of the
villi, in which also inflammatory proliferation is to be noted in tlie
sti'oma and in the ejiitlielial covering, so that there is considerable
hypertrophy of the villi with fibrous degeneration of their ti.ssues.
PATHOLOGY OF FOiTAL SYPHILIS 231
The quantity of l>lood circulating in the foetal part of the placenta is
thus diminished, and the organ becomes more or less anivniic, with
results to the fcetus which can readily lie understood. But the
maternal part of the placenta may also suffer ; here and there lui'uior-
rhages may be found in it showing various stages of resorption, and
these, partly by their effect on the maternal blood spaces, and partly
by separating the placenta from the uterine wall, tend still further to
diminish the circulation passing through the organ, and so render
fcetal death, which is already probable, almost inevitable. The so-
called " gummata " of the placenta are probably ha?morrhagic in their
origin, or are due to fibrous patches which have become more or less
caseous ; possibly, however, true gummata may in exceptional circum-
'stauces be met with. An attempt has been made to separate into
two groups the morbid alterations which are met with in the placenta
— in one group are placed the changes in the villi and in their
vessels, and when these alone are found it is supposed that the disease
has originated in paternal infection ; in the other are the changes in
the decidual tissues and the parts arising from them, and when these
alone are found a maternal source is predicated — but it can hardly
be safely concluded that any such grouping is warranted by the facts.
It has also been stated that the placental pathology differs with the
date in pregnancy when the infection took place — another statement
which is easily made but with difficulty substantiated or disproved.
The umbilical cord. — The commonly occurring change in the
funis in cases of fcetal sypliilis would appear to be a thickening of
the vessel walls so great as almost to produce obliteration, along with
the formation of thrombi in these narrowed vessels. The vascular
changes in the cord, taken along with the morbid alterations in the
placenta, play no doubt a very important part in diminishing foetal
vitality and leading to intrauterine death. Forming as they do the
first lines of defence, the placenta and cord bear the brunt of the
attack, and being also as it were the key of the position, their failure
to resist is immediately disastrous. In neofoetal life it may indeed
be doubted whether the syphilitic poison very often reaches the
organism at all ; it attacks the decidual membranes and leads rapidly
to abortion by the changes produced in them. Among other changes
in the cord in cases of syphilis, absence of the jelly of Wharton causing
dissociation of the vessels has also been observed (Mace and Durante,
Ann. de gym'c, xliv. 221, 1895).
The liquor amnii. — There can be no reasonable doubt that a
quantitative change in the amniotic fluid is a very frequent result
of foetal syphilis. Hydramnios is so common in connection with this
malady, that some have been tempted to regard excess of the liquor
amnii as pathognomonic of syphilis. This conclusion, however, is
not warranted, indeed it must be conceded that hydramnios is very
common in all pathological states of the fwtus ; it is pathognomonic
rather of fcetal disease and deformity than of any one foetal disease
or deformity. At the same time, this generalisation does not in any
way lessen the value of the well-established fact that hydramnios
is common in foetal syphilis, it only prevents us from ascribing too
232 ANTKNATAL I'ATlIOLOCiY ANIJ llVCilKNF,
.threat u diagnostic importance to it. The association of liydianinids
with syphiHs does not aid very materially in clearing uj) the vexed
(juestion of the origin of the liquor amuii; it does not even enable us
to allirm its maternal or fcetal origin. Apparently there may be
iiydramnios, not only when the fo?tus is distinctly .syphilitic but also
when tiie fcetus is free and the niotiier alone afiected. It is, however,
a fair working hypothesis to regard tlie hydramuios as largely due to
increased pressure in the umbilical vein, caused by lesions in the
placenta, in the cord itself, or in the fcctal liver ; it may be compared
with postnatal ascites due to circulatory troubles in the portal
system, and it may even be regarded as taking the place of portal
ascites in the fcetal economy {v. P. Bar, L'hydramnios, These, Paris,
1881). Cardiac and pulmonary lesions in syphilitic fretuses may*
also impede the circulation and lead to hydranmios. Possibly, then,
it may lie safe to regard the presence of hydramuios as of grave
import in cases of syphilis, for the reason that it indicates visceral
lesions in the foetal economy (placental, funic, liepatic, pulmonary,
or cardiac) ; but it is wise to be slow, very slow to formulate views
on these matters, the antenatal pathologist being like a storm-tosstd
mariner with a continual lee-shore largely unknown to him but
dangerously near. Meanwhile, let the reader keep in mind the
association of hydramuios and fuetal .syphilis. IVIuch nuglit be learned
from carefully made analyses of the composition of the liquor aninii
in cases of foetal .syphilis in which the foetus is alive at birth ; but
alas • such analyses are sadly wanting. Quantitative alteration in the
amniotic fluid in this foetal malady then is undoubted ; qualitative
changes probably almost certainly exist, but are of unknown nature.
The liver. — Next in importance to the changes in the placenta
must be ranked those of the liver, for the foetus is largely dependent
upon the state of its placental and hepatic tissues. The occurrence
of birth excludes the placental factor, and thereafter the liver shares
with the lungs the tirst place in pathogenesis ; in the uew-born infant,
therefore, .syphilitic alterations in the lungs and liver are of great
moment. Yet with regard at least to the" hepatic alterations, little
or nothing was known till 1849, when A. Gubler published his article
on .syphilitic jaundice {Bull. Soc. Anal, dc Paris, xxiv. 66, 1849) ; since
then many monographs dealing with the same subject have appeared,
among which that by Lucien Hudelo {Contrihution a I'l'tude des lesions
dufoie dans la si/philis hMditaire, Varis, 1890) may he singled out
for special mention ; but Gubler it was who broke fresh ground in
this direction — a memorable name and date therefore — Gubler IS.'tO.
To be quite exact it was in 1847 that Gubler first noted .special
changes in the liver of the sypliilitic new-born infant, but the
publication of the fact was in 1849. What, then, are the changes
met with in the foetal liver in syphilis ?
In the first place, lest I by any cliance omit to make the state-
ment, tlie liver may show no alterations whatever, exhibiting only tlie
naked-eye and microscopic cliaracters common to all new-born infants ;
in other cases in which the ftctus has died in utero, the organ will
reveal the aiipearances due to macerative change, and these may
1
Plate x
PATHOLOGY OF F(ETAL SYPHILIS 233
entirely obscure any specific peculiarities. This statement is true
not only o^ tlir- liver but also of all the organs in foetal syphilis.
In tht second place, the liver may be the seat of very special
changes, macroscopic and microscopic. To the liver thus altered by
syphilis the French writers have given the names " foie silex " (Hint
liver) and "foie silex avec grains de semoule" (Hint liver with
semolina grains) ; the two names to some extent indicate two
diH'erent alterations, for the " flint liver " may show none of the
" semolina grains " ; but it is common to find the two groups of
lesions combined in the same liver, the semolina change being the
usual concomitant of the flinty (" c'est la satellite habituelle de la
li'sion silex," Hudelo). Some years ago I obtained from an lui-
doubledly syphilitic fcetus the liver which is produced in I'late X.,
it exhibits very clearly the " semolina grain " appearance. The flint
liver (" foie silex ") is larger and heavier than normal and its margins
are rounded ; its surface is smooth, and the consistence of the organ is
much incrtuised ;ind at the same time is elastic; the colour has been com-
pareil to that of tlint (hence the name " silex "), and on ections this
colu'-n*'' m is very evident, along with a semi -transparency and a loss
of th< outlines of the lobules. Sometimes the flint appearance is
genei 1 ("foie silex generalise"); at other times there are two
eolo- to be recognised, the flint tint and a rather deep b'-owuish-red
('■ f' i' ilex partiel "). Most commonly , as has already been hi.ited,
th< ci.rious semolinp-grain aspect is found in association with the
yello'v fl'nt chan-re (Plate X.). When a section of the organ is care-
f^'ly 3y imined, it can be noted that scattered here and there are little
opuXj . white spots not unlike grains of flour or semolina ; many (if
th«-i... e a diameter not greater than one millimeter; they are
coiiv »y arranged in groups with the larger ones at the centre; and
they are nu .^ numerous and of greater size in the partial form of the
flint liv.H. Under the microscope several changes can be recognised,
which are doubtless stages in the process which results in the produc-
tion of the flint liver with semolina grains. There may be simply a
generalised in'.ltration with embryonic colls, a change which Hudelo
(loc. cil.) "ound only in foetuses born preuiuturely ; the infiltration may
be the result of diapedesis or of prolifei'ation of connective-tissue cells
or even possibly of the hepatic cells themselves. In other cases there
may exist small patches of fibrous tissue, which proliably precede the
difl'use sclerotic change which is characteristic of the typical flint
liver of foetal syphilid. This diffuse interstitial sclerosis was called
fibro-plastic induration by Gubler, and infiltrating syphiloma by
Wagner ; it may be generalised or partial in extent. Some of the
liver cells remain unaltered, but many of them in the neighbourhood
of the chief tracts of sclerotic tissue show various stages of atrophy.
Tlie portal spaces are enlarged on account of the presence of much
fibrous tissue in them; the bile-ducts in these spaces are usually
quite unaltered, but the veins and sometimes the arteries also show
thickened walls and a diminished calibre. The capsule of the organ
sliows httle change. It has been stated that there are histological
signs of an exaggeration of the haematopoietic function of the liver in
234 ANT]'.NATAL I'ATII()L()(;Y AND HYGIENE
fcEtal syphilis. UiuIlt liu' uiici'n.sedjit' the scuiohiia grains ("miHai\-
syphiloinata " <>f Wagner, " miliary gumniata" of Virchow) pieseut
themselves as rounded collections (circular, oval, elliptical) of nuclei,
varying in number from twenty to one lunnlred in each grain, and
situated both in the hepatic lobules and in the portal spaces. They
vary in size from quite microscopical structures to bodies having the
diameter of a portal sjaace. They would appear to originate iu the
neighbourhood of the vessels, and may arise from diapedesis or from
proliferation of the enddthelium nf the capillaries.
In the third place, the liver in the syphilitic foetus may occasion-
ally show changes of a gummatous kind which are more commonly
associated with the manifestations of pmstnatal syphilis. For instance,
nodular gunnnatous hepatitis has, in a few cases, been met with in
premature foetuses : the viscus is brownish-red or normal in colour,
slightly increased or normal in size, and of an unaltered consistence ;
in it are the gummatous nodules, size of a jiin-head to that of a pea or
bean, lying on the surface or embedded in the suljstance of the organ,
circular or less regular in form, greyish-white or yellow in colour,
firm in consistence, and not to be enucleated from the sin-roundlug
hepatic tissue. Doubtless they represent a later stage than the
miliary syphilomata (semolina grains). Under the microscope they
show degeneration at the centre, and sometimes giant cells are found.
The presence of recognisable gummata like those of postnatal syphilis
is very uncommon in the foetal liver, but some few cases have been
reported {e.g. Hervey, Bull Soc. mat. dc Far. (1870), xlv. 2(jr, 1874).
In the foiirth place, changes which are not in any way distinctive
of syphilis may be met with in the liver. For instance, wa.-y dc
generation of the hepatic tissue has been found in patches and usuar
in association with gummatous nodules ; liut it is rare in the fcetus or
new-born infant.
Such, then, are the structural lesions met with in the liver of the
syphilitic fcetus ; but it may be added that the capsule may show
thickening (perihepatitis), that the portal vein and hepatic artery in
their course outside the liver may exhibit hyperplastic changes in
their walls, and that the bile-ducts may be obliterated. That the
hepatic changes taken as a whole represent for the fcetus the chancre
of syphilis acquired postnatally, can hardly be considered as probaiile ;
the early appearance of gummatous nodules must Itc regarded as due
to the factors which come into play in /dial syphilis and which are
common to all fcetal maladies. There is a hypertrophic cirrhosis
arising ^jrobably in the neighbourhood of the vessels which by it are
compressed and obliterated ; and although such changes may not
develop till late in postnatal syphilis, in the antenatal malady there
are circumstances which permit their jirecocious evolution.
T/ic lunr/s. — It has been maintained that pulmonary lesions are
more fre([uent in foetal syphilis than hepatic lesions (I*. Bar, lor. cit.),
but there are special reasons why the pulmonary changes are more
often observed {e.g. greater resistance ottered liy the lungs to macer-
ative changes, earlier postnatal death from ])ulmonary than from
hepatic alterations, etc.), and possibly tliey are not really more
PATHOLOGY OF F(KTAL SYPHILIS 235
connnon. Like the chauges in the liver to which refeieiicc has
been made, they are no doulit largely instrumental in leading to
the production of hydranmios through obstruction of the circulation.
The morbid anatomy of the lungs resembles in many points that of
the liver, and the patliological appeai-ances fall into four categories.
There may be (1) a generalised, diffuse gelatinous infiltration —
pneumonia gelatinosa specifica ; (2) a form in which there exist
thickened patches, white in colour, and consisting of air vesicles
crowded with epithelial cells in a state of fatty degeneration —
pneumonia alba syphilitica; (3) a variety in which there are
scattered miliary syphiloniata (gummatous growths) with signs of
interstitial pneumonia in their neighljourhood ; and (4) clearly
marked interstitial fibroid pneumonia due to hyperplasia of the
liulnionary connective-tissue — pneumonia interstitialis fibrosa chronica
congenita. Much remains to be done to clear up the pathology of the
pulinonary changes in fostal syphilis and to differentiate between
the syphilitic lesions and those caused by e.g. foetal tubercle and
foetal or intranatal sepsis.
The heart, blood resscls, and blood. — Changes in the heart have
not been often noted, but miliary syphiloniata and rarely gummata
may be met with in its substance. The vessels, as will douljtless
have been ah-eady gathered, show, as a rule, widespread and almost
constant alterations, consisting for the most part in endarteritis and
periarteritis with resulting diminution in calibre. According to
Helmut Scharfe (Hegar's Beifr. z. Geburtsh. u. Gynael:, iii. 368, 1900),
the antenatal death of the syphilitic fcetus is often due to narrowing
of the ductus arteriosus through changes of the above kind (" durch
kolossale Intimawucherung "). Bar and Tissier {Ann. dc dermal, et
syph., 3 s., vi. 1156, 1895) also deal with this generalised periarteritis of
foetal syphilis. Observations on the blood of the syphilitic foetus are
sadly lacking, even in the case of the new-born infant they are few :
but it seems reasonable to expect that some changes are present in
both the fluid and corpuscular elements of the blood. After birth, at
any rate, a pseudo-leukciemic an;emia has been described ; and F. Cima
{Pediatria, vi. No. 12, 1898) found marked diminution in the amount
of hivmoglobin, some poikilocytosis of the red cells, but no leuco-
cytosis other than that commonly present during the first weeks of life.
There is a fruitful field for investigation in the examination of blood
from the umbilical cord in the case of syphilitic foetuses ; information
is also lacking as to the value of the Justus blood-test in the new-born,
and the bacillus of syphilis (when isolated) will have to be carefully
looked for in the blood of the cord and placenta.
The thymus. — Morliid alterations in the thymus gland have long
lieen descriljed in connection with foetal syphilis, and it has been
customary to regard them as of the nature of small abscesses or
degenerated patches of syphiloniata; but there is some reason to
look upon them as cystic formations in developmental epithelial and
glandular relics emliedded in the thymus (Otto Eberle, Uebcr eongcnitale
Lxtes der Thymus. Diss., Ziirich, 1894). Their precise pathological
significance and relation to syphilis are unsettled. The gland may
236 ANTENATAL PATHOLOGY AND HYGIENE
he uoriuiil ill size and weii^ht ; it may also exliibit induration
(E. Schlesinger, Arch.f. Kiiidcrhll:, xxvi. 205, 1899.).
The suprarenal capsules. — The adrenals are usually somewhat
enlarged, and histologically they may exhibit an infiltration with
embryonic cells, or a hyperplasia of the connective-tissue witli atrophy
of the cells peculiar to the organs. In some cases hyjjertrophy of the
epitiielial cells has been noted, constituting what may be looked ujion
as small adenomata; ha-morrliages are not uncommon, Init are proliably
in no way characteristic of syphilis. (L. Petit, Lesions ties capsules
stirrcnales dans la syphilis eowjenitcde. These, Lyun, 1900-190L)
The spleen. — This organ is practically always enlarged in the
syphilitic foetus (E. Keckev, Dcutsches Arch.f. klin. Med.,\y.\. 1, 1898),
There is a spilenitis ^Mc</crt, although Bar {loe. eit.) did not meet with il
in the cases examined Iiy him, and regarded the hypertrf>phy as purely
the result of circulatory disturbances in the portal system. There is a
small-celled iutiltration of the large and medium-sized l>lood vessels.
Tlie pancreas. — In the pancreas, lesions similar to those in the liver
may be encountered; there is a small-celled iutiltration, with fil)rous
tissue formation, induration, and consequent hypertrophy of the organ.
The vascular walls are thickened, while the proper epithelial tissue of
the gland is in a more or less atrophic state. The vveight is increased.
The kifbici/s. — The kidneys, like the other organs in the syjihilitir
foetus, show an increase in weight so that they become one eighth-
sixth instead of about one hundred and twentv-third of the total liodv
weight (Hecker, Jahrb. f. Kinderhlk., n. F.," i. 375, 1900). Of late
their histology has been accurately studied Ijy Hecker {loe. eit.), and in
a very complete fashion liy J. J. Karvouen (Die Nicrcnsyphilis, Akad.
Abhandl., Helsingfors, 1898). The latter writer states that renal
lesions are rarely met with in the syphilitic fcetus, possibly l)ecause it
perishes before they have time to develop : but the former found
them in every one of ten dead-born syphilitic fietuses. At first there
is a small-celled infiltration of the small vessels of the cortex and
sometimes of the larger vessels of the medulla ; frequently also tliere
co-exist a proliferation of the interstitial connective-tissue and an
endo- and peri-arteritis of the small vessels of the cortex. In full-
time fcetuses the vascular and perivascular infiltration is less marked,
but degeneration, more or less marked, of the epithelium is quite
recognisable. It is rare to find parenchymatous lesions unless the
fictus has survived birth. A most interesting histological pecvdiarity
— the presence in the kidney substance of fcctal epithelial relics — is
discussed at length l)y Carl Hochsinger (Studicn nher die hcreditdei
Si/2}hilis, p. 415, 1898); it was pointed out by Stroebe some ten years
ago {Cenfrlbl.f. all;/. Path. u. path. Anat., ii. 1009, 1891).
The intestines and peritoneum. — Intestinal lesions in fo'tal syphilis
{e.g. atrophy of small intestine) have not been often describeil. but fur
many years antenatal j)eritonitis has lieen regarded as sypliilitic i)i
nature. As long ago as 1838, J. Y. Simpson pointed out this associa-
tion of ])eritonitis and sy])liilis, and stated that " a great proportion nf
those children that die in the latter months of pregnancy may yet
be shown to have perislied under attacks of peritoneal inliannnation
\
PATHOLOCiY OF I-XETAL SYPHILIS 237
(ObsM)-ic IJ'orls. vol. ii. p. ]52, 185G). Xn doubt peritonitis, oI'Ilmi
accompanied by eftiisiou (fcetal ascites), is fre(piently met with in
syphilis; but it is not, of course, pathognomonic, and it may arise
from quite other causes. The presence of fluid in the peritoneal
cavity, in the absence of other changes, cannot be regarded as peri-
touitis; there must be not only serum but also flakes of lymph, and
the intestinal coils must lie more or less adherent to each other and to
the abdominal viscera. In the case of syphilitic fcetuses that have
succumbed in utero and undergone a certain degree of maceration, the
presence or absence of peritonitis is most difficult to determine. The
other serous cavities may likewise contain fluid effusions (e.g. hydro-
cephalus, hydropericardium, and hj-drothorax).
The testicles. — The changes in the testicles resemble those in the
other viscera. There is a small-celled infiltration of the connective-
tissue in the neighbourhood of the vessels, and at a later stage the
special tissue of the organ becomes affected by the surrounding sclerosis,
and atrophy of the seminiferous tubules follows.
The nervous system. — That the nervous tissues suffer in foeta!
syphilis cannot he doubted ; but the morbid alterations that are
found in them are better described as malformations or dystrophies
than as diseases. The reason is probably to be found in the fact that
the brain is, even at the end of the foetal period, still in a state of
incomplete development, and that peccant matters acting ujMn it will
therefore determine anomalies of construction rather than diseases in
the strict sense of the word. To these dystrophic states I shall
return immediately. The spinal cord, however, which is almost fully
developed at birth, may show signs of fa?tal syphilis ; these take the
form of diffuse meningo-myelitis with an infiltration of small cells,
and lead to a pathological state resend^ling in nature the interstitial
hepatitis which has been described above (Gilles de la Tourette, A'^our.
iconor/. de la Salpetriere, ix. 80, 1896).
The skeleton. — The osseous sy.steni, like the nervous, is in a state
of development even at the time of birth, and is therefore like it
also the seat of malformations ; but in addition to these, to which
reference will again be made, it shows frequently some ^'erv charac-
teristic changes which fall into the category of diseases. To these
changes the name of Wee/ner's sign has been given, for G. Wegner
was the first to draw special attention to their diagnostic importance
(Arch. f. path. Anat., 1. 305, 1870). At the dividing line between
the diaphysis and the epiphysis of a long bone such as the tibia, there
is a jagged, broad yellow line separating the bone of the shaft from
the cartilage of the extremity. In non-syphilitic foetuses there is
no such line, there being simply a sharply defined boundary where
cartilage ceases and osseous tissue begins. To ascertain the presence
of this yellow line of foetal syphilis, the head of one of the long bones
(e.g. of the femur) is cut down upon, and, having been exposed, is
split vertically by means of a strong cartilage knife. The condition
may be found in various stages or degrees from a slight thickening
of the normal thin white dividing line to the marked, broad, irregular
yellow tract described above. In the major degrees there may be
2:'.8 ANTENATAL I'ATHOLOC;^' AND HYC.IF.NK
also some ihickeuiiii,' of Ihe pciinsleum aiul peiicliuiiilriuni. Tlie
process which leails lo these (■han<j;es lias lieeii called syphilitic osteo-
chondritis ; the iiewly-l'ormed cells between the cartilage and the
hone are of low vitality, and undergo degenerative changes of a
fatty or caseous kind. During or after birth, separation of ihe
head from the shaft of a long bone may take place ; possibly
this may also occur in utero with subse([uent healing of the
separation and the formation of much callus (osteojjhyte). Other
conditions of the bones (both long and Hat) have been described
in connection with syphilis ; and J. Parrot {La syphHU ht'rMilairc
ct Ic rachitis, Paris, 1886) has gone so far as to state that racliitic
changes are always the results of the action of the syphilitic
virus, a statement, however, wliicli lias not been cunfiruu'd by
others.
Such are the visceral and skeletal changes which may lie met
with in the syphilitic fcctus ; it cannot be athrmed that any one of
them must Ije present in order to prove the e.xistence of fu'tal
syphilis, but the presence of several of them in condiinatiou may be
held to fulfil all the requirements of even an e.xacting diagnosis.
It may even be found that the presence of the peculiar osteo-
chondritis of the long bones is sutticient in itself to constitute a post-
mortem diagnosis of the malady, but it is not invariably present.
T!ie association of increase in weight of the viscera, along with the
bone changes and those in the liver, kidneys, lungs, and tliynuis,
ought to enable the pathologist to be certain that he is dealing with
foatal syphilis ; and there need to be no doubt at all if there exist
also placental changes and hydramnios.
In order, however, to complete our survey of the morliid anatomy
of foetal syphilis, we must pass in review the alterations met with
in the skin and subcutaneous tissue at the moment of birth.
The skin. — The .syphilitic fcrtus may come into the world with
the bulke of pemphigus in full eruption ; the characters of this
syphilitic form of pemphigus have been already described, and need
not be dealt with further, but it may be remarked in passing, that
this cutaneous manifestation of the disease is {when it hapiKns to he
present) of very great diagnostic value. Besides pemphigus, however,
the skin may show an alteration to which the name of ichthyosis
has sometimes been applied. Let it be at once noted that this con-
dition is not the same as that called fietal ichthyosis: that is a
malady which will be described as one of the tyjies of the idiopathic
diseases of antenatal life ; it has very clearly marked characters, and
is nearly always associated with an absence of all indications of
syphilis in the parents. The condition referred to liere, as occurring
in the syphilitic fn-tus, is more of the nature of an excessive cuticular
desquamation, a pseudo-ichthyosis. It shades off by degrees into the
inacerative states of the skin fnund in the sy]ihilitie fictus which has
died in utero. It must, however, be borne in mind that, although the
.syphilitic infant often dies in utero, and is expelled showing all the
alterations due to ]>ost-mortem maceration, yet a macerated fcctus is
not necessarily a syphilitic fietus. It is doubtful, indeed, whether
DYSTROPHIES OF ANTENATAL SYPHILIS L'^O
there are any jieculiarities about the inacerative changes in fci'tal
syphilis which will enable the pathologist to ditterentiate tliem from
the alterations whicli follow upon intrauterine deatli due to non-
syphilitic causes. If death have not preceded birth too long, it may
be possible from the discovery of the characteristic osseoiis, hepatic,
renal, aud pulmonary changes, to state definitely that here was a case
of death from syphilis; but in many instances no such conclusion
can be safely drawn. Certainly the condition known as hydrops san-
(jwinolcntus, which is simply well-marked maceration, is not of neces-
sity syphilitic. General tVctal dropsy or general anasarca of the infant
born ahve may sometimes be syphilitic in origin, but assuredly it is
not always so, being, in fact, a symptom of various morbid states
rather than itself a distinct morbid entity. Finally, in describing
the cutaneous manifestations of foetal syphilis, it has to be noted
that the eruptions (erythematous, papular, and the like) which are
so characteristic of the malady in infants are seldom present at birth,
at least have seldom been noticed then ; this immunity may perhaps
be due to the intrauterine environment (as has already been sug-
gested).
It may be added that fissures, ulcerations, and condylomata
about the mouth and anus, as well as other syphilitic affections of the
mucous membranes, would appear to be rarely observed in the
syphilitic infant at the moment of birth.
It must be borne in mind, that of the pathological conditions
which have been described, many are rarely met with, while some-
times hardly any of them will be markedly present. On the other
hand, the pathologist occasionally, although perhaps very rarely,
meets with a case in which nearly all of them can be recognised in
the same fcetus. Thus G. Mathewsou {Prag. vied. Wchnschr., xx.
llo, 1895) has described a seven-months' foetus in which there were
the following morbid states : pemphigus ; encephalitis ; gummata of
the meninges, thymus, lungs, myocardium, liver, kidneys, and right
femur ; hypertroi^hy of the spleen ; osteo-chondritis in the long
bones ; multiple ecchymoses ; hydrothorax and ascites ; and placental
infarcts.
Dystrophies of Antenatal Syphilis.
Now, in order to complete the picture of the morbid anatomy of
foetal syphilis, it is necessary to mention what ha^'e been called the
dystrophics. A reference to what has been written on page 185 con-
ceruing the embryonic factor in foetal pathology, will enable the
reader better to understand the relation of the dystrophies to the
ordinary pathological changes of antenatal syphilis. It has already
been pointed out in the description of foetal typhoid and fcetal
tubercle (pp. 201, 214), that sometimes the infant of a woman
suffering from one of these maladies showed not the ordinary mani-
festations of typhoid or tubercle, but slight anomalies of structure, or
actual malformations, or abnormal tissue reactions leading to early
postnatal debility and death. In the case of tubercle, I called these
240 ANTFAATAI, I'AIIlOI.OCiV AND HYGIENE
the nou-liiln;rcul;u- manifestations of antenatal tuliercle; similarly in
the case of syiihilis they might be called the uon-syphilitic mani-
festations of antenatal syphilis. At the same time this nomenclature,
although in one sense convenient, is probalily the ei;]iression of an
erroneous conception of the real nature of the malformations and
anomalous tissue reactions which are met with in the otlspring of
tubercular or syphilitic parents. Perhaps it is best (in the ease
of foetal syphilis, at any rate) to retain the name "dystrophies."
What then are these dystrophies which are found sometimes in the
foetuses of syphilitic parents, and what is the probable explanation
of their mode of origin ?
Eduiond Fournier has written a large work (Stu/matcs dysiroph-
iqucs do I'/u'n'do-si/philis, Paris, 18f)8), into which he has condensed
most of the information which has been accumulated regarding
foetal dystrophic states. Fournier points out that syphilis has two
sorts of hereditary consequences, namely, (1) the transmission of
syphilis itself, in nature and in substance, from the ascendant to
the descendant : and (2) the transmission of various pathological
characters, having nothing syphilic in them, and consisting either in
innate inferiorities of constitution, of temperament, or of vital resist-
ance, or in arrests and imperfections, as shown in deviations of
physical and intellectual development, in organic malfornuitions, and
even in monstrosities. The first of these groups of pathological
conserpiences constitutes syphilitic heredity proper, and the second
may be called the dystrophic, parasyphilitic, or toxinic results of
syphilitic heredity. I may interpolate here my objection to the use
of the woi-d " heredity " in the above senses ; to my mind, it is less
likely to confuse, if one speaks of two sets of consequences of the
transmission of the syphilitic poison from parents to offspring: (1)
the ordinary pathological manifestations of syphilis, e.(/. small-celled
infiltration, thickening of vessel-walls, syphilomata ; and (2) the
syphilitic dystrophies or anomalies of structure and of tissue re-
action, which difi'er from the patently syphilitic manifestations of the
first group.
It is impossible to give in detail the description of the various
dystrophies that Fournier has found in the progeny of syphilitics ;
but I have cast some of them into the following tabular statement : —
A. General Dystrophies —
1. Simian or senile pliy.'^iognomy.
2. Infantilism and " dwavf-fa'tus."
3. Rachitis (?).
4. Osteogenic exostoses.
B. Parti. \i. Dystrophies —
1. Cranial dystrophies, including cranial malformations, asym-
metry, synostoses, microcc]ihalv, and hydrocephaly.
2. Dental and maxillary d3'strophies, including microdontisiii,
absence of certain teeth, dental vulnerability, and iiial-
formatious of the jaws.
DYSTROPHIES OF ANTENATAL SYPHILIS 241
3. Hare-lip, cleft palate, and occlusion of nares.
4. (Jcular and aural dystrophies, including colobonia, strabismus,
and various malformations of the external ear.
5. Spinal malformations, e.g. spina bifida and scoliosis.
6. Dystrophies of the limbs, including partial giantism, micro-
niely, Polydactyly, syndactyly', ectrodactyly, ectromely,
congenital dislocation of the hip, and club-foot.
7. Cerebral dystrophies and anomalies of the spinal cord, deaf-
mutism.
8. Cardiac and vascular anomalies, congenital cyanosis, Kay-
naud's disease.
9. Anomalies of the digestive sj'stem, e.g. anal iniiierforation,
hernia.
10. Genito-urinary malformations, e.g. vesical and testicular
ectopia, epispadias, cryptorchidy, uterine and vulvar
anomalies.
11. Cutaneous dystrophies, including ichthyosis, alopecia,
nrevi, scleroderma, and dermoid cysts.
12. Anomalies of the fcetal annexa, e.g. tightness of amnion,
hydatid mole.
13. Monstrosities, e.g. exomphalos, anencephalus, pseuden-
cephaly, meningocele, etc. etc.
C. Dystrophies of Intellectual Development —
1. Eetarded development, e.g. backwardness.
2. Arrested development, e.g. idiocy.
D. Dystrophies op Predisposition —
1. Hsemorrhagic diathesis, general or liieal obesity, and par-
o.xysmal hsemoglobinuria.
2. Tubercle.
3. Nervous diseases, e.g. convulsions, Little's disease, epilepsy,
hysteria, neurasthenia, etc.
Truly the dystrophies of syphilis, as enumeiated by Fournier, con-
stitute a lengthy and imposing list. Of course, it is not claimed
that in all the individual cases narrated in Fournier's work {oji.
cit), syphilis was the cause of the dystrophy ; in some instances
the malformation and the syphilitic taint were no doubt accidentally
associated; but the important conclusion remains that we cannot
regard the co-existence of anomalies of structure {and more especially of
malformations) and a syphilitic parentage as accidental. In isolated
cases the association may be a coincidence, but the coincidences are
numerous enough to enable us to affirm a relation of cause and effect.
Xumerous as are the recorded dystrophic states which have been found
in syphilitic offspring, I would add to their number the instances
of the presence of embryonic relics in the thymus gland and kidneys,
to which reference has already been made.
It may be insinuated that the very variety of the dystrophies
is proof that they cannot be of syphilitic origin; but it may be
said in answer that the polymorphism of syphilitic manifestations
i6
242 ANTKXATAI. PA 11 lOI.OdV AM) HYGIENK
('-.(/. tlie cut;uK'inis iilil'ctioiis of infantile KVphilis) is pruvt'i-hial. A
niiiie inijiortanl oljjeclion is fimnd in the remark that many of tiie
dystrojiliic states named in connection with antenatal syphilis may be
found also in the progeny of tuljercular and alcoholic parents. That
is quite true; but, as will be shown immediately, when the probable
explanation of these parasyphilitic signs is considered, this is just
what might be expected.
If the reader will now turn back to pages 7-12 and 185, he will
be the better able to understand the explanation of the dystro])liies
which is here set forth. He will Hnd it pointed out in these passages
that before the fa>tal period of antenatal life there is a formative or
embryonic epoch dviring which the organs are being constructed. It
may be taken as a good working hypothesis that morbid agents, such
as the virus of syphilis, acting upon the organism in this organ-
forming period, will produce results of the nature of malformations
{i.e. malforming of organs). It may be supposed, therefore, that some
of the dystrophies are due to the action of the syphilitic poison or
toxin upon the organism in its embryonic state, i.e. in the first six
weeks of pregnancy. The dystrophies so produced will be of a grave
character, e.g. monstrosities, and such malformations as hare-li]>,
exstrophy of the bladder, and anal imperf oration ; for it is ^ery
improbaljle that any morljid agent could produce these changes after
the embryonic period is past. But, further, it will be remembered
that I pointed out in my corrected scheme of antenatal life {vide
p. 10), that all organ-formation is not finished in the embryonic
period; some embryonic developments occur during the fo'tal period,
among which may be mentioned the complete formation of the .skin
and its appendages, of the genital organs, of the limbs, of the eye and
ear, of the face, of the brain, and of the skeleton {ride " Scheme of
Development of Organs," on p. 97). Let us suppose, then, that the
morbid agent {e.g. syphilis) continues to act tipon the organism in its
fcetal epoch of intrauterine life, it will interfere with the yiroper
formation of the organs which are now in the formative p.hase, lho.se,
namely, that have been mentioned above. So here again a series of
dystrophies will arise of a less grave type, and afiecting the skeleton,
the limbs, the face, and sense organs, the skin, the genitals, and
the brain. If the reader will glance at Fournier's list of dystrojihies,
he will find just these very organs holding a foremost place. But it
will no doubt have been already noted that some of the dystrophies
therein enumerated are the dental anomalies and infantilism, that is ,
to say, malformations which cannot well be supposed to have originated ;
in the fcetal period. But, as I pointed out in the scheme already ;
referred to {vide p. 10), some small amount of organ-formation takes
place in postnatal \Ue, e.g. the teeth, and it is also after birth that;
there is a continuance of the growth of all the tissues and organ.=.
It must, tlieu, be seen that dystrophies d\ie to the continued (ii^.-it-
natal) intiuence of the syphilitic or other virus will take the form
of dental and growth anomalies, that is, they will find expression in|
the sjiecial pathological possibilities of the epoch. It thus comes
about that one morbid cau.se can yet produce such diverse anomalies
PATHOGENESIS OF FCETAL SYPHILIS 243
iiuil lualt'ormatioiis as are euuuiei'ated in Founiiev's list nf ilystrophies.
The dystrophies, let it be also uoted, luay occur in combination with
the ordinary pathological changes of syphilis, or (rarely perhaps)
alone. The ordinary manifestations of syphilis, I take it, are those
due to the action of the virus upon the organs or tissues whose
development is so to say complete, which have in other words passed
out of the embryonic stage and entered the epoch of growth and
functional activity. It is quite possible, therefore, that l)oth the
dystrophies and the ordinary morbid changes of syphilis may be met
with in the same infant at birth ; in syphilis acquired late in preg-
nancy, the grave dystrophies are practicalh' certain to be absent, and
indeed nothing may then be found save the ordinary results or
syphilitic lesions in the strict sense of the word. To sum up, there-
fore, it may Ije said that the dystrophies are the result of the action
of the syphilitic poison upon the organism during the embryonic
stage of antenatal life, or upon such of its organs and tissues which
during the foetal (and even the . postnatal) period are still in the
embryonic or formative condition.
An interesting question may be referred to briefly at this stage :
How far do other morbid agents (apart from syphilis) produce
dystrophies ? There is good reason to believe that tubercle often
does (vide pp. 214—216), so also does alcohol; and there is some
evidence that sepsis and the enteric poison may occasionally produce
dystrophic effects. It may ultimately be found that all the agents
which produce disease in formed organs and tissiies produce mal-
formations or dystrophies in developiug or forming structures.
Another question remains to be answered under this heading : Can
the dystrophies of syphilis be regarded as in any way special and to be
distinguished from (let us say) those of alcohol or tubercle ? Fournier
is of opinion that to some extent they can be, and refers especially to
infantQism (a group of dystrophies), cranio-facial malformations, and
dental anomalies, as characteristic (especially when all co-existing in
one subject) of the dystrophies of syphilis ; but it may be doubted
whether there is sufficient evidence to warrant this conclusion. I
believe that it can hardly be affirmed that any of the dystrophies
are peculiar to any one of the morbid causes (syphilis, tubercle,
alcohol) ; indeed, the dystrophies may be met with apart fi'oni any of
these states. Possibly the dystrophies of syphilis may be special, in
the sense that they are very numerous and very various. The whole
question of the nature of malformations and monstrosities will, of
course, receive full consideration in a future volume dealing with
the pathology of the embryo and germ. The reference to it here is
due to that projection of embryonic into fcetal life which I have
already several times alluded to {vide pp. 9, 12, 185).
Pathogenesis.
I have now to deal with a very complex and difficult part of the
subject of fffital syphilis, namely, its pathogenesis. In considering the
mode of origin and of transmission of this malady, it is, in the present
244 ANTKNATAI. PATHOI.OCY AND HYGIENK
state of our knowledge, impossible to seijurate fa'tal from embryonic
and germinal syphilis. We must of necessity to some extent consider
them togetlier ; and we are thus led into a veritable maze of theories,
views, opinions, and hypotheses, with here and there a stray fact or
pseudo-fact turning out on closer inspection to be far otherwise.
We must abbreviate as far as is possible this wandering about
among innumerable theories and apparent facts.
With regard, in the first place, to the nature of the cansal wjent in
syphilis, it may be taken as a working hypothesis and as a probable
conclusion that it is niicrobic or parasitic. It is more than likely
that before long it will be found lliat sy]ihilis will take its place
alongside of tubercle, typhoid fever, and malaria as due to the action
of a microbe or parasitic organism upon the tissues of the liody. As
long ago as 1841, Vanoye pulilished a note u])on an animalcule found
in syphilitic pus {Ann. Soc. d. sc. nat. de Bruges, ii. 39, 1841); and in
1868, J. H. Salisbury gave "a description of two new algoid vegeta-
tions, one of which appears to be the specific cause of sypliilis and
the other of gonorrhrea" {Amer. Jmirn. Med. Sc, n. s., Iv. 17, 1868);
but it was not till 1880 that the search for the causal organism of
syphilis became really prolific in results. From that date (1880),
when Bermann published his article on " The Fungus of Syjjhilis "
(Arch. Med., New York, iv. 263, 1880), up to the present time there
has been a steady output of articles dealing with the " bacteria,"
" microbes," " bacilli," " streptococci " and " micrococci " and " fiuigi "
of syphilis. The subject has been dealt with by .such authorities as
Doutrelepont, Finger, Kassowitz, Hochsinger, Lustgarten, Doehle,
and Xeisser : and on several occasions it has been declared with more
or less confidence that at last the causa causans was found. Eecently
it has been affirmed with more than usual confidence that the liacillus
of syphilis had lieen isolated by Justin de Lisle and Jullien {Acad,
dc mid., Paris, 3 s., xlvi. p. 50, 1896) ; it is descril)ed as poly-
morphic (short, threadlike, etc.), it is said to produce (in the guinea-
pig) an indurated ulcer with swelling of the nearest lymphatic glands,
and the blood of syphilitic ])atients added to a three days' nld culture of
the bacillus causes agglutination of the latter. For culture ]iurposes
de Lisle and Jullien used blood plasma separated fi-om the serum,
and also fluid from blisters, for they hold that the negative lesults
previously obtained were due to the presence in the coagulated
blood of a bactericidal alexin, and they regard the above media
as alexin-free. Whether this polymorphic micro-organism be at
last tlie real bacillus of syjihilis or not, does not, from the pre-
sent standpoint, matter very much ; it is sufficient to accept
as a good wurking hypothesis the idea that sy]ihilis is due to a
microbe.
In tlio second place, we have to consider the mode of transmission
of syphilis to the unborn infant. As this matter is most complicated,
I give here a taljular statement of the manner in which I jnopose
to discuss it, to serve as a sort of mcmoria tcchniea. It will
be noted that I take the jKriods of antenatal life as my jniniary
divisions : —
PATHOGENESIS 245
1. FcETAL Period.
(a) Transmitter.
(b) Mechanism of transmission.
(c) Results of transmission.
(d) Reverse current.
2. Embryonic Period.
(a) Transmitter.
(b) Mechanism of transmission.
(c) Results of transmission.
3. Germinal Period.
(1) Unified Epoch.
(a) Transmitter.
(b) ^Mechanism of transmission.
(c) Results.
(2) Dual Epoch.
(a) Transmitter.
(b) Mechanism of transmission.
(c) Results of transmission.
A reference to the scheme of antenatal life on p. 8 \yill serve to
explain these snb-divisious, and more especially those of the germinal
period.
1. Transmission in the F(ital Period.
(«) In the foetal period, which may be regarded as extending
(roughly) from the end of the sLxth week to the full term, there are
only two possible transmitters of the syphilitic poison. One of these
" possibles " is at once evident — the mother. If we accept for syphilis
the same possibilities as for smallpox, typhoid, malaria, measles, and
the like, then it must be regarded as certain that the virus of the
disease will in some cases at any rate pass from the maternal to the
fcetal organism. The mother who is syphilitic transmits syphilis to
her foetus. This is sometimes called the maternal variety of syphilitic
heredity, but, as I have already stated, I prefer not to use the
word " heredity " for any morbid state transmitted after the occur-
rence of conception (post-conceptionally). With regard to the second
possible transmitter there is no such ob\aousness or certainty ; but I
think it may be that, so to say, the embryo may transmit the poison
of syphilis to the fcetus. The embryo may have been infected by the
mother during the embryonic period, or again the embryo may have
had an infection handed on to it from the germ (fertilised ovum) ;
and it may as it were pass it on to the foetus. It may be that there
was no time for the poison to take eftect in the germinal or embryonic
period, or its effects, if there were any, might not 1 le recognised as such ;
so the first distinct signs appear in the fcetal state. I admit that this
idea of transmission is unusual, and that it perhaps implies the accept-
ance of the theory of latency ; but, to my mind, it seems to be necessary
246 ANTKNATAL PATHOLOCIV AM) IIV(;!HNK
if we are to accept the hypothesis of germ and sperm infection with
syphilis.
(h) With regard to the mechanism of transmission in tlie fii'tal
period, it must, if the mother be the transmitter, be looked ii])iin as
chietly transplacental. It is, of course, 2'ossihlc that it might be
through the li(iuor amuii or transamniotic, but that method cannot
be common, if indeed it occur at all. I do not projjose to consider
here tlie various possibilities of transplacental transmission of disease
from mother to fu'tus; these have been fully dealt with in Chapters
XI. and XIII. (" placental factor in fcetal pathology," " fo-lal tubercle,"
etc.), and need not be re-enumerated for fo'tal sy])hilis. Whether or
not it is necessary for the placenta to be diseased {>'.>/. ha-morrliagic)
in order that the virus may pass, cannot be yet regarded as a settled
question. The mechanism of transmission from embryo to foetus is
still more obscure and uncertain. It may be that the undiscovered
" microbe " or " fungus " of syphilis lies latent in the embryonic tissues,
and is thus carried over into the foetal period, becoming active in the
fu^tal organs ; but here the maze of hypotheses is so bewildering that
we refuse to wander further.
(c) As to results, it must be accepted in the first place that
the fcetus may escape infection and be born free of syphilis. This
has been shown to be the case with tubercle, variola, measles,
typhoid, and other maladies which are transmissible, and analogy as
well as direct clinical evidence lead us to e.xpect it in syphilis also.
Again, and this is no doubt what most often haijpens, the poison of
syphilis expends its full virulence upon the placental tissue, sets up
morbid changes in it, and so kills the foetus : abortion or piremature
labour then follows, the former in the early and the latter in the later
months of foetal existence ; or, the foetus may not die in utero but
after expulsion as a result of its prematurity. Again, we may suppose
that the syphilitic virus, so to say, forces the placental barriers and
attacks the intracorporeal foetal organs ; then there occurs the long
.series of morbid alterations of bone, skin, liver, spleen, blood, kidneys,
thymus, etc., to which reference has been made ; and, as a result of
this syphilitic infection of the fietus, it is expelled alive with the signs
thereof upon it, or dies in utero and is born in a more or less macerated
condition. Again, the foetus may at the time of l)irth exhibit not
only the oi'dinaiy signs of syphilis, Init also -some of the syphilitic
dystrophies or malformations ; but probably the dystrophies will be
found to be only those of organs which are in an emhi'vonic or form-
ative state in the foetal period, e.i/. ears, eyes, genitals, limbs, etc.
Once more, the fcetus may lie born alive and only show external signs
of syphilis some weeks after birth ; or, it may never do so, and may
even give evidence of immunity against syjihilis.
The question of the possible transmission of immunity has caused
much discussion. The belief that a mother in the secondary stage of
syphilis can confer immunity from that disease upon her unliorn infant,
is an expansion of the statement made by Profeta (and liy I'.eln-ciun
that a healthy cliild born of a syphilitic motlier can be nourished safely
liy that mother or by a syphilitic nurse ; for " the law of Profeta," as it
PATHOGF.NKSIS 247
is generally called, is now liekl tn be that healthy children born of
syphilitic parents are not susceptible of infection. It is extremely
doubtful whether in its expanded sense the law of Profeta can be ac-
cepted as the statement of even an occasional occurrence. There is a
certain individuality of the unborn infant to be taken into account
which is independent of all maternal influence, and now and again a
case of innate immunity to syphilis may occur. Again, it has been
found by G. Ogilvie {Brit. Journ. Dcrmaf., xi. 45, 89, 1899) and others,
that of reliable evidence in favour of intrauterine immunisation there
is extraordinarily little, so much so that Buret {Progres med., 3 s., xi.
377, 1900) declares that Profeta has made a hasty generalisation from
a few cases, and that he has been deceived by a mirage (" il a etc la
dupe d'un mirage "). On the other hand, there is a fair amount of
evidence in support of the modified belief that mothers who are
syphilitic before conception rarely communicate the disease to their
ofl'spiring in extrauterine life ; but there is some proof that in post-
conceptional syphilis (i.e. maternal syjjhilis acquired when the offspring
is in the foetal period of his antenatal life) the child may be contamin-
ated by the mother after his liirth. It is only with this last-named
possibility tliat we are here concerned. There are so many possible
fallacies {c.r/. difficulty in ascertaining the facts of the case, unknown
modes of action of the tissues of the placenta and foetal organs on
toxins and anti-bodies, influence of treatment, etc.) that it seems im-
possible to decide for or against the " law of Profeta," save perhaps to
the extent that it is at any rate certain that it is not " a law." The fact
that the mother is in the tertiary rather than in the secondary stage
during her pregnancy does not simplify matters much. Theoretically,
it may be reasonably admitted as a possibility, that a pregnant syphil-
itic woman may occasionally transmit to her foetus alexins or bodies
which enable the fcetal organs (including the placenta) to manufacture
alexins which render it immune to syphilis for a short time after
birth. The last point is to be emphasised, for Hutchinson {Tv-enticth
Century Practice, xviii. 396, 1899) and others freely admit that im-
munity although possible is only temporary. Analogy with vaccinia
and malaria and possibly tubercle in pregnancy supports, although
not very strongly, the theory of occasional intrauterine immunisation.
Among the most curious results of transmission must be placed
those which occur when twins are found in the uterus. When both
twins become syphilitic no need for surprise exists ; but when the in-
fants are born showing syphilis in very different degree, or still more,
when one twin is born healthy and remains so while the other is
manifestly syphilitic, the occurrence seems incongruous and even
grotesque. Such observations have been several times recorded, as
Alfred Fournier (L'herdditc sypMlitiquc,^. 294, 1891) and others have
shown. No very satisfactory explanation can be found, indeed
Fournier (op. cit., p. 296) says " c'est la une cnigme de plus dans un
sujet qui en comporte un si grand nombre " ; but it may be remarked
that if the mother can transmit immunising material to her fcetus, it
is possible that one fcetus of twins (the one, for instance, with the
stronger heart) may conceivably cause alexins or antitoxins to pass
248 ANIKNA'IAL I'A lli()I.()(;V AND IIYCUKNK
to the otlier fu-tus. This oxplaimliuu (or sJiaduir of an explaiiatiou),
however, will scarcely hold in the case where the jilacentas are
separate. If the so-called " law of Profeta " had been found to he
a law, we might have expected another " law" that the healthy twin
in cases of syphilis would show immunity from tiie disease after
birth! " Une I'uigme de plus!" It may be noted here that the
infection of one of two fu-tuses in utero is not a phenomenon observeil
in syphilis only ; it has been recorded in connection with fo'lul
variola (ride y. 190).
{d) liut no allusion has yet been made to what may be called the
" reverse cm-rent " of infection in fo'tal life, to what has been termed
" syphilis par conception," " conceptional syphilis," " syphilis by cliuc
en retour," or " maternal retro-infection." Whether or not this re-
verse current of infection from fa>tus to mother exists, has been the
subject of great controversy, and of the most extraordinary diver.sity
of opinions, and it must also be admitted of a most regrettable amount
of theorising from most insufficient data, indeed from no data at all.
Some few things seem fairly certain among much that is most un-
certain. They are these. There is a physiological reverse current
from firtus to mother whereliy efi'ete materials and carbonic acid are
carried to the ]dacenta and thence pass through it into the maternid
circulation {oidc p. Wo). There would also appear, from experi-
mental evidence, to lie a matripetal current carrying such poisons as
strychnine, curare, hydrocyanic acid, etc., from the fo'tus {ridr pp. 168,
164). Finally, there is some slight experimental evidence in support
of the belief that the toxins of the bacillus pyocyaneus and of
diphtheria may likewise reach the maternal circulation. When,
however, we leave the fairly firm ground on which these statements
rest, we find ourselves in a veritable quagmire of hypotheses, in a
shifting .sand of theories. This nmch, I suppose, may be said with
some slight degree of confidence. When a mother infects her ftctus
transplacentally with syphilis and this sets up syphilitic processes in
the fcctal organs and tissues, it is quite possible that toxins formed in
the fretal bodj' may pass through the placenta into the maternal
organism ; it seems even strongly ])robable that this occurs. It may
also be believed that such toxins thus reaching the mother may liave
some injurious effect upon her; in foetal smallpox there is some
evidence that the maternal fever is increased when the fcetus is in
the sujipurative stage. But the supporters of the reverse current go
much further than this: they imagine a healthy mother becoming
infected through her firtus, she herself being up till then free from
infection. It is supposed that the father was syi)hilitic at the time of
fruitful coitus, and that tlirongh his infected sperm the impregnated
ovum also was infected, that the infection lay latent in the germ and
embryo till the fu>tal period, and that then syphilis develupcd in
the fa?tus and infection of the mother through the placenta followed
by virtue of the reverse current. This theory is neces.sary in order to
offer an explanation of the cases in which a ))regnant woman, pre-
viou-sly non-syphilitic to all appearance, develops the secondaries
(sometimes the tertiarics) of syphilis during her pregnancy,
PATHOGENESIS 249
apparently witliout any precedent primary sore or chancre. The
maternal disease thus acquired manifestly lacks the primary stage,
antl in its abbreviated form is called " syphilis decapitce," an acephalic
syphilis so to say. (Too much need not, however, be made of this
headless condition of so-called coneeptional sypliilis, for the syphilis
whicli develops in the fojtus in utero is also always a decapitated
syphilis). Manifestly the acceptance of this view entails the belief
that the father's syphilis (even in a latent condition) can be passed
on through the ovum and embryo and f(etus, and infect the maternal
organism in this circuitous manner — circuitous as to route, delayed
as to time. This is just the crux of the whole matter ; and while
tliere are some who admit this direct paternal infection of the germ
with transmission onwards to the fcetus, there are others who stoutly
maintain its impossibility. Manifestly, there are only two possible
transmitters of syphilis to the foetus in the foetal period, the mother
and the embryo, and the embryo must have got the infection origin-
ally from either the mother or the father. With the question of
germinal infection I deal later : but if we postulate germinal patei'nal
contagion, then w"ith regard to the possibility of that contagion being
handed tlown from germ to embryo and from endjryo to foetus, and
then at last infecting the mother, all that can be safely said is that it
is of course possible, but its mechanism is outside ordinary physio-
logical laws of transmission and requires the assumption of the genesis
of heredity.
But coneeptional syphilis is not the only result that may follow
upon the presence in utero of a syphilitic ftvtus. It has been noticed
that if an apparently healthy mother give birth to an undoubtedly
syphilitic infant she may nurse that infant with impunity, in other
words, she does not develop a mammary chancre. This has been called
Colles' or Baumes' law ; and, like many other things in connection
with antenatal syphilis, it has been the occasion of no small difference
of opinion. Little wonder ! The phenomena of the transmission of
diseases are difficult indeed and capable of being interpreted in
various ways, but when we come to consider the phenomena of the trans-
mission of immunity against diseases, the difficulties are multiplied
and the possiljle divergencies of interpretation are greatly increased.
And yet the antenatal pathologist has to struggle with these difticul-
ties. Will the reader bear with the writer in his poor efforts to bring
some order out of the " rudis, indigestaqne moles " of this subject ?
Maternal immunity against syphilis may be, to begin with, an
idiosyncrasy possessed by her ; under these circumstances the presence
of a syphilitic foetus in her uterus will neither give her syphilis nor
can it be described as conferring upon her an immunity against
syphilis, for that she already has. It is possible that some cases
regarded as instances of Colles' law may be explained thus. In
the next place, it is possible that the mother may take from her
foetus a latent form of syphilis, or that she may already be suffering
from the disease in a latent state ; at a later period, namely after
lactation is over, she may show tertiary sympitoms, or, on the other
hand, by that time the latency of the disease may have become a
250 AX'rF.XATAI, I' A IHOLOCIY AND HVdIF.NE
j)eniuui(jul iiaiiiuiiily. (All liypotliL'.sus, (J t'liciully ii-iuler 1) Again,
it may be tliat the mother has acquired immunity from the fa'tus,
that she lias been rendered immune liy the toxins or antitoxins m
anti-bodies coming to her through the placenta from the foetus (c/'/i
K. von Diiring, Monatsrlu: f. lyi'dli. Dermat., xx. 245, 1895). Tin-
mechanism of this immunisation I must leave unexplained, fur
physiology has not worked out the matter yet, but ap])arently it is
necessary to regaixl it as either transjjlacental or transamniotic. But
yet again, the maternal immunity may l)e capable of another explana-
tion. It may be, as Boulengier {Jouni. d. mal. cutan. ct. syph., 2 s.,
vii. 722, 1895) supposes, that the mother really takes syphilis, but
that all the strength of the virus is exerted upon the very active
organs of the f(ctus (placenta included), which are, as it were, a most
favourable culture medium for it ; according to this supposition, the
mother has really given syphilis to the foetus, it has passed through
her without touching her, and there is then no need to sui)]>ose that
the foetus obtained either the disease or the power to infect or
immunise the mother from the father. It is a little difficult to
accept Boulengier's further conclusion, that the foetus who has got
the disease in this sort of unconscious way from the mother can then
actively immunise the mother ; but, as he himself says, it is " hypothese
pour hypothese," and who knows !
After all, CoUes' law is not absolutely a law ' Exceptions to it
have been reported {cfj. by Drennen, Juurn. of Cutan. and Gcn.-
Urin. Bis., xv. p. 125, 1897 ; by J. A. Coutts, laticet, i. for 1894, p.
1443; by Neuhaus, Monatschr. f. pralct. Dermat., xxviii. p. 616, 1899;
and by several others). We may take Jonathan Hutchinson's con-
clusions (Tiventieth Centura/ Practice, xviii. p. 375, 1899) on this matter
as being practical and as near to the truth as it is at i:)resent pos-
sible to get, — namely, that the apparently healthy mother may nurse
her syphilitic child, the risk to lier is iniinitesimal wliile the gain to
the child is incalculable, hut the risk is not absolutely excluded.
Possibly the exceptions to Colles' law may be due to a morliid con-
dition of the placenta ; possibly also the occurrence of cases showing
Colles' law may be due to a morbid condition of the placenta. The
reader may even make his own choice ' In all this bewildering
subject it will be well to remember that it is always very ditticult to
get the truth, the whole truth, and nothing but the truth, from
syphilitic patients, and that still even on the part of the physician
skilled in clinical methods humaiudn est errecrc.
2. Transmission in the Embryonic I'ekiod.
(a) In the embryonic period of antenatal life (roughly tiic first
six weeks, nun-e exactly the time between the formation of the first
rudiments of the embryo in the embryonic area and the a])pearance
of the transition organism, ride p. 7), there can be little doubt that
syphilis in the mother produces an effect upon the organism in her
uterus. The mother in this period, as in the fwtal, must be the chief
transmitter. At the same time it is possible that the emljryo may lie
PATHOGENESIS 251
iufectt'il from the germ, and the germ in its turn eitlier from the
father or the mother ; it is even possible that the syphilitic peccant
matter (microbe, "fungus," toxin) may exist in the spermatic Muid
alongside of the spermatozoa, and may prove the means of infecting
the embryo directly after its germinal life is finished. Of this, how-
ever, more anon.
(b) As to the mcclianisvi of transmission, in this early period very
little can be said with even a shadow of confidence. Probably the
virus will travel again in the blood stream from mother to tlecidual
membranes, and will sometimes pass their barriers to reach the
embryo either by the omphalo-mesenteric veins, the allantoidal (umbil-
ical) vein, or (doul)tfully) by the liquor amnii. From the practical
point of view of immediate results it will matter little whether it
reach the embryonic organism or not, for the decidual membranes
are, as regards the continuance of antenatal life, the really vulnerable
part. How the syphilitic microbe or toxin is carried over from the
germ into the embryo and its membranes, we do not, of course, know ;
possibly it is latent in the germinal period, possibly it sets up
changes in the germinal period which are simply continued in the
embryonic.
(c) The results upon eml)ryonic life no doubt vary. In the first
place there may be abortion due to changes in the decidual mem-
branes ; this may well be believed to be very common. It may be
preceded Ijy embryonic death, but of this little or no evidence is
forthcoming. At any rate, the occurrence of abortion is equivalent
to embryonic death. In the second place, it is possilile that it may
be the cau.se of dwarfing or non-development of the embryo ; and, in
the third place, from what is known of experimental teratogenesis
taken in conjunction with clinical experience, it is very probable that
the syphilitic poison coming into contact with the forming organs of
the emljryo will cause them to form badly and so produce malforma-
tions and monstrosities. These matters will be more fitly described in
the part of this work which deals with the pathology of the emlnyo ;
they are introduced here simply to complete the survey of the possible
modes of transmission of syphilis to the foetus.
3. Transmission ix the Geemixal Period.
The germinal period, it will be remembered (if the reader does
not recollect, let him consult pages 8, 9, and 10), consists of two
divisions, a long period prior to impregnation, and a very short but
very active period following after impregnation. In the former or
ante-conceptional period, there is the dual life of the spermatozoon
and the ovum ; in the latter or post-conceptional period, there is the
unitied life of the impregnated ovum. In the former the locus of the
hfe is the interior of the sexual gland (ovary or testicle) ; and in the
latter it is the interior of the uterus, and for a short time the interior
of the Fallopian tube (that is, if we regard impregnation as occurring
prior to the arrival of the ovum in the uterus).
Let us consider the possible transmitters of syphilis in this germinal
252 ANTKXATAI, I'A rHOl.Od'i AND incUJ-.NK
period ul' ;iuleiial;il lifo: and now, for thu first time, we are brouulit
face to face with the large problem of the direct influence of the
father in infection. But let us deal first witli the mother as triins-
mitter. It is possible that the syphilitic virus in the maternal uterus
or Fallopian tube may infect the ovum as it is being transfernd
from the ovary to the uterine interior ; it is possible also that the
ovum may be already impregnated before it leaves the ovi-sac.
These things are possible, but he would be foolhardy who ventured to
state them as facts. Our knowledge of the action of microbes and
toxins upon the human ovum either before or after impregnation is
practically nil; we are again, thei-efore, wandering in a maze of
theories. But, and this is the important point, all the observers and
writers who have dealt with this matter have not kept in mind that
it is a maze of liypotheses ; some, in fact, have made extraordinarily
confident assertions about its most doul>tful parts. ]Many of them
seem to forget that no one has ever seen the penetration of the human
ovum liy a spermatozoon! It has, of course, been shown experi-
mentally that tubercle bacilli may be introduced into the hen's egg,
and that the bacilli may apparently remain latent in the embryo
chick, setting up tuberculosis only after the chicken has left the egg;
but there is a great distance between such an experiment and the
assertion that a syphilitic microbe can pass from the mother into an
ovum in one of her ovaries and set up syphilis in the fcctus that
develops from that ovum. We cannot deny its jjossibility ; we may
even, from clinical evidence, be very sure that something producing
such a result does occur ; but the slenderness fif the evidence and
the lack of knowledge of the mechanism must ne\'er be forgotten.
Similar remarks apply to the theories of the father as trans-
mitter of syphilis, either alone, or more often in conjunction with the
mother. The idea which seems to be present in the mind of those
who believe in infection of the foetus a patrc is that of a spermato-
zoon carrying a bacillus or a toxin of syphilis with it into the ovum,
and at one and the same time impregnating the ovum and inoculating
the new organism with syphilis. This hypothesis of bacilliferous
spermatozoa and their effects may, of course, turn out to be correct;
but it has to be remembered that it is purely hypothetical. What
happens when Viacilli are brought into contact with spermatic fluid ?
What follows when a spermatozoon is penetrated by one or more
bacilli ? Does the sexual cell eat them or do they weaken the sexual
cell ? Must it not be very unlikely that the bacilliferous spermato-
zoon shall be also the impregnating spermatozoon ? Does — but let
us get out of the maze of hypothetical cross-questions again if we
can. The evidences of purely paternal infection may be enumerated
as follows : — (1) The occurrence of cases of fu'tal syphilis in which the
father alone was syphilitic (a very rare occurrence, let it be remem-
bered) ; (2) the frequency of abortions when the father is syphilitic
and the mother healthy, the abortions being regarded as evidence of
syphilis : (3) the good effects of anti-syphilitic treatment of the father
alone in such cases, future pregnancies going on to the full term :
ami (4) tile infection of the mother liy her f'o'tus or conceptioual
pathoc;enesis 253
syphilis, on the supposition that in such instances the germ has been
directly infected by the father. As a proof of direct paternal
infection of the germ, this last occurrence must be left out of account ;
but the other three pieces of evidence have a certain value, a value
so great as to make many believe in the possibility of direct paternal
infection without being able to offer any satisfactory explanation of
its meclianism. On the other hand, cases supporting the view are
admittedly very rare, and sometimes a syphilitic (even a recently
syphilitic) father neither gives his wife syphilis nor procreates a
syphilitic fcetus. Further, frequent abortions do not of necessity
indicate the existence of syphilis, while the results of treatment are
of necessity of the nature of post Jioc enjo propkr /i op evidence. It
has been said also that animals cannot be inoculated with diseased
spermatic fluid; but, as A. Foui-nier {L'MvMih' syphilitique, p. 49,
1801) reminds us, inoculation of the subcutaneous tissue is one
thing, and impregnation of an ovum is another and a very different
thing.
The reader will, I think, have by this time come to the con-
clusion at which the writer has arrived, that direct paternal infection
of the germ (ovum or ovo-sperm) with syphilis can, in the present
state of our knowledge, neither be proved nor disproved — it must be
left unsettled, lying, as Fournier says, as " une veritable pomme de
discorde jetee clans le camp des observateurs." It may be added that
direct paternal infection has been afdrmed in foetal malaria, tubercle,
and even in fo?tal smallpox {vide pp. 203, 216, and 190).
From what has been written regarding the transmitters in the
germinal period, it will be gathered that nothing of any importance,
nothing at any rate with any certainty, can be affirmed about the
mechanism of transmission in this epoch. We may imagine the ovum
or spermatozoon bathed in syphilis-infected fluid and absorbing or being
penetrated by the fluid or its bacilli; hut it is a vision which may or
may not be a foreshowing, but still indubitably a vision.
Then, as to results. Again, the antenatal pathologist must plunge
neck deep into a morass of hypotheses and conjectures. Theoretic-
ally, it is to be expected that the results of syphilitic infection in
the germinal period will differ very markedly from those following a
later infection. Possibly they may take the form of unrecognised
(because so precocious) abortions, and of anomalies in the formation
of the decidual and fcetal membranes (hydatid mole) ; possibly, also,
the syphilis may lie latent and only cause morbid changes in
embryonic or fcetal life. This matter, however, will be returned to
again in the discussion of the pathology of germinal life. In the
meanwhile the antenatal pathologist may scramble out of his morass
of hypotheses and rejoice to be once more on firm earth ; it may turn
out to be only a little island he has reached in the midst of his
([uagmire, and that he will be found floundering again almost immedi-
ately ; but for the time he has a firm foothold. I have said what
had to be said regarding the pathogenesis of fcetal syphilis, and must
now look at some of the effects of the disease.
254 AXTKNAIAI. PA II l()L()(iV AND HVCUENl",
Effects of Foetal Syphilis.
The effectK of KVphilis upon aiiloiialiil life are so serimis as to
lead writers to search the vocabularies of their various languages for
words strong enough to express tlie degree of gravity arrived at.
Fournier, for instance, writes in the following sentences of these
results : — " La syphilis est essentiellement uieurtriere pour la jeuiie
age ; elle fait de veritables hecatonibes d'eui'ants : elle les tue avant
la naissance, au moment de la naissance, apres la naissance, dans les
premieres semaines on pendant les premieres annes (hen'do-syphilis).
Mais ce qu'il y a le plus a redouter ce sont I'avortement syphilitique
et la polymortalitu infantile" [Bchjique Med., Ann. vi. p. 711, 1899).
It cannot be said that Fournier's language exaggerates the baneful,
murderous, and malignant effects of syphilis on antenatal life, and it
is easy to agree with him when he says that syphilis, alcoholism, and
tubercle " constituent la triade des pestes contemporaines."
At any one of the three periods of antenatal life syphilis may
prove murderous ; it may kill the germ, it may lead to the casting ott'
of the embryo in a recognised or unrecognised abortion sac ; it may
kill the fatus either directly or by leading to its premature expulsion
from the uterus ; and it may send the infant forth into its extra-
uterine environment so weak or so diseased as to entail its early
demise. It may also permit an extrauterine life, but one rendered
so miserable by deformity and weakness as to lie almost less to Ije
desired than early death. These are some of its ordinary and
manifest effects, and they do not include the evils that may come
upon others, or even the later ill-effects of the dire malady upon
the individual himself (syphilis hereditaria tarda). For instance,
a healthy mother, who has escaped direct infection from her
husband, may, if we accept the possibility of conceptional syphilis, '
receive the poison from the infant in her womb, becoming infected
because she is about to become a mother. Again, there are the late '
developments of congenital syphilis, including the so-called Hutchin-
sonian triad of (1) malformed teeth, (2) ocular inHammation, and (3) '
ear disease, especially otitis media, as well as obscure mental conditions
and nervous maladies, and the predisposition to suiier severely fimii '
many other diseases.
And yet the list of possible evil effects is not finished 1 There is
some reason to suspect that syphilis may pass on (without any '
fresh infection) to the next generation. Concerning " syphilis of the '
third generation," as it is called, there is, of course, no lack of ditler-
ence of opinion. If it be true that the virus can thus pass from the
child of a syphilitic parent to the grandchild, then it would seem to
imply that at birth the ova in the ovaries of a syphilitic infant are
already infected. Cases in which transmission to the third genera-
tion was alleged have been recorded l)y a consideralile ntnnbcr of
observers, and thirty-eight of these cases have been collected by
F. de Armenteros (These, Paris, 1900); and the consideration of the
clinical evidence therein contained would lead us to the conclusion
that the manifestations of this retransmitted syphilis are of the
EFFECTS OF F(KTAL SYPHILIS 255
nature of abortions, dystrophies, malformations, monstrosities, and
even of the more ordinary syphilitic, visceral, and cutaneous lesions.
But there is always one weak link in the choin of evidence brought
forward to prove these cases ; the putative parent may not have
been the real parent.
Surely Fournier has not used too strong language in describing
the results of antenatal syphilis ! But even the efl'ects that have
been enumerated do not end the tale of disaster, for national life and
prosperity also suffer from this antenatal malady, and a fall in the
birth-rate acconqianied liy an increase in infantile mortality cannot
be lightly regarded by social economists. Again and again we read of
cases in which syphilis has so affected the results of marriages as to
give from fifty to a hundred 2}cr cent, of dead-born or quickly perish-
ing infants. The record (sad record indeed !) for the present seems
to be nineteen dead infants as the result of nineteen pregnancies.
(D'Aulnay, Arch, dc toco/, ct de ijijncc., xxi. p. 910, 1894). "Well may
Fournier exclaim, " Quelles statistiques ! Quelles horribles tables
mortuaires ! " If we take even the average results (private and
hospital practice), we find them to be 46 per cent, of the pregnancies
ending disastrously, with an infantile mortality of 42 per cent.
Of course these results are intiuenced to a large extent by circum-
stances. Let us then try to ascertain what the modifying circum-
stances are.
Among the circumstances which modify the effects of syphilis
upon antenatal life we may place, /?•«<, the age of the pregnane}' when
the infection takes place. If we divide the evil effects into deaths,
and deaths plus syphilitic manifestations, we find, according to
Fouruier's tables, that when infection has occurred before conception
the mortality is 65 per cent, and the morbidity 70 per cent. ; when
conception and infection have occurred simultaneously (a hypothesis),
the mortality is 75 per cent, and the morbidity 91 per cent.; while,
when the infection has taken place after conception, the mortality is
39 per cent, and the morbidity 72 per cent. "We may draw the con-
clusion, therefore, tliat so far as antenatal life and health are concerned
the most disastrous results are due to infection in the germinal period,
and the least disastrous to post-conceptional infection. It has been
maintained by some that maternal syphilis acquired in the last three
or last two months of pregnancy spares the unborn infant, but un-
fortunately there is evidence to show that even then " la syphilis est
meurtriere pour la jeune age." It may be said, however, that syphilis
acquired post-conceptionally is more dangerous for subsequent off-
spring than for the fretus then in utero.
In the second place, the results are modified by the transmitter.
To quote from Fournier's tables again, when the transmitter is the
father alone, the mortality is 28 per cent, and the morbidity (" noci-
\'ite ") .■•!7 per cent. ; where the transmitter is the mother alone, the
figures are 60 per cent, and 80 per cent. ; and where both parents
may be supposed to transmit, the mortality reaches the high figure of
68-5 per cent, and the morbidity the appalling height of 92 per cent.
There is then an ascending scale of disaster in which both the mortality
L'56 ANl'KNAr.M. I'ATHOI.OdY AM) H'XllKNi:
and the iuJux of liannfuhiess reach a iiiaximuiiL wlien hoth parents
are transmitters, while the mininiuni is found when the fatlier aluiic
transmits. Of course, we must not forget that some writers do iidt
admit paternal infection ; but tlie statistics given are comi)iled from
cases in which the father was apparcntlij the sole transmitter.
In the third place, the age of tlie syphilis in the transmitter would
appear to have a modifying ett'ect ujum the results to the fictu.s.
It would seem that the three years following infection are much
more fatal to pregnancies and their results than any later tliree years.
More than this, the first year is by far the worst of the three. It is
during this period that the disease is in the stage of the secondaries.
The first year after infection Fournier terms " lannce terrible," and
with good reason ' Of ninety women infected b}- their husbands and
who became pregnant during the year following their infection, fifty
aborted or had dead-born infants, thirty-eight gave birth to children
who soon died, and only two gave birth to infants who survived. As
the syphilis Ijecomes older the danger to the product of conception
becomes less, and the question at once arises whether there is any
age beyond which lies complete safety to the fcetus. There seems to
be no doubt that transmission may occur even when syphilis is in the
stage of the tertiaries ; but in the case of the father two years would
appear to be a working limit, so to say, to the power of transmitting,
while in that of the mother it may be extended to seven or eight years.
Of course, exceptional instances have been recorded of transuussiou by
either parent after much longer periods {e.g. ten to fourteen, even
sixteen to twenty years) ; but these are quite unusual and are pro-
bably instances in which no ameliorating effects (r.//. from treatment)
came into action. Hutchinson (Arch. Surij., xi. 78, 1900) thinks the
prolonged ability of the mother to transmit to her offspring may be
due to a storing up of the syphilitic virus in the ovaries and infection
of future foetuses by a sort of telegony. " Ova are remarkably retentive
of imjnessions, and are perhaps good storage places for morbid
poisons." Perhaps they are.
In the fourth place, the chai-acter (as regards gravity) of the
disease in the transmitter may be supposed to have some influence
upon the certainty of transmission to the unborn infant. This is,
however, in all probability a pure assumption. It has been shown
that a very grave type of sypliilis in the transmitter may entail no
very disastrous effects upon the offspring. Unfortunately, alas ! this
is only one side of the picture, for it has also been shown that the ex-
istence of mild syphilis in the transmitter does not assume mildness
in the consequences which may follow for the fcetus in utero. There
is, however, some evidence to support the belief that the state of
activity or quiescence of the syphilitic manifestations at the time of
impregnation usually has a modifying eh'ect upon the results to the
unborn infant.
In the. /(/?/< place, treatment very clearly and very actively iniln-
ences the results of syphilis as regards antenatal and inmiediately
postnatal life. In the cases in which the transmission has been by
both parents, anti-syphilitic treatment, if persevered in, causes a con-
TREATMENT OF FCETAL SYPHILIS 257
sideralile fall in infantile mortality, and in the cases in which paternal
transmission alone is supposed to be in action the fall is even more
marked (namely, from an infantile mortality of 59 per cent, to one of
3 per cent., Fournicr). The question whether the treatment is general
(through the matei-nal system) or local (vaginal applications to the
cervix) may be found to ha\'e a marked influence upon the degree
of good effected so far as the intrauterine contents are interested
(G. Eiehl, irien. klin. Wchnschr., xiv. 627, 1901).
Finally, in the sixth place, there can be no reasonable doubt that
these various modifying factors (age of pregnancy, age of disease,
adoption of treatment, etc.) may act in some cases in combination,
and produce, on that account, greater or less effects. It is possible,
also, that the good effect of one factor may simply neutralise the evil
effect of another. Time and treatment, as a rule, lead to attenuation
of the transmission-results.
Treatment.
It will be more convenient to take up the treatment of antenatal
syphilis in the chapter devoted to Antenatal Therapeutics in general.
In fact, the treatment of antenatal syphilis is the key to all antenatal
treatment ; it is, further, almost the only instance of antenatal treat-
ment which can be said to have shown distinct successes. The
reader, therefore, is asked to peruse at this point the chapter on
Antenatal Therapeutics with which this volume closes.
I have now endeavoured, as best I have been able, to arrange in
order what is known regarding the transmitted diseases of the foetus.
In the immediately succeeding chapters I shall have to consider the
transmitted toxicological and toxinic states, and the diseases which we
are compelled to call " idiopathic." But, both about the subjects which
have been discussed and about those which remain to be discussed,
let me say one thing —
" Little we know.
Mucli is to be known.
Hardly is it to be learned.''
17
CHAPTER XV
Types of transmitted Toxicological Conditions: Sources of luformation ; Pi-oblein^ ;
Lead Poisoning ; Mercurial Poisoning ; Pli()S[)horu3 Poisoning ; Arsenical
Poisoning ; Poisoning with Copper and Sulpliuric Acid ; Carbonic Oxide
and Coal Gas Poisoning ; Effects of Chloroform and Ether ; Morphine
Poisoning ; Tobacco Poisoning ; Alcoholism.
In the preceding chapter I have endeavoured, not, I am afraid, with
great clearness, Ijut with good intention enough, to give an account
of the diseases which may be transmitted from (or tlirough) the
mother to her unborn infant, ilany of these diseases are known to
be due to microbes ; all of them are suspected to have such origin ;
and their transmission must therefore be regarded as essentially a
transjilacental passage of germs or of their toxins from the maternal
to the foetal organism. Further, it has been shown that there is
some measure of proof forthcoming of a reverse current of microbes
and toxins from fojtus to mother, with results for the linked ,
organisms which are not yet very clearly aseertainal3le, but which
are doubtless of very considerable importance. A sphere here exists
for research of an interesting kind, pregnant with possibilities both '
pathological and therapeutic. I have been led also to touch upon ^
the great question of the transmission of immunity from the one
linked organism to the other, a problem of enormous magnitude and
vast importance for the single organism, how much more for the ^
intertwined fceto-maternal economy ! Into this problem the antenatal
pathologist is not yet alile to enter fully, and can at the most speculate
somewhat vaguely aliout possible anti-bodies, antitoxins, and alexins
which may l^e produced in the mother or in the placenta (?), and be ,
passed through the placental barriers to neutralise the lyssins and to
destroy the bacteria in the foetus. The speculation may embrace
also a reverse current of antilyssins and microbicidal ]iriuciples
from the ftetus and the foetal part of the placenta to the mother.
With regard at any rate to foetal typhoid, it has lieen shown that the
clumping iirineiple, the hypothetical agglutinin or paralysin, passes
from mother to fcetus ; and, as touching syphiHs, there is some reason
to believe in the action of antitoxins and alexins manufactured in the
mother or fretus, and producing immunity in the fietus or mother.,
Into this maze of pathogenic possibilities and protective mechanisms,
I have not, I trust, led the reader too far ; I have tried rather to
suggest, tiian actually to put into words, many of the problems which
exist and which will doubtless in the future come to light. It will
be noticed, iiowever, that the discussion has to some degree passed
from microbes and bacteria to toxins and antitoxins ; and this is a
258
FCETAL TOXICOLOCUCAL STATKS 259
circumstance of very considerable importance, for it means that we
are approaching the purely chemical side of the causation of disease
and health, and of disease-manifestations and liealth-phenomena. It
need hardly be said that we are not in a position to translate into
chemical symbols the composition of lyssins and alexins and such
vitally important compounds; but the tendency of investigation is
in that direction. It is therefore suitable, eminently desirable
indeed, that I gather together in this chapter what is known of the
transmission from mother to foetus of the snljstances whose chemical
composition is well known and comparatively simple. No doubt,
between the phenomena of the transplacental passage of the toxins
of disease and those of the transmission of the metallic salts and
vegetable poisons, there is, so to say, a wide and unbridged river ;
but there is some hope of a bridge being ultimately built, of at least
some pontoon arrangement being thrown across, and it will be well
to anticipate this by constructing the indispensable piers. Let us
then, in this chapter, prepare the j)ier on the chemical side of the
dividing river. Let us, in other words, consider the transmitted
toxicological states of the fcetus.
Of many poisons, mineral and vegetable, which might be intro-
duced into the maternal organism and pass over to the foetus, we
have absolutely no information, either of a clinical kind from
observations on the human subject, or of an experimental nature
from animals. With regard to a few poisons we have scanty details,
both clinical and experimental ; and concerning two or three toxico-
logical substances we have enough knowledge to warrant us in
making some statements. On the whole, however, there is great
ignorance on a very important matter. I may, for the sake of clear-
ness, arrange this scanty information according to its sources into
four parts. These are — (1) The clinical and post-mortem evidence
available when a pregnant woman takes, or is given, accidentally or
with criminal intent, one or other of the active poisons, mineral or
vegetable; (2) the information which can be obtained from the
chronic poisoning of pregnant women engaged in dangerous trades or
in an unhygienic environment ; (3) the facts ascertainable when
medicines are administered to the mother during or just before her con-
finement; and (4) the results of experiments upon animals, when, for
instance, a poison is injected or otherwise introduced into the maternal
or fcetal organism, and its effects upon the fcetus or mother noted.
With such som'ces of information at command, I shall endeavour
to answer the following questions regarding certain poisons and their
effect upon the unborn infant ; and I shall condense as far as possible,
for, after all, the facts are often so scanty as scarcely to justify
generalisations. The questions are — (1) Does the poison pass the
placental barriers and reach the foetus ? (2) When it passes, is it to
be found in all parts of the foetus and annexa, or only in special
organs ? (3) What changes does it produce in the fretal tissues ? and
(4) Does it cause fostal death, and if so, by what mechanism is this
brought about ? Questions, these are, which the reader will soon find
to be more easily propounded than answered !
2 GO ANTKNATAI, I'ATHOI.OCiY AND HYGIENE
It will be convenient to consider first the cases of poisoning with
lead, mercury, phosphorus, arsenic, and copper ; thereafter, those due '
to carbonic oxide, chloroform, and ether, and to opium, tobacco, and
alcoiiol, will be dealt with.
Lead Poisoning.
It has beeu shown by Porak {Arch, dc mnl. r.rjidr. et d'anat. path.,
vi. 192, 1894), by means of experiments upon pregnant guinea-
pigs, that lead passes from the maternal into the fcetal body ; it does
not seem to accumulate in the placenta, but passes at once through
it to the foetus; having reached the unborn infant, it tends to be
more widely difiused than in the adult, and has beeu observed in the
skin, liver, nervous centres, and elsewhere. Porak did not find that
it caused abortion. J. Balland (Gaz. held, dc mM., Paris, xliii. 1141,
1896), however, by poisoning guinea-pigs with neutral acetate of
lead, produced five abortions out of ten cases ; he did not search for
lead in the ftetal tissues. With regard to the human subject, direct
evidence of the passage of lead from mother to foetus is wanting;
but Hermann Legraiid and L. Winter (Co)npt. rend. Soc. de biol.,
Par., 9 s., i. 46, 1889) found lead in the liver of an infant, w^ho only
survived birth fifteen days; in this case both parents were the'
subjects of lead poisoning. The conclusion that in the human subject'
the existence of saturnism in the parents produces evil etiects upon
the foetus in utero is, however, founded not upon experiments upon:
animals, but upon clinical observations. In order to establish firmly'
this conclusion, ob.servers in the future would do well to submit to
chemical analysis the abortion-sacs and dead-born foetuses and
infants of jiarents known to be suffering from plumbism.
With regard to the nature of the effects produced upon antenatal
life, much more is known. It was in 1860 that Constantin Paul
(Arch. fihi. dc mt'd., i. 513, 1860) made a discovery which marked a
new era in our knowledge of the relations existing between lead
poisoning and pregnancy. He proceeded from the known fact that
syphilis in the parents may either kill the foetus or produce syphilis
in it ; and, from certain observations to lie referred to innnediately,
he came to the conclusion that, in cases of lead poisoning in the
parents, tlie offspring might be expected either to perish in utero, or
to suffer after birth from diseases the result of the parental
saturnism. " On comprend que c'est 1;\ un sujet de recherches
excessivement vaste, et qui exigerait, pour etre complet, uu grand
nombre d'annees d'un travail assidu." (True, Monsieur Paul!)
His observations were made upon workers in type-foundries, and hif
attention was drawn to the subject by the following case which he
studied in the Necker Hospital. It was that of a woman who had
worked for eight years in a type-foundry, and who was suffering
from metrorrhagia. Her history was that she had had tliree health}
infants as the result of three normal pregnancies before she became i.
w^orker in lead ; thereafter, she had suffered several times from leac
colic, and out of ten pregnancies there had lieen eight abortions, one
LEAD POISONING IN THE F(ETUS 261
dead-born infant, and one child at the full term, who died at the age
of five months. This too striking fact (" ce fait trop frappant") led
I'aul to make further ini|uiries regarding other workers, women and
men, in the same tuide ; and, in all, he collected eighty-one observa-
tions. These he arranged in six series, about which I will (with the
reader's kind indulgence) say a few words.
In the first group he placed women who had had more or less
serious signs of plumbism. There were four women in this series
who had had fifteen pregnancies, of which ten had ended in abortions,
two in premature labour, one in a dead-born infant, one in an infant
that died in twenty-four hours, and one in an infant that survived
birth. In a second group were placed five women (including the
original case referred to above), who had had normal pregnancies
prior to their working in lead, but who afterwards out of thirty-six
new pregnancies had had twenty-six abortions, one premature labour,
two dead-births, five infants of whom four died in the first year, and
two infants who survived. In the third series is a single case, that
of a woman who had ceased to work in the type-foundry ; as a worker
she was five times pregnant, and had five abortions ; after ceasing to
work she had one pregnancy, the result of which was a living and
healthy infant. In the fourth series were two cases — (1) That of a
woman who had ceased to work in the foundry, gave birth to a living
infant four years later, and had then returned to work, and had
since had one abortion and probably three others ; (2) that of a
woman who had on two occasions ceased to work, and in each
interval had had a living (and surviving) infant, and who had there-
after worked continuously and had two abortions. The fifth series
was very interesting ; it contained seven cases, in which either the
husband alone was exposed to lead poisoning, or in which, although
both parents were exposed, the husband alone suttered from signs
of saturnism. Out of thirty-two pregnancies, there were eleven
abortions and one dead-birth, while of the twenty infants born alive
eight died in the first year, four in the second, five in the third, and
three survived. The conclusion drawn is that the father as well as
the mother may transmit the evil effects of lead poisoning, although
in a less grave degree, to the offspring ; but to do so he must be
suffering from the lead (" en puissance de plomb ") at the time of
fecundation. In the sixth and final series were the cases where the
blue line on the gums was the only sign of plumbism : there were six
women in this series, who had twenty-nine pregnancies, among which
there were eight abortions, one premature labour, twelve dead
infants, and eight living infants ; so that, when the eflects of the
lead on the parent were less marked, the results to the offspring
were also less severe. Paid draws the evident conclusion that, while
lead poisoning does not prevent fecundation, it very gravely interferes
with antenatal life ; for, out of a total of one hundred and twenty-
three pregnancies, in seventy-three the product was dead before
expulsion from the uterus, and thirty-five infants born alive died in
the first three years of life. Manifestly it is a grave matter for the
fuetus when one or both its parents are " en puissance de plomb." In
2G2 AXTKNATAL I'ATHOLOCY ANJ) HY(;iENE
a later article {Comjit. rend. Soc. de hioL, o s., iii. 4, 1862), Paul addrd
two other cases to the list, giving a total of one huiulred and forty-uiic
pregnancies, ninety-one abortions, dead births, and premature labours,
and tliirty-tive infants who died in the first tiiree years of life.
Fournier's exclamation regardhig syphilis is surely not inapplicable
here also : " Quelles statistiques! Quelles horribles tables mortuaires!"
Paul's observations were so evidently important that they at
once called forth a leading article in the Gazette des Iwpitaux (xxxiiL
225, 1860), and stimulated observers in other countries to make
further investigations, lienson P)aker {Trans. Ohst. Soc. Lond., viii.
41, 1866), for instance, recorded three cases in which lead j)oisoning
in both parents was apparently the cause of one or more aljortions ;
but in one instance there was syphilis also. Baker was of opinion
that the lead killed the foetus in ntero, and that thereafter and on
that account abortion took place ; but he admitted that the expulsion
of the uterine contents might be due to the action of the metal on
the uterine muscle. Lincoln {Boston Mnl. and Surg. Joitrn., Ixxxvii.
306, 1872) had an article on "the influence of the exhalations from
fresh paint upon the ftetus in utero." J. T. Arlidge also, in a
pamphlet on The Diseases 'prevalent among Potters (London, 1872),
referred to the great infantile mortality in the offspring of such
workers in lead ; and R Eoque {Compt. rend. Soc. de hiol., 5 s., iv. 243,
1874) ascribed to the working in lead not only the high infant death-
rate, but also the frequent occurrence of idiocy, imbecility, and
epilepsy; in most of Eoque's sixteen families the father alone
suffered from plumbism. Sireday {Journ. de med. et cJtir. prat.,
xlvii. 63, 1876) and Ganiayre {These, Paris, 1900) also considered
the relation of abortion and lead poisoning : and Lefour {B/'ll. Soc.
d'anat. et p)hysiol. de Bordeaux, viii. 84, 1887) dealt specially with the
father's influence.
An observation, resembling in some of its details that made by
Eoque, was published by 0. Itennert {Arch. f. Gynaclc, xviii. 109,
1881). He found that of the children of eleven men wlio were
workers in pottery-glazing, many had certain cranial anomalies. All
the eleven men suffered from plumbism ; in two instances the wives
were also markedly affected, and in some other cases they showed
slight signs of poisoning, but some of them were quite free. Either at
birth, or soon thereafter, the heads of the infants were in many in-
stances noted to be S(piare-shaped, with very evident tubera frontalia
et parietalia ; they increased rapidly in size, but the fontanelles were
not hirger than usual, the sutures did not gape, and the orbits and
liosition of the eyeballs were normal (no hydrocephalus, therefore).
There were no signs of rickets in the bones of the chest, linilis, and jaws ;
and the other organs were healthy. These infants grew fairh' normally,
neither their intelligence nor their general strength and nourishment
being affected; but they had a very special tendency to convulsiims
(tonic and clonic contractions of the back and limbs), and a great num-
ber of them died (twenty-eight out of fifty-six who were afl'ected, or
50 per cent.). Most of the macrocephalic children suflered from com ul-
sions, but even the non-macrocephalic were sometimes affected in this
MKRCURIAL POISOXINXi IN THE Fd-yrUS 263
way : and out of the total number of seventy-nine infants, fifty-six, or
71 per cent., were affected either with macrocephaly or convulsions or
both, but it is to be noted that six dead-born foetuses are included
amongst the non-afi'ected. Eennert divides the cases into three groups :
— In the first, both parents were aflected, and the proportion of macro-
cephalics was 95 per cent, (eighteen out of nineteen cases, the remaining
infant being dead-born) ; in the second group the mothers were only
slightly affected, and eighteen out of twenty-seven cases (G7 per cent.)
were affected ; and in the third group the mothers were healthy, and
twenty out of thirty-three cases (61 per cent.) were affected. In
Eennert's cases the influence of syphilis and alcohol was apparently
excluded. The localisation of the effects of the lead upon the brain
and cranium is interesting when taken in conjunction with Porak's
experimental results, in which the metal was found specially in the
nervous centres. From Legrand and "Winter's case (loc. cit.), the
conclusion, however, may be drawn that lead tends to localise in the
liver and spleen ; it was calculated that in the liver, which weighed
45 grammes, there were from 7 to 8 milligrammes of the metal ; but
unfortunately neither the nervous centres nor the placenta were
available for analysis. The visceral changes present were of the
nature of irritative lesions of the liver and kidneys ; and in the
latter there was also a developmental arrest in the absence of the
zone of glomeruli in process of formation. It is difficult to regard
M. Anker's case {Berl. klin. Wchnschr., xxxi. 577, 1894) as a genuine
instance of antenatal transmission, for the child was eight years old,
and may have received the poison in other ways.
From these scattered references to lead poisoning it is clearly
unsafe to draw many conclusions ; but it may be tentatively suggested
that there is a certain resemblance between the resulting phenomena
and those found in syphilis. There is the marked tendency to
abortions and dead-births and to infantile multi-mortaUty ; there are
indications of dystrophic changes, perhaps located specially in the
brain ; and there is some evidence of peculiar visceral lesions due to
the ii-ritative effects of the metal on the tissues. Apparently, also,
there is paternal as well as maternal transmission.
Mercurial Poisoning.
When a pregnant woman is the subject of acute merciu'ial poison,
abortion has been known to follow ; but Wynter Blyth {Poisons, p.
643, 1895) referred to the case of a girl who swallowed 4i oz. by
weight of the liquid metal in order to procure abortion, but without
any such effect, although she suffered later from tremor and paralysis.
It is, however, with the effects of chronic mercurial poisoning upon
pregnancy and the foetus that we are more directly concerned. As
with workers in lead, so with pregnant women employed in trades in
which mercury is employed, there is evidence that the absorption of
the metal leads not infrequently to abortion, and that even when the
infant is born alive it may show signs of poisoning, e.g. mercurial
tremors. A. Lize {Union med., 2 s., xiii. 106, 1862) has found that.
2(14 ANIIA'ATAI, l'Alll()l,()(;V AND lIVCilENE
auiuiij;- wciiuen exposetl to tlie fumes of nitrate of mercury, pregnane;:
was luuUiubtedly interfered witli. Of twelve pregnancies of womeii
(not tliemselves workers) who were married to workers in mercurj
there were two jiremature laljours, two dead -born infants, three chili
dren who died during the first four years of life, and five childrei
wlio survived ; of the five sui'viving cliildren, however, one only wa-
strong, and it is noteworthy tliat, at the time of his conce]ilion, hi'j
father was not a worker. In two cases both father and mother war
exposed to the poison, and of fourteen })regnancies which followec;
five ended in the birth of dead-born fcetuses, and of tlie progeny c
tlie other nine, only three infants survived their fifth year. In thre
cases the mother alone was exposed ; there were seven pregnanciei
three of whicli ended in aljovtions, one in a dead-birth, and of th
living infants one was tubercular. A curious observation is referre
to by Wynter IJlyth {op. cit., p. G44, 1895) ; it was that of a womai
twenty years of age, employed in making barometers, and who suffere
from tremor and salivation ; during a three months' pregnancy tb
tremor ceased, but again appeared after she had aborted ; she agaii
became pregnant, and the tremor ceased until after her confinement;
With regard to the passage of mercury througli the placenta to th
fcetus, Porak {loc. cit.) found from experiments upon pregnant guinea*
pigs that the metal showed a marked tendency to be stored up in thi
placenta, and that it was not to be discovered in the other fcete
organs ; it caused abortion in two cases out of six. A. Plottie
(These, Geneve, 1897) found no mercury in the placenta, liquor amni
and fwtus of a guinea-pig that had received peptonate of mercury il
the form of subcutaneous injections ; but in tiie case of a pregnatj
rabbit, that received the mercury in tlie same form and manner, tkl
metal was found both in the placentas and the fa?tuses, but not i'
the liquor amnii. In the case of the human subject, the mof
important evidence available is got from the cases of syphilis i
pregnancy in which mercury has been administered. The results d
the examination of the fcetus for mercury in such cases are contaj
dictory, but H. Cathelineau and H. Stef {A7i7i. dc dcrmat. et dc sypl
i. 972, 1890; Bidl. Soc. fran^. dr dcrmat, i. 167, 1890) found tt
metal in the placenta, liquor amnii, and fcetus in fi\'e pregnanci*!
in the human subject, and one in tlie rabbit. The mercury wj
detected in the liver, spleen, heart, ki«lneys, meconium, lungs, an
Imxin ; the amount in the liver was 0-00121 gramme in 10 gramnw
of tlie organ, or 0-0182 gramme in the whole viscus ; the other orgai
named contained less. Strassmanu (Arch. f. Phydol., Suppl. Ban
s. 95, 1899) and D. Mirto {Gior. di mcd. leg., Lancisiano, vi. 1, 189J
have also made observations on the transplacental ]iassage of merciir
Tlie following conclusions seem fairly warrantable. IMercui
given to the pregnant woman in the treatment of sy]ihilis jiasses i'
the foetus, liquor amnii, and placenta ; in these circumstances it seen
not to cause but to prevent abortion. In non-syphilitic women, bov
ever, who have received mercury into the sj'stem in connection wil
their work, and who are suH'ering from mercurial poisoning, tl
results would appear to be abortions, dead-births, and congenit
PHOSl'llOULS I'OISONINC; IN 111]-, FCKTUS 265
debility; but mercury does nut seem to lie so fatal in these respects
as lead. In one instance at least the si",nis of maternal ]ioisoning
largely disappeared durinu; pregnancy (concentration of toxic action
upon the fietus or accumulation of the metal in the placenta ?).
Mercury apparently passes to the fcrtus in the rabbit also, but not
in the guinea-pig ; in the latter ease it is stored up in the placenta,
and, therefore, in one sense reaches the fretus, the placenta being
looked upon as one of its organs. It is not known what changes the
mercury produces in the placenta and fo'tal organs when it reaches
them.
Phosphorus Poisoning.
That phosphorus passes in some form from mother to foetus is proven
bv the presence of phosjihates in the latter ; but in what form the
metal passes is not known (ride p. 149). Nevertheless, several ex-
periments have lieen carried out to settle this point. As far back as
1857, L. Eestelli (Gior. d. r. Accad. med.-chir. di Torino, 2 s., xxix.
257, o21, 1857) made analyses in the case of puppies ; and much more
recently, L. IJorri {Scttimana mcd. d. Spcfimevtalc, 1. 267, 1896), using
much more exact methods, detected phosphorus in the foetuses and
placenta of poisoned rabbits. Both observers obtained positive
results, but left the cj^uestion of the form in which the metal passed
uncertain. Porak (loc. cit.) got negative results in the case of guinea-
pigs.
There is sufficient evidence, both from the lower animals and the
human subject, that in maternal phosphorus poisoning, lesions exist
in the fcetus similar to those found in the mother. I. M. lliura
{Arch. f. path. Anat., 9 F., vi. 54, 1884) found fatty degeneration of
several of the fcctal organs along with subserous ecchymoses in two
rabbits and two guinea-pigs that had been poisoned with phosphor-
ated oil administered by the mouth. Pulewka {I)is>i., Konigsb. i. Pr.,
1885) and S. Friedliinder (Diss., Konig.sb. i. Pr., 1892) reported cases
of phosphorus poisoning in pregnancy, and the latter noted changes
in the fcetal organs (fatty degeneration). In 1893, also, C. Seydel
( Vrtljschr. f. gericht. Mcd., 3 F., vi. 280, 1893) recorded a case of
phosphorus poisoning in which the victim gave birth to twins, dead-
born ; with the exception of sanguinolent effusion into the serous
cavities, the fcetuses showed no naked-eye changes, but, on microscopic
examination, extensive fatty degeneration of the liver cells was dis-
covered ; the kidneys and heart exhibited no microscopical altera-
tions. G. Corin and G. Ansiaux (Vrtljschr. f. gericht. Med., 3 F., vii.
84, 1894) carried out experiments upon dogs ; one of these was
pregnant with eight puppies. The membranes were separated from
the uterine walls by blood effusion in which small oil globules were
suspended ; the placental ^•illi were much degenerated, and showed
fatty streaks ; the liquor amnii had a reddish colour ; the fo'tal heart
contained jjartly coagulated blood : there was yellow fluid in the
pleural and peritoneal cavities, and there were ecchymoses on the
pleural and peritoneal membranes ; and although the analysis of the
fcetal organs did not indicate the presence of phosphorus, the authors
266 ANri'.NATAI, I'ATllOI.OCi^' AND HVCIF.NK
couchulud fioin Lhu other signs thai the poison had passed to llie
fcEtuses.
The preceding statements refer to acute phosphorus poisoning :
but the question arises whether in the chronic poisoning associated
with certain trades any eHects upon pregnancj' and the fcetus liave
been noticed. According to I'alazzi {Ann. di ostct. c ijincc, xxiii. 350,
1901), a case is on record in which for eight days a pregnant woman
took small doses of phosphorus causing subacute poisoning ; never-
theless she ultimately recovered, and was delivered two months later
of a living and well-formed infant. With regard to the women
workers in match factories, the facts elicited by Korri were contra-
dictory, in some factories abortions lieing common, and in others not
above the average. Possibly the risks of serious results are nowadays
much lessened through improved hygiene.
Arsenical Poisoning.
There are few observations regarding the ehect of either acute or
chronic arsenical poisoning on antenatal life. Keber ( Vrtljschr. f.
rjericM. u. off. Med. x.xiii. 300, 1863) records the case of a woman,
pregnant at the fourth month, who poisoned herself with arsenic in
the hope of producing abortion. After an illness of two days she
died, and apparently aborted after death, for a fcetus about 5 inches
long was found lying at the ^"ulva. On chemical examination no
trace of arsenic was discovered in the foetus. Similarly in G.
Pilomusi-Guelfi's case {Gior. intcrnaz. d. sc. mcd., Napoli, n.s., x. 392,
1888) no arsenic was detected in the macerated seven mouths' foetus
of a woman who had premature labour sixteen days after being
poisoned. Keber {loc. cit.), however, refers to a case published in
1846 in which traces of arsenic were found in the uterus, placenta,
and foetus, but not in the liipior amnii.
Experimental evidence goes to prove that in the guinea-pig at
any rate arsenic passes through the placenta to the foetus. De
Arcangelis is quoted by I'alazzi (Ann. di ostct. c ginec, xxiii. 350,
1901) as having demonstrated that the metal is foimd in the fcrtus
and in the liquor amnii, but in smaller amount in the latter ; the
quantity which passed was greater in acute than in chronic poison-
ing ; the passage was quick and occurred at all dates iu pregnancy.
Porak {loc. cit.) also found that arsenic passed (with difficulty) to the
foetus, and that it was there stored up chiefly in the skin ; a some-
what remarkable observation, when the therapeutic ettects of the
drug in skin diseases is borne in mind. Porak also found it to be a
powerful abortifacient in the guinea-pig, probably on account of the
placental hemorrhages which resulted. In the case of the rabbit,
Plottier (op. cit.) also got a positive result as to the pass;vge of arsenic.
Data regarding tlie efi'ect of arsenic on the foetal organs are too
scanty to warrant the drawing of any conclusions.
As to tlie intluence of poisonin// vith copper upon antenatal life,
next to nothing is definitely known. Of experimental evidence there
CARBONIC OXIDE POISONING 2G7
is likewise little ; but I'hilipeaux {Comjit. rend. Soc. de hio/., 7 s., i.
227, 1880) found that by mixing basic acetate of copper with the
food of a pregnant rabbit, small quantities of it could be detected in
the fcetal tissues. Porak (loc. cit.) noted that, in the case of guinea-
pigs, the copper tended to accumulate in the placenta, liver, central
nervous system, and sometimes in the skin ; Ijut he did not observe
any abortifacieut action.
Casper (Handbook of Forensic Medicine, New Sydenh. Soc, ii. p.
82, 1862) records two cases of poisoning with sulphuric acid in
pregnancy ; in one of these in which the gestation was at the fourth
month, the liquor amnii had a decidedly acid reaction ; Casper regrets
that in the other this point was not investigated. I'alazzi (loc.
cit.) refers to a case seen by Otto in which the mother was poisoned
with sulphuric acid, and the five months' fa?tus had a reddish brown
skin as hard as parchment, with healthy internal organs ; the con-
clusion is drawn that the acid can only have reached the liquor
amnii. This case raises, without in a great degree settling, the
question of the cause of fcetal death in such forms of poisoning ;
probably it is in most instances due to the effects upon the mother,
while in a few cases it may be caused by the direct action of the
poison on the foetus. To this matter, however, I shall return under
the heading of foetal asphyxia.
It will now be well to consider certain poisonous gases and their
effects upon antenatal life. These are carbonic oxide, chloroform,
and ether.
Poisoning with Carbonic Oxide or Coal Gas.
Cases of carbonic oxide and coal gas poisoning may be considered
together. Breslau (Monatsclir. f. Gehurtsk. u. Frauenkr., xiii. 449,
1859) narrates how two pregnant women were poisoned by inhaling
coal gas (which contains carbonic oxide) ; one woman gave birth
twenty-four hours later to a recently dead foetus ; the other, who was
less affected Ijy the gas, had a living infant some time afterwards.
In I\I. B. Freund's case (Monatschr. f. Gclnrtsk. u. Frauenkr., xiv. 31,
1859) the poisoning was less marked, merely causing headache, but
five weeks later a macerated foetus was expelled from the uterus.
D. T. Nelson (Chiccujo Med. Gaz., i. 42, 1880) also recorded an
instance of " coal gas poisoning of a foetus at term." F. Falk
( Vrtljschr. f. gerichtl. Med., n. F., xl. 279, 1884) gave interesting
details of a case of carbonic oxide poisoning in a woman, forty-two
years of age, who was in the eighth month of her pregnancy. Her
blood had the bright red appearance due to this form of poisoning,
but the blood of the female fcetus in utero had the usual dark colour,
and Falk concludes that the placenta does not usually permit
carbonic oxide gas to pass to the fcetus. At the same time he refers
to a case noted by Liman, in which both the maternal blood and that
of a six months' fcetus showed the spectroscopic appearances peculiar
to carbonic oxide poisoning.
2G8 AXTEXATAL PATHOLOGY AND HYOIEXK
1
There is also some evidence, derived from exjieriments, bearing
upon the transmission of this <ras from mother to fo'tus. A. Hiigyes
{Arch./, d. ijes. F/u/siol., xv. :V.M), 1877), for instance, poisoned two
rabbits with carbonic oxide in from one to one and a half minutes ; Ijut
the spectroscopic examination of the foetal l)lood gave negative results.
Fehling {Arch. f. Gynaek., xi. 523, 1877) found, however, that if
rabbits be submitted to the effect of coal gas mixed with air for a
longer time, the blood of the fcetuses sometimes but not always showed
traces of carbonic oxide, but always to a less degree than did the
maternal blood. N. Grchant and Quinquaud (Comjit. rend. Acad. d.
sc, Paris, xcvii. 330, 1883) exposed pregnant dogs to the fumes for
thirty-five minutes, and found the gas in the blood of the fcetuses,
but always iu small quantity. The conclusion, therefore, seems to be
justified that, in experiments upon animals, carbonic oxide does pass
in small amount through the placenta, but that in the case of the
human subject the fcctal death is due rather to the maternal asphyxia
than to the direct action of the poison. But, again, the cases are too
few to warrant the safe drawing of conclusions.
Chloroform.
When chloroform was first introduced into obstetrics, fears were
widely expressed lest it might injure the infant. How can we'
" know or ascertain the possible consequences of the use of such an
agent on the Ijrain of a child ? And how can we calculate what may
be the ultimate consequences of its action in reference to the
development of the mental faculties ? " These questions were asked
in April 1848 ; and in October of the same year Simpson answered
them by stating that out of 150 infants born under anicstbesia, all
except one (a macerated fcetus) were born alive, and that he was not
aware that any of them had siirce suffered from "cei-ebral etfusions,"
" convulsions," " hydrocephalus," or any other of the " aii'ections which
have been prophesied as certain to befall all such infants " {Obstetric
Works, ii. 638, 1856). The matter was also discussed in Germany
(L. Meliscber, Deutsche Klinik, iii. 271, 1851). Of recent years the
question has been raised anew but iu a modified form, for it has been
asked whether jaundice in the new-born infant might not be due to
the effect of chloroform on the foetus. H. Fehling {Arch./. Gyiiaeh,
ix. 315, 1876) found no trace of any such infiuence, an experience
shared in to a large extent l)y P. Zweifel {Arch.f. Gynaek., xii. 252,
1877); but Hofmeyer {TaycU. d. rcrsamml. dcntsch. Xaturf. v. Aerztc,
Eisenach, Iv. 295, 1882), in the case of twenty-two infants, the
offspring of mothers who had been chloroformed in labour, found all
of them more or less icteric and showing albumin and tube casts in
the urine. In Hofnieyer's ciises, however, the labours were long and
the amount of chloroform inhaled considerable (30 to 100 grammes);
manifestlv other infiuonces were at work besides the chloroform.
F. Ahlfeld {Lchrl. d. Gchurtsh., 201, 1894) is inclined to think that
the prolonged use of chloroform in labour may asphyxiate the foetus,
and bases his belief on ten cases of Cesarean section, in eight of
EFFECT OF ETHER ON THl'. FOETUS 2G9
wliich meconium was found in the liquor amnii. Ordinary everydaj'
experience, however, shows that chloroform given in laboiu' has little
or no injurious effect upon the foetus.
AVith regard to the experimental proof of the passage of chloroform
from the maternal to the fcetal blood, there is as yet no aljsolute
certainty. P. Zweifel {Berl. Idin. Wchnschr., xi. 245, 1874) found
that the urine of infants born to chloroformed mothers had a
reducing effect upon Fehling's alkaline copper solution. In a later
research, Zweifel (Arch./. Gynaeh., xii. 238, 1877) tested the placental
blood more accurately, and in six out of seven cases noted quite
distinctly the smell of phenyl-carbylamine (isonitrile), a peculiar and
penetrating odour. Fehling also got positive results with tlie
carbylamine test {Arch.f. GynacI,:, xi. 554, 1877). There is, there-
fore, strong evidence in favour of the lielief that chloroform gas passes
into the ffftal blood ; and, it may be added, that there is no strong
evidence that when there it produces any serious effects.
Ether.
Gloomy forebodings about the effects of ether upon the foetus
in utero were freely entertained, just as we have seen they were
regarding chloroform. One writer in 1848 (G. T. Gream, Pamphlet,
1848) expresses his fears as follows : " It is admitted by all that the
pulsations of the fcctal heart are greatly inci-eased during inhalation
— indeed, to such an extent has this been noticed, that in some
instances the pulsations could not be counted, so much were they
accelerated. Are not effusions to be feared from this ? Are not
convulsions after bii'th likely to ensue ? And may not that occur
which would make the most heartless mother shudder at the bare
possibility of herself, by want of courage, being instrumental in
producing ? May not idiocy supervene ? Of this we have as yet no
experience, nor shall we have, perliaps, for years ; but when oue such
case occurs, will there be found any one who will afterwards be
persuaded to submit herself to etherisation during pregnancy ? "
Fortimately we are often more frightened than hurt, and suffer often
more in apprehension than in realit}' — Plura sunt quw nos terrcnt,
quam quce 2)remunt ; ct scepius opinionc quam re lahoramus !
As with chloroform so with ether, its transplacental passage to
the foetus has not been absolutely proven, although it is extremely
probable. To recapitulate, there is no reason to doubt the passage of
either chloroform or ether to the fretus, neither is there any reason
to apprehend toxic effects unless the maternal anaesthesia be very
deep and long continued.
I now pass to the consideration of the action of opium, tobacco,
and alcohol upon the unborn infant.
Poisoning- with Opium.
The subject of the possible poisoning of the foetus with opium is
chiefly remarkable for the lengthy debate, occupying three meetings,
270 AN'll-.NATAI. l'ATll()I,()(iV AND HYCilKNK
to which it gave rise at the Xew York Ob.stetriciil Society in 1677.
At tliese meetings, or as a direct result of them, a considerable
amount of clinical e\idence, of a curiously contradictory sort, was
gathered together, mainly in reference to the etl'ect which mor])hine,
administered to the mother during pregnancy or at laljour, had upon
the unljorn infant. The discussion arose out of a case of eclam])sia
in the mother treated hy hypodermic injection of morphine, witli
asphy.Kia and subsequent convulsions in the cliild, the account of
which was communicated by J. B. ]\Iattison at the January nieetiug
of 1S77 {Amrr. Journ. Ohst., x. 299, 1877). In all, one and one-third
grains of morphine were administered ; the infant was asphyxiated at
birth, was resuscitated with difficulty, and thereafter passed tlirough
nine convulsive seizures ; lioth mother and child recovered. (.)n the
motion of Paul F. MiTudc', tlie su])jeet was made the sjiecial topic for
discussion at the next meeting (February 1877), and Mundi' himself
opened that discussion, which was entitled "The Iniluence on the
Fcetus of Medicines, particularly Narcotics, administered to the mother
during pregnancy and labour." He recorded a case {Aiiter. Journ. Ohst.,
X. 300, 1877) in which a woman liad been taking from twelve to
sixteen grains of morpliine daily during the whole course of her
pregnancy ; foBtal movements were normal, and the infant was bom
alive and apparently quite healthy. Mundi' suggested that there:
may have been gradual habituation of the fo'tus to the morphine.
It may be noted hei-e that Ernest Kormann (Dcufsrlic vied. Wchnschr.,
iii. 356, 1877) reported a very similar case, in which a truly
" morphiophagous woman, who took from two to four times daily a
quarter of a hypodermic syringe-ful of morphine — " Dies wurde die
gauze Schwangerschaft hindurcli fortgesetzt, imd trotzdem erfolgte
keiue der prophezeiheteu Storungeu " — and the fu-tal movements
were in no way almormal, and the infant was born alive and liealthy.
Kormann concluded tliat very little or no morphine reached the fcetus
through the placenta. ,
To return to the discussion in the New York Oljstetrical Society,
Fordyce Barker gave his clinical experience on tlie matter, and con-
cluded that there was no evidence which could be accepted by
science, that narcotic drugs, administered to the mother, ever pro-
duced their specific effects on the foetus in utero. W. M. Chamber-
lain expressed similar views, founded upon the fact that he had
reported a case in which a woman took during pregnancy, labour,
and lactation, twenty grains of morpliine every day, and tlie child
showed no ill efiects. Peaslee continued the discussion, exjiressiiig
very strong opinions on the innocuousness to the fwtus of opiuiu
given to the mother ; he asked sarcastically, " Does any pliysician ,
know of a narcotic \vhicli, given to the motlier, will even put a fcptus
asleep o' nights, in cases where the mother is kept awake and in
distress 1)V too forcible and continuous fcvtal movements?" W. K-
Gillette, however, gave ([uite a different aspect to the discussion : he
bro\ight forward the details of six cases, in all of which morphine was
administered to tlie degree of producing its physiological phenomena,
and in all of these instances the infant was born in a more or less
EFFECT OF OPIUM ON THE FQa'L'S 271
asphyxiated condition and with contracted pnpils. All the infants
save one recovered, and in the one that died intense cerebral con-
gestion was found. The morphine was given in labour instead of the
usual anaesthetics (chloroform or ether). The recovery from the
asphyxia was quite unlike that in ordinary cases of apncea neo-
natorum. In two other cases, Gillette gave atropine hypodermically
to the mother in the second stage of labour ; in one of these the
infant's pupils were markedly dilated. Skene believed, with Gillette,
that morphine, given to the mother, would produce its specific effects
on the fretus. Thomas added notes of two cases in which the foetal
heart-beats seem to have been slowed by morphine.
The discussion closed, as so many such discussions do, with the
expression of a very decided difference of opinion among the medical
men taking part in it ; but to the reader at a distance the impres-
sions given are that Gillette and those who agreed with him had at
least some facts on their side ; and that morphine, given to the mother
to the extent of producing specific efl'ects upon her, produced
them also upon her ftetus in utero. It is true that soon afterwards
"\V. T. Lusk {Amcr. Journ. Obst., x. 413, 1877) gave details of eleven
cases in which Gillette's experiment was repeated ; only twice did the
infants show asphyxia. To this Gillette replied (Amcr. Journ. Obst.,
X. 612, 1877) with a second series of fifteen cases, in which he
obtained results almost identical \vith those previously got by him-
self; and he attributed Lusk's failure to obtain a similar efifect to
the fact that he (Lusk) " did not push the drug to a sufficient
extent to produce even its safe phenomena." E. L. Partidge's
observations (Amcr. Journ. Obst., x. 558, 1877) went to support
Lusk, while J. J. Lamadrid's case {ibid., 466, 1877) added a little
strength to Gillette's opinion. Thus the great battle ended with a
splutter of fire on both sides and a few stray shots in the gathering
darkness.
Elsewhere than in New York the effect of morphine on the fcetus
gave rise to discussion. Fehling (Arch. f. Gynatl:, ix. 315, 1876)
thought that cases which he had seen pro\'ed that the asphyxia
neonatorum (with cereViral congestion) which sometimes followed
might be ascribed to the morphine. Ahlfeld (Lchrbuch, p. 202, 1894)
also met with a case which he regarded as one of congenital opiiuu
poisoning. Both he and Fehling regarded the negative results of
others (e.g., F. Benicke, Ccntrlbl. f. Gi/ndk., iii. 179, 1879) as due to
habituation of the foetiis to the effects of morphine. P. Kubassoff
(Di.ssc7-t., St. Petersb., 1879) also found that opium produced distinct
effects upon the foetus.
The actual presence of morphine in the infant at birth was shown
by Bureau in 1895 (Journ. de. mdd. dc Par., 2 s., vii. 597, 1895); the
mother took one gramme of morphine daily, the infant w'as born with
a club-foot, and morphine was found in the blood of the vessels of the
cord and placenta. A. Plottier (llihe, Geneve, 1897), in the case of
the rabbit, discovered morphine in the foetuses and placentas, but got
doubtful results for the liquor amnii : E. Marcj^uis (cited by Plottier)
obtained similar results with fcetal kittens.
272 ANTENATAI, rATlIOI.OdY AND H^XUKNK
A curious piece of evidence which goes to support the view that
morphine produces an effect upon the fietus in utero, is supplied by
Fere (Sensation et Mouvemcnt, p. 96, 1900). He narrates the case of
a pregnant woman with the morphine liahit, who, when she attempted
to abstain from the (hnig, was so tormented liy excessive ftetal move-
ments that she had to return to the opium, whereupon the fcetal
spasms ceased. He had oliserved the same phenomenon in connection
with bromide of potassium.
The general conclusion may therefore be drawn, that niorpliine
given to the mother affects the unborn child, but that while the Itahit
persisted in during pregnancy seems to produce no had elVects on the
fcetus, the taking of large doses at the time of labour predisposes to
asphyxia neonatorum. Tliere is no ground for supposing that it leads
to abortion ; olsviously such a result is not to be expected. There is,
however, room for much more investigation here; and these views
may require to be modified. Alas !
Tobacco Poisoning.
The main question which has arisen regarding the effect of
tobacco poisoning upon antenatal life is whether pregnant women
working in tobacco factories are more liable to abort tiian other
women. There is again a sharp difference of opinion : for while
Decaisne {Rev. d' hyg., i. 914, 1879) and those who took part in the
discussion following the reading of his paper (ihid., ii. 35, 216, 1880)
were quite convinced that abortion was very frequent in women
workers in tobacco in France, and while T. Kostial ( Wehnhl. d. I: k.
Gcsellseh. d. Acrzte in Wien., viii. 313, 1868) bore the same testimony
with regard to Austria, Ygonin {Lyun MM., xxxv. 397, 1880) and
Piasecki (^cy. d'hyrj.,\\\. 910, 1881) formed an opinion diametrically
opposed. The views of Piasecki and 'Ygonin have been sujiporteil
recently by G. Etienne {Ann. d' hyg., 3 s., xxxvii. 526, 1897) with
regard at least to the women workers in the factories at Nancy. In
de Pradel's case {Bull, ct mem. Soc. dc mdd. 2}rat. de Paris, p. 592,
1888) it cannot be proved that the death of the foetus was due to the
influence of the tobacco.
AVhile there is much doubt, therefore, regarding the evil eflect of
nicotism in cuttiug short antenatal life, there seems to be no shadow
of doubt that there is a very large infantile mortality in postnatal
life among the offspring of women workers in tobacco. Possibly this
may be due in part to the influence of the milk, but it is more pro-
bable that it is on account of congenital debility. Of course it is
difficult to exclude the other possible causes of abortion, premature
labour, and infantile mortality {e.g. syphilis).
Alcoholism.
Eound the question of the effect of maternal (and paternal)
alcoholism upon the unborn infaut there has raged a fierce battle, a
battle the issue of which is still in doubt. The arguments which
FCETAL ALCOHOLISM 273
have been advanced on both sides have not always appealed solely
to the medical and scientific aspects of this question, and doubt-
less preconceived notions have been allowed free play ; but tliere
have gradually emerged certain fairly well established facts, and
these I may now consider under the headings of experimental and
cHiiical.
With regard, in the first place, to experimental evidence, it has to
be recorded that until recent years no absolute proof was forthcoming
that alcohol passes from the mother to the foetus. It is true that
Plottier {Thhc, Geneve, p. 26, 1897) found alcohol in the liquor amnii,
foetuses, and placenta of a rabbit into whose stomach he had intro-
duced 15 grammes of alcohol (with 25 grammes of water) ; but
Palazzi (Ann. di ostet. e ginec, xxiii. 357, 1901) got negative results
in the case of a pregnant rabbit, into whose subcutaneous tissue
iujections of 20 c.c. of ethylic alcohol had been made. M. Nicloux,
however, may be said to have settled the question of the passage of
alcohol from mother to fcetus, both for animals and the human subject,
by a careful!}- regulated series of experiments, the results of which
were published in 1900 (Z'Obstdtriquc, v. 97, 1900). By means of a
somewhat complicated but reliable appai'atus, he was able to ascer-
tain with exactness the amount of alcohol in the blood and tissues, and
thus to introduce a new element of certainty into his experiments.
In tlie case of six pregnant guinea-pigs he introduced from -h to 5 c.c.
(per kgr. of body-weight) of absolute alcohol into the stomach by an
(jesophageal tube ; one hour later he killed tlie animal aud extracted
the fcetuses from the uterus, and tested both the maternal and the
foetal blood and tissues for alcohol. He found that alcohol passed in
very considerable quantity, and that the amount in the foetal blood
was relatively almost if not quite as much as in the material ; even
when the amount given to the mother was very small, it could
be detected in the fcetus. Nicloux extended his experiments to
the human subject; he gave to the woman in labour about GO c.c.
of rum (containing 45 per cent, of absolute alcohol) mixed with
milk ; this was administered about one hour before the infant
was born; and in all the cases (six in number) alcohol could be
easily detected in foetal blood from the umbilical cord and placenta.
There was no evidence of the presence of aldehyde or acetic
acid, but only of alcohol. It may, I think, be taken as proven
that alcohol passes, as alcohol, from the maternal to the foetal
circulation.
I have now to consider the experimental evidence regardmg the
effects produced by alcohol on the foetus. To quote from Nicloux :
" La realitc du passage de I'alcool de la mere au foetus demon tre la
possibilite de I'intoxication du foetus ; quelle ne doit pas etre alors la
toxicitii de I'alcool pour un organisme et surtout pour un systeme
nerveux en voie de formation ? " Now, although it is a priori
possible, and indeed probable, that ill effects follow the presence of
alcohol in the foetal tissues, and more especially in the central
nervous system, yet we must not accept probabilities as if they were
proven facts. AVhat then are the facts ? M. Carrara (Eiv. di med.
274 ANl'I.NAIAl. 1>A1H()1.()(;'>' AM) 1 lYCill'.NK
liij., Milan, ii. 177, 1898-'J'.l) examined tiie nerve centres of the
feetuses in two pregnant guinea-pigs that had been treated with
alcohol ; he noted the extraordinary freshness of all the tissues (pre-
serving j)Ower of the alcohol ?), and observed that, in the large cells of
the anterior horns of grey matter in the spinal cord, the chromophilie
zones were indistinct, hut the nucleus was well marked. Evidently
these observations were not such as to justify the drawing of con-
clusions therefrom, so I'alazzi {Ann. di ostct. c ginc.c, xxiii. 357, 1901)
instituted experiments upon fifteen rablnts treated in such a way as
to imitate chronic alcoholism (they were injected liypodermically,
twice daily, with from 5 to 20 c.c. of alcohol) ; seven of these animals,
although mixing freely with the males, remained sterile ; five became
pregnant and give birth to living and well-formed ftetuses: of the
twenty-four fwtuses, only one showed any microscopic anomalies;
while neither the liver nor the kidneys had, so far as Palazzi had beeu
able to examine them, exhiljited any microscoi)ical alterations. On
the other hand, the experiments made by Fere {Bull, et mhn. Soc.
mid. d. hop. de Paris, 3 s., xi. 136, 1894, etc.), in which various
kinds of alcohol and aldehyde were injected into the hen's egg
in incubation, yielded many jDOsitive results in the form of non-
developments, malformations, and monstrosities. It may l)e added
that iVIairet and Combemale {Comjit. rend. Acad. d. sc, c^'i. 667, ,
1888) noted that an alcoholised bitch ga^e birth to deformed
puppies. To these teratological results of the action of alcohol, ■
attention will be paid elsewhere when I come to deal with the 1
pathology of the embryo. In the meantime, it may be stated here J
that experiments with alcohol upon the foetuses of rabbits and j
guinea - pigs have given negative results in so far as structural i
lesions are concerned. •'
Let us turn now, in the second place, to the clinical evidence •■
iipon these matters. There is, to begin with, a very considerable f
volume of opinion, with some statistics to strengthen it, that parental '
inebriety leads to sterility, to abortion, to premature labour, and tO
dead-births. J. Matthews Duncan (Trans. Edinh. Ohst. Sue, xiii. 113, •
1888) gave a useful summary of the older evidence on tliis matter, ;
adding some confirmatory facts from his own experience, ilany
others have written on the same subject and expres.sed similar views;
but the contribution which W. C. Sullivan {Jonrn. Mcnt. Sc, xlv. 489,
1899) made in 1899 stood out from most of the others by reason of
its exactness and avoidance of fallacies. He specially investigated ■<
the reproductive history of chronic drunkards (women) in the Liver-
pool prison, and he avoided, as far as possible, the cases which were ,
complicated by other degenerative factors. He found that of 120 :
female inebriates were born 600 children, of whom 335 (ri5\S per cent.) .
died under two years or were dead-born, while the remaining 265
(44-2 per cent.) lived over two years. In the case of sober mothers i
related to the women above mentioned, the rate of dead-birth and
early infantile deaths was only 23-9 per cent. Further, there was
found to be a progressive death-rate in the alcoholic fanrily, the
number of dead-Ijirths and deaths under two yenvn increasing as time
F(ETAL ALCOHOLISM
275
went on. This fact is broiiglit out by one of Sullivan's tables, which
I reproduce here : —
Cases.
Dead and
Dead-born,
per cent.
Dead-born,
per cent.
First-born
Second-born
Third-born
Fourth and fifth-born ....
Sixth to tentli-born
80
80
80
111
93
33-7
50-0
52 '6
65-7
72-0
6-2
11-2
7-6
10-8
17-2
" These figures," says Sullivan, " illustrate very clearly the pro-
gressively augmenting character of the influence of the mother's
alcoholism ; it is specially noteworthy that the rate of still-births
shows almost as marked a tendency to regular increase as does the
death-rate among children born alive." Further, there was a sensibly
higher death-rate among the infants of the mothers whose inebriety
was developed at an early period ; thus, of 31 women who began to
drink at least two years before their first pregnancy, 118 children were
born, of whom 74 died in infancy or were dead-born (62-7 per cent.).
Sober 2J<^i<:i'nity seemed to have little influence, was indeed " almost
negligible " ; neither did an inebriate ancestry appear to produce any
great efi'ect. In seven of Sullivan's cases in which there was con-
ception in a state of drunkenness, in six the children died in convul-
sions during the first months of life, and in the seventh case the child
was still-born. Amidst all this statistical gloom there was but one
little bright light, one " scintilla," so to say, or spark of hope, — the
fact that residence in prison, with of course a stopping of all alcohol,
often enabled an inebriate mother to give birth to a living and sur-
viving infant. For the female habitual drunkard it is apparently
the best thing to be committed for a term of imprisonment early
in her pregnancy ; the prison baby may be the best ! A sad fact,
but a fact pregnant with hope !
It is unnecessary to dilate upon this aspect of the clinical effects
of maternal alcoholism ; but I may here refer to the results of acute
poisoning with alcohol, a somewhat uncommon accident in pregnancy.
Drappier {Arch, dc (/ym'c. ct dc tocol., xxiii. 476, 1896) has recorded
the case of a lady, pregnant for the sixth time, who drank a litre of
brandy ; she exhibited all the signs of acute poisoning, and died two
days later ; but before death occurred she was delivered of two dead
fcetuses of an intrauterine age of six months. Drappier ascribed the
premature delivery to an excessive amount of carbonic acid in the
uterine vessels and to death of the foetuses. How far dead-births
and abortions are due to the direct effect of alcohol, and how far to
placental disease set up by it, is a question not at present to be
answered. Facts are much wanted.
276 ANTl.NATAL PATHOLOdV AND HYGIENE
Another nue.stioii concerned witli the effects of alcohol uijou
antenatal life remains to be considered, namely, the dystrophic or
teratological i-esults. With regard, for instance, to epilepsy developing
after Ijirth, there is a great deal of evidence that pai'ental alcoholism
is an undoubted and powerful etiological factor. Ferii (Famille
nhTopalhiijue, p. 55, 1898), F. Combemale {La descendance dcs alco-
hoiiqufs, Montpellier, 1888), L. Leter {These, Venis, 1892), Lancereaux
{Levons de cliniquc malicalc, p. 59, 1892), and many others have written
on this subject; and Bourueville {Proyres vu'd., 3 s., xiii. 2G2, 1901)
has recently giveu some startlmg statistics. Of 2554 children (2072
boys and 482 girls) who were admitted to the Bicetre and Fondation
Vallee between the years 1879 and 1900, all of them suttering from
idiocy, epilepsy, inil)ecility, or hysteria, 1053 were the offspring of
drunken parents (933 had drunken fathers, 80 had drunken mothers,
and 40 had both parents drunken). About 450 of the.se children no
information could be gathered; while 1051 had sober parents.
Certainly 235 were conceived during the drunkenness of the father.
The fact which emerged from these statistics, therefore, was that
41-1 per cent, of these idiot and epileptic children had drunken
parents. Fere says it is difficult to decide how far we are to blame
the alcohol for these results ; for they may be due to the primary
neuropathic state which led the parents to become drunkards; but
when we are dealing with a vicious circle of causes and effects, it is
always difficult to allocate the blame correctly. SuUivau {loc. cit.)
found that out of the 219 children of alcoholic mothers who lived
beyond infancy, 9 or 4'1 per cent, became epileptic, an extremely
high proportion as compared with authoritative estimates of the
frequency of epilepsy in the general mass of the population (1 io
6 per 1000). Other writers found that from 12 to 15 per centj
of the surviving offspring of alcoholics became epileptic.
Besides the predisposition to become epilejitic or imbecile, the
children of drunken parents are, it is stated, often malformed. E.
Fournier {Stigmatcs dijstrophiques de I'hMdo-sijphilis, p. 318, 1898) has
\shown that, as with syphilis, so with alcoholism, the progeny is apt to
exhibit structural anomalies, such as iufantilism, multiple malforma-
tions {e.g. ectrodactyly, defect of occipital bone, etc.), hydrocephaly,
cranial asymmetry, porencephaly, and mierocei)haly. This statement
is simply the modern expression of a belief as old as the times of
Hippocrates ; and the deformed Vulcan was regarded as the result of
Jupiter's drunkenness. In several of the cases of foetal jiathology
which I have examined during the past twelve years, alcoholism in
the parents (one or both) has been met with, e.g., in a case of vesical
exstrophy, in one of congenital heart disease, etc.; but it is, of cmirse,
always very difficult to exclude all other causes of malformation, and
to be sure that alcohol aloue is the etiological factor. If we follow
the same principles of fu'tal ])athology which have been laid down
already, we must regard such dystrophies as due to the action of the
poison upon the organism in the embryonic stage of intrauterine life,
or upon some part of it which still shows embryonic characters while
in the foetal or postnatal period of existence.
i
FCETAL ALCOHOLISM 277
Into the question of the hereditary transmission of a craving for
alcohol I do not propose here to enter, for that falls to be considered
under the pathology of the germ ; but it may be said in passing that
the children of a drunkard are not necessarily drunkards, although it
is probable that they will show weakness in many directions, and one
of these directions may be a proneuess to alcoholic excess.
The action of quinine, salicylate of soda, cocaine, etc., upon the
foetus will be taken up more appropriately when antenatal treatment
is considered.
It will be remembered that at the beginning of this chapter it was
pointed out that our knowledge of the transmitted toxicological states
of the foetus was most imperfect and even chaotic, an opinion in which
the reader, I cannot doubt, now shares. It is therefore most unsafe
to attempt to form any general conclusions regarding the effects of
poisons on the unborn infant. All that may with any assurance be
said is, that there is experimental proof that some poisons reach the
fcetus, and that sometimes these poisons produce structural altera-
tions in the foetus and placenta ; and that clinical evidence to a
certain extent justifies us in asserting that a similar transmission and
similar effects may be met with in the human subject. Here is but a
small scientific " scintilla " in a truly Egyptian darkness.
CHAPTER XVI
Ill-defined Jlorbid States of the F(etus : in Maternal Eclampsia ; Cancer ;
Diabetes ; Leukicniia ; Heart- Disease, etc. ; Conclusions.
This chapter is devoted to the consideration of certain ill-defined
morbid states of the foetus in utero, which may possibly be due to
toxinic or toxic principles passing from the maternal circulation into
the fcetal. I have considered and reconsidered the advisability of
writing about these obscure morbid entities (it is not even certain
that they are entities) ; but I have come to the conclusion to do so for
several reasons, and for two in particular. In the first place, I
believe that pathological states of the mother, such as eclampsia,
jaundice, cancer, diabetes, and the like, do, in some instances, produce
morbid changes in the fa3tus, and that these changes are not neces-
sarily of the same nature as those occmi-ing in the mother ; the fcetal
states are due to the maternal maladies, but they are not identical or
even similar in their manifestations. In the second place, I believe
that these states are of importance because they bridge over the gulf
between the transmitted diseases of the foetus (c.r/., variola, syphilis,
etc.) and the so-called idiopathic maladies ; in the former, it is (piite
evident that the mother transmits her own malady as such to her
unborn infant, while in the latter there is as yet no evidence that the
foetal disease is due to a maternal morbid state. jMidway lietween
these two classes of diseases lie the ill-defined patliological conditions
of the fcjetus to which I have referred, and which fall to Ije considered
in this chapter. Whether it is as yet profitable (in view of the scanty
knowledge we possess) to consider them at all is of course a matter
of opinion ; but, " deliberando sa;pe perit occasio," and, after all, it is
but a question of a few pages, which the reader may pass over if he
so please. At the end of the chapter an attempt will be made to
give some cohesion to the various statements which have been
considered.
Fcetus in Maternal Eclampsia.
It has been constantly observed that in cases of maternal albumin-
uria and eclampsia the chances of the foetus being born alive aiul
surviving birtli are very few. When we attempt to go beyonil this
single observation we plunge at once into a veritable jungle of theories,
hypotheses, isolated statements, coincidences, and physiological and
pathological assumptions, among which one may long wander looking
for the light. It is not possible, with our present knowledge, to find a
])athway right tlirough this jungle, at best we can only hope here and
F(p:tus in FXLAMPSIA 279
there to find traces of a more or less beaten track ending blindly. Let
ns try to follow up for a little way one or two of these " blind alleys."
We may commence with the assumption that eclampsia is due to
retention of urea in the blood of the pregnant woman ; then, in the
experimental scientific mind, the suggestion at once arises that, by
injecting urea into a pregnant animal, the observer may be able to
produce in the fwtus the same morbid changes as are met with in the
human fcttus in eclampsia gravidarum. Accordingly, A. Charpentier
aud L. Butte (A^ouv. arch, d'ohst. et de gynic, ii. 397, 1887) made an
iajection of urea into the jugular vein of a pregnant rabbit ; they
found urea in excess in the tissues of the fcetuses, and the fcetuses
died before the mother ; they concluded that the fcEtal death was due
to rapid accumulation of urea in the unborn infant. But evidence in
support of the view that the maternal eclampsia is due to an excess
of urea in the blood is unfortunately not forthcoming ; in fact, there is
evidence of the opposite kind, for the blood of women in eclampsia
has been found sometimes to show no excess of urea and their urine
to show no diminution (or only a very slight fall) in that constituent.
The physiological basis of the experimental work is therefore insecure.
It is not a road likely to lead us out of our theory-jungle ; it is a cv.l-
dc-sac.
In another direction it may be possible to make some progress.
Let us examine the morbid anatomy of the foetuses of eclamptic and
alliuminuric patients. The findings are various. Sometimes the
fcetus dies in utero and is born macerated, and then the specimen is
next to worthless for pathological purposes, for the post-mortem
changes mask those due to the toxins (if such indeed exist). Some-
times the foetus is born dead, but under circumstances which justify
us in stating that it was the obstetric interference imdertaken on
behalf of the mother that killed the infant. Again, the infant may be
born prematurely and succumb from congenital debility or want of
the mother's milk ; then there will be the histological peculiarities of
prematurity existing side by side perhaps with those due to the
maternal disease. Again, the fcetus may be born recently dead and
in a contracted state : this may mean that the infant has suffered like
his mother from eclampsia ; it may also mean nothing more than rigor
mortis. Yet again, the infant may be born alive, may show albumin
in the urine, and may later develop convulsions, and then die ; but
albuminuria of the new-born is not uncommon quite apart from the
history of maternal eclampsia, and convulsions in an infant are not, of
course, always of renal origin. It is even thought that the infants of
albuminuric mothers may live, exhibiting no other peculiarity than a
tendency to develop nephritis when attacked by scarlet fever, etc.
(Fieux, Journ. de rnkl, July 25, 1899). But, it may well be asked,
what facts are there regarding the morbid anatomy of the fcctus of
an eclamptic mother ? It may be answered that such foetuses are
generally under weight, even if born at the full term. This fact I
have noted myself, more particularly in a case which I saw in con-
sultation with Dr. Robert Stewart in December 1891. In that case,
also, there was some atrophy of the liver, some congestion of the
280 ANTENATAL PATI lOI.OCY AND IIVGIKNK
kidneys, and a con.sideralile iiieniii;j;i'al liaiuunliane ><\vv the lefl siile
of the cerebrum. It cannot be said, however, that the internal changes
met with in these foetuses of eclamptic or allmniinuric mothers are by
any means constant, far less pathognomonic. Several observers iiave
worked in this field of morbid anatonij-, and their labours have been
summarised by E. Alfieri (Ann. di ostet. e fjinec, xxii. 1077, 1900);
some found lucmorrliages in the kidneys, in the convoluted or collect-
ing tidiules, or in Henle's loops; others found hii'morrhagic foci in
both the liver and kidneys ; others described degenerative clianges in
the renal epithelium and exudations into the glomeruli ; others met
with blood effusions into the cranial cavity and the spinal canal ; and
yet others detected changes in the liver, such as extra- and intra-
lobular dilatation of vessels, atrophic and rarely fatty degeneration of
the hepatic cells, hyaline thrombi in the blood vessels, etc. Manifestly
many of these alterations were to lie regarded as the results of trau-
matism in labour, some of them were possibly normal, and all of them
were irregular in tlieir occurrence. Alfieri (loc. cit.) himself made a
painstaking investigation of the subject, and examined carefully
twenty-two fretuses, five of which came from eclamptic mothers, ten of
which were cases of asphyxia neonatorum due to various causes, and thr
remainder were the offspring of mothers with albuminuria, typlioid
fever, etc. In the fu:'tuses born of eclamptic mothers he found, with a
certain degree of frequency, particular alterations in those organs which
are. usually affected in the mothers, namely, liver, kidneys, and supra-
renal capsules. These altei-ations, however, were not constant, nor
exclusive ; neither were they characteristic of eclampsia. Further,
although it was possible that they contributed to determine the death
of the foetus, it was more probable that they were simjily the expres-
sion of a particularly toxic state, and that, in certain instances, other
circumstances (c.ff. broncho - pneumonia, cerebral haemorrhage, etc.)
might be superadded to cause the fatal issue. Similar changes were
found in the fietuses of albuminuric women who did not develop
eclampsia ; and, finally, the foetuses from cases of eclampsia may show
no abnormal alterations. Obviously, in the present state of our know-
ledge, the morbid anatomy of these infants leads us to no useful
conclusion ; here is, then, another " blind alley."
Again, there has of late been advanced a somewhat novel theory
of the origin of eclampsia, to wit, the fwtal tlieory. According to
this view, it is not the maternal liver or the maternal kidneys that
are to be l)laraed for the supervention of the convulsions of pregnancy,
but the fn'tal organism or its annexa. It is thought that by the
reverse current, to which allusion has already been made, toxins and
toxinic products find their way from the foetus to the mother, and
produce in her such a toxic condition that eclam])sia supervenes. The
theory, as thus stated, will hardly commend itself : l)ut it is quite
possible that if the mother's liver and kidneys be inadequate, thr
arrival from the foetus of an extra (juantity of toxinic products may
turn tiie scale already inclining towards the dreaded eclampsia. But
it may quite well be argued tliat the maternal hepatic and renal in-
adequacy have led to the state of fcetal tox;emia, which in its turn
FtETUS IN ECLAMPSIA 281
reacts upon the health of the mother. Here, tlien, is a vicious circle
of cumulative cause and ett'ect. No " Ijlind alley " in our juugle of
theories is this, hut a wandering in a circle with obfuscating effects.
For, when we come to examine the " foetal " theory of origin of
eclampsia more closely, it is found to rest upon a clinical observation,
namely, the disappearance of the maternal alljumiuuria after the intra-
uterine deatli of the fcetus ; but it is now known that foetal death is
by no means constantly followed l>y disappearance of the albumin in
the urine. In fact, E. Jardine (Internat. Climes, 11 s., ii. p. 27, 1901)
records two cases in which the feetus was not only dead but macerated,
and yet the urine contained albumin, becoming, in one instance, nearly
solid on boiling.
Again, there is the state of the placenta in albuminuria and
eclampsia to be considered. What effect may alterations in it
produce upon the foetus ? It is well known that placental haemor-
rhages are common in cases of albuminuria, and they are met with
in eclampsia, but apparently only in the cases which have been
preceded liy albuminuria. May not the hiemorrhage allow toxinic
products to pass more freely from mother to fcetus or from fcetus to
mother, causing fcetal death and maternal eclampsia ? It is c^uite
possible. But if the htemorrhages be slight and their' occurrence in-
frequent, a fibroid condition of the placenta may be produced, which
will prevent the free passage of materials from mother to foetus, and
vice vcrsd ; under such circumstances the fcetus will be unable to obtain
oxygen or to get rid of effete products, and so will pass into a state of
intrauterine asphyxia or of intrauterine uncmia. Doubtless there is
a certain degree of truth in this view ; the placental factor in these
ill-defined morbid states, just as in syphilis, variola, typhoid fever, and
the like, plays an important part. In this direction progress will no
doubt ultimately be made ; in the meantime this path also ends blindly '
Another line of investigation has recently suggested itself : since
the effete products going from fcetus to mother and viee vcrsA must
pass through the placenta, that structure ought itself to produce
serious toxic effects. In order to test this conclusion, Palazzi {Ann.di
ostet. e gincc., xxiii. 237, 1901) carried out experiments on the toxicity
of the placenta. He made a sterilised infusion of the placentas of
five healthy women, and injected this into the circulation of a
rabbit. One rabbit died of asphyxia, but two other rabbits showed
no changes. Further, the one that died had a very large dose
(2-70 c.c). The placenta, therefore, is not toxic in the ordinary sense
of the word.
The attempt has been made to connect maternal albuminuria and
eclampsia with inadequacy of the maternal thyroid gland. M. Lange
{Ztsehr. f. Gehurtsh. -ii. Gyncik., xl. 34, 1899) pointed out that when
the normal pregnancy - hypertrophy of the thyroid was absent,
albuminuria was very commonly present. Theoretically, it may be
supposed that the function of the thyroid, and possibly of the
parathyroids also, is to regulate body-metabolism and to keep within
bounds the c^uantity of toxins circulating in the blood. In pregnancy
it is evident there will be a special need 1 or such a regulating intiuence ;
282 ANTKNATAI, I'ATHOl.CKiV AM) IIVCIIKNK
hence the liypertiopliy. Failing the hypertrophy, toxins will accumu-
late and will throw a heavy strain upon the kidneys ; if these organs
chance to be inadei|uate. eclampsia may follow. Oliphant Nicholson
{Scott. Med. and Surg. Journ., viii. 503, 1901) has elaborated this view,
and has recommended and tested thyroid feeding as the line of treat-
ment in such cases. The matter is still sub judicc. It has been
suggested that when the maternal thyroid fails the fo'tal thyroid may
take on a greater activity. Be this as it may, there can be no doubt
that it will be wise in future post-mortems to examine ver}' carefully
the state of both the maternal and fietal thyroid.
Foetus in Maternal Cancer.
When a woman far advanced in cancer becomes pregnant, what,
it may be asked, is likely to be the state of her unborn infant ? In
a case reported by Levaditi and Paris {Journ. dc j)hysiol. et de 'path,
gen., i. 490, 1899), the mother was in a state of marked cancerous
cachexia when her child was born ; it died in six weeks, and during
its short life it had a subnormal temperature and evident wasting ;
and at death the viscera showed a general streptococcic infection with
a predominance of the hepatic lesions. The authors lielie\ed that
on account of the mother's illness the child was born with its tissues
predisposed to afford a suitable nidus for the microljes which are
always present on the skui and mucous membranes, but which are
not always so virulent in their action. In S. Macvie's case {Trans.
Edinh. Obst. Soc., xxiv. 130, 1899), also, the infant died at .six weeks,
possibly from the same cause ; lint in this instance there was pre-
maturity of birth to be taken into account. L. X. Bourgeois {Be
I'injlucnce dcs maladies de la femvic pendant la grossesse sur la con-
stitution et la sanUde I'enfant, p. 394, Paris, 1861) collected details of
eleven pregnant women suffering from cancer : four gave birth pre-
maturely to dead-born infants ; one was confined at term of an infant
that died on account of the necessary obstetrical interference ; tlie
remaining six were delivered of weakly infants, three of which suc-
cumbed to marasmus, one died of convulsions, and two survived, one
of whom showed signs of struma. Statistics in greater amount are
sadly needed, bearing upon this important matter; in the meantime,
it may be pointed out that lioth the maternal cachexia and anamia
may have an injurious effect upon the fa>tus in utero. "What form
the maleficent iufiuence will take we are not at present able to say.
It must not be forgotten that the cancerous mother may have
children who become cancerous when they become adults ; whether,
however, this tendency towards malignancy is due to the passage
of toxins from the mother to the fietus in the fcetal and embryonic
epochs, or to inherent peculiarities in the ovum in the germinal
period of antenatal life, must be left unanswered, but the latter
hypothesis is more in favour at the present time. There is an ante-
natal aspect of the cancer problem just as there is of Uie consumption
question, — an aspect, however, not at all clear nor likely to be clear for
some time to come; at present the microbic or jiarasitic theory has
FCETUS IN DIABETES " 283
the wind iu its sails, while the theoiy of the predisposed soil is fallen
upon light and variahle airs, if it Ije not altogether Ijecahned.
Fcetus in Maternal Diabetes.
I have already referred (p. 223) to the snpposition that diabetes
mellitus might be transmitted as such from mother to fcetus ; of this
there is no sufficient proof, although the recently reported observa-
tion of Chambrelent is strongly suggestive {L'Olstetriquc, vi. 276,
1901). It was the case of a 4-parous woman whose three first
pregnancies had ended in abortions ; just before the commencement
of her fourth pregnancy it was discovered that she was sufleriug from
diabetes melUtus. During the first three months of gestation the
sugar diminished iu amount, but thereafter it increased, attaining to
34 grammes per litre. Under autipyrin it fell to 16 grammes per
litre at the time of the confinement. The infant weighed 3600
grammes, and had to be resuscitated ; its urine on the eighteenth day
of life contained over 2 grammes of sugar per litre, but on the
twenty-fifth day there was no trace of it.
Apart from the transmission of diabetes, per sc, to the fcetus,
there is sufficient evidence to show that this disease in the mother
has disastrous consequences for the unborn infant. In 1882, Matthews
Duncan ( Trans. Ohst. Soc. LoncL, xxiv. 256, 1883) gathered together
the histories of twenty-two pregnancies in fifteen women suffering
from diabetes, including personal observations (three in number) and
cases by W. L. Eeid, Newman (2), John Williams (2), Lecorche, A.
Husband, Bennewitz, Winckel, Davidson, Freriehs, and Seegen. There
were four maternal deaths. In seven out of the nineteen pregnancies
the child died in antenatal life after having reached a viable age,
and in two more it succumbed within a few hours of birth. Hydram-
nios was frequent, and in Husband's and probably in Eeid's case
there was sugar in the lic[Uor amnii. Some of the dead infants
evidently showed other than mere macerative changes ; for instance,
the child, a female, iu Bennewitz's case weighed twelve pounds, and
in one of Duncan's cases the infant was " enormous." In seven
pregnancies in women with diabetes, reported by Lecorche (Ann. de
gynec, xxiv. 257, 1885), all save one went to the full term ; of the
infants, one died in two days, a second succumbed to hydrocei^haly
at the twenty-first mouth, a third also had hydrocephaly along with
a double congenital hydrocele, and two others were very delicate.
From a larger number of observations, Ch. Vinay {TraiU des mcdadies
de la grossessc, p. 796, Paris, 1894) found that pregnancy was inter-
rupted in from 36 to 37 per cent., while the infants died in 48 per
cent, of the cases. The interruption of pregnancy is probably to be
accounted for by morbid changes iu the uterine mucous membrane
(Vinay). An interesting case was reported by Charrin and Delamare
(Progres med., p. 21, ii. for 1901), in which a woman suffering from
diabetes was attacked with eclampsia during labour ; the liver of the
foetus exhibited changes similar to those seen in eclampsia, while the
blood was like that of diabetic patients (red blood corpuscles were
284 ANTKNATAL I'A'JHOLOCiV AND HYCilENR
staiiialile by iiiagenta red, etc.); tlie authors explained these foetal]
changes on the supi)ositioii that tlie special morbid agencies of both]
diabetes and eclampsia had forced tlie placental barriers and attacked]
the tissues of the unliorn infant.
Fcetus in Maternal Leukaemia.
One of the most interesting of the pathological inter-relationshijis
between mother and fcetus is that met with in maternal leukicmiu ni
leucocythemia. Apparently the leuk;eniic state of the mother has
little or no eflect upon the blood of the foetus. At the same time it
must be borne in mind that very few cases are on record in which'
a woman sufi'ering from leucocythemia has become pregnant — six
well described cases in all, according to Yinay (op. cii., p. 801). One
of the most interesting observations was that made by James C.
Cameron {Interned. Journ. Med. Sc, n. s., xcv. 28, 1888). The patient
had a splenic tumour during her sixth pregnancy, but it was while
she was carrying her seventh child that she became seriously ill. At'
the seventh month of this pregnancy her red blood corpuscles only
amounted to 1,070,000 per c.mm., and there was one white for every
ten red ; she suffered greatly from dyspnoea and attacks of epistaxis.
Premature labour occurred, not a drop of blood was lost, but there
was the usual amount of liquor aninii. She recovered. The infant,
a female, weighed -ih lbs., and measured ISh inches in length ; it was,
apparently strong, and throve nicely for the first day ; but on the:
second day the mother put it clandestinely to her breast ; it sickened,
at once, developed a purpuric rash, and died on the fourth day.'
Two hours after birth the maternal and infantile bloods were as
follows : maternal Ijlood 990,000 red corpuscles to the c.mm., fcetal
blood 5,210,000; maternal blood 1 white corpuscle to 4 red, fa-tal
blood 1 white to 175 red. The placenta was carefully examined :
there was something special in its appearance ; the blood in the,
sinuses seemed thin, pale, and watery, that in the placental vessels
was of a dark rich colour, only slightly clotted. In the umbilical
vein there were 4,610,000 red corpuscles per c.mm., and 1 white to
173 red; in the umbilical artery there were 5,400,000 red corpuscles
per c.mm., and 1 white to 270 red ; but in the placental sinuses there
were only 950,000 red corpuscles per c.mm., and 1 white to ol red
(circa). In the foetal blood nucleated red cells were present, but not
in abnormal numbers. The autopsy of the infant revealed nothing
of note : the thymus and thyroid were normal, the spleen was not
enlarged, and the bone marrow was red and abundant everywhere
An interesting point in the history of this remarkable case is that
several of the earlier children of this woman seem to have been
leuka-mic, and her mother, grandmother, and brother seem to have
been affected with the same disease. Obviously, however, the foetuf
of the seventh pregnancy was not leuk;vmic.
In Sanger's case (Arch. f. Gynaelc, xxxiii. 171, 1888) also, the
infant, a female, was born alive ; it showed no enlargement of the
spleen or liver; the lilood from the umliilical cord had norma.
FCETLS IN LKUK.EMIA 285
characters; and six months later the child was tliriving well and
showing no indications of leukremia. 11. Paterson {Edinh. Med. Juurn.,
XV. 1073, 1869-70), in tln-ee cases of leuka-niia in pregnancy seen by
him, remarked npon the healthy state of the infants at birth. Some-
times, however, the pregnancy is interrupted (G. E. Herman, Brit.
il/cf?. Jouni,, ii. for 1901, p. 1085), and then the infant may succumb.
Further, there is some evidence that a toxic product may occasionally
pass to the fietus and cause its death (E. Kirstem, Dissertation,
Konigsberg, 1893). So far, then, as our present knowledge carries
us, the leukfemic mother does not give birth to a leukaemic infant.
This is a fact of some importance, for foetal leuksemia exists as a
morbid entity, and instances of it have been reported by Klebs {Frag,
nicd. Wchnschr., iii. 489, 509, 1878), Sanger (C'entrlU. f. Gyniik., v.
371, 511, 1881 ; Arch./. Ghjnack., xxxiii. 198, 1888), Siefart (Monatschr.
f. Geburtsh. u. Gyncu-k., viii. 215, 1898), and L. rollmauu {Miinclicn.
Died. Wchnschr., xlv. 44, 1898) : but in none of these was the mother
leukttmic (in Sanger's and Siefart's cases she had nephritis, in
Pollmann's she may have suffered from an infectious process in
pregnancy, and in Klebs' she seems to have been quite healthy).
It has been rather hurriedly concluded that proof is thus afforded
that leucocytes cannot pass the placental barriers ; but, as we have
seen (p. 142), there is evidence that the contrary is sometimes the
case. It may at any rate be reasonably believed that morbid con-
ditions of the maternal blood are not immediately reflected in the
state of the foetal ; and obser\ations on anaemic pregnant women
(p. 139) support this conclusion, for in tliem the blood of the unborn
infant, although exhibiting some slight poverty in red cells, is by no
means an;emic.
FcEtus in Maternal Heart Disease.
Heart disease in the mother is not infrequently productive of
premature labour and abortion ; sometimes also there is hjdramnios,
more especially in the cases which are complicated by albumin-
uria. According to Durozier's statistics (Arch, dc iocol., ii. 577, 1875),
the pregnancies of forty-one women suffering from heart disease
ended in twenty-one miscarriages and dead-births, in five premature
labours at six months, and in thirty-seven living infants who died
before the age of four years; but these figures no doubt give too
gloomy an impression of the effects of these maternal maladies.
Vinay (o/j. cit.) met with thirty-two infants, the progeny of women
with heart disease, and the}' were nearly all born alive at the full
term. The presence or absence of cardiac compensation must, of
course, markedly influence the results. Martel (ThUsc, Paris, 1896)
has endeavoured to discover the condition present in the delicate
infants of women suffering from heart disease, tubercle, pneumonia,
etc., and has come to the conclusion that their slow increase in
weight and frequent untimely death are due to disturbed cellular
interchanges represented by an excessive excretion of urea (azoturia) ;
their cells do not fix and retain the substances necessary for their
286 ANTKNATAl. I'ATIIOI.OOV AM) IIVCIKNK
vegetative life. Such an infant "est un tiltie qui laisse passer eu
graude partie les inaticTes assimilables." TIk; defects in assimilation
in theii- turn are ])ossibly due to tuxins which pass from tlic mother
to the fu'tus, traversing the placenta. Thus is produced one of those
ill-defined morbid states of the fcetus witli whicb tills cliajjler deals.
If it were profitable, some space might be given to the considera-
tion of the state of the fu'tus and new-born infant in cases of maternal
gout, osteomalacia, goitre, jaundice, myxa'dema, and the like ; but it f
is not protitable, for the facts are far too scanty. At the same time, i
there is no reason to doubt that progress will yet be made in the j
investigation of these matters, and that results of value in estimating i
the intluence of maternal upon fecial conditions will ere long be |
forthcoming. It would, for instance, be of great interest if we could j
obtain reliable oliservations upon the maternal and fa'tal blood in i
one of the rare cases in which a hiumophilic mother gives birth to a r
hiemophilic infant. Elsewhere (126a), I refer at length to a h;emo- ;
philic woman who gave birth to two h;tmophilic male children ; in
her third pregnancy she was put under medicinal treatment, and
gave birth to another male infant, and in it there were no signs of
haemophilia. It is difficult to know what to say about such cases,
for they are usually quoted as instances of truly hereditary diseases
(i.e. as morbid states transmitted from parents to children prior to
conception) ; but it is just possible that the maternal intUience may be
exerted upon the fcetus during the whole period of its antenatal life, (
and that the so-called hereditary diseases may be in part the result j
of toxinic activity going on during the foetal epoch. This matter, j
however, will again fall to be discussed (vide Pathology of the Germ). !
Conclusions.
Can we draw any conclusions regarding tliese ill-defined morbid <
states of the fcetus which are associated with maternal diseases?
Any conclusions at any rate worth drawing? It is doubtful; but '
the following cogitations may at least be recorded : —
In the first place, it is quite evident that the mother may be '
seriously ill with diabetes, cancer, leuk;emia, heart disease, and even )
eclampsia, and yet tlie foetus be born alive and apparently well. In '
such instances the infant may even survive birth and show no weak- <
uess and no anonuily of assimilation. At first sight, these facts are '
startling, in view of what has been written about the passages of
microbes and toxins from mother to fa?tus : but a little reflection will '
serve to dispel some of the surprise. With even the most easily
transmitted malady (c.ff. smallpox), cases are cm record in which
apparently no transmission took place ; and no great stretch of
imagination is recpiired to admit that the same (or a similar)
mechanism which prevents the passage of the definite disease (e.g.
smalli)0x) may ])revont also the passage of the i)roducts whicli set
up the ill-defined niorliid state. I'robalily it is an easier matter to
save the unborn infant from one form of maternal morbid infiuence
CONCLUSIONS 287
than from another ; but that is a matter of degree which does not
affect the validity of the main proposition.
In the second place, it is exceptional to find the maternal morbid
state {e.g. gout, cancer, eclampsia) reproduced as such in the foetus.
But, again, this ought to e.xcite no great sui'prise, for the conditions
of foetal life are not such as to predispose to morbid changes, which
occur by choice in adult and even in senile tissues ; even the new-
born infant and young child does not take cancer and gont and
eclampsia in the same way as its parents. Some ill-defined morbid
state is just the result which ought to be looked for in the fcetus ; it
may be a disease, or a malformation, or an anomaly of physiological
reaction, or a predisposition to develop a disease differing from or
resembling that existing in the parent. In a fatal case of eclampsia
which was under my care in the Edinburgh Maternity Hospital in
April 1901, the mother perished two hours after delivery, having had
complete suppression of mine for several hours ; the foetus, which
died in birth, had a urinary bladder reaching as high as the um-
bilicus, distended with limpid urine. This is but one of many
illustrations which might be given of the dissimilarity of maternal
and foetal morbid states. The dissimilarity, hovxver, does not disprove
a connection.
In the third place, the commonest result in the fcetus of these
various maternal maladies probably is foetal death. The fatal issue
may be due to the premature termination of the pregnancy, or it
may occur quite independently from pathological alterations in the
fcetus, or more commonly in the placenta. In the latter case, the
unborn infant is the subject of an anto-intoxication, due to the
accumulation in its tissues of carbonic acid, and possibly of other
effete materials {vide Fa?tal Death). If the cases of foetal death be
excluded from consideration, the majority of the remainder will pro-
bably consist of the infants born weakly, who lose weight, or at least
do not gain any for two or three weeks, and then die either " de rien "
or of some intercurrent disease which, under other circumstances,
would probaljly be recovered from.
In the fourth place, it would seem that in these ill-defined morbid
states are antenatal conditions which it may yet be found possible
to prevent, or to some extent ameliorate, by appropriate antenatal
treatment. It is not always possiljle to save these infants after birth,
but might not medicinal treatment of the mother, prior to birth,
enable the placenta always to do what it apparently sometimes
spontaneously does, namely, prevent the transmission of toxins or
toxinic products to the fcetus ?
CHAPTER XVII
Idiopathic Diseases of the Fdtus — Typos : (jeiieral Futal Dropsy- — Definition,
Clinical History, Symptomatology, Morbid Anatomy, Etiology, Patho-
genesis, Diagnosis, Treatment ; General Cystic Elephantiasis of the Fo-tus —
Definition, Clinical History, Morbid Anatomy, Pathogenesis ; Congenital
Elephantiasis — Definition, Clinical History, Syiiiptoiiiatology, Physical
Signs, Pathogenesis, Treatment ; Congenital Myx(uclema ; Atrophic .States
of the Subcutaneous Tissue.
The so-ciillcd idiopathic diseases of the foetus constitute a large, hut,
as I helieve, a diminishing group of antenatal maladies. As more
accurate knowledge is acquired regarding these morhid states, there
can be no doubt that one and another of them will finil their way
into the groups of the transmitted diseases, toxiculogical conditions,
and ill-defined toxinic states with which the last five chapters have
dealt. Further, there arise serious difficulties of definition and
classification in connection with this matter, for it is almost imposs-
ible to draw a hard and fast line between transmitted and idiopathic
foetal states. For instance, we have seen how a fcctus may be born
with smallpox upon it, although the mother was free from tliat fever
during her pregnancy. In which group are we to place this case,
among the transmitted or the idiopathic ? The mother, we must
suppose, transmitted something to the foetus ; on the other hand, the
foetal tissues alone reacted in the characteristic manner. Again,
there is a large mass of evidence to sliow that syphilis, and possibly
other morbid conditions, may arise in the fcetus through paternal
influence or through maternal influence prior to conception. Are
these to be regarded as transmitted ? They are commonly called
hereditary. Are we then to have a third group to contain the
hereditary disease as distinct from the transmitted and the idio-
pathic ? Is any such separation possible ? I do not think it is ; and
I have elsewhere {Trans. Med.-Chir. Soc. Edinh., n. s., xix. 114, 1900)
given reasons in support of this contention. But it is unnecessary
now to enter into this ((uestion ; I admit that many of tlie idinpathic
foetal diseases may yet be found to be transmitted either in the post-
er ante-conceptional period, and it is now my duty to describe some
types of what are still jirovisionally regarded as idiojiathic maladies
of the unborn. I shall select types in the onler in which they are
placed on page 175.
General Dropsy of the Fcetus. <
General dropsy of tlie foetus was the disease which in 1887 first
attracted my attention to the study of antenatal pathology ; and since
GENERAL F(ETAL DROPSY 289
that year I have had the extraordinary opportunity of examining
eleven specimens of the malady, and have published the results of
the examination of several of them ('So, 49, 51, Gl, 64, 148, and 161).
In my work, The Diseases of the Feet us, I have de\'oted eighty pages
(vol. i. pp. 102-182) to the discussion of general dropsy of the foetus.
The result of all these opportunities and of all this writing is, that I
now feel far less certain about the pathogenesis of the disease than I
did shortly after I had examined my first specimen ! Of this, however,
I have become increasingly persuaded : general dropsy of the fcetus is
not a pathological entity, but a group of structural alterations due to
several different causes, and really representing several diseases in
the ordinary sense of the word.
This being so, it is difficult to frame a satisfactory definition of
general foetal dropsy; but provisionally it may be described as a
morbid condition of the foetus, characterised by general anasarca, by
the presence of fluid effusions in the peritoneal, pleural, and peri-
cardial sacs, and usually by cedema of the placenta, and it results in
the death of the fcetus or infant before, dm-ing, or very soon after
birth. It is the " hydropisie generalisee du fcetus " of the French,
and the " Haut-und allgemeine Wassersucht " of the German writers,
and a common international name for it might be found in " hydrops
universalis fretus." The recorded cases date back to the seventeenth
century ; but it is comparatively rare, for I have only l^een able to
gather together from literature some seventy cases between the years
1614 and 1898.'^ It is common, and indeed almost constant, to find
a state of general cedema of the grossly malformed twin fcetus
(acarcUac, acephalic, and acormic), but that is not included among
the cases of general foetal dropsy properly so called.
The clinical history of cases of this fcetal malady offered several
points of interest. The mother was nearly alwaj'S well advanced in
her child-bearing life, and in only seven out of sixty-five cases was
her age less than thirty ; in only one instance was she primiparous,
in all the others she was a multipara, and had generally had a large
number of pregnancies. For instance, in one of the cases reported
by me (49) the mother was thirty-seven years of age, and her
ninth, tenth, and twelfth gestations ended in the birth of dropsical
foetuses. This character of family prevalence or the repetition of
identical morbid states in successive infants of the same parents has
l;>een noted in several of the clinical histories (cp. Nachtigaller, Dissert.,
Berlin, 1896). The maternal health seems to have been often bad;
but it was generally of an ill-defined character (" delicate," " weakly "),
and in only two or three instances was any special disease, such as
syphilis, recognised. The previous obstetric history was often bad
also; for instance, in Protheroe Smith's case {Trans. Ubst. Soc. Zand.,
xvii. 30o, 1876) the first child was a healthy male, then came two
miscarriages at the third month, then a healthy full-time female, then
an abortion at the sixth week, a full-time female that was jaundiced
and died in three days, then a still-ljorn female at the twenty-sixth
' The bibliograi)liical list will be fuund in the Discrisi-'S of the Fa:lu$. vol. i. pp.
160-16i ; and vol. ii. p. 235.
19
290 ANTl-AATAI. I'A THOI.Od^' AM) I l^(iIKNF,
week, tht'U a still-ljoni male also at tlic twenty-sixth week, aiultinallyl
the dropsical fielusat six aiiilu half months. The previous ])re^nanciej
generally ditlereil very considerahly in tiieir characters, hut agreed il
beini| morbid in one way or another (premature deliver}', ahortiori,]
dead-hirlh, eon<j;enital debility of infant, hydrocephalus, jaundice ofj
the new-born, etc.). Sometimes, but rarely, the paternal niedicall
hist(jry was referred to ; in Seulen's case (Xviie Ztschrft. f. Gcburt&
ii. 17, 1835) the father suffered from jaundice and dropsy; in Fuhrl
{Dissc7-t., Giessen, 1891) he was an alcoholic: and in one of my cases
(49) he was markedly anicmic. The history of paternal syphilis
is remarkalile Ijy its aljsence.
The si/mptomatolog-i/ of the pregnancy which ended in the birth of
a dropsical infant was fre(iuently noteworthy, ^'ery often it ter-
minated prematurely (fourth month to near the full term). The
mother's health was seldom (piite good, and usually slie sutl'ered from
one ailment or another. Maternal dropsy, limited or widespread,
was a comparatively common complication. The unusually great
degree of abdominal distension, a condition <lue in part to the large
size of the foetus and placenta and in i)art to the frequently occurring
hydramnios, was also often noted : and in some cases there was albu-
minuria, and in others amemia. Hepatic derangements, brouchitis^
malaria, alcoholism, and heart disease were met with, liut in isolated
instances as a rule ; and in the great majority of cases maternal
syphilis was pointedly excluded. With regard to foetal symptomato-
logy, the only recorded fact was the occasional statement that tht
foetal movements were feel)le.
The lairth of a dropsical infant was, if near the full term, a tediout
and often an instrumental matter. Abnormal presentations wert
unusually conmion. The delay in labour was sometimes overcome b}
the natural efforts and sometimes by manual or instrumental traction
but in certain instances the procedures which were finally adoptee
before birth (in fragments) was effected, reached the utmost limits o
embryulcia, evisceration, disruption, and dilaceration. In some casei
the medical attendant seems to have lost all nerve, as first one liml
and then another, and then a fragment of the trunk or the head, wa;
dragged to light from the maternal passages. When, howevei', thi
foetal abdomen, lieing within reach, was tapped, it was seldom foimi
necessary to resort to such endiryoclastic procedures. The third stagi
of labour was often rendered somewhat difficult on account of tin
large size and dropsical state of the placenta, and l>y reason of uterini
inertia due to delay in the earlier stages. The puer])eria, it is note
worthy, were generally quite normal ; in fact, the rapid disappearauc
of many of the maternal symptoms, immediately after the emptyin;
of the uterus, suggested the conclusion that the fn^tal condition wa
often the cause rather than the result of the mother's ill-health.
The postnatal clinical history of the dropsical infant was chief!,
remarkable for its abbreviation. Often the foetus escaped antenata
only to meet intranatal death, and if, by any chance, he came into th
world alive, it was seldom that the lungs could act pro])erly, o
account of the fluid accumulations in the thorax and abdomen. I
GENERAL F(ETAL DROPSY
291
Fio. 30.
Vertical Mesial Sectiou of Fojtus witli General Dropsy, left face shown, (i natural size.)
«, Anterior fontanelle ; h, (Edematous scalji tissue ; c, H»morrliage in falx cerebri ;
d, Posterior fontanelle ; c, Cerebellum ; /, Pituitary body ; g, Basi-occiput ; h, Pos-
terior arcli of atlas ; i, First dorsal vertebra ; j, Thynnis gland ; k, Fluid in
pericardium ; I, Liver ; m, Pancreas ; », Pylorus ; o. Fluid in peritoneum ; p. First
sacral vertebra ; q. Umbilical cord ; r, Tunica vaginalis testis ; s, Penis ; t, Trachea.
292 ANTKNATAL l'ATII01,0(iV AND HVCilENK
one case (Seeger, Miscell. Acad. nat. curios., Dec. i., Aim. \.,\i. Kll',
1670), however, life lasted a few clays, aud for a few hours in a few
otlier instances ; but generally the potential mortality of this intra-
uterine malady became real at birth. Stat sua ctiiquc dies! "Water-
babies " these are, with a lirief tenure <jf life !
The study of the morbid anatomy of the recorded instances of
general fojtal dropsy reveals sonic alterations conimnn tn all the cases
and .some peculiar to one or two. I believe that I was the first (in
1887) to study the pathology of this fostal malady by means of frozen
sections, a method which materially assisted in clearing up certain
doubtful points. The appearances presented by one of the slaljs (the
left) (if a vei'tical mesial .section are sliown in Fig. ;]0.
Tlie weight and measurements of the foetus were not often recorded;
l)ut, wlien they were noted, they were always larger than they ought
to have been for the jieriod of antenatal life arrived at. The abdomen
especially was apt to have a greatly increased circumference. A
general dropsical state of the subcutaneous tissue was the most
evident and most constant macroscopic condition, and it was noted in
all tlie recorded cases. It was sometimes stated that certain i)arts of
the body were specially dropsical, e.g. the scalp, the face, the abdomen,
the limbs ; but sometimes there was an equally ditl'used oedema.
Usually the efl'usion was serous in type, but sometimes it resembled
partly congealed gelatin, a condition possibly due to the undeveloped
or mucoid state of the subcutaneous tissue when attacked l>y the
oedema. The fluid oozed freely from superficial cuts or tears in the
integument, and I have several times noted that if a fcEtus showing
this disease were left overnight on a ])late, its bulk was greatly
reduced in the morning. Virchow {Arch. f. jxith. Anat., xxii. 426,
1861) found albumin, but no sugar, in this fluid in one case. The
subcutaneous oedema may sometimes be so great as to cause great
deformity, as a glance at Fig. 31 (which represents the head of a
dropsical fo?tus examined by me in ]May 189."'> (61), which had occurred
in the practice of Dr. F. W. Mann of Ashton-under-Lyne) will im-
mediately and convincingly pro\e. The skin has a dusky red, livid,
coppeiy, or sometimes a pink colour. There is great friability of the
tissues, particularly of the subcutaneous but also sometimes of the
muscular and osseous. It is to this character that we must ascribe
the piecemeal extraction of the foetus which has occasionally been so
grajjlucally described by obstetricians.
In the great majority of the reported cases the presence of tluid
in the pleural, pericai'dial, and peritoneal cavities was noted (Fig. oO).
The presence of Huid in the alxlomen was a very constant feature ;
and the effusion was described as clear, sti-aw-yellow, brownish
yellow, olive-green, clear gi-een, citron, or lirownish in colour, aud
transparent in character. Sometimes flakes of lymph were found
floating in it ; sometimes it was albuminous ; and in one of my cases
there was some liile pigment and a very small proportion of proteids.
Hydrothorax and hydropericardium were also very common ; and iu
a few instances hydrocele and hydrocephalus existed. The appear-
ances presented by the viscera were far from uniform, and indeed
GEXERAL F(KTAL DROl'SY 293
varied within wide liiuits; but the most fi-e(jueiitly recorded char-
acter was a general bloodlessness (t'.//., of the liver, brain, heart, and
thvmus). Furtlier, in a few cases, disease or malformation of the
heart was noted ; in Virchow's case (loc. cit.) there was transposition
of the great vessels, defect in the interventricular septum, and signs
of fcetal endocarditis; in Lawson Tait's {Trans. Ohst. Soc. Load., xvii.
307, 1876) there was a closed state of the foramen ovale with
wide patency of the ductus arteriosus ; and in E. Pott's (Jahrb. f.
Kindcrhlk., xiii. 11, 1879) there was persistence and stenosis of the
truncus arteriosus communis. A diaphragmatic hernia, leading, it
was supposed, to compression of the inferior vena cava, was noted by
Fic. 31.— Gi'iieral Dropsy of the Fiftiis.
C. Behm {Ztschr.f. GeburtsJi. u. Gyndk., ix. 197, 1883). Signs of peri-
tonitis w^ere found in six cases (out of sixty-five) : it was therefore
relatively uncommon, for the presence of fluid in the peritoneal
cavity could not of itself be taken to imply inflammation. The liver
had no constant appearances (" large," "small," " anicmic," "congested,"
" soft and friable," " firm and cirrhotic ") ; and the spleen varied in
much the same way. In some cases the kidneys appeared normal to
the naked eye, in others they were finely granular, in others they
were the seat of cystic degeneration, and in others they were small,
soft, and pale ; but in most of the records no description at all is given
of them. The intestines were generally small, contracted, and wnth a
short mesentery. There was a uterus septus with vagina duplex in one
of E. HiJnck's dropsical fcstuses (Dissert., Kiel, 1887) ; and in a few
cases it was noted that the bones were friable. "t!""!-^"
In very few instances was there any record of the microscopic
294 ANTKNATAl. I'ATHOLCXiY AND HYGIENE
appearances of the tissues. In one ease, that repnrtcd 1)}- E. Schutz
{Frag. ined. Wchnschr., iii. 449, 1S7>S), there existed the histoloj^ii nl
clianges in the vessels and organs wliich are usually regarded as
characteristic of fuctal syphilis; and the mother also showed signs
of syphilis. In a few cases a leuka-mic or leuka-nioid conditicm
was discovered, ami in my own cases (49) there was some incUcn-
tiou of this. There was an excess of white corpuscles in the blo'l
and in all tl)e organs, but especially in tlie kidneys there wtiv
numerous accumulations of leucocytes. .Sanger (./I rcA. y'. GynmL.,
xxxiii. 198, 1888) considered that the instance of fct'tal dro^JSy seiii
by him was really of the nature of congenital splenic or spleiin-
myelogenous leukiemia. It is doubtful whether the few details
available concerning the microscopical appearances in general anasarca
of the fcEtus are sufficient to warrant any conclusions being di'awn :
further researcli is imperatively demanded in tliis direction.
The placenta had somewliat constant characters. It was of laiuv
size, and of great weight (3 lbs. in one case, 3i ll.is. in anotlier, and as
much as 6 lbs. in a third); and it was nearly always soft in con-
sistence, markedly oedematous, and easily torn. It was also coumionly
anwmic and pale, almost Heecy white in colour. W. Jakesch {L'l n-
tralhl.f. Gyniik., ii. 019, 1878), witli what he admitted to be a souk-
what daring freedom of imagination, compared the birth of the
placenta to the slow rolling forth of wool from an overfilled torn
woolsack (" dem langsameu Hervorwiilzen von Wolle aus einem
uberfiillten angerissenen Wollsacke"). The umbilical cord was
commonly thick and oedematous, often friable, and sometimes irre-
gularly inserted into the placenta. In one case, the chorion and
amnion were thickened; but it was seldom that any allusion to
their characters was made. Hydramnios was a common but not a
constant concomitant condition. In a few cases the microscopic
appearances of the placenta were mentioned. In one of my cases the
villi of the chorion were swollen, showed a slight increase in the
amount of stroma, and had some degree of oedema in their epithelial
covering. In Siefart's case (Monatschr. f. Gchurtsh. u. Gynuck., \m.
215, 1898) the villi were very large, the inter\'illous spaces were
small and contained little blood, the stroma of the villi was oedematous,
and the walls of the capillaries were thickened.
With general fcetal dropsy, as with all tlic so-called idiopathic
foetal diseases, the ^)a</(o,'/f?w'.sw is very obscure, and even tlie etiology
is imperfectly known. Doulitless, if the obscurity were less marked, ,
the disease would be found to have passed out of the group of the
idiopathic di.seases into that of the transmitted morbid states. At
the same time, it must be borne m mind that investigators have some-
times made these questions more difficult than need be. For instance,
it has seldom fallen to the lot of one observer to examine more than
one or two cases of the disease, and it lias followed, naturally enough,
that he has considered these cases as typical ones. Now, if a jihysician's
knowledge of dropsy in the adult were limited to two or three cases, ,
it is not likely that it would be at all sufficient. Further, there is no
reason to expect tliat all cases of fcptal dro]isy sliall be due to one
GENERAL F(KTAL UHOl'.SV 295
ami the same cause or shall present identical characters ; in the adult,
dropsy is a sign of various att'ections residing in various organs ; the
same state of things may hold regarding foetal dropsy. Unfor-
tunately these almost self-evident facts have not always been kept
in mind.
According to some writers, the cause of fcetal dropsy is to be
sought for in purely maternal states. ]\Iaternal alcoholism, maternal
hydra'Uiia, and maternal nephritis have all been adduced as possible
factors. H. Strauch {Dissert., Berlin, 1880) strongly advocated the
theory ,of maternal nephritis : the mother had a contracted kidney,
producing increased arterial tension and venous stasis ; there was,
therefore, increased pressure in the maternal portion of the placenta
and an exudation of serum into the inter\"illous spaces, an occurrence
further predisposed to by the hydremic state of the maternal blood ;
the placenta being the place of least resistance, cedema occurred there
even if not in the other maternal organs ; and the blood coming from
the fretus in the umbilical aiteries met with resistance in the
placenta, which caused increased venous pressure and oedema in the
foetus. A purely paternal cause has been referred to tentatively by
some writers, and it is a suggestive fact that the first four cases of
the disease whicli I met with were the offspring of a woman and her
sister-in-law, and both the woman and her brother showecl the same
gravely amiemic state.
According to other writers, the cause of foetal dropsy resides in the
foetus itself, and the disease is truly idiopathic. Thus Lawson Tait
{loc. cit.) thought that he had found the fons et origo morhi in
premature closure of the foramen ovale ; the closure was not complete,
a crescentic valvular opening yV-inch in size forming the communica-
tion between the two auricles. W. Osier {Keating's Cyclop. Dis.
Children, ii. 752, 1889) found a very similar cardiac anomaly, but he
could not recognise a very clear connection between the state of the
heart and the fcetal disease. Other writers looked to the cystic state
of the kidneys as the cause, obviously a very inadecpiate theory.
G. Eaineri (Gaz. vied, di Torino, xliii. 21, 1892) considered that the
oedema of the foetus and placenta might be ascribed to the hindrance
of the hepatic circidation and the obstruction of the renal secretion,
due to the infiltration of these organs with leucocj'tes, for he regarded
the state of the liver as similar to the interstitial hepatitis of the
syphditic foetus. Abnormal states of the foetal blood have been
regarded by some as the causes of the dropsy, and perhaps the most
popular of recent theories has been that of a " leukiemoid if not
perfectly leuka-mic " condition.
Finally, many writers, recognising the inadequateuess of either the
maternal or the fcetal causes, have sought for coexisting causal condi-
tions in both mother and foetus. Virchow {loc. cit.), for instance, found
the immediate causes of the dropsy in narrowing of the pulmonary
ostium of the heart, accompanied bj' cirrliosis of the liver and incipi-
ent granular degeneration of the kidneys. The state of the heart he
ascribed to foetal endocarditis, and this in its turn he sought to trace
to syphilis or rheumatism in the mother, but could get no information
296 ANTl'.NATAI. I'A 11 l()I.()(iV AM) mXUKNE
oil the innul. The thninilioses in the iiiateiiial placental sinuses he
regarded as a third series nf disturbances, wliich by liindeiing the
circulation in the ftptus tended still further to iironiotc the general
dropsy. Siinger (loc. cit.) regarded maternal nephritis as the primary
cause: this set up leukiemia in the fu'tus, not in a mechanical way.
but because the hydnemic state of the mother's blood interfered with
the normal formation of the foetal. The leuka'iuia thus produced wa>
the immediate cause of the dropsy, for the conversion of leucocytes
into erythrocytes being interfered with, the f( inner accumulated in the
fo'tal blood, escaped through the thin vessel walls, and formed lymjih-
oid infarcts hi the skin and glandular and other organs, and serum,
escaping along with the leucocytes, caused oedema of these structures.
Sanger considered that a similar transudation of serum took place in
the foetal part of the placenta, and that Huid passed from the vessels
of the villi into the stroma. Fuhr (c^j. cif.), also, looked for a complex
causation. He summarised the pathogenetic stages thus : — (1) Chronic
maternal endometritis, intensihed by nephritis; (2) hyperplasia of
the chorionic villi due to decidual increase following u])on the endo-
metritis ; (3) excessive ab-sorjition of Huid blood into the fcetal
circulation (partly from maternal hydramia), over-filling of the
circulation in the foetus, with resulting obstruction and oedema; (4)
hydramnios, due to increased secretion from the fwtal kidneys, an
increase, not, however, sufhcient to overcome the obstruction ; and
(5) oedema of the placenta due to secondary obstruction in that
organ.
It is of course quite clear from all that has been stated, that the
pathogenesis of foetal dropsy is obscure ; it is probable also that its
obscurity has been increased by neglect of a proper comi^rehension of
the peculiarities of foetal physiology. It would seem that it must, in
the first place, be admitted that its causes are not always the same:
as in postnatal so in antenatal life dropsy is a sign of ^•arious morbid
states. Provisionally it may be supposed that general o-dema of the
faHus may arise in the later months of fcetal life from maternal causes ;
possibly, conditions which increase the blood pressure in the placenta,
by causing structural changes in its maternal and (secondarily) in its
foetal parts, may thus lead to liackward pressure and transudation of
serum in the foetal body. Again, it may be supposed that in the early
foetal or late embryonic period structural anomalies may arise in the
foetus (heart, kidneys, liver, blood) which will directly produce the
dropsy as it is produced in the adult, although with slight diherences
and exaggerations on account of the peculiarities of the intrauterine
environment. These fa'tal conditions, it may yet be found possible
to trace liack again to morljid maternal states : and it may even
be that maternal or paternal conditions existing in the sexual
cells before impregnation may be potent to direct the life of
the impregnated ovum into abnormal manifestations. Let us
here leave this subject : it is clear that it is obscure ; thi.s alone is
clear.
It can scarcely he hoped that much success will attend attempts
at antenatal diagnosis in regard to general foetal dropsy. The presence
CYSTIC ELEPHANTIASIS 297
of the maternal morbid states (dropsy, albuminuria, heart disease, etc.)
which have been regarded as causal may arouse suspicion, and the
history of the earlier occurrence of a dropsical fcetus in the same
family may greatly strengthen the suspicion ; the diagnosis of hydram-
nios will also aid. As a rule, however, the foetal disease will only be
detected during the progress of labour, and the sooner it is then
detected the better will it be for the patient and her medical
attendant.
The antenatal treatment will consist in the correction of maternal
disorders by means of milk diet, iron, chlorate of potash, strychnine,
etc., and will be possible, as a rule, only when the mother has already-
given birth to a dropsical infant in an earlier pregnancy. The intra-
natal treatment will take the form of a reduction of the bulk of the
foetus by the aspiration of the peritoneal effusion ; extractive inter-
ference (forceps, hands) may be needed before the child can be born.
After birth the aspiration of the thoracic cavity might be practised in
the hope that respiration might be established, and that the dropsical
conditions would gradually disappear. I have had under my care a
case of A'ery serious neonatal anasarca which ultimately recovered, and
I am inclined to hope for a similar happy result in some cases of
antenatal oedema. In some instances, at any rate, the examination
of the tissues and organs showed no lesions sufficiently grave to
exclude all hope of independent postnatal life, if once the pulmonary
respiration could lie fully established. *S)jcs incerta, perhaps ; but still
a flicker of hope.
Congenital Cystic Elephantiasis.
The curious deforming malady known as congenital cystic elephan-
tiasis is probably nearly related to general foetal dropsy. It is,
however, a disease which affects chiefly the subcutaneous tissue, leading
to an increase in its dimensions and the formation in it of cysts of
various sizes, with clear serous or curd-like contents. It may impli-
cate the subcutaneous tissue all over the body, but frequently it is
very pronounced in a special region, e.g. the back of the head and
neck. Fluid in the body cavities is sometimes but not always met
with, and in this character the disease differs from general foetal
dropsy. Cystic elephantiasis is doubtless related also to the local
conditions known as cystic hygroma of the neck, fibroma moUuscum,
and some forms of congenital sacral tumour.
There are not many cases on record in which the morbid condition
of the subcutaneous tissue was the sole anomaly from which the foetus
suffered ; in fact, the disease is very rare alone. There are, however,
not a few cases in which it occurred along with grave malformations
or in associatiim with other foetal diseases. Thus, there are instances
in which it was met with in the grossly malformed twin of the so-
Ccxlled parasitic type, as in the specimen described by me in 1S92
(Diseases of the Fcdus, i. p. 18-1) ; and F. Caruso {Arch, di ostet. c ginec.,
vi. 193, 1899) has put on record a case in which it was combined with
foetal " rickets." If, however, we confine our attention to the cases in
208 ANTENATAL I'ATllOl.OCiV AND H'lCaKNK
whicli llie condition of tlie subcutaneous tissue was the chief, if imi
the only anomaly, we arrive at the following conclusions.
The mother was j^enerally a multipara, and had enjoyed fairly good
health till the commencement of the pregnancy which ended in the
birth (if the fo'tus with cystic elephantiasis. That pregnancy nearly
always ended prematurely, and was generally associated with hydram-
nios ; and during its course the mother suffered from dropsy,
albuminuria, and unusual abdominal distension, with the symptomatic
consequences of these alterations. The infant rarely survived birth,
a result due in some cases as much to the prematurity as to the morbid
changes.
The foetus was generally larger and heavier than it ought to have
been. Its bizarre appearance was due not so much to the general
gelatinous anasarca, as to the cystic accumulations in the subcutaneous
tissue of special areas. A. Meckel (Arch. f. Anal. u. Fhi/sio/., y. 149,
1828) called his specimen a " monstrose Larve eines Fiitus " (monstrous
mask of a fcetus), and used to e.\hil)it it with lions', elephants', and
calves' heads as an example of what the older writers named " molae
spuriiB " ; he regarded it at first as an acephalus, for it seemed to
consist solely of a trunk with limbs bearing a fleshy, spongy mass
instead of a head ; but when he came to make a section through the
mass, he was greatly surpiised to find underneath a well-formed fictal
face (vide Figs. 32, 33). Meckel said he felt like a child wdio sees a
man, masked like a bear, throw away the mask and reveal his face.
H. Steinwirker's specimen (Dissert., Halle, 1872) was somewhat similar
in appearance, but was not so grossly malformed ; and F. Neelsen
(Berl. klin. Wchnschr., xix. 36, 1882) compared his case of cystic
elephantiasis to the plum mannikins of tiie Christmas markets in
Germany.
The dissectional appearances varied considerably. In C. Everke's
specimen (Dissert., Marburg, 1883), for instance, there was a fibro-
myxomatous stratum, 6 mm. in thickness, between the skin and the
subjacent muscles, and the large swelling on the back of the neck
was found to contain six smooth-walled cysts with yellowisli brown
semi-Huid contents ; there were some anomalies of the abdominal
viscera (contracted state of intestines, enlarged spleen, etc.). In
A. 0. Lindfors' case (Ztschr. f. Gehurtsh. u. Gyndk., xviii. 258, 1890)
there was an umbilical hernia and an amniotic band attached to the
left hand ; there was a large occi]>ital tumour consisting of a thin-
walled cyst with serous contents ; tlie heart showed a common ventricle
and a common auriculo-ventricular opening, and the auricles were very
incompletely separated.
Xeelsen (lor. rit.) gave details regarding the mici-oscojiir appearances
of his sjiecimen. The skin was fairly normal, but the lymjihatics of
it and of tiie subcutaneous and intermuscular structures were greatly
dilated and tortuous, and here and there formed real cystic spaces ;
possibly the large cysts marked a further evolution or the same
changes. In one or two cases the placenta was oedematous and
friable, but details regarding both it and the membranes were seldom
forthcoming.
CYSTIC ELEPHANTIASIS
299
300 ANTKNATAl. I'AlllOI.OCiV AM) HYCilKNl-.
Tlie utioUigy was most oliscure in all the recordcMl eases, — and
there seemed to l)e nothing to suggest a maternal cause. The nature
of the morbid process was a condition of dilatation, or of dilatation
and occlusion of lymphatic spaces and vessels, a lymphangiectasis.
Upon this point most of the observers agreed ; liut whether the
distension of the lymphatics or the hyperplastic changes in the
subcutaneous tissue were to be regarded as tlie primary phenomena
there was very considerable difference »{ (jpinion. In the absence of
general agreement upon these questions, it is needless to spend time
discussing the correctness of the term " elephantiasis " as applied to
the disease. In all probability it is in its first stages oedematous
in its nature : but on account of the early period of intrauterine life at
which it commences it takes on changes (due to the embryonic state
of the tissues) of a quite peculiar kind, changes which are not easily
reconciled with the alterations found in later antenatal life. Of
course it is not the same disease as elephantiasis Arabum, but it is
related to the malady known as congenital elephantiasis, a morbid
state which must now engage our attention. 4
Congenital Elephantiasis.
Congenital clcphiintiasis is a name which has been somewhat
widely and loosely applied to all the hypertrophic or hyperplastic
states of the subcutaneous tissue or tissues which may be present at
birth. It has, as we have seen, been given to the soft cystic variety
of this disease ; it is given also to the widely distributed as well as
to the strictly localised hard and soft varieties {elephantiasis congenita
dura, mollis), and by a forced process of extension to such morbid
states as multiple cutaneous neuro-fibromata and filjroma moUuscum.
At one end of the series of pathological changes it passes over by
gradations into general fcctal dropsy of the gelatinous type (as seen
more particularly in the twin fcrtus), and at the other end into a
confused and heterogeneous group of neoplasms, including nerve
nsevus (so called) and congenital unilatei-al hypertrophy or partial
giant-growth. An eminently good and complete account of this
difficult chapter in fcetal pathology is given by F. Ksmarcli and
D. Kuleukampff in their monograph. Die ElejJiantiastischen Formoi
(Hamburg, I880), which extends to nearly 300 pages, and which
contains all that pathologists (and more particularly (Serman patho-
logists) had said on this matter prior to the year 1885. It is not
ray intention here to describe the three forms named Elephantiasis
telangiectodes, E. fibromatosa, and E. neuromatodes ; these closely
approximate in their characters to the congenital neoplasms ; hut I
shall confine myself to the cases of hypertro]ihif thickening of the
subcutaneous tissue of one or several limlis or parts of the body which
are found at birth, and which are more nearly related to the instances
of cystic elephantiasis (already referred to). It is true that in them
the vessels and nerves and even the bones and muscles and fibrous
tissue in the neighl)ourhood may be involved in the hyperplastic
processes, and thus connecting links with elephantiasis telangiectodes,
coxgp:xital elephantiasis 30 1
neuroniatodes, fibioniatosa may be ibinieil ; but the outstanding
character is hyperplasia of tlie subcutaneous tissue with special
involvement of the lymphatics. In this restricted sense let us deal
with congenital elephantiasis.
The clinical history of cases of congenital elephantiasis is chiefly
remarkable for the occasional record of iamily prevalence and of
hereditary transmission. M. Xonne {Arch. f. path. Anat., cxxv. 189,
1891), for instance, met with eight instances of the disease in fourteen
individuals in the same family in three generations. There was the
man H. H., whose age when examined by Nonne was 34 : his father had
been healthy, but his mother had suflered from a congenital enlargement
of the lower limbs. H. H. was born normal, but almost immediately
afterwards it was noticed that his feet and legs were unusually large,
and the enlarged extremities grew proportionately with the rest of
the body. The hypertrophy was chiefly below the knee, and aflected
very markedly the dorsum of the foot, and just above the malleoli were
two grooves on the right and one on the left leg. The surface of the
skin had a normal appearance (elephantiasis glabra), but there were
some papillary growths attached to the toes. There was pitting on
firm pressure, and the pitting remained long. H. H.'s sister, H. M., age
30 years, had a condition very similar to that described above ; but in
her case the right leg and foot were normal, the anomaly being
restricted to the left side ; there was the same swelling especially of
the dorsimi of the foot, the same grooves, and the same papillary
growths attached to the toes. H. M. was married and had had four
pregnancies : the first ended in the birth of an infant with enlarged
lower limljs, who died in infancy ; the second was an acephalic
(anencephalic ?) full-time infant with similarly affected lower ex-
tremities ; the third pregnancy resulted in the birth of a female child,
still alive (age 6 j'ears), with elephautiasic enlargement of the right leg
and foot ; and the product of the fourth gestation was a full-time
male infant, showing the same abnormality in both lower limbs liut in
a less degree. As has been already stated, the mother of H. H. and
H. M. had also suffered from congenital elephantiasis of the legs, and
one of her sisters had the same condition in a more aggravated form.
When the family history was traced further back, the inevitable
maternal impression appeared, for the grandmother of H. H. and
H. M. had been frightened during pregnancy by a woman with
dropsical legs. J. H. Jopson's two cases {Arch. Fccliat., xv. 173,
1898) were brothers, and their father had suflered like them from
congenital enlargement of both lower limbs below the knees; and
Milroy {Proc. Nebraska Med. Soc, p. 27, 1892) recorded twenty-two
cases of hereditary oedema of the lower limbs in ninety-seven
individuals in six generations, and in all but two the oedema was
congenital.
There is, as a rule, little information to be obtained regarding the
character of the pregnancy which ends in the birth of an infant with
elephantiasis ; but one of iloncorvo's cases formed an important
exception. In 1895, Dr. Jloncorvo (Eio de Janeiro) kindly sent me
a photograph of a little patient suffering from congenital elephanti-
.302
ANTKNATAI. I'A'I'IIOI.Od^" AM) IIVCilKNK
asis, which is repMiducL'd liere (vide Fig. ?A); aiul I coimuuiiicated
the details of the case to the Ediiiburgh Obstetrical Society at its
December meeting {Trans. Edinh. Ohst. Soc, xxi. 25, liSOG). The
infant was a male, of mixed race, five months old. The father had
suliercd from acquired syphilis, and on several occasions had liad
lynipliangitic attacks affecting the limbs, and principally the arms.
The mother, a half-breed like her husband, had had seven childrin.
of whom four (the first, second, fourth, and fifth) were already dcml.
While nursing her second last infant she had been attacked li\-
lymphangitis in the left breast, going on to suppuration.
FlK. 34.— Congenital EIpiilianti.i.sis.
During the last pregnancy she had had several falls, followed by i
more or less troublesome results. The fii'st, a fall in the street, with
bruising of the abdomen, at the fourth month, had been followed '
for eight days by abdominal pains; two months later, the abdomen I
was bruised again by a second traumatism ; this was succeeded by ■
abdominal pain, a rigor, and rise in temjierature ; at the seventh '
month she fell across the tramway rails in the street, agaiii bruising
the hypogastrium, which became the seat of a lymphangitic attack, :
going on to suppuration and fever of a remittent type, and lasting
about a week; again, at the eighth month, she received a I)low on
the al)domen. Labour took i)lace at the full term, and it was at once
noticed that although the infant was alive and active, he had an ab-
CONGENITAL ELEPHANTIASIS :',0:5
normally large right lower limb. He showed, also, signs of hereditary
syphilis. There was marked hypertrophy of the right lower limb
from groin to foot, which was most evident in the foot and lower
two-thirds of the leg, and there were deep grooves to be recognised
(Fig. 34). The skin was smooth and of normal colour and tempera-
ture, but drier than in other regions, and firmly adherent to the
subcutaneous tissue. Palpation revealed a feeling of elastic hard-
ness of the tissues, more marked on the dorsum of the foot, less so on
the thigh. The circumferential measurements of the right thigh
were about 2 cms. greater than those of the left, while those of the
leg and foot were from 4 cms. to 6 cms. greater in the right than in
the left limb. Sensibility to touch and the reaction to electricity
were less marked in the right than in the left leg. The micro-
scopic examination of the mother's blood showed only a slight
exaggeration of the number of leucocytes, whilst blood serum
taken from the lower third of the right leg of the infant
revealed the presence of a certain number of tlie streptococci of
Fehleisen, either single or grouped, as diplococci or in chains. The
infant was put on a course of iodide of potassium, and the limb was
subjected to elastic compression, with the result that the dimensions
of the hypertrophied extremity were considerably reduced. This was
the tenth case which Dr. Moncorvo had seen {Satellite, vi. 35, 1892 ;
Ann. dc derviat. et syph., 3 s., iv. 233, 1893 ; ibid., v. 186, 1894 ;
Journ. de elin. et de therap. inf., iii. 663, 1895), and in one or two of
them there was a family history of proclivity to lymphangitic attacks.
Further, in one of the three new cases which he contributed to my
journal {Teratologia, ii. 79, 1895) in 1895, there was a doubtful history
of abdominal traumatism and lymphangitis in the mother at the
eiglith month of pregnancy. I have given full details of Moncorvo 's
cases, for they have an important bearing upon the question of
pathogenesis, to which reference will immediately be made.
Some idea of the si/mptomatology and physical signs of foetal
elephantiasis will have been gained from what has lieen recorded
above ; but certain facts may be added. Although the lower limbs
are frequently the seat of the disease, they are not constantly so ;
for, while they were afi'ected in the cases already mentioned and in
those described by Otto Schloss (Dissert, Bonn, 1890), P. Archambault
{Ann. de dcrmat. et syph., 3 s., iv. 448, 1893), Waitz {Arch. /. klin.
Chir., xxxix. 229, 1889), and Steinthal {Med. Cor.-Bl. d. ^viirttcmh.
arztl. Ver., Ixvi. 33, 1896), yet in that reported by Osier {Journ.
Anat. and. Physiol., xiv. 10, 1879) it was the right upper limb, in
W. B. Coley's {New York Med. Journ., liii. 706, 1891) it was the face
and scalp, in T. Spietschka's {Arch. f. Dermat. u. Syph., xxiii. 745,
1891) it was the whole body except the right upjjer limb and the
genitals, and in M. Mainzer's {Deutsche med. Wchnschr., xxv. 436,
1899) it was the left upper limb and the external genitals as well as
the lower extremities. In most of the cases the condition did not
interfere with the postnatal life of the child, and in some there was
a distinct tendency to diminution in the amount of the subcutaneous
hypertrophy. There was some difficulty in progression when the
J04
ANTKNATAI, I'A 11 lOI.OCiV AM) H^(;ll■.M■.
lower limbs were affected ; there was always the deformity ; and in n
few Cfises the usefulness of the liniljs was seriously interfered with.
The skin covering the diseased part was generally normal in appear-
ance, but in a few cases there was an excessive vascular development,
and in one of Rose's cases ( .Vonatsschr. f. Gehurtslc, xxx. 339, 1867)
the enlargement was almost entirely due to fat. Now and again
grooves wei'e described on the allected limbs, and in G. Iteinbacli's
case {Beitr. z. Jdin. Chir., xx. G45, 1898) the grooves seem lo have
been due to amniotic bands encircling the part. Although in most of
the cases the ajjpearances did not closely resemble elephantiasis
Arabum as met with in the adult, they did so in a very striking way
in the patients seen liy Mainzer {loc. cit.) and Eeinbach {loc. cii.). In
the former the external genitals were affected : the labia majora, the
nymphw, and the clitoris all showed the elephantiasic thickening,
and between the posterior commissure and the anus was a reduplica-
tion of loose skin. Both legs and the right foot exhibited the same
enlargement, which by the help of the Kiintgen rays was seen to
have left the bones untouched. The left upper limb was enormously
enlarged, and the thickening was especialh' marked in the forearm
aud hand. On the toes of the right foot were some grooves suggest-
ing amniotic bands. The skin everywhere retained its normal colour,
and there were no traces of angiomata or fibromata ; but in the areas
of thickening there was some cutaneous dryness and roughness. The
child had neither heart disease nor nephritis, and the thyroid felt
normal ; there was no syphilis.
It is a curious speculation to inquire whether the fabulous people,
the Sciapodi, described by Ctesias, had perchance their origin in the
birth of an infant with congenital elephantiasis of one foot. They
are represented as possessing a single foot which was so large as to
be used as a sunshade, aud pictures of them are to be found in the
older works on Jlonstrosities.
The jxithogenesis of congenital elephantiasis has that common
character of antenatal morbid states — obscurity. It has lieen sug-
gested that the hypertrophy may be due to an amniotic liand encircling
the limb ; aud in a case of multiple nialformatious in a fcetus which
I examined some years ago, there were indications that this view
might occasionally be correct. In J. Schnitzler's case ( Wiener klin.
Rundschau, ix. 165, 1895), also, there was confirmatory evidence.
But obviously it cannot account for all the cases. Some have seen
in the disease a true elephantiasis Arabum of intrauterine origin;
but there is next to no evidence of the transplacental transmission
of this disease (vide Prince A. Slorrow, in Twentieth Century Praeticc,
xviii. 424, 1899), and E. Sarra (Pediatria, iii. 155, 1895) found no
traces of filarire in a case of fretal elephantiasis examined by him.
Its origin in the passage of streptococci from mother to infant, which
was supported by Moncorvo, cannot be accepted as frequently correct,
for it is rare to find any liislory of maternal lymphangitis or erysipelas
in pregnancy. A family predisposition to neoplastic changes in the
connective tissues, as imagined by Spietschka, cannot be accepted
as a satisfactory explanation, for family prevalence and heredity,
CONGENITAL ELEPHANTIASIS 305
although met with, are not at all frequent. It may possibly be due
to long-continued irritation of the subcutaneous tissues by some
toxin circulating in the blood; but this supposition does not of
course satisfy the requirements of an adequate theory of patho-
genesis.
It is cheering to be able to chronicle improvement and even
recovery under ti-eatment with iodide of potassium, electricity, and
elastic compression. There is sometimes a natural tendency towards
cure, and possibly to this, as much as to the treatment, the improve-
ment may be due. So that, after all, the cheerfulness of the believer
in therapeutic successes in antenatal maladies may be premature.
The above maladies (general foetal dropsy, general cystic elephan-
tiasis, and congenital elephantiasis) I have selected as types of
idiopathic diseases affecting chiefly the subcutaneous tissue ; but it
will be evident to the reader that indications are not wanting of
their possible transmitted character. In some instances, at least,
there is ground for believing that the maternal (or paternal) health
had a determining influence upon the evolution of the fcetal malady.
The diseases are retained in the idiopathic group, but there is reason
to expect that ere long they will have to be transferred to the
transmitted.
There are also certam morbid states of the subcutaneous tissue
which have not yet been established as truly present at birth ; among
these is myxoedema, due to the absence of the thyroid gland. Bourne-
ville {Progres vied., 3 s., ii. 33, 49, 1895) explains the absence of the
symptoms of myxoedema in the early months of life as due to the
influence of the mother's milk ; after weaning, the defective state of
the thyroid makes itself felt, and the pachydermatic cachexia be-
comes evident. It seems more probable, however, that the thyroid
in the foetus and at birth does not possess the same regulating
influence over body metabolism (including of coui'se that of the sub-
cutaneous tissue) as it does later ; possibly, therefore, its defective
action will not reveal itself by the same alterations in the subcut-
aneous and other tissues at birth as it does later (vide p. 166).
Atrophic as well as hypertrophic states of the subcutaneous tissue
have been met with in the foetus. F. Ahlfeld (Berl. Jdin. Wchnschr.,
xxxi. 812, 1894), for instance, has described a foetus with atrophy of
the subcutaneous adipose tissue in a case of defect of the liquor amnii
(ohgohydramnion) ; the mother was a deaf-mute, and so perhaps was
the father. Possibly the " living skeletons " who are exhibited at
shows and fairs and Christmas carnivals are in some cases examples
of this congenital atrophic state of the subcutaneous tissues. The
so-called " elastic skinned men," also, show a condition which is
probably due to congenital defective growth of the subdermal rather
than to abnormal elasticity of the dermal tissues.
CHAPTER XVI II
Idiopatliic Diseases of the Fiutus (cont.): Types of Skin Diseases: Fdtal
Ichtliyosis (Grave Form) — Definition, Synonyms, Clinical History, Sympto-
matology, Ai)pearances (Macroscopic and Microscopic) ; Fu'tal Iclithyosis
(Mild Form) ; Tylosis Palm;e et Planta; ; Ffital Keratolysis ; Ilyper-
trioliosis congenita — Definition, Synonyms, Recorded Cases, Clinical History,
Pathogenesis ; Localised Form of Hypertrichosis ; Congenital Alopecia —
Clinical Characters, Pathogenesis ; Antenatal Pemphigus or Epidermolysis
bullosa hereditaria ; Congenital Absence of Skin ; Acanthoma or Amnioma
of the Skin.
Id this chapter I propose to consider some types of fcetal disease of
the skiu. Some difficulty has arisen in selecting these types, for
there is a large number to choose from, as may he seen liy a reference
to my scheme of classification of foetal skin affections {Diseases of the
Faitus, ii. p. 227, 1895). Some of the maladies therein enumerated
{e.g., those connected with the transmitted morbid states, the fevers,
syphilis, purpura) have, it is true, been already considered ; but tliere
still remains a large number of others. From these I select fcetal
ichthyosis (one of the epidermidoses), tylosis paluue et plauta' (one
of the acanthoses), hypertrichosis and hypotrichosis (two of the
trichoses), pemphigus (one of the angiotic acantholyses), and con-
genital absence of the skin (an atrophic dermatosis). The various
forms of uffivus I do not specially deal with, as every text-book on
Dermatology and Surgery devotes consideralile space to them.
The same general principles of Antenatal Pathology {vide Chapter
XI.) must be applied to the study of the skin diseases as have been
applied to the other maladies with which the preceding chapters
have been occupied. Incidentally it may lie remarked that the
congenital skin diseases have come prominently before tlie notice of
the pulilic as well as the profession ; for the sull'erers from thom bulk '■
largely in shows at fairs, in " dime museums," and at Christmas ,■
carnivals. The curiositj' of the public with regard to "alligator /»
boys," " hairy men," " spotted girls," and " freaks " of that kind is ,j
great, and while it may be far from commendable, it, at any rate, pro- ,(
vides funds for the support of these victims of antenatal pathology. '
Fcetal Ichthyosis (Grave Form).
This malady may be provisionally defined as a skin disease of
the faHus, developed probalily about the fourth mouth of intrauterine
life, characterised by the existence over the whole surface of the body
of horny epidermic plates, separated from each other by fissures and
Fa-:TAL ICHTHYOSIS oOT
furrows, associated with certain deformities of the moutli, nose, eyes,
ears, and extremities, and leading to the death of the infant very
soon after birth.
It has gone under various names. It was first described about
the end of the eighteentli century (Eichter, Disscrtatio dc IiifanticicUo,
1792), and up to the middle of the nineteenth century it was called
a congenital hypertrophy of the epidermis or " cutis testacea "
(Behrend, Tlionogr. Darstell. der niclit-syph. Hautkr., p. 84, Plate xxix.
1839). A. Keiller {London and Edin. Month. Joiirn. Med. Sc, iii. 694,
1843) simply described his case as one of " thickening and deep
fissures of the skin in an infant at birth " ; but J. Y. Simpson, who
communicated Keiller's case, entitled his paper " Intrauterine
Cutaneous Disease," and went on to say that " it would appear to he
much more analogous to ichthyosis than to any other skin disease
that can be referred to, and therefore, suggested for it the name
of ' Ichthyosis Intrauterina.' " This designation, or its synonym
" Ichthyosis congenita," has been widely adopted and is now in
general use, although recently there has been a tendency to prefer
" Hyperkeratosis " or " Keratoma." The peculiar appearances of the
infant affected with this disorder have led to the occasional employ-
ment of the singularly descriptive name of " Harlequin Foetus "
(Bland Sutton, Trans. Med-Chir. Soc. Zand., 2 s., li. 291, 1886).
It would seem that the disease is rare, for up to the year 1895
there had only been recorded some forty-two cases ; and, taking into
account the very striking appearances that the infants present, it is
unlikely that many escape recording.
With regard to clinical history, it is most noteworthy that the
parents of infants suffering from ichthyosis were generally themselves
free not only from ichthyosis, but also from all kinds of skin
affections. Anton Wassmuth (Beitr. z. path. Anat. n. allg. Path.,
xx\'i. 19, 1899), however, has recorded a case in which the parents
were cretins. The obstetric history was in the great majority of
instances good. One striking fact, however, must be noted — the
occm'rence of more than one ichthyotic infant among the offspring of
the same parents, or family prevalence. Thus, Okel's two specimens
{Verm. Abhandl. v. einer Gesellsch. pract. Aerzte zxi St. Petcrsb., viii.
185, 1854) were borne by the same mother ; so were Houel's two
eases {Compt. rend. Soc. de hiol., iv. 177, 1853), and those of G. A.
Haus {Norsk Ma<j.f. Laegevidensk., Ixii. 542, 1901) ; and the mother in
Oestreicher's record {Arch. f. Dermat. u. Syph., xxiii. 837, 1891) had
three normal infants by her husband, and after his death three
ichthyotic foetuses in three successive years illegitimately, and
presumably by the same man. The condition of the foetal skin
seems occasionally to have retarded the progress of labour ; but a
premature ending to the pregnancy was common. Obscure abnormal
symptoms have been described by the mother during gestation ;
hydramnios has been met with ; and there has been the usual crop
of stories of maternal impressions.
The infants were all weakly when born, and died within a few
days or hours thereafter ; and it is particularly noteworthy that only
308 ANIKNATAI. I' ATI lOI.OdV AND Il^dlKNE
in one recorded ease (J. F. .lalin, llhxcrt., I>eipzig, 18G'.)) was tlie
subjeel dead-born, so that it may he conehuled that fu'tal ielitliyosis is
not fatal to intrauterine althou<::h it is most uniformly so tn post-
natal existence. Tliis latter result is in large measure brought
aljout by the associated deformities, and especially by the state of the
mouth, whicii practically prevents sucking. The child usually cried
loudly and continuously during its short tenure of life ; but in some
cases the cry was weak and buzzing ((r. Vrolik, Tab. ad illustr.
Emhryog., 1*1. xcii., 1849). Respiration was impeded, but urination
and defecation usually took ])lace naturally; in Souty's case {Bull,
de I'Acad. roy. de mi'd., viii. 82, 1842-3), however, no urine was
passed. In most instances the infant slept little, and in some cases
(Jahn, op. cit.) special reference was made to the highly offensive,
cadaveric smell which came from the skin.
Tlie appearances of the general body surface, with its thick horny
yellowish epidermic plates of all sizes and shapes, with intervening
cracks or fissures of a red or bluish tint, are very characteristic
(Fig. 35). Some of the older authors described the eyeballs as absent
and their place taken by two red tieshy masses : but it is now known
that these tieshy tumours are really the greath' swollen and congested
conjunctival surface of the eyelids everted in ectropion (Fig. 36), for
on separating these we can see the normal eyeball.
The whole body presents a particularly hideous and repulsive
appearance, and we can scarcely wonder that such epithets as
"horrilile" and "terrible" have been freely used by writers in
describing their specimens. The thickened jilates with intervening
fissures have been compared to a coat of mail, to the bark of some
trees, to the dermal covering of the armadillo, the coat of the tortoise,
and (by a stretching of the imagination) to the dress of the harlequin.
The epidermic layer is much harder than usual ; it is variously
described as " leather like," " horny," and "cartilaginous" ; it is cold
to the touch. The plates differ greatly in size and shape, and the
appearance produced l)y them has been compared by Eadcliffe Crocker
(Diseases of the Skin, 2nd Edit., 343, 1893) to a "loosely-built stone
wall," to a stone-dyke as we call it in Scotland. The thickest plates
are on the back, chest, and scalp; the thinnest ai-e on the hands and
feet and round the anus ; their margins are usually bevelled off and
their surface is commonly smooth, but sometimes shows small spines.
The deepest cracks or fissures are generally found on the scalp in the
neighbourhood of the greatly deformed ears ; some of them are
bridged over by a thin, transjiarent pellicle, but this is often absent.
The hands and feet are greatly thickened and malformed ; the digits
reseudjle birds' claws (onychogryphosis), are sometimes united to
each other, and are sometimes absent. The dissectional appearances
of the internal organs would appear to be unimportant : congestion
seems to have been fairly constant, and the cause of death was
generally found in a In-oncho-pneumonia or pulmonary oedema. In
1901, Drs. A. S. Daniel and L. Cordes kindly sent me a photograph
of a very ty])ical case reiHirtod liy them {Jonrn. Amcr. Med. Assoc.,
XXXV. 1081, 1900). In tiiis case the kidneys showed the lesion of
FCETAL ICHTHYOSIS
309
Fig. 35.— Sti-aiibe's Case of Fcctal Ichthyosis,
310
ANTKNATAI, I'ATIIOLOGY AND llYdlKNE
acute exudative nephritis; the rliild had died suddenly twenty-seven
hours after birth.
The microscopical apjmiranccH of tlie skin (Fi<,'s. 37, 08) have been
Fk:. 30.— Kyliei's Case of Fiutal klithyosis.
well described by E. Kyber {Medizin. Jahrh., .-^QT, ISSO) and T.
Carbonc {Arch, per le Sc. vud, xv. 349, 1891). The most
striking feature is the enormous thickening of the epidermic layer,
FCETAL ICHTHYOSIS
311
Fig. 37.— Skin of Palm of Hand in Fojtal Ichtliyosis (Kyber).
Stratum corneum with sweat canals ; 6, Stratum Malpigliii ; c, Projection
passing down between the papillte ; d, Sweat ducts ; e, Sweat glands.
312
ANIKN'A'IAI. I'AlllOI.OflV AND HYC.IF.NF,
■ '-.^
i
j ';
d
i
<i '"
/'
d 6 ^''^'^- b d ^ ,
•■V.' ' !S^ . 3
■■■.; 1^^'
■ ■: .. ?i
■ ■ ■•; Sii
e ■ ■ ■ '■'!. ■
'•.' "'ii'--
^ '4k
^^'
Pig. 38.— KvIiit's .•<)..
if r.-Ml 1.1, til-
Fig. 1. — Vertical Section of tlie Skin of the Clicst in a thirkuiieil area, a. Stratum
(■oineiim, with liair canals containing; lanugo liairs ; 6, Stiatuni tlal]>igliii ; c, Sweat
gland.s ; d, Hair sac ; c and /, Sdiaccous glands fdlcd w itli fat cells ; ;/, Lanugo
hairs ; A, Cerium.
Fig. 2. — Vertical Section of Hair Sac with Sebaceous Gland from Skin of Head (Kyher).
FCETAL ICHTHYOSIS 313
which is ahnost entirely situated in the stratum corneum, the rete
Malpighii, with the exception of the interpapillary prolongations,
being even diminished in tliickness in some instances. It is xisually
stated that there is no stratum granulosum of Langerhans, and no
layer of flattened cells containing kerato-hyaline ; but G. A. Haus
(loc. cit.) found both. There is a well-marked stratum lucidum, and
the passage from it into the horny layer is not sudden and sharp as
in normal fcetuses but more gradual. In the normal infant, also,
osmic acid stains deeply the deepest and the most superficial layers
of the stratum corneum, leaving the intermediate layers vmstained ;
but in foetal ichthyosis there is no such colour reaction, or only the
presence of some fine black lines. This diflerence has been
attributed to impeded sebaceous secretion. It is doubtful whether
the cells of the rete Malpighii show signs of great activity or not.
The hair follicles are, in many instances, completely plugged by the
thickened horny substance, and the external root sheath of the hair
is also thickened. The sebaceous glands are atrophied and the
hairs themselves are thin. The sudoriparous glands, however, are
hypertrophied (Kyber) and their ducts are elongated ; but Carbone (loc.
cit.) did not note this hypertrophy. The cutis vera is fairly normal ;
certainly the papilLe are longer than usual, but they are also thinner,
and probably are not much if at all increased. The amount of
adipose tissue is smaller than usual, but the subcutaneous tissue, like
the true skin, shows feebly indicated alterations or none at all. In
the furrows between the horny plates the histological appearances
differ from those above described, chiefly in the absence of any
marked thickening of the stratum corneum ; and the rete Malpighii
may be made up of only two or three rows of flattened cells. In
some of the deep cracks the fissure extends directly down to the
cutis vera, upon which lie only some pus cells and broken-down
epithelial cells. Intermediate types are also met with.
To summarise : the changes in the skin consist in hyperkeratosis,
along with the results which this alteration produces upon the hairs
and sebaceous and sudoriparous glands. The condition of the rete
Malpighii is puzzling; but possibly at one stage or another in the
evolution of the disease it may show signs of proliferative activity.
If, however, the disease is primarily due to an anomalous growth of
the epitrichium of early foetal life, it may not be necessary to look
for changes in the rete Malpighii. The chemical analysis of the
epidermic scales, made by B. Livingstone {Amer. Journ. Ohst, xv.
988, 1882) showed fat, cholesterine, and possibly hippuric acid ; and
the burnt residue was made up of salts of lime, magnesia, and iron.
Very little information was forthcoming regarding the placenta,
membranes, and cord ; but the ejiidermic thickening does not seem
to have extended to the sheath of the cord, — a striking fact. There
was hydramnios in Jahn's case (Dissert., Leipzig, 1869) and in W. E.
Smith's {Amer. Journ. Ohst., xiii. 458, 1880), — also striking facts, but
standing almost alone. A thorough investigation of the foetal
annexa in these cases is a desideratum.
Fig. 3. — A'ertical Section of Skin of Palm of Hand in a Normal Infant (Kyber). a.
Stratum corneum ; b. Stratum Malpighii ; c, Interpapillary projections ; d, Corium ;
e, Sudoriparous glands ; /, Adipose tissue.
Fig. 4. — Transverse Section of Hair Sac containing Hair from Skin of Head (Kj'ber).
314 ANTENATAL I'ATHOI.OCJV AM) IlY(iIKNi:
The etiology of ftt'tal iehtliyosis is unknown. The parents were
generally quite free fnjui skin disease of all kinds and from syjdiilis.
Sex seems to liave no imjioitance. Fauiily jirevalence, however, was
unusually common when we remember how rare the disease is ; and
in one case (Carbone's) the parents were nearly related (uncle and
niece). The pathogenesis, likewise, is most obscure. "NMietlier or not
the disease is ichthyosis modified by intrauterine environmental
conditions, is after all comparatively unimportant. The real dilHculty
is to find any explanation for the extraordinary thickness of the
stratum corneum of the eiiidermis. H. C. L. Barkow (JJeitr. z. path.
Enttviekclungsgeschichte, iv. 52, I'reslau, 1871) thoui;]it tliat the first
stage in the production of the disease was i)enq)higus: after the
blebs had formed they burst and the tears remained as the fissures
between the epidermic plates ; the hypertrophy constituted the
second stage. There is little to commend this view, for IJarkow's case
seems to have been the only one in which there w-as any sign of
pemphigus. A more attractive theory is that w"hich regards the
thickened horny layer of the epidermis as the direct derivative of
the epitrichium {q.v., page 85). This theory has been commended
by Ohmann-Dumesuil {Tcratologia, ii. 149, 1895), who thinks that
through an arrest in the development of the hair and sebaceous
glands the epitrichium remains attached to the underlying stratum
corneum and stimulates it to excessive growth. I suggest, however, .
that absence or defective development of tlie epitrichium, also, may |
permit a more luxuriant growth of the underlying horny layer.
Why in certain cases this anomaly in the formation of the ei)itrichial I
layer should exist is, of course, a difficult question. It may be noted
that J. M. Winfield (Journ. Cutan. and Gen.-Urin. Dis., xv. 516,
1897) has recorded a case of congenital ichthyosis with absence of]
the thyroid. If we accept the view that fojtal ichthyosis is due
either to persistence or to absence of the epitrichium, we place the '
condition among the monstrosities rather than the diseases of
antenatal life ; but this is no great objection to the theory. For it
has been pointed out that during the ftrtal period some embryogenesis
is still going on {e.g., in the skin), and morbid causes acting on these
parts still in the embryonic stage would produce teratological results.
There is nothing inherently improbable in the view' that fojtal
ichthyosis is a monstrosity rather than a disease. Truly, the appear-
ances which it presents are monstrous enough !
The prognosis in cases of foetal ichthyosis is of the gravest.
Although not fatal to the beginning of postnatal life, it is absolutely ]
so to its continuance, and death has invariably followed at a time
varying from a few hours to nine days. The infant is often
premature, is sometimes inherently weak, is unable to suck, and the
cracks and fissures in the skin soon become "the haiuits of pyogenic \
microbes." He is called the " harle<[uin foetus"; but truly liis
postnatal life is a lirief and a sad harlequinade enough 1
Foetal ichthyosis has been noted in the lower animals {e.g., the
calf), and F. Ii. Liebreich (Dissert., Halle, 1853) has found a possible
paternal cause in some of these cases.
I
FCETAL ICHTHYOSIS 315
Foetal Ichthyosis (Mild Form).
An infant suffering from the mild type of fcetal ichthyosis is
born with a continuous layer of a collodion-like substance over the
whole body ; after birth this substance desquamates in small tissue-
])aper like tlakes. It is sometimes but not often accompanied by
an ectropion condition of the mouth, eyes, and anus. This is the
" collodiou ftPtus " then ; it is the attenuated form of foetal ichthyosis
(Hallopeau and Watelet, An7i. dc dermat. ct syph., .3 s., iii. 149,
1891').
In this type, as in the grave form, the parents are generally free
from all kinds of skin disease ; and, as in the grave form, family
prevalence has several times been noticed. Some curious occurrences ^ __.0
have been recorded. In a case of H. Auspitz {Arch. f. Dermat. u.
Si/ph., i. 253, 1869), the pregnancy was plural, the twins were of
different se.xes, the ichthyotic one was a male and the normal one a _^-
female. In F. Warner's observation (Med. Times and Gaz., p. 144, i.
for 1882), two sisters married their cousins (two brothers), and each
woman gave birth to an ichthyotic foetus. In G. T. Elliot's case
{Joiirn. Cutcui. and Gen.-Urin. Dis., ix. 20, 1891), a man, wdio had
been twice married, had by his first wife healthy children, and one
with palmar hyperkeratosis ; by his second wife he had two ichthyotic
infants. Family prevalence was met with by ilichelson {Berl. klin.
Wchnschr., xxiii. 520, 1886), by A. J. Munnich {Monatsh. f. prakt
Dermat., v. 240, 1886), and by others.
In no case was the infant born dead, and in only a few instances
did it succumb soon after birth ; so the mild form of foetal ichthyosis
cannot be regarded as fatal to either intrauterine or postnatal life,
although it is exceedingly difficult to cure completely. In one or
two instances there was recovery, in others there was a localised
involution of the malady with a tendency to revert ; but in most of
the cases the lesion either remained in statu quo (as adult ichthyosis
or xeroderma), or showed an increase in severity with advancing age.
The appearances at or soon after birth are very characteristic.
Tiie subject has already been called the " collodion foetus," for the
whole Ijody is covered with a firm, dry, shining, and tense membrane
(" fest wie ein Trommel," says Behrend in the Berl. Jdin. Wchnschr.,
xxii. 88, 1885); and M. Perez (Froi/res mdd., vii. 524, 1880) spoke of
the infant as covered by a horny cuirass, an "ongle immense."
Cracks and fissures traverse this collodion-like covering, but are
generally quite superficial. Soon after birth desquamation com-
mences, the epidermis being shed in large yellow squames, or in
small fragments like films of white tissue paper. The associated
deformities of the mouth, nose, ears, eyes, and limbs are evident, but
are never so marked as in the grave form of foetal ichthyosis.
The microscopic appearances of the skin have been specially
studied by J. Caspary ( Vrtljschr. f. Dermat., xiii. 3, 1886), and are
reproduced in Fig. 40. (Fig. 39, also taken from Caspary, is given
for the sake of comparison ; it represents the skin of a normal but
somewhat atrophic infant.) The skin has only half the normal
31G
ANTENATAL PATHOLOCiY AND HYCIIKNK
thickness, and tlie subcutaneous adipose tissue is also diininislied ;
but tlie ejiidcrniis is relatively increased, and constitutes fully one
:f^:ym^^^,_ :
■ — -^^rt]
!h
Fi«. 39. — Skin of Normal Infant (Caspary).
f. Stratum corncum ; !, Stratum lucidum ; g, Stratum graiuilosum ; Sj),
Stratum spinosum ; ch, chorium ; d. Sudoriparous glands ; /, Fat cells ;
m, Transvei-sely cut bundle of non-striped muscular libres ; t, Sebaceous
glands ; v, Vein.
FCETAL ICHTHYOSIS 317
([uarter of tlie total skin thickness. There is no superficial fatty
layer, and no sebaceous glands are to be seen ; and there are only a
few hair follicles, but the sudoripai'ous glands appear to be well
formed. All the layers of the epidermis (stratum corneum, stratum
lucidum, rete Malpighii, and even the stratum granulosum) are
thickened. Caspary's description applies to an infant of eighteen
months, but in the absence of observations on the foetus it must be
taken as typical.
dl.
d.
Fig. 40.— Skin of Ichthyotic lufant (Caspary). Letters as iu Fig. 39.
The same remarks apply to the etiology and pathogenesis of this,
the minor form, as to the grave type of fcetal iclithyosis. Patho-
logically it is ichtliyosis ; probaljly it is due to an anomaly in the
development of the epitrichium. It is an interesting fact that a
typical case of the disease with very marked deformity may appar-
ently lie developed after birth, as Lang's case seems to prove {Berl.
Idin. Wchnschr., xxii. 819, 1885). It would be of the utmost value
if, in the case of ichthyosis developed iu childhood, details of the
318 ANTFAATAL PATHOLOGY AM) HYGIENE
state of the skin at the time of birth could always or often be
obtained. With rej^ard, for instance, to iclithyosis hystrix (the so-
called " porcui)iue disease "), it is usually stated that the disease was
not present at birth, and it is therefore not included amo7if< the
fcftiil diseases ; but a careful intjuiry has in some cases elicited the
information that, although the skin was not ichtliyotic at liirth, neither
was it normal. For example, it has sometimes been stated that at
l)irth red spots, or raw-looking areas, or bruises were visible upon the
skin ; these have a pathological significance, and ought to be inquired
into.
Tylosis Palmae et Plantae.
Under this name, or under its synonym " keratoma plantare et
palmare hereditarium," has been described a congenital disease
characterised by a hypertrophy of the horny layer of the epidermis
of the palms and soles only, and not of the general surface of the
body. . The horny plate upon the jialms and soles has a thickness
varying from one-eighth to one-sixteenth of an inch, and its surface i.s
cither smooth or pitted. In the case described by the late Dr. George
Elder and myself (87), tlie palmar plate had a dirty yellow colour, and
a hardness and roughness readily noticed on shaking hands with the
little patient (a girl, 8 years of age). The thickening was greatest on the
hy])othenar eminences ; but it was present also on the thenar eminences
and on the palmar aspect of each finger ; indeed, no part of the palm
was quite free from it except along the lines of flexure. It did not, how-
ever, reach the dorsum anywhere, and it was sharply limited at the line
of flexure of the wrist. Peeling in fairly large scales occurred at times,
usually every spring and autumn. The soles were similarly affected.
In this case (.seen by Elder and myself) there was, as has been so
often found l;iy other writers, a distinct history of transmission from
ascendants to descendants. The mother had the same disease of the
palms and soles, so had an aunt, and so had the great-grandmother
and her sister. In this family tree all the affected persons were
females ; but this is not an invariable occurrence, for in another
" liard-handed " family, one member of whicli I have seen, the disease
was found in males and females in almost equal nundiers. The latter
family was that referred to by Dr. Allan Jamieson at a meeting of
the Edinburgh Medico-C'hirurgical Society {Trans. Med.-Chir. Soc.
Edinh., n. s., xx. 3, 1901). Further, in Thost's case {Dissert., Heidel-
berg, 1880), in Vnws!?. {Vrtljrschr. f. DerrnaL, x. 231, 1883), in G. H.
Fox's {Juurn. Cutan. and Vener. Bis., iii. 145, 1885), in "W. Horton
Date's {Brit. Med. Journ.. p. 718, ii. for 1887), in Hutchinson's {Arch.
Surf/., i. 158, 1890; ii. 74, 1891), and in EadclitTe Crocker's {Brit.
Journ. Dermat., iii. 169, 1891), many members of the family were
afl'ected, but sex seemed to have ab.solutely no determining iutluence.
Family prevalence and transmission from parents (or grand-parents)
to children have been more fre(|uently recordeil in connection willi
this malady, perhaps, than with almost any other; this is a striking
fact, and must have a meaning. But what ?
Tylosis palmaj has rarely if ever l)een observed at the moment of
TYLOSIS I'ALM.E ET PLANT.E 319
birth ; but in some instances it was noticed in tlie first week of life
and became very noteworthy when friction began to act on the palms
and soles. Probably, if these parts of the body were carefully
scrutinised at birtli, some slight morbid change would be recognised.
The lesion is usually painless ; tactile sensibility is blunted, as is
sensibility to heat, cold, and pain ; there may be either dryness or
increased secretion (hyperidrosis).
According to Thost {o]3. cit.), the microscopic appearances are as
follows : " The papilUie are increased in length five-i'old, although their
breadth is somewhat less than uormal ; the prickle cells are not
enlarged or altered, but are greath' increased in nimiber, and the rete
Malpighii is on this account much thicker ; the stratum granulosum
is normal ; the horny layer is much thicker, and the cutis vera and
vessels are also somewhat enlarged."
In its pathology it is probably more of the nature of a hyperacan-
thnsis than of a liyperkeratosis ; but all dermatologists are not agreed
upon this point. To solve the difficulty by calling it a na^vus is to
darken what is already dark, for ntevus is not a precise pathological
term. Its pathogenesis remains most obscure. It seems to require
intermittent pressure after birth to develop it fully, whereas in foetal
ichthyosis the thickening of the epidermis has occurred to its fullest
extent autenatally. It is remarkalily hereditary, in the usual sense
of the word ; and it has been suggested that it may be a reversion to
the type of our arboreal ancestors. The exact limitation of the lesion
is remarkable ; and even if the disease be due to some anomaly in
the e]iitrichium, the localisation of the anomaly is still imexplained.
Tlie malady does not endanger life, although it may give, trouble
to the sensitive mind ; and treatment has generally been directed
towards diminishing the disagreeable roughness of tlie palms of the
hands. Pumice-stone has generally been used, and some benefit
has resulted from painting the affected parts with a solution
of salicylic acid in ether.
FcEtal Keratolysis.
In my work. Diseases of the F(etus (vol. ii. 188, 1895), I have
descrilied, under the name of fcdal keratolysis, a state of abnormal
looseness of attachment or of actual desquamation of the epidermis
of the living fcetus. Peeling of the cuticle normally occurs after
birth, and when it takes place antepartum it is generally regarded as
a sign (and a sure sign) of fcetal death and commencing maceration ;
liut there seems to lie no doubt that occasionally the living infant
comes into the world with desquamation in full progress. I have
already (p. 73) referred to the exaggeration of normal neonatal
desc[uamation, whicli is called keratolysis neonatorum or Eitter's
disease, but in that malady there is not always reason to believe
that there were any changes occurring antenatally. In the present
morbid state desquamation is already in active progress when the
infant is born.
Its medico-legal importance is very evident, for, as Dluudell
320 ANTKNATAL PATllOLOdV AM) IIVCIKNK
(Obstetric Medicine, p. 341, 1840) puts it, "Though the desquauiatiou
of the cuticle is a strong ^»YS(<?/(_/)<('w argument in allirniation of the
death of tlie fa3tus, it certainly is not demonstrative, for cases havr
been related — and among the rest one by Dr. Orme — in which t\w
cuticle has separated in consequence of cutaneous atlcclioiis, thi'
cliild being alive notwithstanding."
I place fectal Ivcratolysis here among the idiopathic maladies, not
because 1 think that it is never the manifestation of a transmitted
disease (e.g., measles, scarlet fever, erysipelas, .syphilis), Init simjily In
emphasise the fact that sometimes no such patliogenesis is possible.
Doubtless, in some instances, it is the evident sign of the antenatal
occurrence of syphilis or of one of tlie desquamative exanthemata :
but in others a ditlerent explanation has to be souglit. Thus, it is
sometimes associated with general anasarca : in several of the cases I
have examined I liave noted this association, and A. Eibemonl-
Dessaignes (Ann. dc t/yndc, xxxii. 8, 1889) ascribes it then to rupturr
of little epidermic vesicles containing opalescent Huid. In otlicr
instances it may be the sign of foetal pempliigus, and in several of
G. F. Cx. Hueter's eighteen cases (Dissert., Marburg, 1858) it may
thus have originated ; in yet other instances it may simply indicate
post-maturity of the fcetus due to a protracted gestation of the
mother, as in the observations of A. W. Edis (Brit. Med. Journ., i. for
1875, p. 44), and A. E. Manby (ibid., ii. for 1879, p. G91). Finally,
it may be due to some disturbance of the nutrition of the skin of a
local kind, e.g., compression of a large Iilood-vessel (H. T. Hanks,
Amer. Journ. Obst., xiii. 595, 1880). In Cordon's observation (Journ.
de nidd., chir., et pharm., xxv. 556, 17G7) there was family prevalence,
three infants being born with it to the .same mother. C. L. Gbckel
(Miscell. curios., Dec. ii., Ann. vi., obs. 151, p. 313, 1688), finding that
the mother had suttered from malaria in pregnancy, thought the
fcetus had been scalded by the hot liquor amnii — " dieses Kind isi
gebrlihet auf die Welt kommen " he unhesitatingly averred.
In many of the recorded cases the infant died soon after birth, but
in most of Hueter's observations it was alive when the mother left
the Maternity Hospital. In some instances the desquamation was
universal, affecting the wdiole body (e.g., in Charrier's case, Ga~. d.
hop., lii. 989, 1879) ; but in most it was more or less localised, and it
is noteworthy that the localisation was not always to the parts which
had been subjected to pressure in labour. Information regartling the
vernix caseosa was not always forthcoming; in some of Hueter's
cases it was absent, but in otliers it was copious. The desquamation
itself was sometimes described as furfuraceous, sometimes as in " large
flakes " ; usually the exposed surface iiad a pale rose or salmon tint,
and not the bright red colour seen in ])ost-mortem maceration. The
last-named character is not constantly distinctive, and Schidd (Arch, dc
tocol. et dc gynic., xix. 385, 1892) has reported a case in which both
varieties of desquamation were present. The postnatal treatment will
consist in the protection (by ointments, vaseline, cotton-wool, etc.)
of the denuded areas of skin from the effect of cold, from irritation,
and from septic infection. In the absence of antenatal diagnosis.
HYPERTRICHOSIS CONGENITA 321
treatment before birth is impossible. The relation Ijetween this
disease and keratolysis neonatorum, if indeed any relation at all
exist, is not well known ; much research is needed upon this point,
as also in regard to its bearing upon the normal desquamation of
the new-born infant.
Hypertrichosis Congenita.
Hypertrichosis or excessive hairiness is a term having a somewhat
wide range of application. The old woman who develops scattered
hairs upon the chin, and the old man with bushy eyebrows and a
copious growth in the nostrils, external ears, and over the body, are
both instances of hypertrichosis of the senile type. The adult man
whose body, either in a special and unusual locality or over its whole
surface, is provided with hair, and the adult woman whose hairy
covering resembles in extent and distribution the male type, are
examples, the one of heterotopic, and the other of heterogenic
hypertrichosis. Further, at the period of puberty the hair which
then normally appears in both sexes may be excessive, and the girl at
this time may show the arrangement and development of hair which
belong to the boy ; again, the appearance of the hair at puberty may
be precocious in either sex : these, likewise, are hypertrichoses.
There are also hypertrichoses which are due to injuries and diseases
of nerves, to trophic disturbances, and to chronic inflammatory states.
The nrevus which carries liair on its surface (n;evus pilosus) has b}'
some writers been regarded as a hypertrichosis, but it is advisable to
restrict the use of the term to the cases iir which the underlying skin
is apparently normal. Finally, the infant at the time of birth, or
very soon thereafter, may show a general or a localised excessive
growth of hair, to which the name of congenital hypertrichosis
(iiniverscdis, localis) is correctly given. In the other varieties,
congenital predisposition may, and doubtless does play an important
part, but it is with the truly congenital form that we are here
specially concerned.
If Inrth occur prematurely, the infant will show a sort of
physiological hypertrichosis universalis, for the lanugo of foetal life
will still be present. This, however, is not what is meant by general
congenital hypertrichosis, which is rather the persistence till birth at
the full time and throughout postnatal life of this same lanugo, more
or less altered in its physical characters. It is not yet definitely
known in what relation excessive hairiness stands to the foetal
lanugo, and it is therefore not justifiable to define hypertrichosis as a
persistence of the lanugo. Accurate reports are much needed of the
condition of the hair at and immediately after birth in the subjects
of this trichogenetic anomaly ; doubtless this lacuna in our knowledge
will ere long be filled, and we shall then know with some certainty
whether the lanugo itself becomes the hair of the " hairy infant,"
or whether it falls off and is replaced hy an entirely new growth.
Various names have Ijeen given to general congenital hyper-
trichosis, among wliich are 'polytrichia, trichauxis, hirsutics adnata,
322
ANTF-NATAL I'ATHOLOCiY AND HVCIKNK
dasytcs, pilosism, and hypertrichiasis. Imlividuals afi'ected with the
anomaly in its most marked form liave been called " hairy men,"
" homines pilosi," " human monkeys," " missinj; links," and " Esaus."
German equivalents are " Haarmenschen," " Waldnienschen," and
" Hundemenschen " ; and in French the expressions " les hommes
veins," " les hommes des hois," and " les hommes-chiens " are met with.
Cases of general hypertrichosis congenita are rare. The first
recorded case seems to have been that of Esau, who " came out red
all over like a hairy garment" (Gcni'sis xxv. 2:'i), or moi'c literally
"all of him as a cloak of hair." The meaning of this hairy liirtli
has greatly puzzled the commentators, and Kalisch iminti'il tn it as "a
foreboding of the animal violence of Esau's character." In the ^Middle
Ages there was a difference of opinion also as to whether or not Esau's
state constituted a monstrosity, and Pohlius, in 1669, wrote a work
with the interrogative title, " De Questione an Esau fuerit ^lonstrum."
Among other historical examples was the girl born near I'isa, hairy
all over (" totam hirsutam "), whose mother had been gazing at a
picture of John the Baptist during her pregnancy {vide T. Fienus, Be
Tiribus iraayi nation in, j). 224, 16:!r)): and there was the hairy child
belonging to the Ursini faiuily, who had bear'.s claws as well as the
hirsute covering. There was the remarkable hairy family (' homines
hypp:rtrichosis congenita 323
sylvestres ") from the Canary Islands described by U. Aldrovandiis
(Monstrorum Histona, p. 16, 1G42); and there was also "Die haarige
Fauiilie von Ambras," consisting of a hairy man, his wife normal in
the matter of hair, and his hairy son and daughter (Figs. 41-44),
described fully by C. T. von Siebold {Arch. f. Anthrop., ix. 253,
1877-8). Another well-known example of hypertrichosis was
"Barbara Ursler,"who was publicly exhibited in London in 1655, and
who is described in Caultield's Portraits, Memoirs, unci Charc(cters
(vol. ii. p. 168, London, 1794-5), and has been recently considered
by Strieker {Arch. f. path. Anat., Ixxi. p. Ill, 1877). John
Crawford, who studied medicine in the University of Edinburgh in
the early years of the past century, and who was afterwards envoy
to the Court of Ava, brought before the notice of European authors
the famous hairy family of Burma {Journal of Embassy to the Court
of Ara, London, 1834); and many others have since contributed
details regarding this family. It consisted of a hairy man married
to a normal woman, of his hairy daughter, and of two hairy grandsons
the children of the daughter by a normal man ; the dentition of these
individuals seems to have been defective {vide J. J. Weir, Nature,
xxxiv. 223, 1886). Eeference must also be made to the hairy
Mexican woman, Julia Pastrana, described by J. Z. Lawrence {Lancet,
ii. for 1857, p. 48), H. Beigel {Arch, f path. Anat., xliv. 418, 1868),
F. L. Neugebauer {Kilka sloiv o mczldem owlosicniu u Kobict, 1897),
and by J. Eanke ( Verhancll. d. Miinchen. anthropi. Gcsellsch., 1-4,
1888) ; she seems to have had hypertrophy of the maxilla (E.
Magitot, Gaz. med. de Paris, 4 s., ii. 609, 1873). In Chowne's case
{Lancet,!, for 1852, pp. 421, 514; ii. for 1852, p. 51) the hamness
was widespread although hardly universal; the patient, a woman,
had a hairless brother and one hairy sister (Wilson, Lectures on
Dermatology, p. 102, 1878). The girl Teresa Gambardella, described
by C. Lombroso {L'uomo hicnieo e I'uomo di colore, p. 155, 1871),
resembled Chowne's patient to a certain degree. Then there were
the famous Russian " hairy men " or the " Kostroma people " described
and discussed by many authorities (E. E. Perrin, B%dl. Soc. d'anthrop.
de Paris, 2 s., viii. 741, 1873 ; C. Eoyer, ibid., p. 718 ; C. S. Tomes,
Brit. Med. Journ., i. for 1874, p. 413 ; E. Virchow, Berl. Uin.
Wchnsehr., x. 337, 1873 ; G. T. Jackson, Med. Record, New York,
xxvii. 568, 1885 ; and A. Ecker Gratidationssc.hrift, Braunschweig,
1878) ; these two men (father and son ?) had a very remarkable
skye-terrier appearance, they were both nearly edentulous, and their
nails were soft and thin (J. VnvveiAi, Deutsche Monatsschr. f. Zalinhlk.,
iv. H. 2, 1886). Finally, among the well-known instances of hyper-
trichosis, there was Krao, " the missing link," who was seven years
old when she was exhibited by Farini in London in 1883. When
seen by A. H. Keane {Kcdure, xxvii. 245, 1882—3), she was of average
intelligence, her face and low forehead were covered down to the
bushy eyelirows with deep black, lank, and lustreless hair, Mongoloid
in type ; her whole body was overgrown with a less dense coating
of soft black hair ; the skin beneath was dark olive brown ; the feet
were prehensile, and the hands could be bent back at the wrists ; and
324 ANTENATAL PATHOLOGY AND HYCJIENK
there was slight prognathism. She was said to he tlie chikl of
Siamese parents {Nature, xxvii. 579, 1882-3). Fauvelle (7/^///. de In
Soc. d'anthrop. de Paris, ?> s., ix. 439, 1886), writing in 1880, wln-n
Krao was about eleven years old, found the second dentition complete,
save that the upper canines had not yet been cut.
From the preceding summary of the best known of the recorded
cases of congenital hypertrichosis, certain outstanding characters
in the clinical history and syiivptomatology will lia\e been recognised.
Heredity has lieen very evidently present in several cases, as in the
von Anibras Family and the Hairy Family of Burma ; family
prevalence, also, was noted in several instances. In two cases
reported by P. Michelson {Arch. f. pnth. Anal., c. 66, 1885) these
chai-acters were also present: in one, the hairiness affected a man,
(Joseph Fieber), a native of Silesia, his eldest daughter, his mother,
and two brothers ; in the other, the father was the subject of hyper-
trichosis, and so were two of his sons. In both of Michelson's family
histories defective dentition was present, and it was sometimes
transmitted along with the hirsuties and sometimes apart from it.
The sisters Francina and Fytje 1*., described by Cleyl {liiol. Ccniralbl.,
viii. 332, 1888-9), were examples of the minor degree of hypertrichosis
universalis. Lina Naumann, the hairy girl, seen by L. Fiirst {Arch,
f. path. Anat., xcvi. 357, 1884), was, however, an exception to the
above rule, for she was apparently the only member of her family
affected ; but she resembled Krao and Julia I'astrana in the
possession of normal teeth set on hypertrojihied alveolar margins.
Marietta S., also, reported by C Hennig {Jahrh. f. Kinderhlk., xl.
107, 1895), seems to have been a solitaiy instance of hypertrichosis;
but from the description it would appear to have been a case
complicated with ntevus pilosus.
Details of the state of the hairy infants at birth are sadly lacking.
In Geyl's two patients(/oc.f(Y.), marked hair on the scalp and long lanugo
on the forehead and cheeks were present at birth, but at the age
of two and a half years there was a sudden increase in the hair over
the limbs and body. In Ftirst's patient {loc. cit.) the abnormal hairi-
ness of the body was clearly visible within the first week of life, and
bushy eyebrows were noticed at birth. In the "homo hirsutus"
described by Krebs {Hosp.-Tid., 2 E., v. 609, 1878) the excessive
hairiness did not appear until the third month of life. It was usually
found that the face and hands were specially hairy, and this gave a
very characteristic animal appearance to many of the indiviiluals ;
but in I'ickells' patient {Edinh. Med. and Sury. Journ., Ixxvi. 316,
1851) the face and hands were free, wliile the rest of the body was
hairy. In some, the hair was very coarse, but in others it was soft
and silky ; usually it followed the lines of direction taken by the
lanugo in foetal life. The hypertrichotic condition apparently did
not interfere with postnatal existence in any of the recorded cases,
and it was not associated with sterility. There was sometimes a
correlative variability seen in the dental development, and reference
has been made to the alveolar hypertrophy in Julia Pastrana and
others ; but sometimes there was apparently compensatory defective
HYPERTRICHOSIS CONGENITA 325
development of the teeth, as in the Eussian " hairy men." It may be
noted here that congenital alopecia has also been found associated
with dental defects (vide infra), and Magitot (loc. cit.) has referred to
it both in hairless men and in the hairless Chinese dogs. The Ainos
of Japan are distinguished from Mongolian and Japanese peoples by
a sort of racial hypertrichosis ; they also show a marked development
of the alveolar border of the superior maxilla with consequent prog-
nathism (Ashmead, Sci-i-hicai Med. Journ., xiv. 183, 1895).
The pathogenesis of hypertrichosis congenita is closely beset with
problems. There seems to be something paradoxical in the idea that
this excessive production of hair is an arrested development ; but on
examination it would appear that the theory of an arrest is better
supported by facts than any other. The persistence of the lanugo is
undoubtedly of the nature of an arrested development, for normally
it is shed before or soon after birth. But is hypertrichosis a per-
sistence of the lanugo ? In order to answer this question, it would
be necessary to have a knowledge of the state of the hair in " hairy
infants " dviring tlie first hours of life, and more especially of its
microscopical characters ; this knowledge is not yet in our possession.
We do not know whether in these cases a casting of the hair occurs
at birth or not. As has been pointed out by P. G. Unna {Histojjath-
ology of the Skin, N. Walker's Transl., p. 1151, 1896), if the former
be the case, and if the embryonic hair follicles, instead of becoming
shorter all over the body at this period of life, retained their double
length, then, in spite of the abundance of hair, it is justifiable to speak
of hypertrichosis as an arrested development. But if on the trunk and
limbs the ordinary casting of the hau- had taken place in utero and
all the hair follicles had shortened, and if, later, these follicles had (as
occurs normally on the scalp) again expanded to the original (doulde)
length, and so given rise to another and a very strong growth of hair,
then the condition would Ije that of a true hypertrichosis, analogous
to the hypertrichosis of puberty. Unna is of opinion that both these
possibilities may occur, and that while for instance the former view
holds with regard to the Eussian " hairy men," the latter explains
such cases as Krao and Julia Pastrana ; he prefers to call the former
(the simple persistence of the foetal hair) " trichostasis " or " hair-
stagnation," while the latter is true hypertrichosis. It is easy to
exaggerate, as I think Unna does, the difficulty of accepting the theory
of an arrest of development ; congenital ichthyosis also is characterised
by excessive growth (of the stratum corneum), and this is probably
due to an anomaly of the epitrichium, likewise an arrest of develop-
ment. If the theory 1 le correct, then in some instances hypertrichosis
is truly a monstrosity rather than a disease, while in others it is more
correctly a disease ; so that after more than two hundred years we
might write again as Pohlius did in 1669, " De questione an Esau
fuerit monstrum." In a similar unsettled state we must leave the
question of the atavistic nature of congenital hypertrichosis.
No treatment has been proposed or indeed thought of for general
hypertrichosis ; but, for the localised form, electricity and the Etintgen
rays have been employed for cosmetic purposes. The localised form.
326 AN'TKNATAL I'A rilOLOCY AND HVdIF.NK
it may be remarked, lias usually Ijeeu confounded witii hairy lucvus
(iKL'Vus jiilosus): Imt it ou^ht to he distiiif^uished from it, for in true
hyperlririmsis tlie underlying skin ought neither to be ]»igmented
nor abnormally vascular. No doubt most of the cjises of " bearded
infants "and babies born with hairy " tails" have been instances of
niTiVus afiecting tlie face or sacral region, and the so-called " bathing
drawers " usvus is a well-known variety of cutaneous ])igmentation ;
but true cases of hypertrichosis localis occur, although rarely. For
instance, there was A. H. Dodd's ca.se of lumliar hypcrtricliosis
(ZaH«'<, ii. for 1887, p. 10G;3), and there was also Balmanno Squire's
(Brit. Med. Journ., i. for 1893, ]>. 1265), in which a patch (jf long hair
was present on the side of the neck. L. A. I'arry (Lanai, i. for
1896, p. 1717) recorded a case of lumbar hairiness afiecting two
sisters. The so-called " lady with the horse mane " was a case of
hypertrichosis localised in the dorsal region ; in this case there was a
defect in the vertebral column (spina bifida occulta) underlying the
hair. This association of lumbar hypertrichosis with spina bifida
occulta has been noted by se\'eral observers in other cases, e.;/.,
by W. Strieker (Arrh. f. ixdh. Anat., l.xxiii. 624, 1878), by F. von
Kecklinghausen (ibid., cv. pp. 243, 373, 1886), by C. Brunner (ibid.,
cvii. 494, 1887), by G. Joachimsthal (ibid., cxxxi. 488, 1893),
and by others. In some of these instances there was a further
complication which came on in later life, namely, perforating ulcer of
the foot. Some of the cases reported as infants with tails were no
doubt instances of lumbar hypertrichosis. Bland Sutton (Lancet, ii.
for 1887, p. 4) wrote suggestively on this subject, as did also Emil
Kruska (I)isscrt., Jena, 1890).
Congenital Alopecia (Hypotrichosis).
It is well known that early baldness (alopecia prematura) is
hei'editary in some families; but true congenital alopecia, or the
absence of hair at birth, is very rare. When this amunaly is met
with, it is usually stated, as in J. B. Luce's case (These, Paris, 1879),
that the infant is hairless at Ijirth, and remains so for months or even
j'ears, but that ultimately a certain degree of hairmess is attained.
P. de Molenes (Aim. de deriiuxt. ct sypk, 3 s., i. 548, 1890) also re-
ported a case in which at birth there were only a few downy hairs on
the scalp and a few eyelashes ; some years pre^■iously the mother had
suffered from alopecia, and she had given birth to another child who
had developed alopecia of the scalp some time after birth ; the present
child, a female, had normal nails, and the first dentition ju-ogressed in
the usual manner ; under treatment, hair began to appear at the age
of four years. The author regarded the alopecia as a trophoneurosis,
and from the standiwint of Antenatal Pathology we may look upon
such cases as instances of delayed sprouting of the hair. In another
group of cases the congenital alopecia persists throughout life. This
was apparently the condition of afl'airs in M. Schedc's two ])atients, a
brother and a sister (Air/i.f. klin. C/iir., xiv. 158, 1S72), who.se heads
were as smooth as a billiard-ball (" wie eine Billardkugel ") ; hair
CONGENITAL ALOPECIA 327
rudiments were found only in the deep layers of the cutis. Possiljly
this was also the case in the Australian hairless individuals (brother
and sister) described by N. iliklucho-Maclay {Vcrhandl. d. Berlin.
Gesellsch. f. Anthrop., p. 143, 1881). In yet another group of cases
the alopecia is associated witli defective dentition and nail-formation
(J. Thuruam, Mcd.-Chir. Trans. Lond., xxxi. 71, 1848). Several
instances of this type are referred to by E. Bonnet {Uhcr Hypo-
trichdsis congenita universalis, Wiesbaden, 1892), who also mentions
examples in the lower animals. It would appear to be transmitted
by heredity (J. Hutchinson, Arch. Surf/., ii. 253, 1891). Perspiration
may also be entirely absent.
It is quite evident that coiij^enital alopecia is an arrested develop-
ment, and its association with defective formation of the nails and
teeth emphasises and confirms this conclusion. Evidently the arrest
may neither be complete nor permanent, and in this manner are pro-
duced the -various types which have been described above. Treat-
ment with stimidating applications and perhaps thyroid extract
ought, therefore, to be persisted in, for it maj" be ultimately rewarded
b}* success. Antisyphilitic treatment ought also to be tried, as
alopecia may he due to syphilis.
Like hypertrichosis, alopecia is a malformation rather than a
disease ; and with it as with hypertrichosis the question at once arises
if it can at all be regarded as idiopathic, since it seems in some cases
to be hereditarily transmitted and to sliow family prevalence. I do
not attempt to justify the inclusion of these two morbid states in the
group of the idiopathic diseases of the fcetus ; but I repeat that I
regard the group as a convenience rather than as an expression of
strict classification. Further, there are many cases in which no
heredity can be traced.
Antenatal Pemphigus.
In 1891, Bar (Arch, de tocoL, xviii. 953, 1891) met with a case of
pemphigus in an infant at birth ; there were also patches of denuded
skin on the scalp, and he suggested that in some instances the
hairless areas of alopecia might be looked upon as the final stage in
the development of the bulla; of pemphigus. Wliether this supposi-
tion prove to be right or wrong, there can be no doubt that in certain
eases pemphigus affects the foetus. I have already (p. 74) referred
to the occurrence of pemphigus in the new-born infant, in whom it
may be due to syphilis or to some septic or infectious condition ; but
there are also instances in which the child is liorn with a strongly
marked and often a transmitted tendency to form bullffi on the slightest
provocation, e.g., a slight blow. In these cases the tendencj' is
doubtless present in antenatal life, although sometimes no bullous
formations are noticed till the second week of life. It has been
proposed to separate this morbid tendency from ordinary pemphigus
neonatorum, to call it " congenital traumatic pemphigus," or to give
to it such names as " epidermolysis bullosa," " congenital bullous
dermatitis," and " hereditary dermatitis bullosa " ; further, attempts
328 ANTENATAL PATHOLOGY AND HYGIKNK
have also been made to separate two sub-varieties, under the designa-
tions of " bullous dermatosis " and " epidermolysis bullosa " ; but
it is generally agreed that in the present state of our knowledge
dermatologists are not warranted in making these distinctions.
There is in all the cases a constant tendency to form YmWx (con-
taining blood or serum) after the most insignificant traumatism : this
tendency is noted at or very soon after birth ; the general health is
unaffected ; sometimes the malady tends to disappear, sometimes it
is accompanied by the formation of epidermic cysts ; and often there
is a distinct history of heredity and family prevalence. The nails
are often defective. A ccmsiderable number of articles have appeared
dealing with this disease, among which I may mention those of
Tilbury Fox (Lancet, i. for 1879, p. 776), A. Goldscheider {Monatsh.
f. frald. Dermat., i. 163, 1882), A. Valentin {Bni. /din. Wchnschr.,
xxii. 150, 1885), Max Joseph {Monatsh. f. praJd. Dermat., v. 5, 1886),
Carl Blumer {Dissert., Ziirich, 1892), H. Hallopeau {Ann. de dermat.
et syph., 3 s., vii. 453, 1890), M. V. Augagneur {ihid., viii. 665, 1897),
Wallace Beatty {Brit. Journ. Dermat., ix. 301, 1897), T. Colcott Fox
{ibid., ix. 341, 1897), and John T. Bowen {Journ. Cutan. Gen.-Urin.
Dis., xvi. 253, 1898). Little is known of the pathology of the
aflection, and much less of its pathogenesis ; to describe it as an
angiotic acantholysis does not add much to our knowledge of its
exact nature. TJie antenatal factor, however, is an important one,
and possibly when the mechanism of neonatal desquamation is lietter
understood, so will also that of hereditary bullous formation. Blumer
{op. cit.) compared the disease with haemophilia: both maladies are
congenital and inherited, and due to a defective formation of the
blood vessels which may 1)e termed " dysplasia vasorum " ; in
hfemophilia bleeding occurs, in epidermolysis exudation. According
to Wallace Beatty {loc. cit.), who.se paper contains many bibliographical
references, the bulhe may form either in the stratum corneum or
may involve the rete mucosum also. Drugs or other treatment
have hitherto been powerless to influence the progress of the disease,
but chloride of calcium might be tried autenatally as well as
postnatally.
Congenital Absence of Skin.
In Marcli 1859, W. 0. Priestley {Trans. Obst. Soc. land., i. 60,
1860) exhibited a drawing taken from the head of a new-born child,
which showed a curious " circular wound " of antenatal origin. It
was quite circular, was as large as a shilling, and was situated
directly over the posterior fontanelle. It seemed as if " a piece of the
scalp had lieen jiunched out by a circular instrument." The process
of repair liail begun, the edges of the wound were still sharply
defined, and its floor was formed by the pericranium with its supjily
of delicate capillaries. The cranial bones were entire and of their
usual form. The child was well formed, there were no skin eruptions,
and a profusion of dark hair covered the head except in the above-
mentioned circular patch. There was no history of syphilis, and the
CONGENITAL ABSENCE OF SKIN 329
labour (the mother's third) had been comparatively easy. In 1880,
Hans von Hebra {Mitth. a. d. embryol. Inst. d. k. k. Univ. in Wien., ii.
85, 1880-83) described a somewhat similar case, in which the
cutaneous defect was also on the scalp but was bilateral and had a
more elongated and irregular form. These patches, reaching from
the outer angle of the eye outwards and upwards, had a reddish-
yellow colour and carried no hairs ; they were thus easily distinguish-
able from the surrounding scalp, which was covered with long hairs.
The parents were healthy and the labour had been normal. The
bones of the head showed no defects, and there were no signs of
pemphigus or any other skin disease. The child died when five
days old from peritonitis. The microscopical appearances showed a
real defect in the development of all the layers of the epidermis and
of the associated glands, fat, and hairs ; the surrounding normal skin
was sharply marked off from the defect. In neither of these cases
were details regarding the placenta and membranes given. A third
case resembling those already described was put on record in 1894
by V. W. Matthes {Dissert., Marburg).
An earlier observation than any of these, seems, however, to have
been that of W. Campbell of Edinburgh {Edin. Jo^irn. of Med. Sc,
ii, 82, 1826) who, under the title of " Congenite Ulcer on the Cranium
of a Fetus," described a case in which there was an area without skin
about the size of a crown-piece situated between the bregma and the
posterior fontanelle ; bleeding from this denuded area took place,
proving fatal, on the eighteenth day of life. Curiously enough, the
mother of this child in her next pregnancy gave birth to another
infant with a similar spot on the scalp, but in this instance cicatrisa-
tion had begun in utero. The labour was easy and natural.
These cutaneous defects, however, are not always localised on the
scalp, for Hochstetter {Charift'-Ann., Jahrg. xix. 542, 1894) met
with the case of a full-time male foetus with patches on each side of
the abdomen, a little above the level of the umbilicus ; these were
somewhat triangular scars which had been bright red at birth ; there
was club-foot on the left side ; and the placenta and membranes were
said to be normal. Other cases were that i-eported by B. S. Schultze
(Ztschr. f. Gehurtsh. u. Gyndk., xxxi. 225, 1895), in which there was
also paralysis of the right facial nerve and contracture of the right
sternomastoid muscle; that seen by Hugo Goldberger (Centralbl. f.
Gyndk., xx. 784, 1896), in which the infant was one of twins, the
other twin being a foetus papyraceus ; and that recorded by F.
Ahlfeld (Erne neuc typische Form dnrcli amniotische Fdden hervonjc-
hrachter Verhildung, Wien, 1894), who regarded the defect as due
to the tearing through of an amniotic adhesion. Ahlfeld referred
also to cases by Dohrn [Ztschr. f. Gehurtsh. u. Gyndk., xiv. 366, 1888)
and R. von Braun {Ccntratbl. f. Gyndk., xviii. 73, 1894), in the
latter of which the cutaneous defect was situated on the knees.
In some instances the skin defect was associated with other
malformations, e.g. Polydactyly, and this fact seemed to Ahlfeld to
support his theory of the amniotic origin of these denuded areas.
We must imagine the existence of a tubular adhesion between the
330 AN rKNATAI, I'ATHOLOdY AND IIY(;IF.NK
amnion ;uul the skin surface; if this is turn across near the skin,
the resulting,' alisence of tlie superticial layers of tlie inte<,nnncnt will
be produced. The whole question of amniotic iniiuence will recjuire
consideration under the headinj^ of Teratogenesis, but in the mean-
time it may be noted that the recorded absence of any gross altera-
tions in the jilaceuta and membranes does not exclude the possibility
of the existence of amniotic adhesions. At first, the anniion is in
contact with the surface of the eudjryo in its whole extent ; normally
it separates everywhere from it as the liquor amnii is secreted ; but,
inider some circumstances, this separation docs not take place per-
fectly, and the attached amnion is drawn out into a band, a so-called
amniotic adhesion. The tearing across of this " adhesion " would
give rise to a raw area if the tear be close to the skin. If, on the
other hand, the tearing across be at some distance from the skin, the
result may be a small projection which might be called an amniotic
appendage or j)erhaps an amnioma. In a case reported by J.
Dalston Jones (Trans. Mrd.-L'hir. Soc. Land., 2 s., xiv. ]i. 59, 18-49), a
cutaneous defect and a nipple-like projection existed side by side.
Such an appendage or nip]ile-like process was, I believe, the congenital
growth which I described some years ago as an acanthoma of the
hairy scalp (98). With its description I may close this chapter on
Tcetal Diseases of the Skin.
Acanthoma or Amnioma of the Skin.
In October 1896, one of my midwifery students at the Western
Dispensary, Edinburgh, informed me that he had been mnch puzzled
to make out the fcetal presentation in a case of labour attended by
him on the previous day. His first diagnosis of a vertex presenta-
tion had been weakened by the detection of a finger-like projection
attached to the presenting part. He was not long in dinibt, however,
for the labour terminated speedily and naturally ; it was then seen
that the vertex certainly had presented, l)ut that tliere was also a
congenital growth attached thereto, and it was this that had sinm-
lated the presence of a finger. It may be said that the infant, a girl,
was the ninth child of a healthy mother, aged 34 years. There were
eight brothers and sisters, some of whom were rachitic, and all the
nine children had been born within twehe j'ears. The present preg-
nancy had been quite uneventful; even the ubiquitous and popularly
omnipotent maternal imjuessiou was wanting. The chilil showed no
other malformations, and there was no family history of deformity.
The tumour showed some tendency to wither; but in three weeks I
excised it, as the mother was most anxious that the deformity result-
ing from its presence should be removed. One small artery spouted
as the base of the growth was being cut through, but two stitches
controlled the ha'morrhage, and the wound healed rapidly.
Attached to the right side of the vertex of the child's head, about
half an inch from the line of the sagittal suture, and nearly midway
between the anterior and posterior fontanclle, was the tinger-like
growth. It will save many words of description if I simply state that
ACANTHOMA OR AMNIOMA 331
it very closely resembled the infant's thumli, both in size and shape.
Of course, however, it carried no nail. It stood out from the sm-round-
ing hairy scalp on account of its being covered by a delicate pink and
hairless skin, and a slight constriction about its middle was clearly
visible (Fig. 45).
At its base of attachment the surrounding skin was slightly
irregular and thickened. • It usually lay flat against the head, but it
could be placed vertically, and, indeed, was freely movable. It had
evidently no connection with the underlying bone or with a suture.
No hard rod could be felt in it, and in fact it had almost the con-
sistence of a lipoma, which at first it was thought to be. At the
same time I was struck by the resemblance it bore to a preauricular
appendage which I met with and removed some time ago. It was
therefore with considerable interest tliat I looked forward to its
microscopic investigation. It may be noted that the skin of the
scalp was normal, and was well supplied with dark hair.
The growth was embedded in paraffin, and horizontal sections
were cut in the usual way. The characteristic appearances are
exhibited in Fig. 46. The most striking feature is the marked
development of the prickle-cell layer of the epidermis, without the
least indication of a coincident increase of the stratum corueum.
There is, therefore, hyperacanthosis without hyperkeratosis.
Another interesting character is the presence of sebaceous glands
in every stage of development, from the simple slight downgrowth of
the epithelium to the fully elaborated gland, and .showing all the
stages between the undifferentiated cell of the epithelium and the
highly specialised cell of the gland. Nevertheless no hairs were to
be seen in any of the sections examined. There is no adipose tissue
3;12 ANTENATAL PATHOLOGY AND HYOIENE
Id 1)C noted, and the corium presents no striking alterations ; here
and there traces of sudoripai-ous glands were visible, but no spiral
ducts were observed. At certain places, and especially near the
terminations of the sebaceous glands, open spaces were noticeable,
l)ut I am inclined to regard these as artificially produced during pre-
paration for histological examination. Finally, there was no central
rod of cartilage, and the vascularity of the tumour was little marked ;
there was no pigmentation.
The congenital growth in this case consisted, as has been shown,
of skin; but it has to be noted that in certain particulars the skin
was in an imperfectly developed state. There were no hairs, although
the tumour took its origin from a scalp well supplied with hair ; the
sweat glands were only represented by traces ; the sebaceous glands
were present in every stage from the most rudimentary to the fully
formed ; and there was a total absence of adipose tissue in tlie sub-
cutaneous layer. The outstanding feature was the hyperplasia of the
prickle-cell layer. The first impression gained from the study of the
histology of the growth was that here we had to do w'ith tissues
which had fallen behind in the general development of the body.
The second notion was that some source of irritation must also have
been in action, for, as Dr. Allan Jamieson (wlio was kind enough to
examine the sections witli me, and advise me thereupon) pointeil out,
the appearances, especially in the Malpighian layer, closely resembled
those seen in some forms of chronic eczema. These ideas, along with
a similarity in tlie appeai-ance and history of the growth, led me to
e.Kamine again a preauricular ap})endage wliich I removed in 1894
from a boy, 12 years of age. Although smaller in size, it resembled
ACANTHOMA OR AMNIOMA 333
in appearance, consistence, and clinical history the tumour now under
consideration. In its histology it showed a similar imperfectly
developed condition of the subcutaneous parts, with, however, a more
mature epidermis and epidermic appendages ; but then, of course, it
must be remembered that it had been attached for twelve years to
the patient's face. A plate representing the microscopical appear-
ances of this preauricular growth accompanied the paper in which I
recorded its history and inquired into its mode of origin (75).
It seems to me that it is a probable explanation of the origin of
both these nipple-like processes, to regard them as due to delayed
separation of the amnion from the body surface, resulting in a draw-
ing out of the underlying parts in the form of a small projection.
The structure of the projection will depend upon the nature of the
underlying parts : if they contain cartilage, so proliably will the
projection ; if they are simply made up of incompletely developed
skin, then that will be the chief constituent of the projection.
At the time wiien I published the above ca.se, I called it
interrogatively an acanthoma on account of the hyperplasia of the
prickle-cell layer ; but that term scarcely conveys to the mind the
idea of immaturity in the elements of the skin, which is, I believe, so
important a character of the appendage. To call it an amnioma is of
course to take for granted its amniotic origin, and it cannot be
definitely proved that such is its origin. Nevertheless, I have placed
the observation here, at the end of this chapter on the Foetal Skin
Diseases, to suggest to otiiers the need for tlie investigation of all
such appendages and so-called amniotic adhesions.
It will have become evident to the reader, if he has carefully con-
sidered the types described in this chapter, that foetal skin diseases lie
on the border line between diseases and malformations. He will be
prepared to admit that .several of them would be miich more correctly
named malformations (even " monstrosities ") than diseases. From
the scientific standpoint also many of them fall into the category of
malformations, for they represent delayed or disturbed formation of
the skin or of parts of it. This is one of the chief reasons (if it be
not the chief) why foetal skin diseases differ so widely in their
characters from postnatal cutaneous affections. That they arise in
the foetal period and yet are malformations is, I need hardly say, due
to the fact that till ipiite the end of the fcetal epoch of antenatal hfe
the skin has not completed its development ; it is still in the
embryonic or formative stage when most of the other tissues have
passed out of that into the stage of growth and active functional life.
But this projection of embryonic into foetal life has been already
(c. pp. 93, 97, 98) discussed, and need not be further referred to. I
may close this chapter with the reflection, which is a most obvious
one, that in the future the dermatologist and the obstetrician must
work more into each other's hands, if progress is to be made in the
study of the pathology and pathogenesis of " congenital skins." Let
a fresh advance be made, then, and by the help of such an obstetrico-
dermatological alliance let progress be accomplished in this direction.
Renovate animos !
CHAPTEE XIX
Types of Idiopathic Diseases of tlie Futus (cont.) : Diseases of the Bones :
Nomenclature ; Classification ; Type A, Characters ; Type B, Characters ;
Type C, Characters ; Type 1), Kxternal Ai>pearances", Clinical History,
Pathology, Pathogenesis ; Type E, Characters ; Bibliography.
Diseases of the Fcetal Skeleton.
To describe with any pretence to clearness and exactness the morbid
conditions of the fcetal bones, is an impossibihty at the present time.
The skeleton at birth is still partly in the embryonic or formative
stage, and diseases and malformations of its constituent ])arts are
associated together in a manner which proves disconcerting to the
pathologist, and altogether fatal to the liest hopes of the nosologist.
Notwithstanding tiie accumulation of many observations of congenital
bone disease, and notwithstanding their investigation by eminently
competent observers, it is still preferalile to avoid any classification
of them. Possibly it would be well to do here as I have done else-
where (8), and group them together under the one comprehensive
title of " osteogenesis imperfecta " ; at the same time it is only fair to
indicate some of the types which have been marked ofl' and described
I)y various workers in this most difficult department of antenatal
pathology.
Before doing so, however, let me point out that the fu_'tal bone
diseases are grouped with the idiopathic maladies simply for con-
venience, and not because it is certain that they always arise, as it
were, spontaneously in the fojtus. They are not, as has been said
already, always diseases, they are sometimes malformations in the
correct sense of the word : neither are they always idiopatlnc, they
are sometimes transmitted in the widest sense nf the word. Some
proofs of this latter statement may here be furnished. I'orak {De
I'achondroplasie, Clermont, 1890), for instance, records a case of the
disease known as achondroplasia, in which both mother and foetus
showed the same anomaly of tiie skeleton. Further, G. Boeckh
(Arch./. Gi/nack., xlin. 363, 1893) gives in detail the family liistory
of an achondroplasic woman, who.se sister, niece, father, and great-
great-grandfather were all afl'ected with the same condition of
dwarfism. It has occasionally been found that other kinds of
antenatal bone diseases show this transmission from ascendants to
descendants. It would seem, however, to be a rare occurrence.
Still more interesting are the results of some experiments by Cliarrin
and Gley {Compt. rend. Soc. dc biol., 10 s., ii. 705, 1895 ; iii. 220, 1031,
I Ul VERSITV I
FCETAL BONE DISEASES 335
1896); these observers succeeded, by inoculation of the parent
animals with the toxins of diphtheria, tubercle, and blue pus, in pro-
ducing some young ones with deformities of the hind limbs resembling
the condition known as " fcetal rickets " in the human subject. The
animals experimented upon were rabbits, and the males alone were
inoculated with the pyocyanic toxin.
Nomenclature.
Many pathologists and not a few obstetricians have written on
the subject of foetal rickets. As a general rule, those who have
written with an experience based upon the examination or dissection
of one case or specimen have not succeeded in clearing up, to any
appreciable extent, the obscurity that surrounds the whole subject ;
their contributions are often of great value as records of individual
cases, generally very fully described, but suggest little that is helpful
to an understanding of the large problem of the relation of antenatal
bone diseases to each other. Those who, like E. Kaufmann ( Unter-
suchungoi ucher die soffcnannte fcetalc Rachitis, Berlin, 1892), have
been fortunate enough to be able to study a series of specimens, have
done more to elucidate the whole subject ; but even they have had
the greatest difficulty with tlie nomenclature of fcetal bone diseases.
Many names have been given and much confusion has reigned, for
one observer, finding that his case did not exactly resemble one
previously reported by another observer, has either coined a new
name altogether, or has added a qualifying adjective to the original
designation. A third observer, finding his specimen to be dissimilar
to that of the second, gave to it yet another name ; and perhaps a
fourth might have a case which was really an exact reproduction of
the first of the series, and yet he might coin still another term for it,
not being aware of the connecting links. In this way, or in some
other yet more complicated way, the terminology of fatal bone
diseases has become almost hopelessly confused, and out of this con-
fusion have come the names, fietal rickets, so-called fcetal rickets,
intrauterine rickets, micromelic rickets, annular rickets, chondritis
foelalis, pseudo-chondritis, osteogenesis imperfecta, achondroplasia,
chondrodf/^troph iafii talis, chondromalacic micromcly, congenital cretin-
ism, cniiiiiiid i/i/a/j/iisiii, ostedjHirosis, ostcopsathj/rosis, periosteal aplasia
with osteojjsuthyivsis, dc/celifc endochondral ossification, and rachitis
cowjenita. So great is the confusion that has arisen, that I am not
using exaggerated language when I maintain that it would be better
if all the names were abolished, and a series of types, named A, B,
and C, instituted in their place. For a careful study of the literature,
and especially an inspection of the accompanying illustrations, shows
beyond a doubt that the same name has been given to different
pathological and clinical conditions, and different names to the same.
" Foetal rickets " is a most glaring example of this, and it, at any rate,
must, I am convinced, be abandoned henceforth ; " achondroplasia " is
another instance, although, perhaps, it may be retained for its con-
ciseness, and perhaps, also, for its indefiniteness (!).
33G ANTENATAL PATHOLOGY AND HYGIENE
Classification.
We have not yet reached the time when a scientific classitication
of foetal bone diseases on patliological lines is possible ; it is not yet
clear, even, whether the various morbid conditions met with in the
skeleton at tlie time of birth are different diseases or simply (HlVerent
stages in the same disease. If any name whatever is to l)e given to
all the foetal b(jne diseases as a group, it might be preferably " osteo-
genesis imperfecta," the denomination introduced hy Yrolik (Tabu Ice
ad illusirandam Emhryoficncsin, Tab. xci. Amsterdam, 1849) in 1849,
and used recently by H. Stilling (Arch. /. jmtk. Anat., c.w. 357,
1889), and others. If this were done, then under this single name
would be assembled cases in which the defect was in the endochondral
ossification (J. Symington and H. A. Thomson, Proc. R. Soc. Edinh.,
xviii. 271, 1891), others in which it attected the periosteal (S. Mtiller,
Milnchcn. vied. Abhandl., 2 E., Heft 7, 1893), and others in which
there was apparent excess in formation of some parts of the skeleton
(J. W. Ballautyne, Edhih. Med. Jonrn., xxxv. 1111, 1890). Kauf-
mann, in his large monograph {op. cit.), employed the general term
" chondrodystrophia foetalis," and grouped under it four varieties
of altered growth of cartilage: (1) a softening of it, constituting
chondrodystrophia malacica ; (2) an arrestment of its growth,
chondrodystrophia h3'poplastica ; (3) a growth unaccompanied by
increase in length of the bones ; and (4) an active but entirely
iri'Cgular growth of it, chondrodystropliia hyperplastiea. I believe it
will eventually l)e found to be possible to group the foetal bone
diseases in classes according to the period in antenatal life when they
were developed ; at the one end of this series might be the changes
in the bones which occur at the close of the intrauterine life, and
which resemble infantile rickets; at the other end would be the
changes which are evidently teratological, and which are doubtless
initiated in the embryonic epoch ; while in the middle would be a
number of cases in which could be traced some resemblances to
infantile rickets along with alterations which could only be regarded
as malformations or deformities. In the meantime, and for lack of
knowledge, I propose to describe certain types under the headings of
Type A, Type B, etc. : this plan may be unsatisfactory, but at least it
avoids the coining of new names, and the alteration of the meaning
of old ones.
FcEtal Bone Disease (Type A).
It will be convenient to take, as Type A, that form of foetal bone
disease which there is some reason to regard as rickets. It resembles
as closely the form of rickets which develops in the second year of
life, as any antenatal disease can resemble any postnatal one; for,
as has been pointed out already several times, the intrauterine
environment must modify the manifestations of disease occurring
before birth, and produce in it characters dissimilar to those develoji-
ing after birth. If I were to adopt any special name for tliis disease,
it should be " congenital rickets," but I simply denominate it Type A.
FCETAL BONE DISEASE 337
Tlie characters are due to abnormal softness of the bones, and are to
be recognised in a state of craniotabes (often very marked), and
in considerable curving and shortening of the long bones. The
disease cannot be diagnosed by simple inspection of the infant, but
requires palpation and careful mensuration. I believe that some-
times the only evidence of the disease is to be found in the state of
the cranial bones, although I admit that if this conclusion be accepted
it becomes very difficult to separate these cases from syphilis. In
1899, Dr. Jas. 11. Watson of Hamilton sent to me for examination
a male infant, six weeks old, who showed very marked imperfect
ossification of the cranial bones. In fact, the cranial vault felt as if
composed of a number of Wormian bones. The history of the case
was interesting. The motlier, age 27, 1-para, had suffered greatly
from vomiting in the last two months of pregnancy, and had been
very weak at the time of her confinement. She had internal
strabismiis of the right eye. The labour was characterised by almost
complete uterine inertia ; Dr. Watson delivered by means of forceps ;
and there was some third stage hiemorrhage. The craniotabetic
condition of the infant was recognised during the labour, and it was
quite marked at the time of birth ; it had not got any worse, in fact
there had been some hardening up of the bones at the time when I
saw the child. There was no hydrocephalic enlargement, and the
occipito-frontal circumference measured 151- inches. The occipital
protuberance was very prominent, and the palate had a high arch
anteriorly. The hands and feet were well formed. There was some
snuffling during suckling, but no history of syphilis was elicited (I
interviewed both parents). I am inclined to regard this case as an
example of Type A. It is an interesting fact that on account of the
vomiting the mother should have been so ill nourished at the close
of her pregnancy. At the present time (November 1901) the cranial
bones are ossified, but the fontanelles still remain open, but sliow
signs of closing. The child has developed a squint resembling that
in the mother. The intelligence is very good.
If we regard this case and others resembling it as examples of
rickets present at birth and developing during the last trimester of
pregnancy, then the question of frequency arises. In respect to
this matter the greatest divergence of opinion would appear to exist.
According to F. Scliwarz {Med. JaJirl., Wien, n. F., ii. 495, 1887), of
500 new-born infants at the Second Vienna Obstetric Clinic, 80'6
per cent, showed rachitic changes in the skull or in the ribs, or in
both skull and ribs ; the mothers had nearly all been under bad
hygienic conditions during pregnancy. According to F. Fede and
E. Cacace {Pediatria, viii. 41, 1900), on the other hand, congenital
rickets is comparatively rare. These observers made a series of very
careful measurements of the length of the body and of the cranial and
thoracic circumferences in 500 new-born infants in Italy. They
employed a special measuring instrument or brefomacrometer ; and
they made observations, also, on the sutures and fontanelles. Only
one case out of the five hundred showed all the clinical features of
rickets, and only four others exhibited craniotabes. Even if the
338
ANTENATAL I'ATIIOLOCIY AND HYCIKNK
cases of craniotabes be admitted as rachitic, it follows lliiit only in
one per cent, of infants born in maternity practice is there evidence
of congenital rickets. Irregnlaritie.s in the sutures and foulanelles
were frequent ; but Fede and Cacacc did not regard these as signs of
incipient rickets, liut as evidence of a retarded development. So far
as my own experience goes, it agi-ees with the estimate made by
Fede and Cacace ratlier ti)an witli that furnishcil liy Schwarz.
Foetal Bone Disease (Type B).
As an example of Type B, I take the specimen of bone disease
sent to me by Ur. Samuel Davidson (Fig. 47) in 189o. The foetus
*;
was the result of the seventh pregnancy of a woman, age thirty-two,
who had enjoyed good health, but who had been married when only
fifteen years old. All her pregnancies had gone to the full term, all
the infants had been born alive, and all had been fed at the breast.
One child had died at thirteen months from " convulsions," and one
at one month from " bowel-hives." During the pregnancy which
ended in the birth of the diseased foetus, the mother had suilered
more from vomiting than on any other occasion, and had not felt
FCKTAL BOXE DISEASE 339
fcetal movements so strongly. There was hydramnios; the infant
was dead when born, but must have died during delivery, as foetal
movements were felt at the beginning of the labour. Tlie umbilical
cord was only a foot in length. There was partial placenta pnuxia,
which caused considerable haemorrhage during labour, and was
probably the cause oi the infant's death. The father was a healthy
man, but much addicted to the use of alcohol in e.xcess. There was
no family history of bone disease. The fcetus, a female, weighed
2160 grms., and its length with the lower limbs in the position seen
in Fig. 47 was 38 cms. ; the distance from finger-tip to finger-tip
with the arms extended was 32 cms. The occipito-frontal circum-
ference of the head was 33 cms., and the occipito-mental, 37 cms.
It was evident at a glance that the infant was abnormal. The lower
limbs were fixed in an unnatural position ; the thighs were sharply
abducted and passed outwards almost at right angles to the pelvis,
the legs were partly flexed, and showed a marked concavity on the
inner aspect, and the feet were turned sharply inwards. Both the
lower and upper extremities seemed slightly shorter than is normal,
and on both there seemed to be some deepening of the natural
flexures. The head was broader than usual, and the nose short and
somewhat flattened, with a depressed bridge ; the eyelids were thick,
and the cheeks prominent ; there was a very evident double chin.
The abdomen was prominent ; and the whole body had a plump
appearance, due to the presence of a tliick layer of subcutaneous
tissue. Palpation revealed a soft and imperfectly ossified cranium ;
the limbs could be moved with ditticulty, and when this was done a
creaking semsation was felt at all the joints. During manipulation
the femora were fractured, indicating the presence of fragility.
A frozen section of the fcetus was made, and the appearances
found are represented in Plate XL The bladder contained more
than 60 c.c. of non-albuminous urine, and the stomach (not seen
m Plate XL, which shows only the right side of the body) was
distended with over 200 c.c. of albuminous fluid (liquor amnii ?).
The section may be usefully compared with that shown in Fig. 17
(p. 102). The thinness of the bones of the cranial vault is to be
noted, as is also the normal ossification of the basis cranii. There
was absolutely no indication of hydrocephalus, a fact which lateral
sections demonstrated more clearly than this mesial one. The
internal organs, including the thyroid and thymus, had their normal
appearances and relations. A plug of mucus (!) was seen blocking
the larynx and upper part of the trachea. The ossification of the
stermun was not far advanced ; and although there was the normal
number of vertebra?, some of those in the dorsal region were evidently
defective. The spinal column exhibited the usual antero-posterior
cm'ves seen at this age ; but there were some lateral bends in the
dorsal region which are pathological. The conclusion to be drawn
from a study of the sectional appearances is, that save in the ossifi-
cation of the sternum, the cranial vault, and the vertebrae, there is
nothing abnormal in the anatomy of the head and trunk. The limbs,
however, were obviously abnormal, for in addition to their curvature
340 ANTENATAL l'ATH()I.()C;Y AM) IIYCIKNE
and to the fragility of the bones, there was some actual shorten-
ing, each arm measuring 14 cms., and each leg 1?> cms., in a stretched
out position. The length of tlie trunk and head from vertex to
perineum was SS'u cms. There was no marked epipiiysial enlarge-
ment of the long bones. The fraetm-es were situated about the
middle of the shafts, and were not " green-stick " in ciiaracter.
It may be asked whether this ca.se and those that rcsemlile it are
instances of rickets or of some other malady, and I think the answer
must be that it is quite ]iossil)le that this malady is rickets. I'erliajis,
also, it may l)e regarded as rickets beginning at an earlier dale in
intrauterine life than in Type A. If, however, any separate name
is to be given to it, tlien the term "osteogenesis imperfecta" woidd
be not unsuitable. rossil>ly several of the many cases collected
together by J. P. Crozer Griffith (Amcr. Jonrn. Med. Sc, cxiii. 42G,
1897), under the name idiojiathic osteopsathyrosis, may have been
examples of Type B. Vrolik's case {loc. cit.) seems to have lieen
an instance of it, as were also proljablv those of G. Barling {Birmiiui-
ham Med. En:, xxxi. 107, 1892), Poraki {op. cit., p. 11), B. 0. :\Iason
{Arch. Pediat., xi. 670, 1894), C. W. Townsend {ibid., xi. 761, 1894),
and many others. Connecting links between instances of Type A
and Type B exist ; they have not all the characters of B, while
they have more than the characters of A. The reader who is
specially interested in fcetal bone diseases may also study with
profit H. Stilling's article {Arch. f. path. Anat., cxv. 357, 1889)
and H. Hildebrandt's {ihid., clviii. 426, 1899).
Fcetal Bone Disease (Type C).
As an instance of Type C, I take the case published by me in 1889
(36). It was a specimen kindly lent to me for examination l)y Sir
William Turner, to whom it had been .sent, without clinical notes or
sender's name, from the Isle of Man. Tlie external appearances are
represented in Figs. 48 and 49.
These drawings represent in a very faithful manner the pecuHar and
characteristic features which the specimen showed. The limbs are curiously
contorted, and nodular swellings mark the position of the shoulder, elbow,
wrist, hip, knee, and ankle joints. In the position of the coccyx is a tail-
like projection. The fingers and toes are long, and are widely separated
from each other. The head a]ipcars to be large in comparison with the
body, the upper jaw is somewhat prominent, and the occipital region is
flattened. There is on the face a peculiar senile look, quite foreign to the
expression of the healthy new-born infant. The nndiilical cord is seen to
be attached to the abdomen, and shows no signs of having been tieil. The
attitude in which the foetus lies is characteristic, and is most probably
approximately that which it occupied in utcro. The head is flexed ui)on
the sternum, the arms are foliled upon tlie chest, and the legs are flexed
and curiously interlocked. The thorax is expanded at its base, and is
narrow from side to side anteriorly. These are the appearani'es shown in
the first drawing (Eig. 48) ; the second (Fig. 49) shows the peculiar
' Poiak's first case, liore rcfi-rrcd to, does not seem to liavr lutii an instance of tim-
achoudroplasia, but of Type B.
FCETAL BONE DISEASE
341
deformities of tlie legs and the curious appearance of the external genitals
and perineum. The swollen knee and ankle joints are very evident, as is
"' ' "i&^
also the projection in the neighhourliood of the coccyx. A penis is present,
but the scrotum is quite collapsed, and does not appear as if it contained
testicles. A median raphe stretches from the root of the penis to the anus,
342
ANTKXATAI. I'ATIIOI.OCJY AND HYCIENK
and the anal aiicrture is situated inuiiediately in front of tlie coccygeal
projection.
Such were the outstanding features wliich tliis specimen presented
to the eye ; the following additional characters became evident on closer
examination. There was inimohility of the limbs at the variou.s joints, and
the right thigh was found on palpation to be fractured. So firmly fixed
were the joints, that an attempt to move, the arm at the shouhler resulted in
the separation (jf the shaft nf the Immerus from the head of the bone. It
was also found that the vertebral column was rigidly fixed in a position of
flexion. The lower end of the sternum was tilted sharjily forwards, and
through the skin the extremely contorted form of the scapule could be
distinctly felt. The total length of the foetus was 47 cms. (18J inches),
and the length of the head and ti'unk from the vertex to the tip of the
coccygeal projectiim was 3-5"6 cms. (14 inches). The circumference of the
body at the level of the ensiform cartilage was 23 cms., and at the level of
the umbilicus 21*7 cms.
The head measurements were as follows : —
Diameter occipito-mentalis . . . = 11-.5 cms.
Diameter occipito-frontalis . . . = 10'2 „
Diameter suboccipito-bregmatica . . = 8'9 ,,
Diameter biparietalis . . . . = 8-9 ,,
Diameter bitemporalis . . . . = Vw ,,
The anterior fontanelle measured 5'1 cms. iu an antero-posterior, and
3 '8 cms. in a transverse direction. These measurements show that the
head, far from being hydrocephalic, is rather below the average size as
compared with the heads of healthy new-born infants of the same length as
this foetus. The anterior fontanelle is, however, much larger than is
normal, and the sutures are wider than they are in healthy infants. The
parietal eminences and the occipital protuberance were well marked, and
the whole head had, as viewed from above, a somewhat polygonal outline.
The thorax had an antero-posterior diameter of 5-1 cms. superiorly, of
7"6 cms. inferiorly, and of 6'4 cms. at the level of the middle of the
sternum. The transverse diameter of the chest at the level of the fifth rib
was 5'1 cms. The swollen condition of the anterior ends of the ribs could
be felt through the skin.
The measurements of the limbs were as follows : —
Circumference of the arm above the elbow = 6-0 cms.
Circumference of the arm at the elbow . = 8'7 „
Circumference of the arm below the elbow = 6'0 „
Circumference of the leg below the knee . = 5'1 ,,
Circumference of the leg at the knee . = ll'O ,,
The circumference of the leg at the knee was therefore more than
twice that below the knee ; and in the case of the arm the circvnnference at
the elbow was half as great again as the measurement below or above that
joint. These figures demonstrate very clearly the enormously swnllen con-
dition of the joints of the limbs.
The alxlomen of the foetus was opened, and there was found in the
peritoneal cavity a small (piantity of serous fluitl ; but there was no glueing
together of the intestines or other sign of infiammation. The testicles,
which ha(i not descended into the scrotum, were found lying, one on each
side, in front of the psoas muscle a little above the plane of the pelvic brim.
The liver, spleen, and kidneys had a normal appearance, and the stomach
FCETAL BONE DISEASE 343
was empty and collapsed. In the thorax the lungs were found in an
une xpanded condition lying posteriorly to the heart, and in the latter organ
the foramen ovale was patent, as was also the ductus arteriosus. It may
therefore be concluded that respiration was never established. Subcutan-
eous adipose tissue was found all over the body, but it was present in
smaller amount than in a healthy full-time infant. The absence of the
testicles from the scrotum served to explain the peculiar appearance of the
perineal region.
I shall now describe with some fulness the appearances presented by
the bones in this foetus, for it was in the skeleton that the most remarkable
characters were visible.
Tlie Cranium. — Whilst all the fontanelles of the head, as well as the
coronal, sagittal, frontal, and lambdoidal sutures, were wider than normal,
yet the ossification of the cranial bones was irregular rather than defective ;
and indeed the bones of the base of the cranium and of the face showed a
more advanced stage of ossification than they do in the healthy infant
at birth. The parietal bosses were large and prominent, but the margins
of the parietal bones were thin, flexible, and comb-like. The occipital bone
was curiously deformed. It had the shape of a hook, the occipitals being
bent at a sharp angle upon the supra-occiput, and the basi-occiput being
acutely flexed upon the exoccipital portions of the bone. The margins of the
supra-occiput were thin and flexible, and this part of the bone was flat, a fact
which explained the flattened appearance of the back of the head already
described. There was no trace of cartilage between the supra-occiput and
the exoccipitals, and the ossification of the basi- and ex-occipitals was far
advanced. Whilst the ossification of the supra-occiput was therefore some-
what defective, the ossific process was far advanced in the basi- and ex-
occipital parts of the bones, — the parts, it will be remembered, which
pass through a pre-cartilaginous stage before becoming bone. The frontal
bone in the neighbourhood of its two eminences was ossified, but the two
halves of the bone were separated by an inter-frontal suture, much wider
than normal. The orbital plates of the frontal bone were thin and fragile.
All the parts of the sphenoid were joined by osseous union, there being no
cartilage between the basi- and pre-sphenoid portions of the bone. The
rostrum of the sphenoid was of unusually large size, being nearly 2 cms.
in length, and was articulated in the usual way with the vomer. The
temporal bones, with the exception of the squamous portions, were well
ossified, and the tympanic ossicles and annulus tympanicus were as well
developed as they are in the new-born healthy infant. The ethmoid bone
was normal in appearance. It was found that the two halves of the lower
maxilla were well ossified, the condyles being even a little larger than they
normally are at birth. The lower jaw contained the usual number of
dental germs, and this fact is specially worthy of note, for it is well known
from clinical observation that when rickets comes on during infancy there is
marked retardation in the eruption of the teeth, and great irregularity in
the mode of their appearance. The superior maxillae, which also contained
the usual dental germs, projected forwards in the middle line, and this
projection I believe to have been caused by the unusually large size of the
rostrum of the sphenoid. This peculiarity of the sphenoidal rostrum may
serve to explain the beak shape of the upper jaw described by Fleischmann
as common in postnatal rachitis. The malars and the other facial bones
were well developed and fully ossified.
The Vertebral Column and Pelvis. — The spine in this case was curved,
and fixedly curved both laterally and antero-posteriorly. There was a
344 anti-:natal pathology and hychenk
convexity to the left side in the cervical ami upper dorsal regions, a con-
vexity to the right in the middle dorsal. The lower dorsal portion of the
spine was straight, and there was a convexity to the left in the lumbar
region. There was also a general anterior concavity of the whole spine.
Such fixed curvatures of the S|jine are entirely absent in the healthy new-
born infant. The sacrum had a marked promontory, and was well ossified.
The coccyx was entirely cartilaginous, and was of enormous size, a fact
which fully accounted for the tail-like projection. It consisted of the usual
number of segments (four). The jielvic brim was contracted in its antero-
posterior diameter, for the transverse diameter at the brim exceeded the
antero-postcrior by 5 mnis. The iliac fossic were slightly deeper than in the
normal foetus, and the crests of the ilia and the anterior iliac spines were
thick and rounded. The ossification of the iliac bones was not so far
advanced as it usually is at birth, whilst that of the ischial and pubic bones
was much retarded. The pelvis, therefore, presented characters quite
different from those seen in the normal foetal pelvis, in which the antero-
posterior diameter at the brim is equal to or greater than the transverse,
and in which the iliac fossae are very shallow. The pelvis, also, does not
show all the characteristic features of a typical adult rachitic pelvis, although
in some of its characters the resemblance is strong. The anterior wall of
the pelvis has an appearance as if it had been compressed and driven back-
wards by the enormously large upper extremities of the femora.
The Clavicles and Scapula: — The clavicles were relatively long when
compared with the rest of the bones. Their inner ends were enlarged, and
the upper surface of the bones showed a marked concavity. The right
clavicle was slightly longer than the left. It measured 3 cms. ; the left
measured 2'8 cms. The chin of the foetus appeared to rest upon the
upper concave surfaces of the clavicles. Loth scapulae were remarkably
contorted. The infra- and supra-spinous fossae were very deep, and the
normal sub-scapular fossa was replaced by a convexity, upon which, however,
was a small concavity corresponding in position to the region of the spine
on the external aspect of the bones. The vertebral border of each scapula
had a marked S-sliape, and the lower angle was twisted forwards. The
spine of the scapula had a distinct projection directed downwards about
midway between its two extremities. The glenoid cavity was not well
ossified.
The Sternum and the Bibs. — The manulirium sterni was very large, and
the first three portions of the meso-sternum were well ossified. The eusi-
form cartilage was large, and its tip was turned forwards. There was a
well-marked concavity on the anterior aspect of the sternum, with a
corresponding convexity on its posterior surface. It may here be remarked
that the heart showed a distinct furrow on its anterior aspect, marking the
sharp bend which the sternum showed. A similar condition of the heart
was observed by Bland Sutton in cases of rickets in monkeys (Introduction
to General Patholoijy, p. 56, London, 1886), and the same author pointed
out that marked thinning of the right ventricular wall resulted frcmi the
pressure to which it was subjected by the sharply-flexed sternum. In this
case the thinning was not well marked, although the depression upim the
anterior asjjcct of the heart was very evident. The ribs, which were rather
slender at their vertebral ends, hatl distinct swellings at their sternal ends.
The swelling on the anterior end of a rib was hollowed out into a little
circular cavity from which a thin costal cartilage passed to the sternum. In
the first three ribs the angle was very sharp, the fourth, fifth, ami sixth ribs
had no marked angle, whilst the lower ribs had an angle not nearly so well
FGETAL BONE DISEASE 345
defined as those of the upper three ribs. These characters of the ribs were
seen to correspond to the convexity and concavity of the scapula. The
lower margins of the middle ribs were very thin, and were distinctly
notched. The anterior ends of the two upper ribs on each side were
directed upwards. In the case of the other ribs they were directed down-
wanls. The intercostal spaces were practically non-existent.
The Long Bones of the Limbs. — The long bones had this peculiarity in
common, that whilst their ends were enormously large, the intervening shaft
was small, short, straight, and nearly quite cylindrical. In the case of the
femur there was a trace of the linea aspera, but in the case of the other
long bones the shafts were quite smooth. The ends of the long bones were
composed principally of cartilage greatly hypertrophied, and of softer con-
sistence than is normal in the new-born infant ; but at the line where the
cartilage stopped and the bone began there was also a great thickening of
the bone, so that the large ends of the bones were partly osseous, although
principally cartilaginous. There was immobility of the joints and a certam
amount of dislocation, especially in the case of the hip, shoulder, and ankle,
and both the immobility and dislocation were apparently due to the
enormous size of the opposing cartilaginous surfaces. Some of the char-
acters of the individual long bones may be given here. The .shaft of the
humerus was straight, cj'lindrical, and short. The two extremities were
greatly enlarged. The upper was somewhat round in form ; the lower was
broader transversely than antero-posteriorly. There were no ossific centres
in the epiphyses. Taking the length of the humerus in the normal infant
as 6 cms., it was seen that in this case the bone was shorter than normal.
The left humerus measui'ed 4 cms. in length, the right 3'9 cms. The
upper end of each humerus had a circumference of 7 cms., whilst the
circumference of the shaft was onlj' 2"1 cms. The radius and ulna were
of equal length, each measuring 3 "2 cms., but the radius extended beyond
the ulna below, and the ulna passed beyond the radius at the elbow joint
above. The interosseous space was 6 mm. in width. The lower end of the
ulna had a marked concavity inwards. The lower end of the radius had a
circumference of 3'-t cms. ; the upper end had one of 2'6 cms., whilst the
shaft measured only 1'3 cms. in circumference. The upper end of the ulna
had a circumference of 3'6 cms., the lower end one of 3'3 cms., whilst the
shaft had one of only I'i cms.
The femur on both sides had a slight concavity in\\'ards of its shaft.
There was a distinct projection on the inner surface of the upper end
corresponding in position to the trochanter minor, but the trochanter major
was lost in the general cartilaginous mass. The head of the femur was no
larger than a pea, but was ossified. The femur measured 4*5 cms. in
length, the circumference at the upper end was 7"2 cms., at the lower end
8-0 cms., and at the middle of the shaft 2'1 cms. The tibia was 3'3
cms. in length, and its shaft had a circumference of 2'1 cms. The shaft
was thicker than that of the fibula, which measured only 1 cm. in circum-
ference. The tibia was displaced forwards on to the dorsum of the foot.
The fibula was situated in a plane posterior to that of the tibia, and more
markedly so than in the case of the normal infant. It had a curvature
convex to the front and internally, and concave posteriori}' and externally.
There was a large elliptical interosseous space 9 mms. in breadth. The
length of the fibula was 3-1 cms., and it reached to a level a little below
that of the tibia. The patella was large and cartilaginous.
The Hand and Foot. — There was no point of ossification in the carpus,
but the sliafts of the metacarpal bones were large and well ossified, as were
346 ANTENATAL PATIIOI.OCY AND IIVCIKNE
also the first and second but not tlie terminal phalanges of the digits. The
bones of the tarsus were cartilaginous, except the os calcis, whieli had a
large ossific centre. The feet were distinctly clubbed (talipes varus). All
the metatarsal bones were ossified. The first and second phalanges of all
the toes were ossified ; the terminal ]>halanges were cartilaginous. The
hallu.x, like the pollex, had both its phalanges osseous.
Such were the characters of the component parts of the skeleton, and
it may be stated in addition, that at the time when the foetus came into
Sir William Turner's posse.ssion there was a transverse fracture of the right
femur in the ujiper third of its shaft. This fracture may have lieen intra-
uterine ; but I am more inclined to believe that it was produced at the time
of birth or subsequently, for the long bones were very fragile, and during
the process of dissection I my.self accidentally fractured the other femur and
the right humerus. In the case of the last-mentioned bones, however, what
really occurred wa-s a separation of the diaphysis from the epijihysis along
the line where cartilage and bone met ; whilst in the case of the right femur
there was a true fracture of the bone itself. Each of the long bones pre-
sented on section ver}' similar characters. The medullary canal was large,
and was surrounded by friable spongy osseous tissue. Near the ej)iphyses
there was a thick layer of hard bone, and the epiphysial extremities of the
bone were composed of soft cartilage of an almost gelatinous consistence.
The microscopic examination of the tissues and organs of this foetus was
not satisfactory, the specimen not being fresh when I maile the dissection,
but the swollen ends of the long bones and the whole of the coccyx seemed
to be made up of large masses of cartilage cells with little or no intercellular
matrix and no deposit of lime salts. The absence of the placenta and
membranes of this foetus is a circumstance much to be regretted, as is also
the want of any clinical history of the case.
The remarkable case which I have adduced as an instance of
Type C resembles in manj' of its characters Kaufmauu's Case 8, but
more especially his Case 13 (oj). cit., s. 130, 1892). It may be also of
the same kind as those reported by W. Stoeltzner (Jahrb.f. Kindcrhlk.,
n. F., 1. 106, 1899), in one of which the thyroid gland was much
enlarged. If I were to adopt Kaufmann's nomenclature, this speci-
men would fall under the heading of chondrodystvophia foialh hi/pcr-
plastica, for in it there is that extraordinarily exuberant overgrowth
of the cartilaginous epiphyses of the long bones which is characteristic
of the hyperplastic variety of foetal chondrodystrophia. The diaphyses
are very short, liut the large size of the epiphyses almost makes up
for the shortness of the shafts, and so the limbs are not so stunted as
they would otherwise be. There is rapid but disorderly proliferation
of cartilage, and the cartilage cells are not arranged in rows, and no
bone formation takes place. The nose shows flattening, and at the
base of the cranium the formation of the os tribasilare takes place
(premature ossification of the bones of the base, namely, pre-sphenoid,
basi-sphenoid, and basi-occiput).
At the present time the cause of the dystrophy which has been
described above is unknown. It may be guessed that the conditions
which produce rickets in postnatal life are active in a modified form
or in a ditfereut degree here, and tliat they arrest the formation of bone
from cartilage, while they allow the proliferation of the cartilage itself.
FCETAL BONE DISEASE
347
FcEtal Bone Disease (Type D).
Under the heading of Type D, I group most of the recorded cases
of achondroplasia and chondrodystrophia fretahs hypoplastica. This
disease does not prove incompatible with postnatal life ; consequently
there are several well-recorded instances of adult achondroplasia, as
it is often called. I have, however, to deal here with the malady as
Fig. 50. — Villa's case of ftetal bone disease.
it is met with in antenatal life. A complete and concise account of
the disease, both as it occurs in adult and in foetal life, is given by
John Thomson in Green's jEncydojM'dia Medica, vol. i., p. 55, 1899.
The external appearances are very characteristic, and most of the
recorded cases bear a very striking resemblance to each other. In
order to bring out this resemblance, the reader may compare together
the cases of E. H. Sonntag {Dissert., Heidelberg, 1844), N. F. Winkler
{Arch. f. Gijnach, ii. 101, 1871), A. Fischer {ibid., vii. 45, 1875),
348 AXTKXATAI, I'ATIIOLOCIV AND HYGIENE
J. B. Borntraeger (Dissert., Kijnigsberg, 1877), J. Storp {Dissert.,
Kiinigsberg, 1887), A. liiskamp (Dissert., Marbiirg, 1874), F. Hoess
(iJissci-t., :\Iaibiii'g, 1876), 1!. Ihimpe (Di.'iscrt., Marburg, 1882), G.
Neumann {Diiiscrt., Halle, 1881), A. St-lmeider (Dissert., Berlin, 1892),
F. Villa (Ann. cli vstet. e ginec, xiii. Goo, 1891), J. Symington and
H. A. Thomson (Proc. Roy. Soc, Edin., xviii. 271, 1890-91),
E. Kaufmann (op. cit.), L. Spillmanu (Lc rachitisme, I'aris, 1900), K.
Cestan (Nouv. ico7io(jr. de la tialpetrih-c, xiv. 277, 1901), E. Apart
(ibid., p. 290, 1901), and F. llegnault (Bull, rt mini. Soc. anat. dc Far.,
G s., iii. 178, 1901). The illustration given by Villa is reproduced
here (Fig. 50). The first glance at such a foetus suggests that the
parts affected are the exti'emities, and exact measurements at once
confirm what the eye has suggested. The arms and legs are shorter
than normal ; they may Ije only half the normal length ; and the
large quantity of the subcutaneous tissue, along with the lax condition
of the skin, gives to the limbs the appearance as if the integument
were redundant, and so emphasises the stunted character of the
appendicular skeleton. The limbs look as if they had on garments
too large for them, and they are often encircled by deep sulci. The
long bones belie their name, for they are short and thick, and have
relatively veiy large epiphyses; but their epiphysial ends do not
attain to the enormous proportions seen in Type C Their curves are
exaggerations of those normally present. The hands show a curious
anomaly in form : when, as J. Thomson first pointed out (Edinh. Med.
Journ., xxviii. 1112, 1893), the palm is flat the fingers do not lie
parallel as in a normal hand, but diverge somewhat, two usually
turning towards the radial and two towards the ulnar side. Good
illustrations of " le main en trident " as it appears in postnatal life
are given by E. Gestan (loc. cit., p. 280). The shortness of the limbs
is the character which has led several authors to name this malady
micromelic rickets or fcetal rickets with micromely.
The trunk, unlike the limbs, is of normal length, but seems to be
narrow on account of the costal and pelvic abnormalities. In size,
the head also is normal, or slightly larger than normal ; and it is
somewhat prominent in front and at the sides. There is a sulcus at
the root of the short, thick nose ; and it appears to be deeper than it
really is on account of the bulging frontal region. The tongue not
uncommonly protrudes slightly from the partly open mouth. The
skin, hair, and nails are connnonly quite nnrmal: but the disease may
be associated with general fo>tal droji.sy (E. Kaufmann, op. cit., s. 7).
The clinical history of many of these fa?tuses extends beyond
antenatal life, for although some succumb a few hours after birth,
many survive and reach the adult state. In fact, their development
seems little interfered with : they are intelligent and vigorous, and
when married are not sterile. As has already been pointed out, a
woman with this disease may give birth to an infant similarly affected
(I'orak, op. cit.). Her labours, hdwever, are apt to be very dangerous
from the existing jielvic deformity. In antenatal life, liydraniuios,
that frequent indication of the presence of fo'tal di.sease and deformity,
may be present, and labour often is somewhat premature.
F(ETAL BOXE DISP:ASE 349
The patliology of the disease is now much better known than
formerly. The internal organs show little or no pathological change,
and this remark applies to the thyroid gland as well as to the other
viscera ; in Symington and Thomson's case, however, a condition of
acute desquamative catarrh was discovered in the thyroid. The
parts at the base of the braia exhibit some anomalies, but these
are due to the curious condition of premature ossification of the
bones of the basis cranii, which results in their fusion into one
jjone, the os tribasilare (so called because it cijnsists of the three
nuclei — basi-occipital, post-sphenoid, and pre-spheuoid). There is
thus a marked shortening of the base of the cranium anterior to
the foramen magnum. The result is that the medulla and pons,
which normally extend from the foramen magnum to the upper
edge of the dorsum of the sella turcica, project above that level,
and have a direction upwards and backwards instead of upwards
and slightly forwards. There are or may be other changes in the
relations of the parts of the brain produced in the same way, and
of the.se Symhigton and Thomson (loc. cit.) give a good description.
The depression at the root of the nose may be due to the premature
ossification of the basis cranii; but it cannot be regarded as indi-
cating with certainty the presence of the os tiibasilare, for it may be
found when there is no tribasilar bone at all (E. Kaufmann, ojj. cit.,
p. 36). The pituitary body has been exammed and found to be
normal. Hydrocephalus has sometimes been described; but it is
doulitful if it is at all frequent.
The chief pathological changes are in the skeleton, and in that
part of the skeleton ossified in cartilage. The bones, therefore, which
are formed in membrane are usually quite normal; such are the
Hat bones of the cranial vault. Further, it has been pointed out
by Symington and Thomson {loc. cit., p. 273) that those bones which,
although formed in cartilage, remain entirely or mainly cartilaginous
till an advanced period of foetal life, and the growth of which there-
fore is independent of endochondral ossification, also show no abnor-
malities ; such are the sternum, patella, costal cartilages, and tarsal
and carpal bones. In a sentence, the skeletal changes are mainly
due to defective endochondral ossification, and the bones affected
are consequentlj' the long bones of the limbs, the ribs, the innominate
bones, and the posterior part of the base of the skull. The formation
of the tribasilar bone has already been referred to ; but, in addition
to that synostosis, the lower part of the supra-occipital, the basi-
occipital, and the ex-occipitals are smaller than normal, and the
supra-occipital is not separated from the ex-occipitals by a cartil-
aginous hinge. The foramen magnum, therefore, is small. The lateral
masses of the ethmoid are smaller than normal, as are the lesser
wings of the sphenoid, and the petro-mastoid part of the temporals.
The inferior maxilla is, as a rule, the only facial bone showing any
abnormality ; it is smaller than usual on account of smallness of
its posterior part. The vertebral column is of normal length, but
its antero-posterior measurements may be reduced : the thorax is
small and flattened, a character due to arrested development of the
350 ANTl'.NATAL I'AI'IIOLOCV AND ll'^dlKNE
ribs, wliich may be less than one-half their normal length ; the
pelvis is contracted in all its diameters, l)ut especiall)' in the antero-
posterior at the brim. Tlie innominate bones are small, and almost
entirely composed of cartilage. Tlie diajihyses of the various long
bones are from one-half to one-third their normal length, but the
epiphyses are normal in size or increased. The shafts have a normal
circumference, Imt they are markedly curved, the curves being an
exaggeration of th(jse normally present ; they are firm, and the
so-called fractures are generally due to sejiaration of shaft frf)m
epiphysis rather than to a solution of continuily of the former.
There is fixation, or very limited movement of the joints of the
limbs, due to the large size of the opposed surfaces. The scapula
and clavicle may be smaller than normal, and the sternum may
be entirely cartilaginous.
The pathogenesis of this type of fd'tal bone disease is hardly
better understood than tliat of any of the other types. From the
microscopical appearances of the bones, however, it is gatliered that
at the junction of the small wedge of endochondral lione and the
terminal cartilage no normal ossification is going on ; " there are "
(to quote Symington and Thomson) " no parallel rows of cells, no
progressive formation of medullary spaces by the projection of
medullary blood vessels into the cartilage ; there is an absence
of vessels at the ossifying junction ; and the typical organ - pipe
arrangement of structures is either not recognisable at all, or only
here and there, and that faintly." The large cartilaginous ends of
the long bones consist entirely of hyaline cai'tilage, and the short
shafts are made up almost exclusively of periosteal bone, in
which a medullary canal is absent, or represented only by some
inter - trabecular spaces, slightly larger than usual. In this way
the growth of the medullary vessels towards the ossifying junction
is prevented. Some endochondral bone may be found near the ends
where it forms the small wedge referred to above ; but it is non-
lamellated, and sim])ly consists of " a very irregular honeycomb,
made up of branching masses, each of which contains a core of
cartilage in the centre ; it may have been formed by a direct con-
version or metaplasia of the cartilage into bone." What the exciting
or predisposing causes of this arrest of endochondral ossification are,
is not known. A great deal of time has been spent over discussions
as to whether the disease is a fcetal form of rickets or of cretinism ;
but sucli discussions must to a large extent be wasted labour, for
it cannot be expected that the characters of rickets (u- of sporadic
cretinism as they occur in postnatal life will be exactly reproduced
in fwtal existence, and especially in the early part of fwtal existence
bordering upon the embryonic state. The cases of Type D which
survive birtli certainly do not grow either into cretins or into rachitic
dwarfs. That it may be duo to morbid action of the thyroid gland
is not b}' any means ju'oven.
That Type D is closely related to Type C is evident, although
in the latter there is a more marked overgrowth of tlie epiphysial
cartilage which partly masks the resemblance. E. Kaufmann empha-
I
F(ETAL BONE DISEASE 351
sizes this resemblance by caUiiig the latter the hyperplastic form
of foetal chondrodystrophia, and the former the hj'poplastic variety ;
but, to niy mind, it is well to regard them as two types. They are
morliid states which must arise near the beginning of fcetal Ufa,
possibly in the ueofcetal period or even earlier : they verge upon
the teratological, even if they are not actually to be regarded as
monstrosities rather than diseases. The projection of embi-yonic
pathology into foetal pathology in them is very evident.
Finally, it may be noted as an interesting fact, that the disease evi-
dently existed and was noted in very early times in the world's history,
r^
for the gods Ptah and Bes were undoubtedly examples of it. Further,
some of the historic dwarfs seem to have owed their dwarfism to
this form of foetal bone disease (Charcot et Eiclier, Lcs diformcs dans
I'art, p. 15, 1899 ; H. Meige, Xouv. iconogr. de la Salpvtricre, xiv. 371,
1901). The disease is met with also in some of the lower animals, as
is seen in dachshunds and bassets.
FcEtal Bone Disease (Type E).
I do not regard type E, which is represented in Fig. 51, as a
fcetal disease properly so called, for it is undoubtedly teratological
352 ANTENATAL l'ATIl()L()(iV AND HYGIENE
in its nature : l)ut I describe it here in order to demonstrate that
it is a still earlier stage of arrest of limb-formation than that seen
in Type D. In the specimen represented in Fij,'. 51, 1 found, on
dissection of the limbs, that their skeleton was represented solely
by tiny pieces of cartilage having a certain resemblance in shape
to the bones of which they were the only traces. They were
eml)edded in a large quantity of adipose and coiniective tissue,
for the muscles were feelily marked. This specimen was shown
to the Edinburgh Obstetrical Society in 1888 (Trans. Edin. Ohst.
Sot'., xiv. 1, 1889) by Professor A. 1!. Simpson, who was kind enough
to allow me to dissect it. The skin was afterwards stuil'ed, so as
to preserve the external appearances, and it is now in the Obstet-
rical Museum in the University of Edinburgh. It was a Maternity
Hospital case, and the mother had already borne several healthy
children. There had been hydranniios. The head had presented,
but the labour had been ended by version. The two halves of
the frontal Iwne were widely separated, and the \"arious ])arts of
the occipital bone were prematurely ossified together and deformed,
with the result that the foramen magnum was greatly reduced in
size. The basi-occipital, basi-sphenoid, and pre-sphenoid were fused
together into one bone (os tribasilare). There was only one artery
in the umbilical cord.
As has been said, this fretus was evidently teratological. In
teratological classifications it would doubtless be grouped under
the heading of phocomelus, although its characters do not quite
agree with those of that type, for the hands and feet are not
directly attached to the trunk, but through the intermediation of
stunted upper arms and forearms and thighs and leg.s. The speci-
men is specially valuable as showing arrestment of limb ossification
at an early period in antenatal life, at a time, in fact, when the
organism is still in the embryonic, and has not yet readied the
neo-foetal epoch. It is a monstrosity, then ; but it has to be
remarked that it is connected by means of Types D, C, and B with
Type A. It stands at the one end of a series of types wiiich has
simple imperfect ossification of the cranial vault bones at the other
end. The ossification of the limb bones has been arrested, while
the ossification of the Imiies at the base of the cranium has been
prematurely accomplished with resulting deformity in eacli. This
same coexistence in the one skeleton of arrested ossification and
premature cssification is present also in Types D and L\ although
to a less marked degree. In Type B, it would appear that the
cranial base is normally formed, although the liml) bones and the
vault bones show defect ; while in Type A the vault bones alone
would seem to be affected. At the one end of the series, then,
is a monstrosity, and at the other a disease ; and there are con-
necting links. Doubtless many of the dillerences are to be accounted
for by the time in anfenatal life when the morliid cause (or causes)
came into operation : but it is also possible that they are to be in
some measure explained by the action of essentially diflerent causes.
By this time it will have become evident to the reader that the
F(ETAL BONE DISEASE ?,53
writer had good reason for the statement which he made at the
beginning of this chapter ; and the foi'mer will now, perhaps, be
prepared to agree with the latter that foetal Ijone diseases are
disconcerting to the pathologist and discouraging to the nosologist.
One is tempted to say about them, as has been said about the
hydatid mole, that they are due to an " unknown something of the
mother " (einen unbekannten Etwas der Mutter). I feel that I
have not succeeded in introducing into this chapter any perceptible
degree of lucidity and order, and in the face of what I recognise
has been a failure I break through my rule, and append a biblio-
graphical list of works on foetal lione diseases, so that those readers
who wish to exphjre this part of Antenatal Pathology further may
at least have the literature at their command. May their success
be greater than mine.
EIBLIOGEAPHY.i
J. H. Klein, Dissert., Argentorati, 1763; M. Romberg, Dissert.,
Berlin, 1817; C. F. Sartorius, Dissert., Leipzig, 1826; M. J. Weber,
Journ. f. Geburfsh., ix. 292, 1829-30; M.\nsfeld, Journ. d. C'hir. n.
Augenh., xix. 552, 1833 ; G. K. A. Schulz, Dissert., Giessen, 1849 ;
Depaul, Bull. Acad, de med., Paris, xvi. 73, 1850-51 ; J. H. Nutting,
Boston Med. and Surg. Journ., Hi. 53, 1855 ; A. J. Lecard, These, Paris,
1856; "\V. JI. H. Sanger, Dissert., Leyden, 1857; Dumenil, Gaz. d.
hop., XXX. 396, 1857; Anon., Journ. f. Kinderhr., xxx. 456, 1858; H.
Lafont-Marron, Tlivse, Paris, 1859 ; W. Hink, Ztschr. d. k. Ic. Gesellsch.
d. Aerde zu Wien, xvi. 107, 1860 ; I. Lederer, Wien. med. Wchnsclir.,
X. 613, 1860; H. Mueller, Wiirzh. med. Ztschr., i. 221, 1860; C.
Braun, Wclnihl. d. Ztschr. d. ii. Jc. Gesellsch. d. Aerzte in Wien, 223,
1861 ; Hecker, Monatschr. f. Gehiirtsl: it. Frauenla:, xx. 462, 1862 ;
L. Tripiek, Gaz. med. de Lyon, xvi. 314, 1864; Scharlau, Monatschr.
f. Gehurtsl: u. Frauenhr., xxx. 401, 1867; A. Filippi, Imparziale, xii.
329, etc., 1872; H. Urtel, Dissert., Halle, 1873; J. Englisch, Oesterr.
Jahrh. f. Paediat., v. 165, 1875; Fehling, Arch. f. Gynaelc, vii. 388,
1875; Depaul, Arch, de tocol., iv. 641, 1877; v., 1. 321, 424, 449,
1878; A. MifLLER, AerM. Int.-Bl. (Miinolien), xxv. 309, 1878; C. J.
Eberth, Die fcftale Rachitis, Leipzig, 1878 ; Wtss, Jahrh. f. Kinderh.,
n. F., xiv. 380, 1879-80 ; M. Smith, Jahrh. f. Kinderh., n. F., xv. 79,
1880; E. Bode, Arch. f. path. Anat., xciii. 421, 1883; Gueniot, Bidl.
et mem. Hoc. de cMr. de Par., n.s., ix. 553, 948, 1883; R. Virchow,
Arch. f. path. Anat, xciv. 183, 1883; C. Taruffi, Mem. r. Accad. d.
sc. d. 1st. di Bologna, 4. s., vi. 661, 1884; R. von Ferro, Wien. med.
Presse, xxvi. 374, 1885; E. Schidlowskt, Dissert., Berlin, 1885; V.
Lauro, Ann. di ostet., ix. 385, 1887 ; J. A. A. F. Kirchberg, Dissert.,
Marburg, 1888; T. Barlow, Trans. Clin. Soc. Lond., xxi. 290, 1888;
A. Kirchberg and F. Marchand, Beitr. z. path. Anat. u. - allg. Path.,
V. 183, 1889 ; 0. Blau, Dissert., Berlin, 1889 ; E. Mori, Rir. di ostet.
e ginec, ii. 513, 1891 ; L. Scholz, Dissert., Gottingen, 1892 ; G. Schwarz-
waller, Ztschr. f. Gehurtsh. u. Giindk., xxiv. 90, 1892; A. Carton,
Tlihse, Paris, 1893 ; H. Paal, Dissert, Wiirzburg, 1893 ; 0. von Franqu^,
Sitzungsh. d. phys.-med. Gesellsch. zu Wilrzhurg, 80, 93, 1893; J. Thomson,
' In tliis bibliogi-aphical list, the works already referred to in the tfxt are not
inehided.
23
354 ANI'KNATAl. I'ATl lOI.OCV AND llYCilKNE
Trails. Eiliiih. Oh^t. So,:, xviii. 195, ISO;!; .1. H. R(rni, Dhsert., liamlierg,
1894 ; roKAK ET DuuANTE, Noiiv. cirili. il'olis/. ft de ijunrr., ix. 298, 1894 ;
C. Salvetti, Uritr. .:. path. Anat. u. r.. all;/. Path., xvi. 29, 1894; J!. C.
HiHST, Mrd. Xeiix, Ixiv. 184, 1894; V. I'ki.lo, Arch. lU Ortoped, xi. 1,
1894; M. Sai,a(!Iii, j'AiV/., xi. 383, 1894; F. Ckuttiiofk, Dissert., lierlin,
1895; K Apeiit, Hull. Soc. anat. ,le Paris, 5 s., ix. 772, 1895; K. Lampe,
Dissert., Mailmij,', 1S95 ; C. .1. de iiiiuvN Koi'S, Nederh Tijdschr. v.
Geneesh., 2. 11., xxxi. 350, 1895; ('.. II. Maki.vs, St. Thomas' IIoxp. Rep.,
U.S., xxiii. 121, 1896; O. Maugarucci, Arch, cd atti d. Hoc. Hal. di chir.,
x. 365, 1896; CiiAMUKELENT, Joum. de mi'd. de liordeaiix, xxvi. 204,
1896; PiruEs, ihid., xxvi. 479, 1896; I'inkuss, Ztsrh. f. Gehurtsh. u.
Gyniih:, xxxvii. 159, 1897 ; T. Tsciiistowitsch, Arch. f. path. Anat.,
(!xlviii. 140, 209, 1897; A. Johannessen, Xorsk Maij. f. hi'ijeridenslc,
Xo. 2, 1898; A. IIkuugott, Rev. mi'd. de Vest, xxxi. 762,"l899; C. V.. .S.
Flemmino, Bristol. Med.-C'hir. Joum., xvii. 21, 1899 ; Opitz, Ztschr. f.
Gehurtsh. it. Gi/ndh:, xl. 316, 1899; B. Schwendener, Dissert., liasel,
1899; G. Klem, Xorsk Mac/. /. Livrievidpn.-ik., 4 R., xiv. 1, 1899; F.
Schmev, Kiiider-Ar:f, xi. 53, 1900; Schkib, Peitr. z. /din. Chir., xxvi. 93,
1900 ; F. Harbitz, Beifr. ::. jinfh. Anat. n. alhj. Path., xxx. 605, 1901, and
Xorsk Ma,/, f. Ut-gevidmsk., 4 R., xvii. 1, 1901'.
I
OCT„g
OF •
Right lung.
Rigitt
ifirarenai
cnpsuk.
Spitui bifida.
CHAPTER XX
Types of Idiopathic Diseases of the Fcetus (cont.): Diseases of the Ali-
nieutaiy System : Fu'tal Ascites, Definition, Clinical Features and History,
External Apjiearances, Morbid Anatomy, Etiology, Pathology, Treat-
ment ; F(etiil Peritonitis ; Congenital Obliteration of the Bile-Ducts,
Definition, Clinical History, Symptomatology, Morbid Anatomy, Path-
ology, Diagnosis, Treatment ; Congenital Hypertrophic Stenosis of the
Pylorus, Definition, Symptomatolog}-, Morbid Anatomy, Pathogenesis,
Treatment.
Less is known i-eganling the diseases which aflect the internal organs
of the foetus than about those involving the skin or those of the
skeleton ; for the examination and dissection of infants that have
died during or just before birth has not been common, and the atten-
tion of observers has been seized only by the more obvious external
morbid states. As a consequence, almost the only antenatal maladies
of the alimentary system about which anything is known are those
wliich are so marked and so far advanced as to produce evident
changes in the external configuration of the body, and so to interfere
with the normal progress of parturition, rromineut among these is
fatal ascites.
Foetal Ascites.
I have examined by the sectional method three specimens of
foetal ascites (58, 197, 221), and the appearances presented by a
lateral vertical section of one of these are shown in Plate XII. I
ha\'e also had an opportunity of examining the case recorded by W.
Fordyce, and fully descrilaed l^y him in my journal {Teratologia, i. 61,
143, 1894). The following account of the malady is founded upon
these four specimens, and upon a consideration of similar cases which
have been reported liy other observers. A good biljliography accom-
panies Fordyce's article {he. cit., p. 135), and on that account the text
here will not be bm-dened with many references.
FcEtal ascites may be defined as the efi'usion of fluid into the peri-
toneal cavity, with consequent abdominal distension due to several
different causes, accompanied by various lesions of the \'iscera, and
leading usually to delay in labour and to intranatal or early post-
natal death of the infant affected with it. It is, just as in the adult,
a symptom or effect of different morbid processes rather than a
disease jxr sc ; but the morbid processes which produce the antenatal
form are almost certainly different from those which lead to the adult
variety. Further, antenatal ascites reaches a far more deforming
degree than the disease ever does when developed in postnatal life.
F. IMauriceaii {Traiti d. mcd. d. femmcs grosses, 3 ed., Paris,
350 y\NTKXATAI. I'All lOI.Od^' AM) HYdlKNK
1G81) was OIK' of the iirsl. to put on record a case of foBtal ascites,
and he gives such a graphic account of tlie interference with the
normal ])rogress of labour caused by this antenatal malady, that For-
dyce in his monograph (loc. cit.) translated the passage into English.
I repid(hic(! l''(irdyce's tran-slation here, for it is well worth reading.
Mauriceau writes :
" In the year IGGO, when I was engaged practising midwifery
in this place, it happened one day that a nurse, who was in attend-
ance on a woman in her confinement, was unable to deliver more
than the head of the child. Finding that it was inipossilile for her
to extract the rest of tlie body, altiiougli she had exhausted herself
in making strong traction i>n the liead, she called in t<i licr assistance
an experienced midwife, who in turn did all in lier jxiwcr to extract
tlie child by]mlling on its head, but with no result beyond dislociiting
the cervical ^■ertebra^ I was then summoned to their assistance.
On my arrival, they at once requested me to examine the patient in
order to discover the cause which had prevented them delivering the
child, although they had pulled so strongly on its head and had
made eflbrts which were more than sufticient to have delivered tlie
shoulders, though these had l>een very large. I very soon concluded
that the difficulty proceeded from some other cause than the shoulders
of the child, for, when I had passed my tiattened hand up to the
entrance to the womb, as far as the shoulders of the cliild, I found they
did not appear to be so large but what they could ha\c ])een easily
delivered. I introduced my hand further, carrying it in front of the
chest of the child as far as the xyphoid cartilage, where I recognised
that the abdomen was dropsical and full of Huid, so that it was im-
possible to extract it withotit liaving first punctured it in order to
give a means of escape to the fluid which it contained. 1 had not,
however, with me at the time a suitable instrument with which to do
this, and was therefore oliliged to send for a doctor from the Hotel -
Dieu. When this doctor arrived, I stated the case to him, and de-
clared that, in order to deliver the child, it was neces.sary to puncture
its abdomen, wliich was distended by llnid. He was, however, un-
willing to agree with me, either because he thought perliaps he i<new
his work without my advice, or because he did not wisli to or could
not believe that the child was dro])sical as I had told liim. What-
ever was the cause, he contented himself — without putting himself to
the trouble of examining the case — with attempting delivery in his
own way. He made traction once more on the head of the child,
and separated it entirelj^ from the rest of tlie body; for it was but
slightly attaclied, owing to the excessive violence of the ellbrts of tlie
midwives who liad been first in attendance on the case. After that
lie introduced a blunt hook into the uterus and draggeil away boll i
the arms of the fcctus, the one after the other, and tlieu some ribs,
and then parts of the lungs and the lieart. F(ir three-([uarters f)f an
hour he employed himself in thus dragging away fragments of the
f(etus (during which time he ])erspired friiely, although the weatlier at
the time was \ery cold), until at last, dislieartened and exhausted, he
was comiiellcd to abandon the task and take a rest. The midwife,
Fa':TAL ASCITES 357
ineauwhilc, succeeded in tearing away some pieces of ribs, usiny; her
hands unly, for of course she could not have been allowed to use the
blunt hook. A second time the doctor tried to extract the fcetus, pull-
ing on the hook with all his strength, but without any success, because
up to this time he had not punctured the abdominal wall or the
diaphragm, not wishing to do it, as I kept telling him each moment
that without this it was impossible to deliver the rest of the body.
" On seeing that all his efforts were, for a second time, useless, he
at last gave me the blunt hook, saying that I might have an oppor-
tunity of tiring myself out as well as the others. I accepted it
willingly and with pleasure, for I was very certain I could soon com-
plete the operation, knowing very well that, instead of amusing
myself as he had done, it was only necessary to puncture the abdo-
men of the child in order to let the contained Huid escape, after
which delivery of the child would be easy. For this object I intro-
duced my left hand right up to the distended aljdomen, and, passing
the blunt hook along it, I turned the point of the instrument towards
the alxlominal wall and forced the point into the abdominal cavity
of the fcetus. Then I withdrew my hand, and at once all the fluid
gushed out in a torrent. After this I drew out the rest of the body
with one hand without any difficulty, to the great astonishment of
the doctor, who had never been able to persuade himself that the
child was dropsical. After delivery, I had the curiosity to till the
abdomen of the foetus with water, in order to see what quantity it
had contained, and what its size was when quite full. I was able to
introduce, without exaggeration, more than live pints of our Paris
measure. This I should have had difficulty in believing had I not
seen it. I record here the full history of the case, in order that the
accoucheur may know how to act on a similar occasion."
Mauriceau's case illustrates very well the difficulty introduced
into parturition when the fcetus suffers from ascitic distension of the
abdomen : nothing need be added to tliis part of the clinical history
of such cases.
The pregnancy whicli ended in the birth of an ascitic fcetus was
seldom cpute normal iu its symptomatology. According to Fijrdyce's
statistics of sixty-three cases (loc. cit.), there were eight instances of
syphilis and nineteen of hydramuios. In two of the three cases
seen by me there was bad health of the mother ; in one (58) there
was gonorrhcea, with rupture of a pyosalpinx during labour, and
death in the puerperium; and in another (197) there was a tubercular
history. In the third case (221) the mother had been subject to the
infection of measles, but had not apparently been affected ; Ijut there
was great hydramuios. Not infrequently there was a history of pain
in the abdomen. In thirty-six out of forty-three cases the pregnancy
termuiated prematurely. Sometimes the fcetal malady showed family
prevalence, as iu the cases reported by E. Virchow (Monatschr. f.
Geburtsh., xi. 161, 1858), by 0. von Franqucj {Wien. vied. Presse, vii.
812, 1866), by Bruce {Edin. Med. Journ., xvi. 167, 1870), and by
JQden {Dissert., Wurzburg, 1890).
To such a serious extent did the foetal disease interfere with
358 ANTKNAI'AI, I'A TIIOl-OC^ AM) I H CI I'.N I',
delivery, tluil in four fuses (lut of sixLy-tliree tlie iuhUuts dicil as
tlie result of tile ]ir(iloiiged laliour ami tlie operative iuterfereuee
(Fordyce). The fo'tus usually died eiliier duriui;' or very so(ju after
its hirtli; but in Crainlall's ease it lived for nearly a uioutli, and in
Courniont's it reeovered after the ahdonieu had been jiunctured and
500 grnis. of fluid withdrawn (Fordyee). The prognosis for the
infant, therefore, is not absolutely hopeless.
The adcrnal apjicaranccs oi the ascitie fo'tusare strikiug(Fig. 52):
tluu'eis marked jirouiineueeof the abdomen, so great in some instances
as to cause a]i}iareut dwarfing of the head and linilis. On ])alpation
the fluctuation thrill can lie easily elicited; and it is evident that the
f'd'tal abdomen contains fiuid. Very sindlar results on inspection and
palpation are obtained in cases where the ftetal bladder is greatly
over-distended, so that it is not always certain at first what the cause
of the abdominal enlargement may be in any given case. The limbs
and face are usually iiuite free from (edema. Sometimes the e.xternal
genitals are malformed, as in Fordyce's case (I'ig. 54). There was
hare-lip in one of my cases (221).
The viorbid anatumy has not been investigated so fully as could
be wished, and in many of the recorded cases the obstetric interest
seems to have been the only one which appealed to the observer.
The fiuid in the abdominal cavity has varied in amount from a few
grammes up to twelve or fifteen litres (!) ; juobably two to four litres
has been the average quantity. It was generally a clear serous fiuid,
but sometimes it was described as brownish red or turbid, with fiakes
of lymjih floating in it. In a few cases it was analysed : in Truz/i's
{Gaz. incd. ital. lomb., 8 s., vi. 139, 1884) it was rich in albumin,
alkaline in reaction, and had a sjiecific gravity of 1002; in C. Jany's
{Klin. Bcitr. z. Gynaclc, ii. 240, 1864) it was alkaline, and contained
chlorides but no urea; and in one of my cases (197) it had a specific
gravity of 1007, an alkaline reaction, and it contained albmnin and
globulin, and a distinct trace of oxyha^moglobiu.
In about half the recorded cases in which a post-morUm examina-
tion was made, the peritoneum was diseased ; it showed the signs of
infiammation, sometimes acute, but generally chronic, which caused
a thickened or granular state of the membrane, with adhesions
between the various viscera, retraction and thickeuhig of the mesen-
tery, etc. The microscopic aj)pearances of the abdominal wall in
F^ordyce's case are shown in Fig. 58 ; the endothelium was entirely
destroyed, and the sub-endothelial connective tissue greatly thickened.
Enormous hypertrophy of the pancreas was referred to in one case
(E. i\Iartin's s]iecimen, Monalschr. /. Grhnrtsk., xxvii. 28, 18G5). It is
a remarkal)le fact that lesions of the liver and spleen seem to have
been rarely noted, a striking occurrence w'hen the pathology of ascites
in the adult is borne in nund. The bladder is sometimes found in
an over-distended condition; and I have elsewhere (58) gathered
together records of seventeen cases in which this association of fo'tal
ascites and distension of the bladder was observed. In some cases
there was also dilatation of the ureters and hydronephrosis. Some-
times there was a urethral septum or valve to account for the vesical
Fig. 52.-^E.xtenial appuaniiLrs of lH,tu,s with asritrs. I'l.ntograi.li from watcT-oolour
sketch made shortly after delivery (reduued Ijy about oue-lialf).
360
ANl'IAAlAl. I'Al'llOI.OC^' AND I1V(;II:M
distension, but sometimes there wiis no sucli striiflini'. In Fonlyce's
case {loc. cit.) and in some others tiie <;enilal orj^ans were malformed,
as were also till' lower ])art of the lari^e intestine and the rectum;
in the former there was a double uterus and vagina, and a tubercle
which pi'obably represented the clitoris (Kig. 54), and in OLshausen's
specimen {Arch./. Gt/naclc, ii. 280, 1871) the bladder communicated
with the uterus, and the clitoris was absent.
I have grouped this foetal morbid state among the idinpatbic
diseases, and, therefore, it may be gathered that I regard its (iivhijji
as unknown. At the same time, there are some cases in which it
seems fair to regard the ascitic condition as the result of foetal
syphilis arising from maternal (or paternal) infection, and con-
sequently as a transmitted disease, or as one of the manifestations of
Fig. 53.— Mii-nwoi.i.' ai.|.i'ar.iii(i's nf scrtimi of Al.dniuiiial Wall
iutciual to tlie JIusciilar Layer, .stained with logwood and
eosin, x 97. a, Muscular tissue ; b, Areolar tissue ; c, Cou-
iiectivc ti.ssue.
a transmitted disease. If, liowever, the syphilitic cases be cxcludcil,
and they arc not numerous, there remain many in whicli tlie ascites
must still be regarded as originating in the fa>tus ai)art from maternal
states. These may yet be traced to diseased states of the niotlier,
but this stage in our knowledge has not yet been attained.
In considering tlie pafholo;/y and patho(/cnfsis of the malady, one
naturally thinks first of hejmtic lesions and disturbance of the jiortal
system ; but it has already been stated that morbid alterations of the
liver in such cases have been very rarely nciticed. It woidd seem
that ascites due to causes in the jiortal system is not, tlicrefore,
common in the fo'tus, a state of matters not so difficult to understand,
if it lie remendiercd tiiat this part of the vascular system is then
comparatively inactive on account of the quiescent condition of the
FCETAL ASC'ITK.S
561
gastro-iiitestinal caual. In Herman's case, however, the cause seems
to have l)een pressure on the portal vein by a large tumour of the
right supra-renal capsule {Med. Times and Gax., ii. 731, 1881). I5ut,
with few exceptions, the ascites seems to have been due to peritonitis,
a conclusion whicli appears t(i be warninted by the luorbiil anatumy
of most of tlie specimens. What the cause of the peritonitis may
have been is not well known, but in one case (Olshausen's, loc. cit.) it
was the escape of urine into the peritoneal cavity. In Fordyce's
specimen {loc. cit.) the peritoneum had lost its normal endothelial
covering, and great thickening of the subendothelial connective tissue
362 ANTKNATAI. I'Al'1 1()1,( K.V AM) lIVdIKNK
had taken jilacc, witli degeneration of some of its siiiierficial layers
(Fig. 5;'.). Hardiiuin and Morcaii {J<<r. ohslrt. interna/., sup}i/., i. 184,
1895) report a case in which tlie fo'lus exhibited ascites, hydro-
thorax, sliglit hydropericariHuni, ahmg with cleft i>alate and cardiac
malformations ; the authors regarded the ascites as due, in this case,
to the anomaly of the heart (absence of com])lete interventricular
septum). It is necessary, then, to keep in mind that f(ctal ascites,
like general fa^tal dro]isy, may he due to several causal factors; at
the same time I'orak and Sevestre (flull. Sue. a mi/, dr Par., 4 s., i.
314, 1876) and Fordyce give the lirsl ]ilacc in the pathogenesis to
peritonitis.
There seems to be no reason why aspiration of the abdomen
should not in some of these cases give relief; if this i)rocedure were
carried out during labour as soon as the cause of the delay was ascer-
tained, not only would the confinement be quickly ended, but the
infant might he born alive and sur\ive (as one case at least has
already demonstrated).
FcEtal Peritonitis.
As has been shown in the preceding paragraphs, jieritonitis is one
of the pathological causes of foptal ascites, but I set apart here a few
lines to the consideration of fcetal jteritonitis itself, both with and
without effusion of fluid into the peritoneum. On this subject J. Y.
Simpson long ago wrote fully and most suggestively {Ohdc/ric Worls,
ii. 152-205, 1856 ; Udinb. Med. Sun/. Journ., i. 390, i838). That ante-
natal peritonitis may occur without ascites is proved liy an oliservation
(131) which I made some years ago. It was that of a female infant
looru in the Maternity Hospital, Edinlnirgh, after a somewhat j)rolonged
and instrumental labour ; the infant died thirty-two hours after birth,
with a considerably distended abdomen. I found that the large and
small intestines were distended with gas, and that the coils were
glued to each other, to the under surface of the liver, and to the ]ielvic
viscera. On separating the opposed surfaces, it was seen that the
peritoneal aspect of the l)owel had a markedly granular api)earance :
but there was no fluid in either the abdominal or pelvic jieritoneal
sacs. There was, therefore, a recent dry peritonitis, which might, it
is conceivable, have arisen during the short postnatal life of the
infant; but in the pelvis were signs of an older peritonitis, which
had produced adhesions between the Fallopian tube and broad liga-
ment and the ca-cum.
It is easily understood that comparatively few cases of foetal
peritonitis witiiout effusion have been recorded, for the condition does
not lead to abdominal distension, and to consequent delay in labour,
and so attention is not focussed ujjou the infant. Even among the
cases which are described as prriionitis, and not as a.scites, it is usually
found, as in the observation of G. Palazzi {Ann. di odd. c i/i)ici\.
xviii. 139, 1896), that there has been Huid in the peritoneal cavity.
Doubtless the dry form is often overlooked; .sometimes also it may
not cause earlv death, but be to a large extent recovered from, and
F(]',TAL ASCITES 363
only be detected later liy the ctlects to which it has yiveu lise. It
has been a cuiiiiuoii practice to ascrilie most of the iiialfonnations of
the abdominal and pelvic organs to t'letal peritonitis and to the
adhesions resulting from it ; no doubt there is a measure of truth in
this theory of causation, but it is only under certain circumstances
that it can be accepted. If the peritonitic adhesions form before the
malformed organ is fully developed, or during its development, it can
be understood that the peritonitis may have been instrumental in its
pathogenesis. Since the genital organs are late in developing, it is
very probable that many of their anomalies (absence of fusion of the
Miillerian duets, etc.) may be due to peritonitic bands and adhesions.
Anomalies in the position of the intestines and other abdominal
organs may possibly be due to the same cause ; Init it is veiy doubt-
ful whether the situs inversus visccrum which e.xisted in Gessner's
ease {C'cntrlU.f. Gynak., xx. 279, 1896) can be so explained. Per-
foration of the intestine has been met with (G. Eesinelli, Ann. di
ostet. e ginec, xxi. 89, 1899), liut whether as cause or effect of the
peritonitis is not known. It is impossible to foretell how far-reaching
maj' be the ettects of foetal peritonitis upon postnatal life, especially
if the generative organs come to be affected ; but this is a subject to
which I have already referred {ride p. 25). Among the many changes
which have been traced, with some show of probability to antenatal
peritonitis, is congenital obliteration of the bile-ducts ; and to that
interesting pathological state I must now devote a page or two.
Congenital Obliteration of the Bile-Ducts.
Among the services which John Thomson has rendered to a
proper understanding of the diseases of infancy must be reckoned his
work on congenital obliteration of the bile-ducts (Trans. Edinh. Ohst.
Soc, xvii. 17, 191, 1891-2; Allbutt's System of Medicine, iv. 253,
1897). What follows is almost entirely a presentment of his views.
Congenital obliteration of the bile-ducts may be defined as an
antenatal lesion of the bile-ducts, of practically unknown origin,
leading to obliteration of their lumen, and accompanied by biliary
cirrhosis of the liver, causing the supervention of jaundice early in
neonatal life, and entailing early postnatal death. Eighty cases or
so have been recorded, and with regard t(j them all the physician has
been compelled to confess therapeutic failure.
There is little or nothing that is special in the clinieal history
of the pregnancy which ends in the birth of an infant with this
anomalous state of its bile-ducts. The mother does not seem to have
suflered in any way. The father also has usually been healthy.
There is an exception, however, to the above general statement,
namely, the occm-rence of family prevalence, often to a very remark-
alile degree ; for as many as se\'en or even ten cases of infantile
jaundice due to this lesion of the bile-ducts have heen observed in
one famil)'.
The symptoiiiatolof/y is at the time of birth practically nil ; but in
a few days jaundice of a more marked and persistent type than the
364 AN'rHNAI'AI. I'AIIIOI.OC'*' AM) IIVdll'.NK
iinliiuii V icicrus lU'diiaLoium scl.s in, iuul soon the stools are observed
to Ije wliite in colour, tlie precedini; motions iiaving consisted of
normal <lark nicconiiun. Sometimes it would seem tlial the stools
were white from the l)eginning. The jaundice often becomes very
dee]), and usually persists till the fatal termination of the case.
There may be hiematemesis or mel;ena or omphalorrhagia; and in
other cases the hicmon-hagic tendency is revealed liy the occurrence
of subcutaneous ecchymoscs, or of epistaxis. The lucmorrhage may be
tlie cause of early death, but, if the infant pass this danger safely, life
is usually prolonged for some months, and then is terminated not
infrequently by an accidental complication. There is some emaciation
(although often this is inconsiderable) before the close, and convul-
sions may also occur. There is deep liile-staining of the urine, and
constipation is the rule.
The morbid anatoiiui of these cases is extremely interesting. The
liver is usually enlarged ; it has an uneven surface and a tough con-
sistence; and it is of a dark olive-green colour. Bands of til)rous
tissue form a network throughout it; and on microscopic examination
the lesions are found to be those of liiliary cirrhosis. Many of the
lesser bile-ducts are plugged with inspissated bile. The large bile-
ducts and the gall bladder are nearly always markedly ah'ected, but
the degree of the affection varies greatly. In one group of cases
(usually those in which death has occurred early) the ducts may .seem
to the naked eye to be little if at all involved, Imt thickening of their
walls is the rule, and complete obliteration of the lumen of the duct,
with fibrous tissue formation around it, is far from uncommon. In
the most advanced examples all that can be seen of the duct may be
a strand of fibrous tissue. The exact site of the oljliteration varies
greatly. The gall-bladder may contain colourless mucus, or very
thick bile, or a gall-stone; or its lumen may be almost obliterated liy
the thickening of its walls. The blood-vessels of the liver are gener-
ally normal; the spleen is enlarged; but the peritoneum is usually
unaffected, save in cases with a syphilitic history, and in tliem thcrr
are adhesions in the neighlwui'hood of the bile-ducts.
The pailioloijy of the disease, for the reasons so often stated
(peculiarities of antenatal environment, ignorance of antenatal
physiology, etc.), is obscure. It would seem that in s(jme cases
chronic progressive inHammatiou of the gall-bladder and ducts must
have begun very early in f(Ptal life (third month of antenatal
existence); these are the cases in which no coloured meconium is
passed. In others, the same process cannot have led to blocking of
tlie ducts till much later, if we are to account for the presence of
normal meconium in the bowel. It may be that a malformation of
the ducts caused narrowing of the available lumen, and so started
the whole morljid process by preventing the escape of the bile ; then,
on account of its retention, or by reason of irritating properties
possessed by it, the bile sets up inflammatory changes in its con-
taining vessels with resulting biliary cirrhosis of the liver. Again,
it is possible tliat the irritating character of the l>ile may be the
starting-point of the chain of morbid changes. H. IJ. IJolleston
CONGENITAL OBLITERATION OF THE BILE-DL(TS ^05
and L. 11. Hayne {Brit. iled. Journ., i. for 1901, p. 758), keeping in
mind tbe fact that poisons reach the fcetal economy and primarily
the liver by the umbilical vein, believe that on this account
some of the irritating material (toxin, poison) will at once set up
ordinary portal or mnltilobular cirrhosis, and that the rest of it will
pass by the ductus venosus into the general circulation. Some of
the poison will, however, also reach the Uver by the hepatic artery,
be excreted into the intra-hepatic bile-ducts, and set up cholangitis
and monolobular cirrhosis. In this way, according to Eolleston and
Hayne (loc. cit.), a mixed portal and biliary cirrhosis is set up; the
cholangitis descends to the larger ducts, and gives rise to an oliliterat-
ive cholangitis ; thus the primary changes are in the small intra-
hepatic ducts. What the poisons are that thus reach the fcetus is
not known, but there is some evidence that they are not syphilitic.
The marked occurrence of family prevalence would seem to show
that they are poisons which may be reproduced in several successive
pregnancies. There is nothing improbable in the view that such
poisons, if they come into action in the neofcetal or embryonic
period, may produce primary defective development of the bile-duets,
while if they act later they may set up first a cirrhosis and then
sulisequent obliteration of the ducts.
The diagnosis of the disease is hardly ever made until some days
after birth have passed, when the persistence of what was regarded
at first as transient icterus neonatorum excites suspicion, a suspicion
which the colourless motions and bile-stained urine, and latterly the
spontaneous luemorrhages, serve to confirm. The progjiosis is always
of the gravest kind, and with regard to treatment it must be confessed
that it is nil — ihcra2}ia nulla. Manifestly, if the whole process be
due to poisons reaching the foetus from the mother, the only hopeful
line of treatment will consist in preventing the formation of these
poisons or in hindering their transmission ; and for this we must look
to the as yet uudi.scovered " placental tonic " and to other forms of
antenatal therapeutics. It would in the meantime be of great import-
ance to find out the natiu'e of the transmitted poisons about which so
much speculation has taken place.
A bibliography of the subject up to 1896 is given l)y Jolm
Thomson {loc. cit.), and some recent references have been added l)y
Eolleston and Hayne {loc. cit.).
Congenital Hypertrophic Stenosis of the Pylorus.
Congenital Hypertrophy of the Pylorus (or Congenital Gastric
Spasm) is another antenatal condition towards the elucidation of
which John Thomson has materially contributed. Besides reporting
three cases, he has advanced an ingenious and very probable theory
of their i)athogenesis, and has published a good bibliography of the
subject {Scott. Med. Surg. Journ., i. 511, 1896; Edinh. Hosn.Ecp., iv.
116, 1896).
Tiie morljid condition of the pylorus and of the neighbouring part
of the stomach wall undoubtedly exists during foetal life ; but on
366 ANTKNATAl. TAil lOI.OC^' AM) I I'lCIF.NE
account of the priuciplo of potential iiKuliiility then existing it gives
rise to no synqitoms till after liirth has taken place, and the gastro-
intestinal tiact taken mi gieater functional activities. Under the
name of " scirrhus of the stomach, j)roliably congenital," T. Williamson
of Leith seems to have described liypertropliy of the pylorus as long
ago as 1841 {Month. Journ. Med. >SV., Edinb., i. 23, 1841), and since
then, but more particularly during the last twelve years, more than
thirty cases have Ijeen reported by various observers.
With regard to .si/iiijiloiiiatolvi/i/, it has to lie noted that at birth
the infant shows no signs of illness and has a well-nourished aii])ear-
ance, for the pathological state, although in existence, has not begun
to produce its dire ell'ects — latcl anguis in hcrhd. Tliere is a record,
in some cases, of maternal sufi'ering in in'egnancy, l)ut this is not
constant. The infant begins to vomit iu from two or three hours to
two or three weeks after birth ; at first the vomiting occurs at com-
paratively long intervals, but these soon diminish, and then every
attempt to swallow even a teaspoonful of fluid sullices to cause the
emptying of the stomach. The ordinary cau.ses of vomiting are
absent. The matters l)rought up are simply the swallowed fluids
mixed with mucus, and they are not bile-stained. The emesis may
be accomplished with great force, and this seems to be more markedly
the case when a laige quantity of Huid is given. Ordinary gastric
sedatives produce no good effect, although gavage may cause only
a temporary amelioration. The fluid being prevented from passing
from the stomach into the duodenum, lies there unabsorbed. There
is usually constipation, and the motions are scanty. IJy alidominal
palpation the hard hypcrtrophied pylorus can sometimes be left in
the epigastric region as a movable swelling, for the abdonunal walls
are lax and the intestines collapsed. Finkelstein {Jahrh.f. Kiiuhrhlh.,
xliii. 105, 1896) was able to make out this physical sign of the disease.
Infants suffering from hypertrophy of the pylorus li\e as a rule not
longer than three mouths; but there is a growing belief that recovery
sometimes (F. E. Batten, Lancet, \\. for 1899, p. 1511) occurs, and
that for treatment, therefore, there may perhai)S exist some little
spark of hojje — lateat scintillula forsan.
The morbid (matomy is practically limited to the ))ylorus and the
stomach wall. The stomach is somewhat enlarged, and its wall is
thin at the cardiac end, and greatly thickened everywhere else. The
pylorus feels almost solid, and has a fusiform or even an oval shape.
The pyloric opening seems closed, although a probe can be passed
through; and the narrowing is due to the hypcrtrophied muscle.
The mucous mendirane is tlirown into folds. In most of the cases
the circular muscular bands were those most affected by tiie hyper-
trophy, but in one instance at least the longitudinal layer was very
markedly thickened. The mucous and submucous coats may he
quite normal; but sometimes the latter was thickened (e.g., in (1. F.
Still's third case, Trans. Path. Soe. Lond., 1. 88, 1899).
The patliogenrsi.'f of this antenatal disease is of course diflicult to
understand: that scarcely rccpiires saying. It would seem that we
must consider the dilatation of the stomach and oesophagus, as well as
CONGENITAL GASTRIC SPASM 367
tlie hypertrophy of the pylorus and adjoining gastric wall, to be due
to increased but disorderly functional activity of this part of the ali-
mentary tract ; it would also appear to be necessary to postulate the
occurrence and the continuance of this over-action for some time
before birth. As Thomson {loc. cit.) points out, there is no evidence
that the spasm of the pylorus is due to a local lesion, such as an
ulcer of the mucous membrane, nor is there much, if anything, to
support the view of tlie ])resence of an irritating fluid in tlie stomach
during antenatal life. That the liquor amnii is swallowed by the
foetus and in large amount, can hardly be doubted {ride p. 153) ; but
that its chemical constitution is ever so altered as to make it a slow
irritant poison to the ffftal stomach, while it is of course possible, is
exceedingly improbable. We are, therefore, led to accept John
Tiiomson's explanation, that tlie nervous mechanism of the stomach
is at fault, and tliat an antagonistic spasm of the gastric and the
pyloric muscles is set up witli resulting hypertrojihy of both, with
stenosis of the pylorus, and with loss of power of absorption of the
stomach. To say that the congenital hypertrophy is a developmental
overgrowth, is really to say nothing at all, nothing at any rate save
what has been inferred in the name of the disease. The acceptance
of Thomson's theory that here we have to do with a " functional
disorder of the nerves of the stomach and pylorus leading to an ill
co-ordination, and tlierefore an antagonistic action of their muscular
arrangement," introduces some novel speculations into the realm of
Antenatal Pathology. Of course it is possible that the functional
nervous disorder may in its turn be due to " faultly development,"
yet the theory, if accepted (and I do not see how one can do other-
wise than accept it), introduces the idea of functional disorders into
antenatal pathology. The idea thus introduced may have far-
reaching consequences ; for it is obvious that it may be applied to
some of the cardiac malformations, to hyperti'ophy of the urinary
bladder and walls of the colon, and even to enlargement of certain
groups of skeletal muscles. Further, it may not only tend to clear
up doubtful questions of pathology and pathogenesis, it may also
suggest new methods of treatment, and instil fresh courage into the
fainting therapeutist, and rekindle that wonderful " scintillula " of
hope. Batten {loc. cit.) indeed has already fanned the " scintillula "
into a flame, albeit a small one, by suggesting that in congenital
gastric spasm the infant be fed by a nasal tube so as to avoid the
starting of peristalsis l>y deglutition. W. Abel {Milnchcn. med.
Wchnschr., xlvi. 1607, 1899), also, has recorded the first case treated
successfully by gastro-enterostomy (Wolfler's method).
There are other antenatal diseases of the digestive organs to
which reference might be made, such as congenital hypertroph)- of
the colon, congenital volvulus, etc. ; but it is impossible to find
space for more than the four types given above, viz. ascites,
peritonitis, jaundice, and gastric spasm. Of these the first is a
good instance of a foetal disease which leads to great delay in labour ;
the second is important on account of its possible bearing upon the
3G8
ANTI'.NATAI. 1' All 1()1.( Xl'i' AND 1 1 YCI I'AK
production of lualldiiiiaiicnis nf the generative organs; the third is
an example of tlial potential niorliidity of the fcetiis which becomes
so real after Ijirth ; ami the fourth has an interest peculiarly its own
because of its probable functional origin. Accompanying the fourth
type, also, is that little spark of liope that bespeaks a possible method
of successful treatment. Let us leave this part of the subject with
that "scintilla" shining clieerily ; may it prove to be im ignis fatuus
or Will-o'-the-wisii !
I
CHAPTER XXI
Types lit' I<linj,,itliii' Disi-asus of tlie Kd'Uis {n,nt.) : diseases of the
Circulatory Ajiparatiis ; Fu-tal Eiiducarditis — Rulatioii to Couguiiital
Cardiac Anomalies, Frequency, Etiology, Characters, Diagnosis, Associated
Malformations, Treatment ; Antenatal Atheroma ; Congenital Goitre, Defini-
tion, Illustrative Cases, Morbid Anatomy, Clinical Results, Treatment,
Pathology, and Etiology ; Diseases of the Kesjiiratoiy System.
Amoni; the idiopathic diseases of the i'o'tiis must be reckoned certain
maladies of the heart, A'ascular system, blood glands, and lungs, such
as foetal endocarditis, congenital atheroma, congenital goitre, and fcctal
pneumonia. Several of the diseases included in this grouii will, no
doubt, yet find their way into the division of the transmitted morbid
states ; abotit others almost nothing has been securely ascertained ;
and, taking the group as a whole, it mnst he confessed that even
more than the nsual ol:>scurity belonging to antenatal matters hangs
round it. Nevertheless the attempt nuist be made to set forth our
ignorance, if we have nothing else to ofl'er.
Foetal Endocarditis.
Fwtal endocarditis is a condition to which reference is so con-
stantly made, more especially in connection with congenital cardiac
anomalies and malformations, that it may be supposed that behind
these multiple references nuist lie a large number of well-ascertained
facts. But this is very far from the truth. Many and careful
indeed have been the reports of cases of congenital malformations
of the heart, and fretal endocarditis is referred to in connection with
nearly all of them ; but a scrutiny of the facts leaves the reader
impressed with the indetiniteness of the references and with the
hypothetical nature of many of the most confident assertions which
are made. Let us see whether anything can be done to throw light
upon this matter.
From the neofcetal period on to the very end of antenatal life,
the formation of the heart may lie said to be in alieyance ; it is
nearly as well formed at the beginning of the second month of
pregnancy as it is a day or two before birth. During this long
period it grows in size and weight, and is very active in sending
the blood round the circulation, but it develops scarcely at all ; no
great changes are seen in it, for all the great antenatal developmental
(processes have been completed before the end of the second month.
'The auricles have been shut off from the ventricles save at the mitral
and tricuspid openings, and the right side of the heart from the left
24
370 ANll'.NAlAl, I'AIIIOI.OCV AM) IIYCII'.NK
.save at the fcnaiiicn ovali; : llic ]iiiliiiiiiiai v artery and the anrta liave
lieen dillereiiliated and liave taken on tliuir sejiarate functions ; and
the valvular apparatus is coniplute. Developnientally the lieart is as
perfect at the second nioiitli as at the ninth. Therefore it is ex-
tremely dillicult to understand how endncarditis supervening^ hctwecn
these two dates can produce lualfonuations which are evidently
arrests of formative processes which are anterior to the first of
these dates. On the other hand, it must lie rememhered that a i)art
of the emhryology of tlie heart is left until antenatal life is over,
and is acconiplislied in the first days of postnatal existence; 1 refer
to closure of tlie interauricular cnniiiiunicatinn and to uhlitcralion of
tlie ductus arteriosus.
Now, let it he sujjposcd tliat endocarditis attacks liic heart at
some time hetween the second month and the full term of antenatal
life. The affection of tlie endocardium, it may he readily adnntted,
will so injure the vitality of the heart that after the infant is l)orn
there may he a delay in the normal closure of the foramen ovale and
the ductus arteriosus ; in this way, it is quite conceivable, may be
jtroduced the ordinary form of con;4enital cardiac anomaly — a jiatent
foramen and a pervious ductus. Perhaps it may lie necessary to
admit that the endocarditis sliall have specially attacked the margins
of the foramen ovale and the walls of the ductus ; but the a.ssump-
tion is not at all an improbable one. Sometimes, also, it may be
supposed that the iuHammatory process will lead to jircmature closure
of the foramen or ductus — a matter already referred to {ride pp. 235,
293). But, it may be asked, is endocarditis coming on in fcvtal life
not instrumental in producing any other of the malformations of the
heart met witli at liirth ? It is eonceivalile that it may interfere with
the rate of growtli of tlie various parts of the heart, although its
supervention may be too late to interfere with their actual formation
In this way may be produced "congenital stenosis of tlie jnilmonary
artery and aorta." It is also conceival)le that endocarditis coming on
very early in foetal life (ncofojtal period) may interfere with the
normal completion of some of the last of the truly formative or
embryogenetic ])arts of tlie development, and so lead, for instance, to
persistence of the interventricular communication or to anomalies in
the separation of the great vessels at the base of the lieart. IVIal-
formations due to the persistence of embryogenetic pliases anterior
to the neofoetal period, can hardly he ascribed to fcetal endocaiditis,
unless, indeed, it can be proved that this disease exists or can exist in
these early periods.
It must not be forgotten tliat there is another aspect of this
relation of fo'tal endocarditis to cardiac malformations. It iinist be
regarded as probalih- tliat iiiflammation will be more lialde to attack
a malformed tlian a well-formed heart. Tlie presence of malforma-
tions will predispose to foetal endocarditis, " Le vice de structure
cree la vulnerabilite " (Mou.ssous, in Grancher's Traiti! dc mal. de
Z'm/ffncf, iii., p. 601, 18!)7).
There are, therefore, two more or less o]i]iosed theories regarding
congi'iiital cardiac anomalies — the teratological and tlie ]iatliological.
F(ETAL ENDOCAHDiriS 371
According to tlie one, they are instances of "errors "in formation;
according to the other, they are tlie results of fti;tal endocarditis.
But the degree of opposition between these views has l}een exagger-
ated ; indeed, the two theories are not incompatible. The structural
defects and malformations and the signs of foetal endocarditis may
have a common origin, and may exist side by side a.s evidence of a
ciimmon cause which has begun to act in the embryonic period of
antenatal life, and has not ceased to do so in the fretal period.
Tiie subject of congenital cardiac anomalies and of the cyanotic
condition {morhiis ciuruleiis) which so often accompanies them is very
large, and can only be touched ujion here. The literature is given
with considerable fulness bj- H. Vicrordt (Die ani/ehorencn Hcr-krank-
heitcn, Wien, 1898) ; to this work the reader who wishes to explore
this interesting dejiartment of medicine is referred. I have tried to
indicate the relation which exists or probably exists between foetal
endocarditis and these congenital heart cases, and in a strict sense
this is the only point at which Fidal I'athology and the " Congenital
Hearts " come into contact. For it must be borne in mind that an
open foramen ovale and a pervious ductus arteriosus are not abnormal
but normal during fa'tal life, and that many of the cardiac malfor-
mations which are present in the fo'tal period of antenatal existence
are truly emlnyonic in origin, and were already present when the
embryo became a fretus. I'rom my present standpoint, therefore, which
is that of Fn_^tal Patliology, the subject is very consideral)ly narrowed
down. At the same time it is necessary to refer, l:iut with Itrevity,
to certain of the anomalies, neonatal as well as embryonic in origin,
with which fietal endocarditis is associated.
It would appear that fa^tal endocarditis is relatively common, if
one accepts the evidence afforded by the presence of white or yellow
thickenings on the endocardium, of contraction of the openings or
cavities of the heart, and of pathological states of the valves.
Theoretically, tliere is no cause to doubt the frequency of fcetal
endocarditis, any more than that of antenatal hepatic cirrhosis ; for
if it lie granted that these diseases are due most often to microbes,
toxins, and poisons coming from the mother to the f(etus through the
placenta, then the two organs first reached by them will be the liver
and the heart, and it is reasonable to look for lesions in these viscera.
In this way, as I have already shown {vide pp. 182, 198, 208, etc.),
fevers, tubercle, syphilis, alcoliolism, and other morbid states in the
mother reaching the fictns through the umbilical vein set up cardiac
and hepatic lesions in the latter. It is possible, also, that some cases
of foetal endocarditis arise from bacilli and toxic products manufac-
tured liy and in the fcetal organism itself : indeed, if we hold the
infective theory of causation of endocarditis, it is necessary to accept
this supposition, for in many instances the mother's health in preg-
nancy has been good, and there has been no chance of a microbic or
toxic invasion of the fcetal tissues by way of the placenta. Some of
the cases, therefore, are really of the natui'e of transmitted maladies,
while others are idiopathic. If the parts in the heart are affected
according to the order in which the toxic or microbic products reach
o72 ANJ'l'.NAlAI, I'ATIIOI.OC;^ AM) 1 1 VC.Il'AK
lliL'iii, il will i'iill(j\v tluit the ruraiiieii oviili', llic uiilral valvf, the
aortic urilice, the trieiisiiiil valve, the imhiioiiaiy aiti'iy, and the
(liictii.s arteiiusiis will he attacked iii that order. Al)Oiit this matter,
however, there can he little more than speculation in the present
state of our knovvledf>;e. Certainly, narrowinjj; of the ]iulnionary
artery would appear to he the most commonly ohserved congenital
cardiac anomaly, and instances of lesions aflecting the tricuspid valve
are not wanting (r//., Brindeau, Ann. dc <jyni'c., xlv. 79, 189G ;
Zariquiey, llcv. mens. d. mal. dc Vcnf., xii. C20, 181)4); hut it must he
liorne in mind that the former of tliese is not admitted hy all or even
hy many writers to he caused hy Icetal endocarditis. Nevertheless
the statement is made with ajijiarent coniidence that the right side of
the ftetal heart is more often all'ected with inllammatiou than the
left. The confidence may he justified ; hut it ought at any rate to lie
l)orne constantly in mind that the fact that the right side of the
heart has as thick walls as the left does not jirove hypertrophy of the
former {vide p. 111). The two ventricles may have walls of e<iual
thickness and yet he normal in antenatal life. This fact and others
like it are too often forgotten or neglected in drawing conclusions as
to the effects of fo'tal endocarditis. Y.V.'W2\fCV {Tnms. Putli. tSoc.
Lond., xlviii. 51, 1896-7), in descriliing the heart of an adult showing
calcification of the tricuspid valve, stated liis helief that it was due
to intrauterine endocarditis, hut lie wisely inserted the w'ord " jiroh-
ably " ill the statement ; it would be well if other writers were
equally guarded and made more use of " prohahly," and also, pei-haps,
of " possibly."
Toetal endocarditis stands out prominently among the other
maladies of antenatal life, by reason of the fact that it has been
diagnosed before birth. H. Padgett (,Soutk. J'rarti/ioner, Kashville,
xvi. 318, 1894), for instance, detected a harsh systolic murmur during
auscultation of the foetal heart in pregnancy ; he made the diagnosis
of mitral heart disease of the unborn infant, and confirmed his
diagnosis by the examination of the infant after birth. Bellot
(Bid/. Soc. anat. dc Par., 5 s., ix. 757, 1895) heard a murmur l>cfore
liirth ; the infant was born in a state of cyanosis, and died on the
fourth daj-; at the autopsy a single vessel (aorta) was found arising
from the base of the heart (from the right ventricle). J. N. Hall
{Arch. Pcdiat., xiv. 905, 1897), in his communication, also gave details
of cases reported l)y Barth, Hennig, and Christo])her ; in the examjile
reported by himself, the lesion seemed to have l)een a roughening of
the lining membrane of the ductus arteriosus, for the murmur which
all'ected the first sound disappeared ten days after liirth. In esti-
mating the value of the antenatal diagnosis of fa'tal heart murmurs,
the possible fallacy of the uterine souffle must not be forgotten ; but
there seems to be sulHcicnt evidence to justify the hope that along
this lino advances may be made in the investigation of fo'tal
maladies. After the birth of the infant the diagnosis of the state of
its heart is made, of course, l)y the ordinary clinical methods; and
the symiitomatology and ])hysieal signs of congenital heart disca.se
and malformation have now l.ieen well estal.ilished, and are to he
FCETAL ENDOCARDITIS 373
fduncl in most text-books of medicine and diseases of children. The
cyanosis (early or late in appearing), the curious polycythiemia or
return of the blood to the fcetal state as regards the nuniber of
tlie erythrocytes, the dyspncea and palpitation, the hypotherniy, the
elubliing of the fingers and tlie cardiac murmurs (usually systolic),
all coml)ine to form a clinical picture which is easily recognisable.
It must lie borne in mind that these signs and symptoms are mostly
due not to the endocarditis, Imt to its results or supposed results,
the cardiac malformations. Difficulties arise when the attempt is
made to diagnose the exact malformation or combination of mal-
formations which are present in any case ; but even in this difficult
department of medicine considerable progress has been made. The
discussion of these questions, however, would lead me outside the
scope of this work.
It is a noteworthy fact that congenital cardiac anomalies, and
therefore also endocarditis (if we accept the inflammatory origin of
some of these anomalies) are often found associated with malforma-
tions of other parts of the body. Thus, to quote from a recent
contribution, John Thomson and W. B. Drummond {Edinh. Hasp.
Rep., vi. 57, 1900) found, in a series of nine cases of congenital heart
disease, that in three of these there were such malformations as
hare-lip, cleft palate, imperforate anus, malformation of external ear,
and horse-shoe kidney ; in another case, there was " Mongolian "
imbecility, and it is a remarkable fact, noted also by A. G. Garrod
and others, that this type of imbecility should be often associated
with congenital cardiac anomalies. All these fragments of evidence
go to support the view that cardiac anomalies, foetal endocarditis,
and malformations of other parts of the body are the results of the
action of a common cause, and that the ditterences in the nature of
the results are due to the fact that the cause acts at different times,
and consequently upon an organism in ditterent stages of develop-
ment. Series implcxa causarum — an involved chain of causes '
I was recently consulted about the case of a woman who had
given bu'th to an infant suffering from congenital heart disease
(patent foramen ovale, etc.), which survived its birth eleven months ;
the father was strongly alcoholic at the time of the infant's concep-
tion and for two years previously, but the woman herself was
practically a total aljstainer. She was again pregnant (seven weeks),
and I was asketl regarding the probaljle prognosis as regards the
oflspring. The husband's habits had shown distinct signs of improve-
ment, and on this account, and because the mother was practically
an alistainer, I gave a more hopeful but guarded forecast for the
infant. I have recently (Xovemlier, 1901) heard that this child was
healthy and free from cardiac trouljle.
Wliile little has been done towards the antenatal treatment of
congenital cardiac anomalies, it is an interesting fact that apparently
they are sometimes recovered from after Iiirth. Evidence supporting
this conclusion is supplied by John Thomson's case {Arch. Feeliat.,
xviii. 193, 1901); possibly similar instances might lie found if care-
fully looked for ; possibly, also, antenatal recovery may not be rare.
374
ANTENATAL I'All lOl.OC^ AND IIVCIKNE
Antenatal Atheroma.
Little is known I'cu'iinliiiLi; discuses nf the lilduit vessels in lu'tal
life, save in connection with the clian<;es which they underjro in
syphilis (vide p. 230). Certainly we should not expect to find morbid
conditions which an; ehai'actcristie of old age in antenatal life,
nevertheless Durante (Bull. Sue. annl. de I'ur., 6 s., i. 97, 1899) has
recorded a case of atheiMiua in the infant at hirth. The child was
born at the seventh month, and died a fortnight later with signs of
general (edema and ]ieritonitis. 'The heart showed no lesions, and
there was no pericarditis. The pulmonary artery, however, had hard
walls with patches of considerable density, s\icli as
are found in the senile aorta ; its inner surface was
white and smooth. The aorta felt uiuisually rigid.
The microscopical examination of the heart (endo-,
peri-, and myocardium) ga\e normal results: but
in the deeper jxirtious of the middle coat of the
pulmonary artery there was marked fatty degen-
eration and calcareous infiltration. The aorta
showed similar but less evident changes. In
neither vessel was the intima atfccted. The
changes could hardly have occurred after liirth,
and the absence of signs of endocarditis })recluded
the idea of postnatal infection. We are driven,
therefore, to the conclusion that atheroma of the
aorta and ]iulmonarv arlerv mav occur in antenatal
life.
Congenital Goitre.
Under the name " struma congenita '" have been
lescribed various swellings of the neck found in
the infant at birth. Along with its synonyms,
"intrauterine goitre'' and "intrauterine liron-
cliocele," it has been made to include not only
enlargements of the thyroid gland and parathy-
Vroids, but also cervical h3'gromata, cervical sjiiua
bifida, and ranula. The name, if it is to be retained
at all, ought to be reserved for swellings of the
p'iP,_ 5g_ thyroid gland alone; but it is not a. good term,
and might be abandoned altogether with more of
profit than of loss. I met with a specimen of this morbid state in
1894, which is represented in Fig. 55: it was a foetus w"eigliing
178 grms., born between the fourth and fifth months, and showing a
general congestive enlargenuMit of the tissues of the neck between
the lower jaw and the manubrium sterui ; the case occurred in the
practice of Dr. E. Coleman I\Ioore, and the parents were free from
any cervical enlargenunit. T have recently examined another casi' of
large cystic swelling in the neck, but it was evidently a congenital
hydrocele or hygroma, and not at all of the same nature as Dr.
Coleman Moore's case.
CONGENITAL GOITRE 375
During the last fifty years a considerable number of observations
of congenital enlargement of the thyroid gland have Ijeen published.
In Edinburgli, A. Keiller {Edinh. Med. and Surg. Journ., Ixxxii. 31,
1855) reported a case in which there was a large irregularly lobu-
lated swelling in the region of the thyroid gland in a new-born
infant ; the child had presented by the forehead, for, on account of
the cervical tumour, the normal Hexion of the head could not take
place ; neither the mother nor any of her relatives were goitrous.
A somewhat similar case was described by J. Y. Simpson {Month.
Journ. Med. Se., xx. 350, 1855) ; it was the tenth child of a non-
goitrous woman ; it was born somewhat prematurely, and, on account
of the compression of the trachea, died in eight hours ; tlie thyi-oid
gland was nearly as large as a hen's egg, and caused delay in labour
and an alniormal presentation (forehead); all parts of the thyroid
were equally affected, and the gland surrounded the trachea almost
entu-ely ; its vesicular cavities seemed not only increased in number
but enlarged in size also, and the septa between them were con-
siderably thickened ; and the thymus gland and adrenals appeared to
be normal. A. E. Simpson (Glasgow Med. Journ., 3 s., i. 181, 1866-7)
also met with an instance of congenital " g<:)itre " in a case where the
mother had been taking chlorate of potash in pregnancy, with a view
to the prevention of miscarriages and premature labours ; the anterior
fontanelle presented and labour was delayed ; the thyroid seemed to
be equally enlarged in its isthmus and lateral lobes ; at first there
was ditficulty in respiration and deglutition, but at the age of four
months the tumour was much shrunken and the child (a male)
appeared healthy.
In addition to these cases, published in Edinlmrgh and Glasgow,
there have been others reported, more especially on the Continent.
Among these may be mentioned the observations of E. W. Crichton
(Fdinb. Mrd. Journ., ii. 149, 1856), of V. Betz (Ztschr. f. rat. Med., ix.
233, 1850), of A. Besnard {Afeel. Cor.-Bl. layer Aerzte, viii. 806, 1847),
of Diener (Schweiz. Ztschr. f. Med. Chir. v. Geburtsh., Zurich, 455,
1848), of Malgaigne {Eev. mi'd. chir. de Far., ix. 368, 1851), of Dan-
yau (Gaz. d. hop., xxxiv. 78, 1861), of Bcraud and Danyau {Bidl. Soc.
de chir. de Far., 2 s., ii. 108, 1862), of 0. Spiegelberg (Wiirzb. med.
Ztschr., V. 160, 1864), of Frobelius (St. Fetersb. med. Ztschr., ix. 175,
1865), of L. Porta (Gior. di ancd. cjisiol, iii. 37, 1866), of W. Miiller
(Jenaischc Ztschr. f. Med. u. Neiturw., vi. 454, 1871), of Efiug (Deutsche
Ztschr. f. Thiermed., i. 349, 1875), of L. Mayer (Beitr. z. Geburtsh. n.
Gyndk., iii. 86, 1874), of H. Lohlein (Ztschr. f. Geburtsh. u. Gyndk., i.
23, 1875), and of others. C. Taruffi (Sulle strume congenitc deUei
tiroide, Bologna, 1892) gathered together a great many of the pub-
lished cases and considered the whole subject, as did also E. Demme
(in Gerhardt's Handbueh der Kinderkrankheiten, Band iii.. Heft ii. 388,
1878), Schenk (Dissert., Heidelberg, 1891), and some others.
The enlargement of the thyroid varied much in different cases,
being sometimes of the size of a hen's egg and sometimes as large as
a fcetal head (A. Billig, Dtsscr^., Heidelberg, 1892) ; its weight has
exceeded 100 grms. The enlargement may affect all the parts of the
r.TG ANTKNATAI. I'Al'l l()I.()( ;Y AND IlVdIKNK
gland, but cases have l)ecii leiioiled in wliicli one lobe only was
affected. In stiuctme the tumour may he (1) of an adenomatous
type, but that is not the commonest form ; (2) it may be made up of
an increase in the vesicular substance of the gland (parenciiymatous
type), and may t lien show colloid or true cystic changes; and ('■'>) it
may be of the ctjugestivo tyi>e. Sometimes tiiere is a concomitant
enlargement of the thymus (!•". Weber, Ikitrdgi- z. jKiih. Anat. der
Ncwjchornen, Lief. ii. 84, Kiel, 1852); sometimes, also, the thyroid
tumnur contains cartilaginous or my.Komatous tissue.
The effects of fietal goitre become apparent as soon us ]iulmonary
respiration is rendered necessary, for tlie swelling usually compresses
the trachea so as to impede breathing, or else ])roduces a similar result
by pressure on the nerves in llie ueighljourliood. ]lef(U'e birth the
life of the feetus is not threatened ; but an abnormal presentation
(forehead, face) may be produced, and so delay, and possibly infantile
death during labour be brought about. After birth, if the first dangers
from difticulty in establishing respiration are overcome, the swelling
in the neck tends to diminish in size, and may almost entirely disappear.
This tendency to wither away must be taken into account in estimating
the result of treatment, as in the case reported by A. Mossi' and
Cathala {Bull. Acad. Med., 3 s., x.xxi.x. 420, 1898), in which a goitrous
mother who was nursing her goitrous infant was treated with dry
thyroid extract with an apparently beneficial eflect upon the infant.
A more radical method of treatment was that adopted by Polo.sson
and reported l)y Genevet {Lyon nu'd., xcii. 30l'>, 1899) : the infant was
the child of a goitrous mother, and was born in a state of apparent
death ; it was resuscitated with great difliculty, and still showed
marked dyspna3a and noisy respiration ; a tumour was discovered in
the neck of doubtful nature : an incision was made in the middle line
and a fairly large goitre was exposed ; the tumour was pulled gently
out of the wound (exothyropexy), and left outside without any dressing
to atrophy ; and Polosson intended to hasten this process if necessary
by punctures with the thermo-cautery. In Brosin's case {Centrlhl.f.
Gyniik., xviii. 1170, 1894) operative treatment did not succeed.
In considering the etiology and pathogenesis of so-called con-
genital struma, we meet with two well-ascertained facts: one is the
birth of goitrous infants by goitrous mothers, and the other is the
occurrence of cases in which the infant has an enlargement of the
thyroid gland, and yet neither the mother nor father nor any other
relative suffers or has sullered in a similar manner. This morbid
state, therefore, would a])pear to have an equal claim to admission
among the transmitted and the idiojiathic diseases of the fietus; or
rather, if the statistics of 1 )emme {op. cit.) are had regard to, the malady
would be placed with those that are transmitted. The condiliun
would seem to be most common in the localities in which goiire is
most common ; in Switzerland, for instance, Demme reported (142
cases, and 53 of these were congenital. Among the 53 congenital
ciises there were 14 in which l)oth ])aienls were goitrous, 23 in which
the mother alone w'as affected, and 10 in which l>oth jiarents were
exempt from the malady. Tlie congenital cases ditl'cr from those in
COXGEMTAL (iOITRK 377
the adult in showing a preference for the male rather than for the
female sex. It is, after all, absolutely necessary for us to know more
aliout the pathogenesis of goitre in general before we can hope to
solve the problem of its transmission or non-transmission from parent
to child. Possibly some of the cases in which there is no history or
evidence of a family tendency to goitre may be really instances of
cystic enlargement of other structures in the neck {ride C. Tarutii,
op. cif.).
It is not my intention to give any space here to the consideration
(if the idiopathic diseases of the lungs and pleura in the foetus. I have
already referred to the state of the lungs in sepsis (p. 217), in syphilis
(p. 234), and in tubercle (p. 208); and after one has named these
occasional morbid conditions, as well as the pneumonia which arises
from pulmonary infection during labour, it may indeed be doubted
whether there ai-e any diseases of the fcetal lungs which are really to
Ije regarded as idiopathic.
CllArTEU XXII
Types nf Idioimthic Diseases of the Kn'tus (amt.) : Diseases (if tlie I'l'iiiarv
Apparatus : Fcetal Nephritis, Distension of the lihidder, Ilyiieitroiihic
Dihitation of the Blarkler, Hydronephrosis, Cystic Degeneration of the
Kidneys: Diseases of the Genital Orj^ans : Conf;enital Prola])se of the
Uterus ; Diseases of the Nervous System : Hydrocephalus ; Little's Disease ;
Congenital Chorea ; Friedreich's Ataxia ; Thonisen's Disease ; Congenital
Cloudini; of the Cornea.
Ix this Chapter I ,L;allier together some of tlie reiiiaiiiiiig- types of
idiopathic disease in the fcotus, although it mtist be freely admitted
that they are scarcely " tj'pical," and that they are only doubtfully
idiopathic. About some of them very little is known, and al>out
others tlie information which we possess is chiefly obstetrical, and
arises from the delay in labour which they cause by the alteration
in the size of the fn'tus which they produce. A short chapter is
therefore all that need l)e set apart for their consideration.
Diseases of the Urinary Apparatus.
I have already (ji. IG'2) adduced evidence to slmw tiiat the
urinary organs are functionally active during fcetal life ; and it may
therefore be concluded that they will be subject to diseases during
this period. Cases, also, are actually on record which demonstrate
this. Some of these produce dystocia by reason of the alidoniinal
distension which they give rise to, and about them a good deal of
information is forthcoming : others do not cause any special enlarge-
ment, and have been little investigated. In the latter group fo'tal
nephritis must l)e placed. Some few facts, however, are kiiciwn with
regard to it, and these may now be stated.
Fcetal Nephritis.
Allusion has already been made to the changes in the kidneys in
fd'tal syphilis, and it has been stated that possibly in some instances
of general foetal dro])sy the starting point of the morbid process
may have been a renal intlammation : but there is some evidence
also that nephritis may arise in antenatal life in an idiopathic
fashion. In a case which I examined and reported on some years
ago (Dixrancn of the Fidmt, ii. 15, 189.")), the prcMuature infant of a
woman suil'ering from bronchitis and imeumonia developed (cdenia
of the lower limlis and trunk within a few hours of birth, and died
FCETAL NEPHRITIS 379
in two days ; during his brief life he passed no urine so far as could
be ascertained. At the post-mortem a condition of intense con-
gestion of the kidneys, and more especially of their cortex, was
found ; under the microscope, cloudy swelling of the cells of the
urinary tubules and small cell infiltration of the Malpighian bodies
was discovered, changes which pointed to tubular and glomerular
nephritis. Of course it is possible that, in this instance, the renal
alterations were entirely postnatal ; some evidence in favour of an
antenatal origin of the nephritis was present, but it was not conclusive.
Stronger proof, however, is forthcoming, for in March of the present
year (1901) I received from i)r. Henry Ashby of Manchester the
notes of a case whicli seemed to have been one of undoubted fostal
nephritis. The case was that of an infant, twenty-one days of age,
intensely dropsical in the face, limbs, and alidomen ; it died in ura-mic
convulsions ; and the post-mortem examination revealed the presence
of kidneys showing marked chronic or subacute nephritis in the " small
wliite " stage. Under the microscope the organs, which presented
tlie ftt'tal loliulations very plainly, showed blood and fibrinous casts,
dilated convoluted and straight tubules, fatty epithelium, and com-
mencing fibro-cellular changes around the glomeruli and between
the tulniles. The mother was a healthy woman, who had not suffered
from nephritis, and there was no history of alcoholism, syphilis, or
any form of poisoning. During the life of the child little urine was
passed ; the dropsy appeared on the second day of life. I agree witli
Ashby tliat it is very probable that this was an instance of fo;'tal
nephritis ; further, in the absence of any other evidence, it must be
regarded as idiopathic foetal nephritis.
As has been already pointed out, albuminuria in the new-l)orn
sometimes occurs even when the mother has not suffered from
nephritis or eclampsia; and this neonatal albuminuria apparently
does not always or often signify permanent renal lesions. It may mean
nothing more than an imperfect development of the renal epithelium.
On this question Hugo Eibbert's article (Arch. f. path. Anat., xcviii.
527, 1884) may he consulted with profit. Nevertheless, the occa-
sional occurrence of nephritis which has begun in the foetus while
still in utero cannot, I think, be doubted. Along this line most
useful pathological investigations upon still-Ijorn infants might be
made. The relation of the f(etal renal lesions to placental morbid
states is also well worthy of study.
Distension of the Bladder.
Many cases are on record in which labour was delayed by an
enlargement of the fatal abdomen caused by an enormously distended
urinary bladder. These cases must, I think, be separated from
those in which the bladder is hypertrophied as well as somewhat
dilated. In the former the morbid state is evidently a distension of
the fo'tal bladder on account of grave malformations of the urethra
and external genitals ; in the latter no such explanation is
feasible, and the condition is rather to be comxmred with con-
380 AXTF.NAIAI. 1' A 11 lOI.OC 1^ AM) IIYCII-.NF,
goiiilal liy]icrtni]iliy 'if tlio ]iyliinis and L'iiliii;j;('im'iit of the colon.
A few Words aiv, all that aic iiccessai y with i('.i,'ard to the fonner
anomaly.
The dislen.siiiii of th(^ Madder with iii'ine may reaeh a trnly
enormous degree, so that the head and lindis of the fo-tns apjicar a.s
insiynilieant appendages to the large glohular trunk. The striking ||
deformity thus produced was very evident in the specimens of F. L
Fabris (Ann. dl oxtd., xvii. 329, ISDo), C. Taruffi (Mem. d. r. Accad. \'
d. nc. d. ftitit. di IJoloi/na, 5 s., iv. 73, 1894), V. Frascani (A//,i Cowj. j^
(len. d. Asfi. vied. Hal., Siena, xiv. 538, 1891), (1. Schwv/.er {Arclt. f. '|
'Gi/naek, xliii. .•'.33, 1893), A. Mueller (ddd., xlvii. 130, 1894), AV. 'i
Westphal (Dissert., Konig.slierg, i. Pr., 189G), Kristellcr (Mimntsehr. I
f. Gelmrtsk. v. Francnh:, xxvii. 1G5, 1866), and many others. In .1
F\il)ris' case, for instance, the fcetus, which was born at the ninth [
month, measured 45 cms. in length, and had a greatly enlarged ab- \t
dominal circumference (exact measurement not given). The bladder '
contained 2i litres of fluid. The undjilical cord appeared to lie ' |
normal, and was inserted upon the greatly distended abdomen in the ' i
usual way. There were no traces of external genital organs, and I
there was also atresia ani ; from coccyx to pubes the .skin wa.s un- ''<■
broken by any depressions, fissures, or elevations. In the alidominal |
cavity was a large sac with a circumference of 40 cms. ; in its upper !
part the sac was adherent to the diaphragm, liver, and stomach ; its
walls were rather tliick when contrasted with the thinned out alj-
donnnal parietes. On the inner aspect of the sac (the bladder) ;
could be seen the openings of the two ureters which were pervious,
but there was no indication of the internal orifice of the urethra ;g
.save a slight depression. The rectum en<led blindly in an enlarge- jl
ment which adhered to the left side of the distended bladder. The *
kidneys and ureters had their normal appearances. There were no
traces of vesicuLe seminales, vasa deferentia, prostate, urethra, and
interaal genitals. Tlie li'juid found in the bladder was clear, trans-
parent, limpid, and had a specific gravity of 1007. There was
marked hydramnios in this case, and the labour was delayed and
had to be terminated artificially liy forceps and puncture "f the
abdomen.
The al)0ve case may be taken as a type of this variety of fietal
disease, although in several of its details it differs from other
instances. Sometimes, for example, there is scarcity instead of
abundance of liquor amnii, and there are also sometimes other kinds
of concomitant malformations, e.g. anomalies of the limbs, horse- ■
shoo kidneys, hy]iosjiadias, ui'cteral dilatations, etc. In Schwyzer's I
specimen (loe. cit.) the fluid in the fcetal liladder is .said to have
reached the large amount of 01 litres. Iii these cases the dislen.sion
of the foetal bladder is evidently the result of the concomitant mal-
formations ; they are not, therefore, strictly to be regarded as diseases,
hut as morbid conditions due to teratologieal states. In this respect
thev dill'er from the cases now' to be referred to.
DILATATION OF THK BLADDKR :J81
Hypertrophic Dilatation of the Bladder, etc.
Ill 181)4 I received froui l)r. W. Cardy Blucka fn'tus, wliich showed
very clearly a state of hypertrophic dilatation of the bladder and ureters
along with hydronephrosis (176). The mother was 37 years of age and
a 6-para ; and the five previous children were all alive, but delicate
and rachitic. In the present iu.stance, labour came on at the eighth
month ; the presentation was the vertex, the position L.O. A.; the labour
lasted eight hours, and the pains were infrequent and feeble ; the
amount of liquor amnii was estimated at not more than one fluid
ounce (oligohydramnion). The father was a strict vegetarian, and
confined his family chiefly to milk and bread. The infant, a male,
was still-born; it weighed 5i lbs., and had talipes varus of both
feet and drop-wrist of the right hand. A rounded tumour could be
felt on the left side in the abdomen. When the abdomen was opened
the bladder was seen to be greatly distended, as were also the ureters ;
in fact, the latter were enormously dilated and convoluted. There
was also bilateral hydronephrosis, but the renal change was more
marked on the left than on the right side. Fluid regurgitated easily
from the bladder into the left ureter, but not into the right. The
urethra was found to be occluded near to the meatus urinarius.
Further examination showed the left ureter to be sacculated ; it was
impossible to pass a probe along it, on account of a series of at least
nine folds of the mucous membrane which had free edges and formed
j)0uches. The right ureter showed similar but less marked changes.
The left kidney contained numerous small cysts, but its pelvis was
not dilated. The bladder wall was thick.
I have had an opportunity of examining another specimen not
unlike the above. Notes of this case were pubilished by I)r. C. Mabel
Blackwood {Minh. Med. Journ., xli. 919, 189G). The mother of the
infant was healthy, and had given birth to two healthy children. In
her third piegnancy the labour was tedious from uterine inertia,
and there was less liquor amnii than usual. The placenta had
several succenturiate lobes. The child, a male, was with difficulty
resuscitated, but lived thereafter for twelve days in an apparently
healthy condition, although it was noted that the abdomen was un-
usually large. After the twelfth day he began to be ill (vomiting,
crying, difficulty in passing water), and died on the sixteenth day.
The kidneys were of normal si/e, liut in Ijoth the capsules could
only be stripped off with dilficulty ; their substance was dense, and
the pelves not dilated. In size and appeai-ance the left ureter re-
sembled the large intestine rather than a ureter. It showed a series
of dilatations which were larger near its vesical end ; its walls were
much thickened, and on one side were longitudinal bands. On
opening the ureter, it was seen that the mucous membrane was
arranged in folds at the points corresponding to the external con-
strictions ; in this way great narrowing of the lumen was produced.
The right ureter presented similar l>ut less marked changes. The
bladder was enlarged and its walls hypertrophied. In yet another
specimen, which is in the possession of Dr. David Waterston (who
382 ANI'l'.NAr.M. I'.VIIIOI.OC^- AND inClKNK
is also investigating anew the two previous specimens), the Madder
walls were so enormously thickened as to cause that viscus to sinmlate
closely the uterus, while the kidney substance was reduced to nearly
nothing; there was no occlusion of the urethra.
I have already referreil to cases of fa'tal ascites complicated
with distension of the bladder (p. 358), and it will be remembered
tliat in one of these there was a meinl)ranous obstruction in the
urethra near the root of the penis (107). It may therefore be sup-
posed that both in the cases with ascites and thf)se witlmut it there
was distension and hy]ievtro]ihy of the liladder (willi dilatatiim of
the ureters and conimencing liydronephrosis), on account of the block
in the urethra preventing tiie e.xit of urine from tlie bladder. There
are, however, recorded instances in wiiich no olistructioft (membranous
or valvular) was found in the urethra, and yet the bladder showed
dilatation and hypertrojihy (tv/., the cases of Lefour, Proi/ris mM.,
2 s., V. 413, 1887, and () Saintu, Joxrn. do mi'J. dc I'ar., 2 s., viii.
332, 1896, and otliers). In (1 Mabel ISlackwood's case {loc. cit.), also,
there was permeability of the urethra. Another very striking in-
stance was that reported by Couvelaire {Bull. Soc. anat. dc far.,
6 s., ii. 287, 1900). The mother was a 1-para, aged 24 years, who had
some albuminuria when laliour sujiervened ])etween the eighth and
ninth months. Parturition was delayed, and even after the head
had been born the trunk could not be extracted ; during attempts at
extraction one arm was fractured, and the infant succumlied; it was
only when the abdomen had been tapped and 550 grms. of iluid
(clear, lemon yellow, iiighly albuminous) had been drawn oil' tliat
the fo'tus could be fully born. The placenta, meml)raneR, and cord
showed no anomaly. The infant, a female, measured 48 cms. in
length, and weighed (without the fluid) 2900 grms. The fluid had
come from the peritoneal cavity, for on exploring the abdomen the
tensely filled and glo1)ular bladder was discovered reaching to the
umbilicus. Its walls were very thick, and the mtu-ous membrane
congested. The urethral canal was normal at botli ends, and a stylet
passed through it easily ; there was no block nor valve in any part
of the urethra. The ureters were slightly dilated ; the kidneys were
a little larger than usual, and showed dilatation of the pelves and
calyces, the renal tissue being reduced to a strip nowliere more than
4 mm. thick. In cases such as these, we are forced to seek some
other explanation of the state of the bladder and ureters than is
found in the presence of a block or valve in tlie urethra. Jolm
Tliomson has suggested (ridi- C. I\I. Blackwood's i>aper) that a dis-
turbed nervous mechanism may require to be invoked. Certainly
this explanation l)ecomes more feasible in view of the discoveries
that have been made regarding congenital hypertrophic stenosis of
the pylorus. For some reason the contractile force of the l)laddcr
meets with resistance from the sphincteric fibres, and as a conse-
(pience of prolonged antagonism (lasting, perliajis, during a consider-
able part of fu'tal life) hypertro]ihy of both sets of muscles takes
place. It is, of comse, taken for granted that some urine is l)eing
secreted by the ftetal kidneys, and doubtless some is expelled from
CYSTIC KIDNEYS 383
the bladder now aud again ; it seems necessary to sujipose this in
tirder to account for tlie great hypertrophy of the bladiler walls
sometimes met with. At the same time, it must be admitted tluit in
some of the cases in which the urethra is altogetlier absent, and in
which there is no exit for the urine at all, the vesical walls still
exhibit the greatest thickening (('.^.,in a specimen described by Opitz,
Zlsckr. f. Gcburtsh. u. Gynak., xl. 316, 1899).
The chances of survival in postnatal life in such cases as have
been described above are not necessarily nil. It is (piite pro))able that
certain instances recover. Unfortunately it is also more than probable
that some cases in which the obstruction to urination is slight
become worse after birth, on account of the greater activity of the
kidneys then prevailing; the ureters become nuich dilated; and
hydronephrosis more and more marked, until death supervenes. A
case which was in all probability of this nature I saw in consultation
with Dr. W. Stewart of Leith in 1900. There was difficulty in the
birth of the child, a male, on account of the large size of the
abdomen. A swelling was found in the abdomen chiefly on the left side,
apparently cystic in character. It did not extend imder the margin
of the ribs. JMicturition was not impossible, but it was not free.
The child died some days later, aud no post-mortem examination
was allowed. I formed the opinion tliat we had to do with an in-
stance of dilatation of the left ureter and hydrone])hrosis ; but it may,
of course, have Ijeen a cystic kidney or a tumour of some other organ,
or even an included tVetus. Surgery may yet devise effective means
of dealing with many of these cases.
It is not my intention to describe here the various antenatal
pathological states which produce hydronephrosis. They are nearly
all of the nature of malformations situated in the ureter (absence,
imperforation, stenosis from kinks, valves, or compression by other
structures, abnormal communication with other organs) or in the
urethra (absence, imperforation, stenosis). Hydronephrosis, therefore,
is generally the result of teratological states rather than a true
disease. H. Brinon (T/idse, Paris, 1896) points out that the presence
of a supernumerary ureter may explain some of the anomalies in
symptomatology and prognosis which are met with in connection
with congenital hydronephrosis.
Cystic degeneration of the kidneys is another antenatal morbid
state which may cause delay iii the delivery of the infant thus
affected (L. Burckhardt, Indiana Med. Joiirn., xiv. 295, 1896). The
condition has been met with in association with a cystic state of the
liver, as in the case shown by Porak and Couvelaire at the meeting
of the Socidtd d'ohstdtriquc, de gyni'cologic, et dc 2}<'diatrie of Paris in
January 1901 ; it has also been found combined with hydrocephalus,
as in Fin Holmsen's case {Norsk Mag. f. Lmgevidensk., Ixi. 411, 1900),
and witli other anomalies. It may be due to sclerosis affecting the
uriniferous tubules specially in the neighbourhood of the papilla^
(" papillitis "), and so causing retention of urine in the kidneys ; but
recent researches rather go to show that it is of the nature of an
I
384 WIIAATAl, I'AIIIOI.OC.V AM) li^CilKNK
adenomatous degeneiatinii. II the lutliT lie tlie correct view, the
condition must he rajjardcd as a iii'ii])1;ibiii. In M. }f. Fussell's case
{Mtd. News, Iviii. 40, 181)1) tlic heai't was mucli liyiierlrophied ; it was
about three times tlie normal size, and felt lil<e a soliil mass of fiesli ;
the ventricles were small in size ; and the valves were normal. What
bearing, if any, the cardiac condition had upon tlie renal is not clear.
Diseases of the Genital Organs.
It is ehirlly mi nccniiiil nf tlii. lad tli.it iho rull dfvclii]iiiient of
tlie genital nrgans ilncs iml lake jilacc till al'lcr liirl h, that diseases
of these parts are nut met with in the I'lclus. 'J'lu' genitals are in an
embryonic state during nearly the whdle of ftetal life; they all'ord a
very clear illustration of the projection of the endiryonic into the
f(Etal jieriod. The morbiil states, therefore, which are met with in
them at the time nf jiirlh are malformations and not diseases. In
regard to the female organs, it is true, it is stated that vaginal sejiUi
are regarded as due to adhesive vaginitis occurring in fo'tal life; but
there is reason to doubt the accuracy of this exjilanatinn, and to
look upon the stenosis as jiroduced by incomplete canalisation of
the vaginal anlngc. Among the transnutted diseases, syphilis, it is
believed, affects the testicles and produces a congenital syjihilitic
orchitis; it may have a similar effect on the o\aries. Itut, with
these exceptions, if, indeed, they be exceptions, diseases of the genital
organs are very rare in antenatal life; this is what the principles of
Antenatal Pathology would lead us to expect. There is, however,
one morbid coudition, at least, which may perhaps l)e called a disease,
which is occasionally met with, and about wdiich some words of de-
scription may here be given. 1 refer to congenital prolapsus uteri.
Congenital Prolapsus Uteri.
Congenital prolapse of the uterus has been verj' seldom rejiorted ;
but it probably occurs more frequently than the list of published ca.ses
would seem to show; for since 1897, when John Thomson and I
recorded our two cases (2:}), the number of observations has nearly
doubled. Our attention was drawn to our first case by Dr. Alexander
Macdonald of P]dinburgh, and to our second by Dr. C. M'Vicar of
Dundee. The notes of the former nf these were as follows: —
The jiatient, a girl, was six days old when lirst seen by Thomson
and myself. She was the ynuiigest of five children, and the others
were healthy and strong. During jiregiiancy the mother had sulfered
from no accident or injury. The child was born at full term on
I'ecember 15, 189G, and, with the exception of the sjiina bifida and
double club-foot, ajipeared healthy. The urine was jiassed ireely and
the bowels were regular, although the digesiinn seemed very feeble.
On Decendjer 17, the spina bilida liurst, and nn the next day (third
day of life) prolapse of the uterus was seen for the first time ; it
seemed to cause continual jiain and straining. After it appeared it
remained constantly down. On December 21, we saw the child for
w
CONGENITAL PROLAPSUS UTERI 385
the tirst time, when we found tlie following noteworthy conditions
(vide Plate XIIl.) :—
(1) In tlie lumliar region there was a large spina bifida, which had
burst; its base measured about Ih inch in diameter. (2) Protruding
for about l incli from the vulva was a red mass closely resemliling
prolapsed bowel. This, on closer examination, was found to be
hypertrophied cervix uteri and the adjacent part of the vaginal wall.
A quantity of clear, gelatinous secretion exuded from the os uteri.
A sound was passed within the os and entered easily for 1| inch ; it
could also be passed into the vagina at the side of the prolapse for
about one incli all round. The prolapse went back readily on slight
pressure, but came down again very soon unless the surrounding
parts were held together. (3) The anus projected unusually, and its
orifice was somewhat patent ; a finger passed within it was not
grasped at all. (4) There was extreme talipes varus on both sides.
The patella was absent on the right side, but present on the left. No
abnormality of the head or of the thoracic aiid abdominal organs was
found, but the infant was evidently very weak. The prolapse was
returned and the buttocks kept in close apposition by means of
plaster and a pad of cotton-wool. The child seemed in less pain
after this, but she got gradually weaker and died the next day
(seventh day of life).
At the post-mortem examination, the heart, lungs, liver, spleen,
kidneys, stomach, and intestines were found to be normal. The
pelvis and the lower part of the spine were removed for further
investigation ; they were placed in a freezing mixture, the prolapse
having been previously reproduced. A vertical mesial section was
then made, and the appearances of the right slab are shown in Plate
XIIL The appearances may be usefully contrasted with those seen
in Fig. 22 (p. 118). There could be no doubt the uterus wa.S really
prolapsed, for its fundus lay at the level of the coccyx instead of
well above the pelvic brim. The cervix distended the vulva, and
protruded slightly from it : but the degree of protrusion was much
less than during life. The direction of the uterine axis contrastetl
markedl)' with that in the normal state. The bladder, whose cavity
on section had a Y-shape, was situated lower in the pelvis than usual ;
and there was also a certain degree of prolapse of the vaginal walls.
The rest of tlie pelvis was occupied by the rectum and the intestinal
coils. The sacrum showed no indication of a promontory, and the
lower part of the spinal column was perfectly straight save for a slight
bending back of the tip of the coccyx. The defect in the posterior
wall of the spinal canal affected the last lumbar and the first two or
three sacral vertebrie, and the cauda equina was seen spread out over
the inner surface of the spida bifida sac. A distinct perineal body of
a triangular shape existed, the vaginal rugie were well marked, and
the distended vulvar orifice showed an unruptured annular hymen.
Dissection of the pelvic contents revealed the ovaries and Fallopian
tubes lying slightly aliove the level of the fundus uteri at the sides of
the pelvic cavity. The Ijroad and round ligaments were greatly
stretched and thinned. The connective tissue in the pelvis seemed
25
386 ANTENATAL I'AI'l 1()I.()(;Y AND HYCIF.NK
to be smaller in ainount. than normal, Imt tlie infant herself was not
at all plump. The urethra was jiatent. The diameters of the false
pelvis were below the normal, while those of the true ])elvis, both at
the brim and outlet, were distinetly aiiove the averajic The total
length of the uterus was o-2 cms., of which 2 cms. lielonged to the
cervix and r2 cm. t(j the body. The transxerse diameter at the
fundus was lb cm., and the antero-posterior only O'o cm.; the cervix
had an antero-posterior measurement of 1-2 cm. and a transverse
of 1-0 cm. Save for a certain but not a great degree of cervical
enlargement, these uterine diameters did not ditier much from those
in normal infants. Tiie distance between the anal and vulvar
apertures was 1"0 cm.
The second case that Thomson and 1 reported was .somewhat
similar. As in the first, the jnesentation at birth was l)y the vertex.
The spina bifida sac had burst during delivery in this instance.
There was double talipes varus, and no patella could be felt on either
.side. Dr. M'Vicar noticed the prolapse of the uterus on the day
following the birth of the infant. There was also slight eversion of
the rectal mucous membrane. The child died in five days. In other
details, clinical as well as pathological, the two cases were very
similar.
Previous to the publication of these two cases, there had been
records of six instances of congenital prolapsus uteri. These were
those of Schultz {Vcrhandl. d. Ver. pfalz. ^ers^c, 1856, Kaiserslautern,
48, 1857), of N. Qvisling {Norsk Mag. f. Laegcridcnsk., 4 K., iv. 265,
1889; Arch. f. Kinderh., xii. 81, 1890-1), of 0. Schaeffer (Anh. /.
Gynach., xxxvii. 244, 1890), of K. Heil (Arch. f. GynacL, xlviii. 155,
1894), of S. Kemy (Arch, dc tocoL, xxii. 904, 1895), and of L. Krause
(in Neugebauer's article in the Gazeta Irkrirska, xvi. 1223, 1896).
Since then cases have been published by Hausson (Mvnchen. mcd.
Wchnschr., xliv. 1040, 1897), bv Radwansky (J/w^f/tr^. med.Wchnschr.,
xlv. 53, 1898), by A. Doleris (t'ywAo/or/fV, iii. 220, 1898). ami by H. E.
Andrews (Trans. Ohst. Soc. Lond., xlii. 109, 1900). From the account
which has been given of the cases reported by Thomson and myself,
and from a consideration of the literature of the subject, the following
conclusions may be arrived at : —
There is an evident and real downward displacement of the uterus
which occurs soon after or at birth ; this is not the same as congenital
hypertrophic elongation of the cervix, although there may be a certain
degree of cervical enlargement present, and in the case of Dolcris the
two anomalies were combined. The pregnancy and labour which
preceded the birth of an infant suflering from prolapsus uteri seem
geiun-ally to have lieen uneventful ; but in the cases o*^ Qvisling (loc.
cit.) and Hansson (loc. cit.) the presentation was by the breech. The
infant was always l)orn alive, but died, with one exception, some days
later. In Krau.se's subject (Centrlhl. f. Gipiak, xxi. 422, 1897) the
prolapse was apparently ]iresent at the moment of birth, and may
have been in existence in f(etal life; but in the other cases the dis-
jjlacement occurred from a few hours to several days after birth. In
Schultz's case (loc. cit.) it did not a)i]iear for ten weeks, aiul therefore
CONGENITAL PROLAPSUS UTERI 387
this observation perhaps ouglit not to be grouped with the others.
In all the recorded instances the prolapse was easily replaced, and in
none had the uterine displacement anything to do with the death of
the child. The concomitant malformations were eversion of the
lectal mucous meuilirane, talipes, spina liifida, and (in Krause's case)
hypertrichosis.
It is a most remarkable fact that in nearly every case there should
have been concomitant spina bifida of the lumbo-sacral region. At
the time when Thomson and I published our two cases, there were
eight cases on record, and in seven of these there was the spinal
defect, while in the eighth it is possible that it was also present
although not referred to. In Hansson's observation there was also
spina bifida. It was therefore with great interest that I perused
Andrews' report of a case in which this commonly associated defect
was not present. In this instance the swelling at the vulva was
noticed a few hours after birth ; it bled when handled ; and it con-
sisted of the much swollen cervix uteri. The anus admitted the tip
of the finger, but the rectum was imperforate, necessitating inguinal
colotomy. The child died on the twelfth day of life, and before this
time the uterus could be retained in position without strapping. It
is noteworthy that in this case, although there was no spina bifida,
yet there was another associated malformation, namely, rectal im-
perforation. In a letter which I received from Dr. Andrews, dated
May 29, 1900, it is stated that the post-mortem examination revealed
nothing abnormal save the imperforate rectum. In Eadwansky's
case also {loc. cit.) there seems to have been neither spina bifida nor
hydrocephalus ; in that instance the prolapse was present at birth,
and the protruded mass measured 4 cms. in length ; there was some
ulceration of the exposed cervix uteri ; great improvement followed
replacement and retention ; and at the end of six months the infant
was still living and the prolapsus was feebly marked. The cases of
Eadwansky and Andrews demonstrate that the association of con-
genital prolapsus uteri with spina bifida in the lumbo-sacral region
cannot be looked upon as constant ; at the same time this association
existed in nine out of twelve cases, and must be regarded as too
frequent to be a mere coincidence. It is no longer justifiable to say
that congenital prolapsus uteri is always a symptom of lumbo-sacral
spina l)ifida ; but it must still be looked upon as sometimes such
a symptom. This leads me to discuss the pathogenesis of congenital
uterine prolapse.
It is natural that most of the observers who have had to deal
with congenital prolapsus uteri have been struck by the presence of
lumbo-sacral spina bifida, and have given it a place in their theories
of pathogenesis. Further, in several of the cases there was a semi-
paretic condition of the lower limits, a circumstance which seemed to
favour the idea of a nervous origin of the prolapse. Possibly the
spina bifida causes defective innervation of the pelvic ligaments and
viscera, with a general condition of laxity of the tissues ; the associa-
tion of slight rectal prolapse favours this view. But it is evident
that the whole causation of the displacement cannot be thus ex-
388 ANTKNAJAL l"AllI()I,()(iY AM) IIVCIKNR
plained, f(jr wliilo spina liitida is comparatively coiiiinon, congenital
prolapse would appear to he very rare. Other contrihuting causal
factors may he found in defective development of the connective
tissue of the i)elvis, in enlargement ol the pelvic inlet and outlet hy
the straight character of the himljo-sacral part of tiie spine, in
narrowing of the false pelvis, in enlargement of tiie cervix (alliiough
this is far from constant), and in increased intra-al)dominal pressure
(due to down-hearing and straining elVorts made liy the infant).
It is noteworthy that the condition is n(jt invariahly fatal, for
Eadwansky's subject was alive at si.K months. In the absence of the
spina bifida (there was none in Eadwansky's case) there seems then
to be the double cliance of survival of the infant and of cure of the
displacement. Even when the displacement is associated with the
defective state of tlie spinal canal, there seems to be no reason always
to anticipate a fatal termination, for spina bifida is sometimes success-
fully operated upon.
In connection with the above description of congenital prolapsus,
I may mention that I have seen (in consultation with Professor
Annandale) a case of congenital rectal prolapse in a female infant,
two years of age. There was great defect of the perineum ; indeed,
the infant's external genitals resembled very closely those of a woman
who had had a had laliour, with a nearly complete laceration of the
perineum. There was, however, no evidence whatever of uterine
prolapse. There was no spina bifida and no other malformations.
The prolapse of the rectal wall was anterior and on tlie left side.
Diseases of the Nervous System.
In attempting to describi' I'ven very brietly the idiopathic diseases
of the nervous system wliich are present in fo'tal life, one is met
at the outset by two very consideralile difficulties. One of these is
the interposition between antenatal and postnatal life of the short
traumatic interval of intranatal life during which the head of the
infant and other parts also are suftering from pressure in the liirtli
canals. There seems to lie little doubt tliat during this intercalaiy
period many of the so-called oljstetrical paralyses occur, and tliat
they are duo to intracranial haemorrhages; but it has to be liorne
in mind also tliat intracranial and even intracerebral effusions may
be the result of fcetal morbid states prior to the advent of labour,
as has been proved by Osier's case (Trrafolof/ia, ii. 13, 189")), to
which reference has already been made (p. 201). At present we
know of no certain metho(l of distinguishing between and of dis-
entangling the one set of maladies from the oMier. The other
difficiUty is due to tlie fact that during foetal life the nerve centres
are still in the embryonic stage, and that therefore the morbid
affections which may occur in them are more of the nature of malfor-
mations than of diseases. That these malformations may give rise
after birtli, and sometimes long after birth, to diseases in the ordinary
acceptation of the word, is undoubted : lait then tiiese diseases caiiiint
accurately be described as existing in tiie fictus. Tiiey are potentially
HYDROCEPHALUS 389
present in it, that is all. To some of these maladies the term
" congenital " is atlixed, and to some others that of " hereditary " ;
the former expression has been used very loosely to signify any
condition which is either actually present or only predisposed to at
the time of birth, and the latter, if taken in its correct sense,
indicates that the morbid state which develops after birth was
present already in the impregnated ovum Ijefore embryogenesis
commenced or ever fcctal life began. Most of the " congenital "
diseases of the nervous system are antenatal only in the sense of
being potentially present at Ijirth ; they are the results of malforma-
tions wliose effect becomes evident after birth. Some are doubtless
" hereditary " also, in the sense that the tendency towards the
malformation of certain parts of the nervous system is transmitted
from parent to child. From all these facts it follows that it is
practicolly impossible to select for description any types of truly
fidal diseases of the nervous system. The most that can lie done is
to refer to certain morbid states of the brain and cord in order to
demonstrate how impossible it is to find any types. The conditions
to which I allude might perhaps be called " teratological diseases "
potentially present before birth ; but the ex^jression is rather of the
nature of a contradiction in terms.
For instance, there is congenital internal hijdrocephalus. Are we to
regard the distension of the cerebral ventricles in this morbid state
as a fu'tal disease, as an embryonic malformation, or as a disease
due to a precedent malformation ? Is it due to an intlanlmatoiy
change in the lining membrane of the cerebral ventricles and of
the central canal of the spinal cord, to an inflammation of the
ependyma ? Is it, on the other hand, purely a malformation of the
lirain ? Is it primarily a malformation which predisposes to inflam-
matory or (jther pathological changes which induce effusion of fluid
into the ventricles ? The pathologist who would venture to answer
any of these queries definitely might be bold, but it is doubtful
if he could claim justification for his boldness. Personally I incline
to the third view. The fact that the parents of hydrocephalic infants
not infrequently are syphilitic or alcoholic, does not greatly clear
up this question, although otherwise it is a fact of very considerable
importance ; for, as we have seen (pp. 239, 276), both syphilis and
alcoholism in the parents may be revealed in the progeny either
l:)y disease or malformation. Neither does the fact of the frequent
coexistence of various malformations in cases of hydrocephalus
prove that the latter is a malformation, although this fact also is
interesting. Hydrocephalus, therefore, must be left as an indefinite
morbid state of the ftetus, likely to produce delay in labour and
danger even to the mother, but with a pathology and pathogenesis as
yet unexplained. The careful investigation of early stages in the
evolution of the morbid state wovdd most probaldy yield results of
great value ; the pathologist ought to lie on the outlook for slight
hydrocephalus in cases in which there may be spina bifida, but in
which there is as yet no cranial enlargement.
Again, there is Little's disease, or congenital spastic rigidity, or
390 ANTENATAL I'ATHOI.OdY AND HYGIENE
congenital cerebral paralysis. In this malaily the iiiiaiit shows
contraclures of various muscles, with ]iaia]Fh'i,'ia or iiioiiojilej^na. The
child begins to walk late, and develii]is tiie jiceuliar sjiastie pdl with
niai'ked cross-legged progression. Tlic dee]) retle.xes are exaggerated,
and squinting is common. There is usually a great deal of mental
disturl>ance, amounting sometimes to indiecility and idiocy. The
name " congenital " is generally applied to tliese cases; but tliere is
good reason to believe that most of tliem are due to tlie traumatism
of birtli (pelvic (ir foreejjs pressure on tlie liead), causing meningeal
luemorrhage, followed by sclerosis and ))iirence]>haly. At the same
time there are some instances which are hardly to be explained
in this way, and whicli, therefore, suggest a truly antenatiil as well
as an intranatal factor in the pathogenesis of the cerebral paralysis ;
but the condition, like hydrocephalus, although for another reason,
cannot be regarded as a typical ftetal disease of the nervous system.
Congenital chorea is another so-called congenital malady of the
nervous system. In some instances the choreic movements have been
noticed at birth. There is an absence of rigidity, although some writers
would apply the name " congenital chorea " to the cases in which there
is concomitant spastic rigidity. The pregnancy has generally been
abnormal; the mother may have suffered from injuries, from friglits,
from prolonged or instrumental labour, or from some disease; and in a
few remarkable cases the mother as well as her infant has liad chorea.
There may be a family history of alcoholism or epilepsy. Birth is
often premature. The infant may be diflicult to resuscitate at Itirtli,
but if successfidly treated shows even within a few hours marked
choreic movements and grimaces, wjiich cease during sleep. He is late
in walking, but ultimately walks well save for a slight unsteadiness ;
in this respect the malady contrasts strongly with Little's disease.
He is backward in his mental development. Here then is a disease
which may perhaps lie taken as a type of the maladies of the nervous
sj'stem which are produced during fci'tallife; but when the etiology
and pathogenesis come to be inquired into, its typical cliaracter soon
disappears. Yignaud Dupuy de St.-Florent {These, V:\v\&, lS9;"i) lias
summarised our knowledge on these points. It would a]»pear that
congenital chorea may be transmitted directly from mother to fo'tus;
in one case, that of Eieder {Miinchen. med. IFchnxchr., xx.wi. 60.S, 1SS9),
the transmission was from grandmother to mother, and then from
mother to daughter. This may be explained either as a transmi.ssion of
the morbid state directly to the fo'tus in utero, or as a hereditary
handing down tlu'ough tlie germ ])rior to impregnation. If the
former view be accepted, the exi)lanation of the pathogenesis 1)ecomes
practically impossible tlirough lack of facts: if the latter view be
maintained, it may be argued that lu-re we lia\r to do willi a
conejeniteil form of Huntingdon's chorea whirh is cNidciitly here-
ditary. It seems, however, to dilVer in .several iiarliculars from the
markedly hereditary instances of tremor (some of them being con-
genital) which were described by C. L. Dana (Internal. Jonrii. Med.
Sc., xciv. 386, 1887). Trobably, or possibly, the three conditions
(Huntingdon's chorea, congenital chorea, ami hereditary tremor) are
HEREDITARY ATAXIA 391
all essentially differeut. At any rate, they do not throw much light
upon each other, even although they agree in being transmitted from
ascendants to descendants. St.-Florent (op. cit.) looks for an anatom-
ical or functional anomaly of development of the fretal brain to
explain congenital chorea ; in other words, he regards it as a disease
due to a teratological state, but includes under the latter term tlie
idea of a. functional malformation , so to say. He also, however, seems
to look to traumatism in labour as the primary cause of the cerebral
malformation. It is, therefore, abundantly evident that congenital
chorea, no more than Little's disease or hydrocephalus, can be taken
as a type of the tretal diseases of the nervous system.
Friedreich's ataxia has sometimes been termed " congenital
ataxia " and " family ataxia," but " hereditary ataxia " is a name
which better indicates its nature; fur it is never observed in the first
nicmths of life, and it is not a constant occurrence that it affects
several members of the same family. Even if the term " hereditary "
be adopted, it must be borne in mind that it is rare for the heredity
to be direct and similar. Further, it is a slowly developed disease ;
there is nystagmus, loss of muscular power, and sometimes of
the patellar reflex, speech disturbance, and mental impairment ;
all these changes appear in late childhood, and are established slowly.
It is due to a chronic inflammatory (?) degeneration of certain parts
of the spinal cord (posterior columns, lateral and cerebellar tracts,
columns of Clarke, etc.) ; and it has been thought that this degenera-
tion has been predisposed to by an arrest of development of the cord
in fo'tal life. In it, also, is seen the association of a disease with
a malformation ; perhaps we may call it a " teratological disease," if
we keep in mind that such an expression is in large measure an
inilication of ignorance.
Of Thomsen's disease, or myotonia congenita, or muscular ataxia, I
need say little. It is often transmitted from ascendants to descend-
ants : it begins in early childhood ; and it is characterised by the
fact that during voluntary movements the muscles respond slowly to
the will, being late in contracting and slow in relaxing again. It
has been regarded as a " congenital " affection of the muscular fibres,
a primary myopathy ; it has also been looked upon as representing a
congenital antagonism between the muscular and nervous systems
with ultimate predominance of the former. Clearly, however, it also
falls into this group of mysterious pathological states, the so-called
foetal diseases of the nervous system.
The same characters of indefiniteness and of confusion between
malformations and diseases extend to the antenatal morbid states
of the organs of special sense. An instance of this is met with in
the condition known as "congenital clouding of the cornea" which may
be due to " an arrest in development " or to an " intrauterine inflam-
mation." It has been ascribed to syphilis, but has been met with
in the lower animals, and cannot, therefore, always be syphilitic even if
it occasionally be so.
I offer no apology for the vagueness of the descriptions of the
nervous diseases of the foetus. It was late in the history of medicine
392 ANll.NAlAl, l'A■m()l.()(;^ AM) 1 1 VCI I'.NJ-:
before tlie adult maladies of the nervous system began to be under-
stood ; even now they constitute a most difhcult part of medicine.
It is not to be expected that the part of Antenatal Pathology
which deals with the morbid changes in the l)rain, spinal ctu-d,
and organs of special sense, will be less ditlicult or less late in being
elucidated. Two matters have led to great obscurity : the inter-
relation of the malformations and tlic di.scases of the fo'tal nervous
system, and the intrusion into the subject of the iilea of antenatal
functional disorders. But these comi)licatiiins and (tbscurations must,
I think, be accepted as inevitable. To luiuimise the difliculties is
to retard real progress; short cuts to conclusions are, in Antenatal
Pathology at least, too often nothing but bliuil alleys ; the way has
to be retraced, and valuable time has l)eeii lost. It must lie slowh'
that progress is accomplished; it must be by careful observing and
accurate reporting of cases, with full details of the jihenomena of tlie
first weeks and nuniths of life and of the events of pregnancy: ami
complete post-mortem examinations will have a paramount import-
ance. Since many of the maladies are hei-editary, and sliow family
prevalence, we may yet learn much from the post-mortem examination
of still-born infants, or of relatives who have died without necessarily
showing any symptoms of the particular disease, for in them the
predisposing malformations which are of so much imthogenetic
importance may perchance be found. Manifesth' the matter is beset
with dittieulties ; therein lies our stinmlus to work: other matters
have been no less dillicult, but have become the commonplaces of tlie
text-book ; herein exists our encouragement.
With the end of this chapter I close the X'ai't of this work which
deals with the idiopathic diseases of the fcetus. It is an unsatisfactory
part ; for all the while that we are considering these maladies we are
wondering whether they really are idiopathic, whether indeed they
are not transmitted from ])arent to child, if not in the foetal jieriod of
life at any rate in the germinal. No doulit some of them will yet lie
transferred to the group of the transmitted maladies. At the same
time it is a most suggestive part of the work, for it has introduced to
us the idea of functional antenatal maladies in connection with
hypertrophic stenosis of the pylorus, and with some of the morliid
states of the nervous system. Further, it has illustrated the interest-
ing albeit most diflicult question of the inter-relation of malformations
and diseases, and of the projection of the embryonic into the fcetal
period of antenatal life, with all the con.sequences which How there-
from. About many of the questions which have arisen in the ] ac-
ceding chapters, I have been forced to give judgment in tlie
unsatisfactory form of no7i liquet ; but although " it is not clear " now
and to me, yet there may be illumination soon and for another. To
have put down the ditlicvdties and the scanty facts in black and white
is something, and marks at any rate a stage, or at least a new
starting point. Vox cmixsa rolaf — lifera scri}}ta manct.
CHAPTER XXIII
Traumatic Jlorbid States of tlie Ftetus : Fa'tal Fractures, AVounds, and Dis-
locations; Congenital Aminitations ; Diseases of the Ftetal Annexa ;
Placental H;eniorrliages ; Fibro-Fatty Degeneration of the Placenta ; Slorljid
States of the Umbilical Cord ; Hydramuios — Definition, Clinical History,
Symptomatology, Physical Signs, Diagnosis, Prognosis, Pathology, Patho-
genesis, Treatment ; Oligohydramnion.
In the classification of foetal morbid conditions given on page 175,
I gave i^laces to neoplasms and traumatic morbid states; ))ut I
indicated that it would probably be necessary to exclude the former,
as their origin in the foetal period was more than questionable. The
tumours, like the monstrosities and most of the malformations, are,
so to say, handed on into the fietal period from the embryonic and
germinal epochs of antenatal life ; the ftetus, as it were, carries them
with it through the rest of intrauterine existence into the light of
day, and they are then recognised for the first time, but their origin
lies far away back in embryonic or germinal life. The more one
studies the so-called traumatic morbid states of the fa^tus, the more
one is forced to l^elieve that they also anticipate the truly ftftal
period. If we exclude the fractures and dislocations, and wounds
and lacerations and avulsions, which occur at the time of birth in
consequence of grave disproportion lietween the size of the maternal
pelvis and that of the fcetus passing through it, we are left witli a
group of enigmatical morl)id states which, on a superficial examination,
suggest the idea of intrauterine injuries of various kinds. A more
careful examination of these conditions (fractures, dislocations,
wounds, and amputations), however, at once raises doubts as to their
traumatic character, if, at least, " traumatic " be tinderstood in its
ordinary sense. Let us consider some of these morl)id states.
Foetal Fractures.
By " fcetal fractures," we mean not so much the fractures met
with at Ijirth which have evidently been recently produced, and to
explain which some manifest traumatism has occurred during the
course of tlie confinement ; the name is or ought to be reserved rather
for the morbid states which have Ijeeu regarded as badly united or
ununited fractures. When one meets with a bone, such as the femur
or clavicle, which shows an irregular swelling or a sharp Ijend of its
shaft, or which exhibits a fracture with two rotmded fragments lying
close together but not united, it has often Ijeen maintained that here
was an instance of a fracture which had been produced during foetal
394 ANTKNATAI. I'A rilOI.OCV AM) IIVdlENE
life by external violence or hy strong uterine contraetious. '11 ic
separate fragnientis liad not lieen l)rou<;ht into exact apposition, ;\iu\
consequently liad united at an angle, or nnieh callus had been tlirown
out, producing the nodular swelling on the shaft : or, in some instances,
the two segments had been too far apart or had been so mobile that
no union at all had occurred, and in time tiie ends had become rounded
and a kind of false joint had l)een produced. When there was no
history of traumatism during hiliour, or of excessive muscular action,
the supporters of the above tlieory of caii.satioii were compelled to
suppose that the fietal skeleton had been unusually brittle, or that it
had at one period of to'tal life passed through a stage of abnormal
fragility. There is reasim to believe that in some exceptional
instances such a chain of causal factors has really existed, as, for
exam])le, in the case reported by Paul Linck {Arcli. f. Gynacl:, xxx.
2G4, 1887), in which the expulsion of tlie infant took place in little
more than one pain, and in which there were over thiity fractures
(old and recent) in the limbs, sternum, ribs, etc. ; or in those put on
record l)y Chaussier {Bull. Fac. dc vied, de Par. (1812-13), iii. 301,
1814), in which lalxnir was easy, and yet from fifty to a hundred
fractures were counted after birth. The exceptional brittleness of the
bones has in these cases been attriliuted to true rickets, to " fo'tal
rickets," and to an " ind<uown intrauterine disease of the fecial
skeleton" (Linck). In the great majority of the so-called fractures,
however, it is practically impossilile to accept such an explanation as
that given above. The difficulties have been recognised liy many
writers, who have attempted to explain them away by affirming that
the membranes have ruptured, letting the liquor amuii escape, that
the solution of o.sseous continuity has been due to contrc-rouji and not
to direct violence, or that stormy contractions of the ftetal muscles
have been active in producing the fractures. But these exjilanations
are all more or less unsatisfactory, and they fail more particularly in
the not infrequent cases in which the fractures are accompanied by
various malformations. Max Sperling (Ztschr. f. Geburtsh. u. Gi/naL.
xxiv. 225, 1892) has recognised this, and has gone boldly in (piile
another direction to find an adequate pathogenesis : to this matter
reference will immediately be made. It has been noted that many
of the so-called fractures are represented at liirth by sharp bendings
on the bones, and that over the angle thus formed are cutaneous
cicatrices ; it has also been observed that there have existed coincident
malformations, such as the absence of one or more digits (IJ. L. Swan,
Med. Press and Circ, n.s., xxvii. 160, 1879 ; Danyau, Bull. Soc. de cliir.
dc Par., iv. 271, 1853-4; Sachse, Journ. d. pract. Hedk., xi. 3 St.,
107, 1801), and sometimes of the filnila as well (Danyau, loc. eil. :
Ithen, Bis-firt., /iirici), 1885), absence of some of the tar.snl bones,
imperfect formation of bones contiguous to the fractureil one, liarc-
lij), cleft palate, hydrocejjhalus, club-foot, club-hand, median fi.ssurc
of the nose, congenital amjmtations, amniotic adhesions, syndactyly,
etc. It is not jiossilile to imagine that these various malformations
can have arisen from traumatism, aiid yet their frequent association
with the so-called fractures must be explained in some way. The
FGETAL FRACTURES 395
way that Sperling {loc. cit.) takes is as follows: He points out the
fre(iuency of the coexistence of the so-called badly united fractures
anil other malformations, and indicates that in most instances the
malformations cannot be regarded either as the causes or the resuRs
of the fractures ; he looks for a cause which shall be common to lioth
the malformations and the fractures. In order to find this common
cause, he goes back to the first and second months of intrauterine
life, to the endjryonic period in fact, and finds there an explanation
m defective formation of the annuon. He shows that the cicatrices
occasionally found near such fractures, as well as the so-called wounds
{vide absence of skin, p. 328) and the various concomitant malforma-
tions, can all lie accounted for by tiie action of amniotic adhesions or
defective developments. I tliink it is necessary, as Sjierling indicates,
to regard most of the so-called fo'tal fractures as originating before
the truly fcctal period of antenatal life, and possibly by the mechanism
of amniotic adhesions or pressure (although it must not be forgotten
that in the human subject the development of the anmion has not
yet been elucidated) ; but, in cases such as Linck's and Chaussier's, it
seems sufficient to regard the multiple solutions of continuity as the
result of extraordinary fragility of the liones, accompanied perhaps by
excessive fVrtal movements or stormy uterine contractions. Hence it
comes about that, in order to explain the origin of the so-called fcetal
fractures, it is necessary to invoke the aid of embryonic pathology or
to postulate the existence of a foetal bone disease.
Foetal Wounds and Dislocations.
Under the heading of " Congenital Absence of the Skin " (p. 328), I
have already considered foetal •' wounds," and have pointed out their
probable amniotic origin. Doubtless in rare cases, and specially in
grave maternal traumatisms, the foetus may lie wounded in a more
direct fashion ; but, to explain the so-called wounds or areas showing
absence of skin, the same mechanism has to be invoked as for fcetal
fractures, namely, imperfect development of the amnion (vide
F. Ahlfeld, Eine ncue typische Form durch amniotische Fadcn
hcrvorgcbraclder VcrUldung, Wien, 1894). The question of the
ftetal dislocations is less easy of solution. The reader is referred to
the paragraph dealing with "Dislocations in the New-l)orn Infant"
(p. 49) for a statement of the views that have been held regarding
the causation of f(ctal dislocations, and more especially of congenital
dislocation of the hip. In these morbid states the iutranatarfactor
is often with difficulty excluded, and, according to a theory which still
can count supporters, it is by traumatism during delivery that con-
genital dislocation of the liip'is produced. If we adnut that it may some-
times be thus produced, it must also be maintained that it is certainly
not always so ; for both in the case of the liip and in that of the other
joints there are frequently present morbid or malformed states of the
articulation which certainly arose long Jjefore the supervention of
labour. Of course, it may be argued that the malformations indeed
were present, but that the actual dislocation of the articidar surfaces
396 ANTENATAL I' \l 1 1( )I.()(i^' AND IlYCIl'.NK
did not occur till the process of parturition had commenced ; but
this view is hardly tenable when the condition of the parts im-
mediately after birth is taken into account. With regard to the
possible occurrence of dislocations in fo'tal life due to violence, and
taking place in articulations not previously malformed or diseased, it
is very diftieult to speak with assurance ; they are possible, but 1 do
not think that many fo'tal dislocations arise in this way. It is very
prol)able that it will be found neces.sary to explain most of the dis-
locations as we explain most of the fractures in utero, by su]i])osing
that they occur in the first two or three months of antenatal life, and
that imperfect development of the amnion is the most impor(a!it
pathogenetic factor in their production. They are, therefore,
traumatic only in the limited and peculiar sense of being due to
possible pressure of a long-continued kind brought to bear upon the
joints by the attached or apposed amnion. They also, tlierefore, are
teratological rather than traumatic ; we might perhaps say that they
are teratologically traumatic, if such an expression be permissilile.
Spontaneous or Congenital Amputations.
It is long since the idea of the truly traumatic origin of the
so-called congenital or spontaneous amputations came to be doubted.
The notion that fracture of one of the limbs occurred in utero, and
that thereafter there was sharp Hexure of the part with ultimate
separation of it from the trunk, cannot be accepted at the present
time. It is necessary to find some other explanation for the cases in
which an infant is born minus a hand, a foot, some fingers or toes, oi'
even a whole limb, and in which there is a well-formed surgical
stump with occasionally some little projections on the surface of it,
which have been regarded as rudimentary, reproduced digits. At
first it was thought that a sutticieut explanation had been found
in the constricting efl'ccts of the umbilical cord, and the idea of
funic pressure produced by the coiling of the cord round a lindi or a
digit was advanced and maintained. It was thought that in early
fcetal life the tissues of the part and even the bone would ultimately
yield before the long-continued pressure of the umbilical cord, tliat au
ever deepening groove would be prodviced, and that finally actual
separation of the distal part would take place. Cases were found in
which a groove existed, and in which the cord was found occupying
the groove, and these were at once accepted as intermediate stages in
the production of the amputation. The amputations were traumatic,
therefore, Init it was an umbilical or funic traumatism that was
understood. Gradually, however, it began to be recognised that
there were grave difficulties iu the way of the acceptance of the
above view, such as the softness of the umbilical cord, the absence of
the amputated part, etc. Tiiere was in ])rocess of time a modification
of the theory, according to which the traumatic j)ressurc was su]iplicd
by amniotic adhesions or bands. Tliis was and still is a jiopidar
theory of origin of the congenital amputations. There is no doubt
whatever of the occurrence of these amniotic bands ; they are
CONGENITAL AMPUTATIONS 397
frequently found associated with congenital amputalions, and in
many respects they fulfil the requirements of the case. It is true
that they are also often absent when amputations are present, and
that they are also associated with all kinds of malformations and
monstrosities : but it was possible to explain away these dillicidties.
The bands might have been absorbed after they had performed their
amputating etl'ects, and so on. Gradually tlie idea arose that perhaps
the amniotic bands set up special pathological changes in the skin of
the constricted part in the position of the constriction, and that
the pathological changes led to annular amputation ; it was thought
that a sort of epidermic dactylitis was set up, and that the disease
and not the amniotic band cut its way through the tissues of the
limb. Ainhuni was adduced as a disease which, occurring in the
adult, produced similar constrictions and amputations, and did so by
means of changes in the skin of the part. Soon a slight modification
of the theory came to be adopted, and in the case of congenital
amputations it was no longer thought that the amniotic bands were
essential, but it was maintained that the morbid alterations in the
skin were eminently so. Jeannel {Arch, dc toco!., xiii. 774, 1886), for
instance, held this view : for he found it difficult to understand how
the amniotic adhesions were produced, and he could not explain why
the depressions were always circular and not spiral, and why the
amputations were not multiple ; he thought it more probable that
the grooves and the amputations were both trophic lesions of a
sclerodermic nature. L. Eaynaud (Journ. dc mal. cutan. et sypli., 2 s.,
vii. 193, 1895) held similar views ; but J. Eouget {TMse, Paris, 1889)
and De Brun {Scmainc mcd., xiv. 397, 1894) thought that ainhum
and congenital amputations had nothing in common. As a matter of
fact, it cannot be said that any satisfactory explanation of the produc-
tion of the so-called spontaneous amputations has yet been advanced.
I believe that they are produced or initiated before the truly fcetal
period of antenatal life, and that they are connected with mal-
development of the amnion : further, I am hopeful that when new
light is thrown upon the exact mode of origin of the amnion in the
human subject, the whole question of the teratogenic efiects of
anomalies in its development will receive illumination. '^ Till that
time come, we must be content to speak somewhat vaguely of
amniotic action, adhesions, bands, and the like. At the same time,
congenital amputations must, I think, be regarded as teratological
rather than traumatic in their origin, as belonging to the jjathology
of the embryo rather than to that of the fretus.
' If, for instanoi". Berry Hart'.s idea, stated at a meeting of the Edinlnirgli Patho-
logieal Club (Noyember 1901) prove to be correct, much that is at present ilitticult of
e.\p]aiiation will become perceptibly easier ; he is of opinion that the amniotic cavity
is formed by the ingrowth and subsequent breaking down of a plug of epiblast in the
enibr3-onic area of the blastodermic vesicle.
398 ANI'F.XA'I'Al, rAIIIOI.OCV AM) IIVCJIENE
Diseases of the Foetal Annexa.
In \ariiiiis ]iarts nf iJiis wiirk ivfrrrncc lias been alrrady iiiailo to
llie morbitl states nf the fn'tal annexa (tlic placenta, unihilieal curd,
chorion, amnion, and liquor aninii) which occur in association with
various diseases of the fu'tus. I have, for instance, spoken of
I)lacental tuberculosis and syphilis, of the state of the jilacenta in
maternal leukamia and in general f<ctal dropsy, of hydramnios, and
of oligohydramnion. There can be no doubt that this association of the
fiptal morbid changes with those of the annexa is the correct plan to
adopt in order to understand the ])athology of the fcctus, for, as has
already been emphasised, the jjlacenta and membranes are organs of
the fcctus as much as its intracorporeal viscera, at any rate a large
part of the ])lacenta certainly is so. In order to obtain a comj)lete
representation of the pathology of any fictal disease, it is, therefore,
necessary to consider together the morbid anatomy of both the foetus
and its annexa. In process of time it will no doubt be possible to
state what morbid changes in the placenta are commonly associated
with the various transmitted or idiopathic diseases, toxicological
states, and ill-defined toxinic conditions of the f(ctus, as well as the
maladies which are accompanied by hydramnios or by oligo-
hydramnion. Unfortunately it is at present quite impossible so to
do, and the changes in the ftctal annexa are commonly discussed
as if they were independent lesions. Sometimes, perhai)s, they are
independent ; sometimes, also, they are due to maternal conditions,
and are effective in producing f(ctal diseases ; but very often they are
so intimately bound up with the pathology of the unborn infant as to
be inexplicable ajiart from it.
It is not my purpose here to consider all the morbid states of the
fcctal annexa. Some are evidently of the nature of malfnrmations,
and will be described under the Pathology of the Embryo : others
have been already described under the various diseases of the fcetus
{e.g., syphilis, tuberculosis, general anasarca), and under the maternal
maladies which have prejudicial but ill-defined effects on the fa>tus
{e.g., eclampsia) : others arise during the earliest part of antenatal life,
and belong to (Jcrminal Pathology; while yet others will fall to be
dealt with in the next chapter under the subject of F(ctal Death.
There remain some morbid states of the annexa, and more especially
of the placenta, which require a passing notice.
Placental Haemorrhages.
Placental lucmorrhages or " apoplexies " occur either in the form of
diffused elfusious of blood into the tissue of the placenta, or in that of
more or less circum.scribed haemorrhages in more or less well-defined
cavities. These elfusions may be found either on the fictal or on the
maternal surface of the placenta, or at various depths in its substance ;
they may be numerous, although it is unusual to find moie than two
or three ; they vary from microscopic dimensions up to the size of a
hen's egg or even larger; they are more or less round in sJiapc: and
PLACENTAL H.EMORRHAGES 399
they may consist of recent blood, recent clot, old clot, fibrous tissue,
or even of calcareous material. Sometimes blood in various stages of
alteration may be found in the same hainorrliagic patch. The lileed-
ing has most often been from the maternal vessels, and the villi with
their vessels are compressed thereby; possibly, however, it sometimes
comes from the fiL-tal \'essels. It is commonly stated that the chief
causes of the placental apoplexies are maternal traimiatism and
maternal disease, and under the latter head are grouped renal and
cardiac maladies and the fevers. Their microbic or toxiuic origin has
lately been much insisted upon by S. Satullo (Arch, di ostet. e ginec.,\.
193,'399, 518, 577, 1898), and F. Caruso {ibid., vi. 129, 1899), and it
is probable that they often are produced in this way, for bacteria are
not unconunonly found in them. Thej' may thus have a very con-
.siderable influence upon the transmission of maladies from mother
to fa'tus, or from ftetus to mother; but in all probability they
themselves are simply incidents in systemic infections afiecting the
mother or the foetus or both. They may lead to the immediate
expulsion of the uterine contents, or they may kill the foetus which
is expelled later, or they may produce effects, the nature of which
is little known, upon the nutrition of tlie fo-tus, or they may appa-
rently cause no evil consequences at all. The result will depend
upon many circumstances, such as the amount of blood poured out,
the area of the placenta affected, the condition of the fo'tus, and
the like. Sometimes it is very puzzling to account for anomalous
cases in which large eflu.sions have caused no visible bad effects, or
in which small h;emorrhages have apparently had far - reaching
consequences. It has always to be borne in mind that a limited
view of the subject will give no trustworthy results. I have often
insisted upon the necessity of examining the placenta in all cases of
foetal disease ; but it is, of course, equally or more important to
examine the infant and mother in all cases of placental disease. It
is only by making a broad survey of such phenomena that one can
arrive at satisfactory conclusions.
Under the name of fihro-fatty degeneration of the placenta have
been described certain changes more particularly affecting the chor-
ionic villi, which lead to the formation of yellowish white jiatches
in the placental substance. These are not infrequently found in
the full time placenta in small numbers and of limited size : they
are then regarded as physiological or as signs of placental senility.
When, however, they are numerous, or when they occupy a large
part of the substance of the afterbirth, they are admitted to be
pathological. In this respect they resemble the placental hemor-
rhages, for they also, when small and limited in number, have been
looked upon as preparatory changes to make easy the separation
of the afterbirth at the time of labour. They consist in a fibrous
transformation of the villi of the chorion, with diminution in the
size of the vessels, and consequent atrophy of these villi. Here
and there fatty changes are produced. It may be that these changes
are the results of the ha-morrhages which have been described above,
400 ANTENATAL I'ATIIOI.OCY AND HY(;iKM',
bill all autlioi-s do not adniil, lliis. It is snuietiines very .sui'jirising
to find to what a large extent tlie placenta may he transt'ornied into
this fibro-fatty material, ami yet the infant be born alive, healthy,
and well nourished. In a recent case at the Edinburj^h ]\Ialeniity
Hospital, I noted that fully two-thirds of the iilacenta were thus
altered, and yet the child not only survived birth, but throve well.
Calcareous deposits on the uterine surface of the placenta have no
pathological significance ; so at least it is commonly believed.
Various luurhid conditions of (he umhiiieal cord have been desciribed,
although it is doubtful how far any of them can be looked upon as
diseases. Excessive torsion has been met with in which the cord
has become thread-like at the twisted part. The fu'tus is then
usually dead ; but the torsion is not now admitted to be of necessity
the cause of death, for it has been suggested that it may be the
result of it on account of the exaggerated mobility in utero of a
ftetus which dies about the mid-term of pregnancy. The cord may
be coiled round the infant in various ways, and even many times.
In a ftetus which occurred in the practice of Professor J. A. C. Kynoch
of Dundee {Trans. Edinh. Obsf. ,Sor., xx. 1, 1895), there were six coils
round the neck. When the unborn infant slips through such a loop
or through several loops of the cord, knots of various degrees of com-
plexity may be pi'oduced, and sometimes apparently these knots
may be drawn so tight as to interfere with the continuance of
antenatal life. In the case of twins in a common amniotic cavity,
some exceedingly curious entanglements have occurred between the
two cords and the two foetal bodies (ride E. Fricker, l/cbcr t'crsch-
linqunij und Knotenhildung dcr Nahclschnilre hei ZwiUingsfruchten,
Tubingen, 1870).
Hydramnios.
Hydramnios, or excess of the liquor amnii (more than two pints
at full term), is so commonly associated with iwiaX morliid states,
as to suggest by its presence the existence of one or other of these
states. At the same time it has to be noted that it may be met
with when neither the foetus, nor the foetal annexa, nor the motlier
herself, shows any sign of a pathological process. Reference has
already been made to hydramnios in this work ; for it may occur
in conjunction with nearly every one of the maladies (transmitted,
toxinic, idiopathic, traumatic) which have been described. Special
attention was called to its presence in syphilis ; but it is met with
also in general foetal dropsy, in fo>tal ichthyosis, in firtal ascites,
in fietal bone ilisease, etc. etc. So often is it a concomitant of
fu'tal maladies, that it cannot be regarded as pathognomonic of any
special one of them. Further, it is very frequent in connection
with the manifestations of embryonic and germinal pathology, for
it is found associated with all kinds of monstrosities and malforma-
tions, and with twins and triplets. It is also met with in grave
maternal states, such as albuminuria and hyperemesis, but whether
as effect, or symptom, or cause, cannot yet be securely determined.
HYDRAMNIOS 401
Its very frequency, then, is a hindrance to our understanding of
its origin and significance. Like pain in adult maladies, lilve con-
vulsions in infants, hydramnios in antenatal life may indicate many
different conditions of varying degrees of gravity, and apparently
it may in some instances exist as itself the sole pathological mani-
festation. The liquor amnii is the immediate envii-oument of the
fcetus, it is indeed the fcetal hydrosphere : and variations in its
quantity come to be the most delicate tests of the inter-relation
between the maternal and fcetal economies. Of variations in its
quality little can be said ; with the exception of some few observa-
tions upon the presence of sugar and drugs in it, and of fairly
numerous records of cases of fo'tal death in which it was stained
with meconium, our knowledge of the qualitative anomalies of the
liquor amnii is nil. I have met with a case in which it was opacjue
and white like milk, and yet the infant was born alive and healthy ;
under the microscope it had the appearance of diluted pus !
The clinical history of cases of hydramnios varies within the
widest possible limits. The mother may apparently have enjoyed
perfect health up to the time of her pregnancy; she may, on the
other hand, have suffered from syphilis, an;emia, heart disease, or
renal disease. There may be no history of the previous occurrence
of hydramnios in the reproductive life of the mother (C. E. Stokes,
Brit. Med. Jonrn., i. for 1895, p. To), or there may be a record that it
has repeatedly complicated pregnancy. There may be a good family
history or a bad. With regard to the >iymptomatolo(jy of the preg-
nancy complicated by hydramnios there is also some difference in
details. There may be the history of an abdominal traumatism,
followed by the sudden development of a high degree of hydramnios ;
on the other hand, there may be no record whatever of any injury or
blow, and the excess of amniotic fluid has apparently been slowly
produced. The condition may occur early in pregnancy (as early
as the second month), or it may come on late ; liut mid-term (fifth
month) seems to be the period of predilection. It maj' be accom-
panied by hypei'emesis, by dropsical conditions, by the symptoms
of albuminuria, by fever, by constipa,tion and jaundice, b}' neuralgias
and insomnia, by dyspncea, by palpitation and syncope, and sometimes
by diarrhcea. The more rapidly the hydramnios is produced the more
marked are the symptoms caused : as a matter of fact, fever is probably
absent save in the more acute cases. The degree of distress may
become quite unbearable, and it may sometimes be necessary at once
to diminish the quantity of liquor amnii in the uterus.
The -physical signs are usually quite distinctive. The abdominal
enlargement is too great for the period of pregnancy arrived at ;
thus at the fifth month the size of the abdomen may correspond
with that usually attained at the full term. The swelling also is
more globular than usual, and occupies the middle line of the
abdomen ; there is dulness on percussion over it, but the flanks
give a tympanitic note, and the area of dulness does not change
its position when the patient turns on her side. Palpation generally
at first suggests fluid in an ovarian cyst or free in the abdominal
26
402 ANTHNATAI. I'AI'I lOI.OClV AM) inClFA'E
cavity ; but now and again contractions sweep over the surface of
the distemleil uterus, giving it a temporary lianluess and allording
a valuable diagnostic indication. Fluctuation is usually obtained
easily, and Ijallottenient (both vaginal and abdominal) may be elicited,
but not with the facility that the presence of a small fictus in a large
amount of liquor amuii would suggest. It is often very difficult,
either by abdominal palpatinn or by the bimanual examinatinn, to
recognise the head and other pints of the firtus, a result due in part
to the elusiveness of the unborn infant, wliicli in its large liydro-
sjihere slips away so quickly out of the hands of the obstetrician.
Auscultation may give negative results, Init sometimes both tlie
ftetal heart and the uterine souffle can be heard. The mother may
herself be ([uite unconscious of fo'tal movements. It may be noted
further, although tlie signs are of less importance, that the alxlominal
walls are either very thin or are markedly o'dematDUS, tliat dropsical
swelling of the labia and of tlie lower limbs is common, and that
circulatory troubles, such as varicnse veins ami lucmnrrlKjids, are
often met with. Albuminuria may be met with, but is nut, of
course, pathognomonic.
From the symptomatology and physical signs the obstetrician
.attempts to form his dia/piosia. He is at once met with dilliculties.
In the first ])lace, he is led by the absence of many of its signs and
symptoms to doubt the existence of pregnancy at all, and to think
rather of an ovarian cyst or of ascites. A careful examination ouglit
usually to exclude the latter : for in ascites the abdomen is more
flattened, being distended laterally, and the dull area changes with
changes in the position of the patient; the intermittent uterine
contractions are absent ; and there is usually some cause (e.g. maternal
heart disease) to account for the fluid eti'usion into the peritoneal
cavity. In the case of an ovarian cyst, there is often a much longer
history of development, and there is sometimes the record that the
swelling was unilateral at first ; intermittent hardening of the swelling
is absent ; and a careful bimanual reveals tlie uterus, little enlarged,
lying to one side of the tumour. The second diagnostic difficulty
is met with after the obstetrician has made up his mind that preg-
nancy exists. He is fairly sure that he is dealing with pregnancy
and with a morliid pregnancy ; but he is at a less to determine
what form of anomalous gestation it is. Is it pregnancy complicated
by ascites or ovarian cyst ? Is it, perhaps, a plural pregnancy, or
a hydatid mole, or simply a very large infant, or a fo'tus enlarged
by some malformation? A careful consideration of all the facts
will lead him out of several of these difficulties. In the case of
the hydatid mole the uterus is somewiiat pear-shaped rather than
globular, fluctuation is not evident, and tliere is often a history of
repeated vaginal discharges consisting of blood. Wlien there is
simply a large fo'tus (and jdacenta), or a large and grossly malformed
infant, he must rely upon accurate palpation of the alulonu'n, tlie
slow rate of the fo'tal heart beat, and the al)sence of fluctuation
and ballottement. When twins are in the uterus, it is sometimes
possible to be sure of their presence by the shape of the organ,
HYDRAMNIOS 403
by tlie palpation nf two foetal heads, one at the pelvic brim and
the other at the fundus or at the side, by tiie hearing of two fcetal
hearts, eacli with its own rate and position of maximum intensity,
and by the recognition of numerous small parts. But, in the diagnosis
of twins, it is possible with the greatest care to go far astray. When
the pregnancy is complicated by an ovarian cyst lying in the abdomen,
it will often lie possible to detect the two tumours (the ovarian and
the uterine), which differ in consistence and shape, and to note that
one of tlieui is more or less central in position, and rises out of the
pelvis : when the cyst is in the pelvic cavity, in whole or in pai't,
a very careful bimanual will be needed, and even then it may be
impossible entirely to exclude an extrauterine pregnancy. By some
sucli process of diagnostic exclusion the obstetrician may be able
to state tliat the gestation is one made abnormal by reason of
hydrauHiios. Finally, however, a third diagnostic difficulty, and that
an almost insuperalile one, arises when there is hydramnios in associ-
ation with twins, or with ascites, or with an ovarian cyst, or in an
extrauterine gestation sac. Under these circumstances the best
methods in the best hands will often fail to differentiate the associ-
ated morbid states. Not until laliour commences, and the cervix
begins to dilate, will the intrauterine mystery he revealed. But
all cases do not belong to the last category ; and it must be reniem-
liered that it is often easy to diagnose hydramnios, and that having
diagnosed it we ought immediately to suspect a morbid state of the
unborn infant.
The prognosis of hydramnios, stated in a very few words, is a
delayed labour with a malpresentation, a dangerous third stage
(on account of uterine inertia), and a deformed, diseased, dead, or
at least a puny infant. These results, however, are by no means
constant. Even the small bulk of the fcetus is not always noted ;
indeed, G. Barbezieux (These, Paris, 1889) found that out of 232
cases of hydramnios, there were only 81 infants which were below
the normal minimum in weight (the normal minimum being regarded
as 2500 grms.). It must also be taken into account that in many
cases hydranniios means premature labour. At the same time, and
making allowance for this, it must still be admitted that excess of
the liquor amnii is the great indication of pathological conditions
inside the pregnant uterus.
■ The ]mtho!o/ji/ of hydramnios is very imperfectly known. Victor
Guillemet (y/ff-.sc, Paris, 1876) says that hydramnios has not, properly
speaking, any pathological anatomy : " I'hydropisie de I'amnios n'a
pas, a proprement parler, d'anatomie pathologique." In a certain
sense this is quite true, for, as has been pointed out, there is no
special state of the fcetus or of the mother which can be regarded as
the constant cause (or effect) of hydramnios. There are, however,
some facts regarding the state of the placenta and memliranes wliich
must lie referred to. Sometimes, as in the s]iecinien which I showed
to the Edinburgh Obstetrical Society in 1894 (170), the placenta
exhibits hypertrophy ; sometimes it is also (edematous (ride p. 294),
or affected with syphilitic changes (vide p. 230) ; and sometimes it is
404 ANTENATAL I'ATIIOIXXJY AND HYCilENE
adherent or tlie seat of tibro -adipose degeneration. But none of these
chanties is constant. Sometimes the umbihcal cord is longer than
usual, much coiled round the foetus, or showing marked torsion ;
sometimes, also, its vessels, and esj)ccially the vein, may Ije more or
less narrowed ; but in other cases tiiese changes are ali.sent. Some-
times the cajiillary network (" vasa propria") described by .linigliluth
(Arch./. Gijnaek., iv. 5o4, 1872), which lies under the amnion on the
fcKtal surface of the placenta, has l)een noted to lie very evident —
so-called persistence of the vessels of Jungbluth — but in many cases
these vessels are not to be seen. Sometimes the amnion and ch(jrion
are thickened; Init sometimes they are not. It is quite evident that
these facts regarding tlie jilacenta. membranes, and cord do not throw
much light upon the pathology of the disorder; indeed, they dee})en
the shadow in which the subject lies. Neither do observations on the
characters and chemical composition of the liquor amnii itself help us
very much, for they are very few in numl>er : sugar may be present
{tide p. 223), and E. Opitz (Ccntrlbl. /. Gynak., xxii. 553, 1898)
has exjierimentally shown the presence of an irritating (lymph-
agogue) substance in the amniotic fluid in cases of hydramnios ; but
there is great need for much more investigation of this important
part of the subject. The quantity of the liquor amnii varies from a
little more than two pints up to such enormous amounts as seven,
twelve, seventeen, and even twenty litres. The pathology, therefore,
of the placenta, memliranes, cord, and liquor amnii is not known with
any certainty ; and the same remark applies to that of the fo'tus and
mother in these cases, for the fa-tus may exhibit practically any, all,
or none of the various diseases and deformities by which it may be
affected, and the mutlier's health may vary from very good to very
bad.
It cannot, then, be expected that our knowledge of the patho<jcncsis
of hydramnios will be in any measure exact or sufficient. Further,
the reader will remember that even the origin and source of the
liquor amnii in normal pregnancies are matters of uncertainty and of
great difierence of opinion {vide p. 152, et scq.). Some writers hold
that the amniotic fluid has a purely fcetal origin, some a purely
maternal, and some that it arises from both fo'tal and maternal
processes. Similarly, when the fluid is in excessive amount, the same
different theories of origin have been advanced. On this subject
Paul Bar's Thhc (Paris, 1881) is still well worth consulting, although
now twenty years old. There is, fiir instance, the idea that the
liquor amnii is fui'tal urine, and that hydramnios indicates increased
renal activity ; but the kidneys may show no pathological changes, the
urethra may be occluded or al)sent altogether, aiul there may even be
entire absence of the kidneys, and yet the fluid be jiresent in excessive
amount. Then there is the theory that various skin diseases of the
fwtus may be the source of the liydraninids, and a few cases in which
pemphigus or nu'vus or other morbid states havt' coexiste<l with
liydramnios have been cited; liut the evidence is very slight, and the
coexistence only occasional. A more }irobable theory looks to
increased pressure in the umbilical vessels (from various morbid
HYDRAMNIOS 405
cliauges in the fretus or cord) as tlie proliable mode of origin of
hydraninios. According to this view (to which reference has already
been made, p. 232), the hydranaiios of antenatal life is e(puvalentJ;o
the hepatic ascites of adult existence ; the pressure in the umbilical
vein may be raised liy morliid conditions in the liver, heart, or lungs
of the fu'tus, and increased transudation of fluid take place. Again,
it has been supposed that the excess of the liquor amnii is due to
a secretion from the cerebro-spinal canal of the fcetus, and cases in
which that canal is open by reason of grave malformations have
been adduced in support thereof ; but, of course, such malformations
are often absent when hydraninios is present. It has been affirmed
that the flaky deposits sometimes seen on the surface of the amnion
in cases of hydraninios indicate the occurrence of inflammation of that
membrane (Seiitex, Mem. et hull. Soc. de mM. ch Bordeaux, 204, 224,
1869), and that the "amniotitis" thus produced has caused excessive
secretion from the membrane in some such way as pleurisy with
effusion takes place. This explanatitm has been specially advanced
in cases where the liydramnios has followed a blow or fall, and it
has been alleged that the traumatism was the exciting cause of
the " amniotitis " with effusion. There are diiBculties in the way
of accepting this view, such as the non-vascular character of the
amnion ; but there is some reason to regard the explanation as
sufficient in certain cases (acute). Further, the structure of the
amnion permits the supposition that lymph may pass easily enough
through it I )y the stomata. It is, therefore, not impossible that in some
of the chronic cases, also, there may be a transudation of serum from
the maternal vessels through the membranes into the amniotic cavity,
e.g., in instances of maternal nephritis, ana-mia, etc. But, again, in
twins, and especially in uniovular twins, hydraninios may occur in
association with one but not with the other; this is an occurrence
which has been explained by some writers as due to the weaker heart
of the fojtus with liydramnios, an explanation found difticult of
acceptance, since that foBtus may apparently have the stronger heart
of the two.
One might, however, write much on the various pathogenetic
theories which have arisen round the suliject of hydraninios, and yet
do little or nothing to simplify the problem. I shall content myself
with making two statements, and then closing the discussion, so far
at any rate as the pathology of the foetus is concerned. In the first
place, it has to be borne in mind that hydramnios is simply the
jiersistence of a state which is normal in the early months of
pregnancy, for at the fourth month the liquor amnii weighs more
than either the fcetus or the placenta and mendiranes. We may
then regard hydramnios as the persistence or rejiroduction of a
relationship between the foetus and its hydrosphere, which is normal
in early fretal life, and perhaps also in neofa;tal existence. In the
second place, the frequent association of hydraninios with so many
different manifestations of both fcetal and embryonic pathology, shows
that it must be due to a factor which is common to these different
morbid states, or else to a very large number of different causes. I
40G ANTENATAL I'ATHOLOdY AND HYdll.NK
am incliiieil Id a(;cc])t the lattev alternative, and to lonk iquin
hydramnios as a syuiiitoni nf antenatal jiatiiological eonditions, and
to regard it as liavin;^ nrigin in several dill'ereiit ways. It may some-
times be due to a cheniical irritant eomin^ from the mother or formed
in the foetus which excites a liow of lymiih or serum: it may be
caused by incTcased pressure in the undjilical vein and its brandies,
arising from various foetal diseases and deformities ; it may 1)6 the
result of changes in the maternal blood which allow incieased trans-
udation ; or it may possibly represent fcetal urine or cerebro-spinal
liuid. I'ossibly the new method of investigating fluids by the diil'er-
ence in their freezing point may thnnv light upon the origin both
of the normal liquor amnii and of the anniiotic fluid in excess.
G. liesinelli (A7m. di ostd. r i/inrc, xxiii. 1029, 1901) has already
published the results of re.searches on the osmotic pressure of the
maternal and fretal blood and of the liquor amnii ; he has found
that it is less in the maternal and fietal blood at birth than in
the non-pregnant adult, and that it is constantly less in the liquor
amnii than in the maternal or foetal blood. Further, in a case of
twins, the freezing point of the liquor amnii of the one fo'tus niaj'
dilTer from that of the other. It is, therefore, (piite possible that
cryoscopy (as this method of research is called) may yet helj) to
clear up certain problems regarding the formation of the li(iuor
amnii both in normal and abnormal amount.
The treatment of hydramnios has generally taken the form of
tapping the memliranes through the cervix, but somewhat high up,
so as to allow some of the Huid to escape, and thus to relieve the
suffering caused by the over-distended state of the uterus. Chloral
and morphia have been used as sedatives. It is possible that dietetic
or medicinal measures may yet prove successful in arresting the over-
secretion of the anniiotic Ikiid. Mercury and iodide of potassium
have been used. In one instance I gave saline pui-gatives with this
end in view ; but, since a few days later laliour supervened and twins
were born slightly prematurely along with a great excess of liipior
amnii, one could not say whether the salines had any ettect u])on the
quantity of Huid, although they may have hastened the adxcnt of
labour. It has been advised that only the smallest quantity of Ihiid
be given with the food in cases of hydramnios ; but of course it will
always be difficult to judge of results. In an interesting case of early
(third month) hj'dramnios, reported by A. A. Scott Skirving {Edinh.
Hosp. Rep., vi. 387, 1900), in which the abdomen was ojjened on the
mistaken diagnosis of ovarian cyst, the hydramnios slowly disaiijieared
after the abdomen had been closeil again, and at the full (cnn or near
to it the jjatient was normally delivered of a living infant, there being
then no sign of hydramnios. From such a ease we are led to believe
that reabsorption of an excessive amount of liquor amnii occurs, and
is jierhajjs to be ho]ied for.
Oligohydramnion.
By oligohyilramnioii is meant th(> absence or marked defieieiicy
of liquor amnii. It would seem to Ijc rarer than hydrainnios, if the
OLIGOHYDRAMNION 407
muaber of recorded cases be taken into account. J\ly own experience
agrees with this ; bnt it is probable that more cases of ohgohydramnion
escape recording than of hydranmios. The anomaly varies in degree:;
sometimes onl}- a diachm or two of thick, viscid material may be
found representing the amniotic fluid.
It might be hoped that a study of the cases of oligohydramnion
woidd thi'ow some light upon the causes and pathogenesis of
hydramnios ; possibly it does, if we were only acute enough to per-
ceive it, but the light is not evident to us as yet. For it is found on
investigation that oligohydramnion is associated with very much the
same firtal diseases and monstrosities that hydramnios is. For
instance, in 1895 I reported a case (176) of dilatation of the urinary
bladder and ureters with hydronephrosis in which there was oligo-
hydramnion ; yet in other cases in which similar anomalies are
present there may be hydramnios. W. W. Jaggard (Amcr. Jonrn.
Obst., xxix. 433, 1894) also reported a somewhat similar case, in
which the bladder was greatly hypertrophied, the urethra obstructed,
the right kidney cystic, the left kidney as well as the rectum and
anus absent, both hip-joints dislocated, and the left sterno-mastoid
muscle wanting. Sometimes the fcetus would seem to be normal and
is born alive ; sometimes, on the contrary, it is the victim of various
morbid alterations, including fractures (Linck, Arch./. Gynaek., xxx.
264, 1887), club-foot, Polydactyly, encephalocele (Strassmann, Ztschr.
/. Gcbnrtsh. n. Gynak., xxviii. 181, 1894), hydrocephalus and scoliosis
(Bonnaire, Arch, de focol., xxi. 157, 1894), sympodia, spina bifida, and
exomphalos {Arch, ili ostct. c f/inec, i. 41, 1894), club-hand and various
ankyloses (E. Apert, Bull. Soc. anat. etc Par., 5 s., ix. 767, 1895),
absence of lower jaw and external ear (A. W. Addinsell, Trans. Zand.
Ohstct. Soc, xxxvii. 204, 1895), etc. etc. The only malformation
which would seem to he more conmon in oligohydramnion than in
hydramnios is ankylosis of joints. Further, the conditions present
resemblances in other directions : in uniovular twins, one fa'tus (per-
haps an acardiac one, as in H. Schiller's case, Ztschr. f. Gehurtsh. n.
Gynilk., xxxii. 200, 1895) may be accompanied by deficiency of liquor
amnii ; the condition may recur several times in the same patient
(Mekerttschiantz, Centrlbl. f. Gynuk., xi. 831, 1887) ; and there is
some connection between oligohydramnion and amniotic bands. In
all these directions hydramnios and oligohydramnion show resem-
blances. Many interesting questions arise out of the study of the
pathology of deficiency of the liquor amnii, although most of them
belong rather to the pathology of the embryo than to that of the
foetus ; but here it may be remarked that the frequency of ankyloses
and of club-foot in connection with oligohydramnion would seem to
support the view that these states are sometimes due to the effects of
pressure of the amniotic mendjrane permitted by the al.isence of the
fluid. It is not likely that this anomaly of the liquor amnii will
enable us to settle the question of the source of the fluid {e.g., from
the foetal kidneys) ; for although absence or cystic disease of these
organs may occur in association with oligohydramnion, they may also
be met with in hydramnios.
408 ANTKNATAI. I'ATHOI.OdV AM) IIYCIKNE
The ]iatliiiliii^icul (■liauges in tlie placenta and nic'nil>i'anes in
oligoiiyilraniiiiiiii liave been liltle investigated. The plaeenta lias
heen noted to lie thick and inegular in form, and to show yellow or
grey patches and even caseous nodules; microscopically, sclerosis of
both the maternal and the f(etal structures has been found, c.'/.,
endarteritis oliliterans and periarteritis (jf the vessels of the villi.
Manifestly these changes cannot be regarded as special to oligo-
hydramnion.
The symptomatology of oligohydramni(jn is not well known, It
may be noted that fo'tal movements are unusually distinct, and that
they may be very painful. Perhaps the obstetrician may observe
that the tVetal parts are unusually ])alpable. As a rule, iiowever, the
diagnosis of deficiency of liquor amnii is not made till labour is in
])rogress, when the absence of a marked bag of membranes and of the
iluid itself will reveal it.
There are other morbid states of the fcetal annexa to which refer-
ence might here be made. There is, for instance, myxomatous
degeneration of the chorionic villi, with its curious occasional sequel,
deciduoma malignum ; there are the various pathological states of
the decidual membranes and the various tyi)es of " mole," fleshy and
sanguineous ; and there are the various anomalies and malformations
of the placenta and its vessels and of the cord and its vessels. These,
however, are morliid conditions, having their origin anterior to the
fretal period of antenatal life, in the embryonic or germinal epoch.
They will, therefore, lie considered with the pathology of the embryo
and germ, as will also many ])oints touching amniotic bands and
pressure, hydranniios, and oligohydramnicm, which have been only
alluded to here.
In the meantime, let it be again repeated and constantly borne iu
mind, that the morbid states of the fo'tal annexa form a part, and an
important jiart, of f(etal pathology ; that they complicate all the
questions of antenatal pathogenesis ; and that in them may be found
an answer to .some at least of the problems of antenatal disease and
deformity.
CHAPTEE XXIV
Intrauterine Death of the Fu-tus ; Jleclianism, Fu'tal Asjjliyxia and Urtemia,
liigor Mmtis, Clinical History, Syinptoniatology, Physical Examination,
Diagnosis, Pathology of Maceration, etc., Abortion, Causes of Firtal Death,
Treatment.
Allusions have been made liere and there throughout this work
to the occurrence of ffetal death, and it will have been gatliered that
most of the morbid states which have been described may be the
causes of, or at least may be associated with, the cessation of intra-
uterine vitality ; but it is necessary in this chapter to centralise and
elaborate the notions upon this sitbject which will have been formed.
Its discussion is suitably placed here, for it demands a preliminary
acquaintance with the phenomena of fa?tal pathology and with the
laws which govern these phenomena, in so far, of course, as they
are known to us.
To the patient who expects to become the mother of a living
iirfant, as well as to her medical attendant, the occurrence of foetal
death brings a disappointment which has a sadness and a vexation
peculiarly its own. Little comfort can be got from reflecting that,
from the forensic point of view, the fu?tus in utero cannot have died
because legally it was never ahve. So long as the proof of live-birth
requires the establishment of pulmonary respiration after the com-
plete expulsion of the infant from the maternal passages, so long will
it be possible to deceive one's self as to the value of fwtal life ; but the
mother of a dead fit'tus does not really deceive herself on this matter,
and her medical attendant feels no less acutely the opprobrium on
his art that the unborn infant should not come living to the birth.
Death before (legal) life may be a paradox ; but death before birth is
a very sad certainty. When, further, the antenatal death is repeated
ill successive pregnancies, — when, so to say, there is habitual fuetal
death, — the maternal disappointment mounts up to complete dis-
couragement and anguish, and the obstetrician feels acutely his
helplessness under the most trying circumstances. A reproductive
life history which is a record of dead births is an appalling cata-
strophe, look at it as we may. I have recently interviewed a woman
who has had six dead-born fwtuses between the sixth and seventh
month of pregnancy, and one eighth-month infant that only lived a
few hours; she had seen several doctors and had taken much
medicine, but had never brought an infant to the full time, and had
only once given birth to a child living at the time of labour. A very
careful examination of the case revealed no apparent cause for this
reproductive failure ; but one cannot put the matter aside and content
one's self with the reflection that there is no evident cause, and that the
410 ANTKNATAL I'ATMOLOCY AM) inCIKNK
patient .siiiiply has " the Iialtit of giving birtli tn ik'ad ljal>iL's." The
niotlior liLTself IVx'ls that tlicie is sdincthini,' very iniiiuifect in the
ol)stetric ait and si'ience wliich canmit liclp her to hiing a living
infant to the light: whe knows that tinn^ after time the fotiis was
alive till a week or a fortniglit l)efore its eximlsion from the uterus;
she took every eare of herself, and she swallowed faithfully all the
medicine that was given her; and yet time after time she noticed
that the ftetal movements ceased ; she waited in sickening dread for
some days, and again gave birth to a macerated fo'tus. The medical
profession cannot he content to leave uninvestigated this prul)lem of
reciuTcnt or " habitual " fn'tal death ; humanitariau as well as economic
necessities impel us.
lleference is not here made to the subject of intranatal death,
although it also has a sadness quite its own. To see a child, large,
strong, well nourished, and free from disease or deformity, ])erish
during its transit through tiie birth canals by reason of great dispro-
portion between the size of the pelvis and the head of the infant, or
on account of one or other of the many dangerous complications of
labour, is indeed a .sad spectacle. AVhen this death is apjiarcntly due
to nothing save a somewhat unusual degree of betal development, and
to an advanced state of ossification of the cranial bones (as in a case
(152) which I saw with Dr. A. T. Sloan in 189;J, and in which four
pregnancies ended in the e.xpulsion of infants still-l)f(rn from the
above causes), there is a peculiar element of vexatious disajiiwintment
in the occurrence. To see the infant pass "from the f(et>is-sluml)er
into the sleep of death, out of the amnios-skin of this w^orld into the
shroud, the amnios-skin of the next"' is to the obstetrician who sets
a high value on infantile life both a humiliation and a reproach.
When the mother also dies in labour with her child, there is produced
a situation which touches every heart, and a calamity which calls
forth universal sympathy. ]Milton's touching lines in his " Ki)itaiih on
the Marchioness of Winchester " might well serve for many a humlilcr
mother thus bereft of maternity and life at one blow :
" Ami now with second liope she goes
And ciills Lucina to her throes ;
But whether by mischance or hhinie
Atropo.'; for Lucina came ;
And with remor.'selcss cruelty
Sjioil'd at once hotli fruit and tree ;
The ]iM]iU'.ss liaUc before his birth
Had burial, vet not laid in earth,
And tlic lani;ui.'<h'(l mother's wondi
\\'(is iKil lonj; a living tondi."
But even in the worst cases of intranatal death there is not the same
feeling of helples.sness which is exiierienced in dealing with antenatal
death. Every year marks new advances in the management of child-
birth and in tlie ])revention of accidents to the foetus in the maternal
passages ; the limitation of the destructive methods of delivery
(embryulcia, craniotomy) liecomes ever more sharply insisted upon ;
' Kichtcr s FImcci; Fruit, and Thorn I'lWrs. Noel'.s Traiisl., i. ;!2S, 1871.
<l
FCF.TAL ASPHYXIA 411
and the obstetrician looks hopefully forward to a not very distant
time when it will lie possible, without increasing the risks to tiie
mother, to give every chance to the cliild. But about antenatal^
deatli the same cannot yet be said ; the problem of the prevention of
intrauterine mortality is much more difficult and much moie com-
plicated ; there are some few hopeful signs, Init as yet they are very
far off. Principiis obsta, check the Ijeginnings, must be the thera-
peutic watchword ! But how ?
Mechanism of Foetal Death : FcEtal Asphyxia.
When it is remembered that the life of the foetus is of a semi-
parasitic kind, it will be readily granted that the explanation of the
mechanism of its death becomes not a little difficult. There are
causes of death which will act upon the unborn infant from beyond
the placental liarriers, and there are causes which may arise in the
foetus itself either as a result of the action of the maternal causes or
possibly independently of them. In the ^'ast majority of the cases
of foetal death, the cessation of vitality is no doubt due essentially to
causes which develop in the fcetal organism, however closely these
may be associated with extrauterine morbid states ; the fcptus dies of
auto-intoxication ; it is poisoned by the piroducts of its own metabolism.
Doubtless there are several kinds of fcetal auto-intoxication, but
little is known with regard to any of them save foetal asphyxia.
Fa'tal uramia may occasionally occur, but next to nothing is known
regarding it. Palazzi {Ann. ili ostet. e r/inec, xxiii. 225, 1901) has
pointed out that when through placental inadequacy there is a risk
of urtemia, there is also a possiliility that the kidneys may vicariously
assist in the elimination of the eft'ete products ; while in the case of
faHal asphyxia there is no foetal organ which can take ou tlie function
of the gaseous interchange when the placenta fails. It may also
be supposed that poisons and toxins passing from the mother to the
foetus kill the latter by their direct ettect upon its tissues ; but it is
more probable that they prove fatal by their action upon the
placenta, which, becoming inadequate, gives rise to foital asphyxia. A
marked and especially a sudden rise in the maternal temperature
may kill the foetus in utero ; it is supposed that the mechanism here
is degeneration of the myocardium of the fretus on account of the
high temperature, l^ut even in this case asphyxia may be invoked as
a link in the chain of lethal factors. It may then be asstimed that
f(etal asphyxia is the great immediate cause of fo'tal death. The
various conditions which may iiroduce this state of the fu'tus will be
referred to later ; in tiie meantime the mode in which the asphyxia
brings about the intrauterine death must be described.
Fcotal asphyxia may be acute or chronic ; the former variety is
due to causes which rapidly and completely throw the placental
system out of action, and the latter to a more slowly produced or a
less complete interruption of the fo'to-maternal interclianges. During
labour (especially after the rupture of the membranes) new factors
come into play, but the result is practically the same as in pregnancy.
412 ANTENATAL PATHOLOGY AND HYGIENE
Carbonic acid ami other waste jmjdiicts aceuumlate in the foetus, and
oxyt^eu is not suj^ilied to it.
In the acute tyi)e of fo'tal asphyxia, it may he supposed that tlie
carhonif- acid in the l)lood first excites the vaf^us, wliicii causes slowing
of the rate of the f(vtal iieart and irregularity. Then, the vagus
becomes paralysed, the heart's action is quickened ; and finally it
stops from paralysis of the sympathetic nerves. Meanwhile the
respiratory centres will also liave been excited, attempts will have
been made to inspire, the liquor amnii will have been sucked into
the lungs, and, through tlie congestion of tiie pulmonary capillaries
thus produced, tlie lilood pressure in the aoita and its Iiranches
(including the uml)ilical arteries) will fall. No doubt the ])rocess is
more complex than has been stated above; but tlie two factors which
have been descriljed lead at any rate by their combined action to the
death of tlie foetus. In the more chronic form, it is believed that
inspiratory efforts are not usually made, the increasingly venous
cliaracter of the blood slowly diminishing tiie excitability of the
respiratory centres in the medulla, so that neitlier the absence of
oxygen nor the presence of carbonic acid stimulate them. In both
types the heart finally ceases to contract, and the fa>tus presumably
is dead. A difficult question, however, here arises. It is possible
that the cause of tlie foetal asphyxia may be suddenly removed just
after the lieart has ceased beating ; under these circumstances, will
tlie cardiac contractions recommence, and if so, after what jieriod of
cardiac inactivity will they so recommence ? It is here that the
semi-parasitism of the fietus comes into play and complicates the
problem. I think it is quite possible that the heart may cease beat-
ing for a considerable number of minutes, and recommence again if
the cause of the asphyxia be removed. Certain facts which were
pointed out in Chapter IX. (p. 134, et scq.) must here be kept in
mind : they were the degree of the automatic activity of the fcctal
heart and its less immediate dependence upon an oxygenated state of
the blood circulating through it. From these characters of fo?tal
cardiac action it might be permissible to conclude that fo'tal death
would generally be establislied very slowly. On the other hand,
there is the well-known fact that in maternal death Ca-sarean section
must be performed very (juickly if the fcetus is to be saved. In the
latter case, however, the maternal part of the placenta is dead, while
in the former it is alive ; further, in tlie latter case the attempt is
made to excite cardiac action by setting up extrauterine (pulmonary)
respiration, probably a more difficult matter than to re-excite cardiac
action by removing the obstacles to placental respiration. On
account of tliese facts, and by reason of the difficulties of antenatal
diagnosis, it becomes a very difficult problem to give an opinion as to
the death of the fa'tus in utero. To this matter, however, I shall
return immediately.
The immediate results of fatal fo'tal asjihyxia are not often to be
observed save in connection with intranatal death, and, as wt' have
seen, true fietal deatli dilfers somewhat from that. So far, however,
as is known, tliey consist in the presence in the vessels of a very
FCETAL RIGOR MORTIS 413
dark coloured blood, eitlier with no clots or with a few dense clots
in it ; in the occurrence of ecchynioses on tlie large vessels of the
thorax and in tlie subpleural and suljpericardial tissues, and some-
times of small intracranial and pulmonary hannorrhages ; in the
finding of liquor amuii and meconium in the air passages ; and in
the transitory appearance of rigor mortis. There may be other signs
noted, but it is doulitful how far they are to be regarded as due to
the traumatism of labour. The advanced post-mortem changes
(c.ff. maceration) are referred to immediately. The changes which
have been mentioned above are evidently due to tlie chemical
changes in the blood and to the [)rematnre attempts at respiration.
What the alterations are in the other modes of foetal death (e.i/.
ura?mia ?) we do not rightly know ; it has lieen stated that degenerat-
ive changes in the myocardium characterise the lethal effect of a
high temperature, but the evidence is slight.
Antenatal Eigok Mortis.
Eigor mortis in the foetus lias been mentioned above. I have
abeady referred to its occurrence on p. 178 of this work, and also in
a special article (80) in Teratologia ; but I may summarise my chief
conclusions here, for they are of some importance. I have seen
several instances of antenatal rigor mortis, including the one described
in the above article. It was a case which occurred in the practice of
Dr. D. Milligan. The child's heart did not beat at birth, nor was there
any pulsation in the cord during delivery. The head presented, and
the labour lasted from four to five hours. The left arm was sharply
and firmly flexed, and there was a similar, but less noticeable,
condition of the right knee. Two hours after birth I saw the infant,
when there was still some stiffness; but soon this entirely dis-
appeai-ed. The foetus, a male, weighed 1220 grms., had a length of
40 cms., and the appearance of a fcetus of about six and a half
months ; the pupillary membrane was still present. A large and
comparatively recent black blood-clot was found in the placenta, on
the maternal surface. I believe that in tliis case the rigor mortis was
passing off when the fcetus was expelled.
The first recorded case of antenatal rigor mortis seems to have
been that of Chowne {Lancet, \h 199, ii. for 1840-1), yet Casper in
his Forensic Medicine (New Sydenham Soc. Transl., i. 29, 1861)
writes : " I have never observed cadaveric stiffening in the im-
mature foetus, . . . even in the case of mature new-born infants and
little children it is feeble and transitory." Further instances, how-
ever, were soon reported by Schultze {Deutsche Klinik, No. 41, 1857),
by Curtze {Ztschr. f. Med. Chir. u. Gchurtsh., 261, 1866), by G.
Tourdes, in twins (article " Cadavre " in Diet. encyclo2i. d. sc. med.,
1 s., xi. 420, 1870), by W. C. Grigg {Brit. Med. Journ., ii. for 1874,
pp. 493, 586, 707), J. A. Thompson {ibid., ii. for 1874, pp. 550, 640,
772), P. A. Young {iiid., ii. for 1874, p. 707), C. H. W. Parkinson
{ibid., ii. for 1874, p. 772), by M. Bailly, in twins {Arch, de tocoL, iii.
641, 1876), by A. Martin {Ztschr. f. Gchurtsh. u. Gyndk,i. 55, 1877),
414 ANIKNATAI, I'A I 1 1( )|.( )(.V AM) IIVCIKNK
liy I.. W. lluUi'v (J)lssni., Maibui-i,', 188U), hy K lJa|,'in(/()Uil (Tliisr,
r'aris, 1S8U), by K. lioxall {Lancrf, ii. for 1884, p. GO), hy 15. -loiifs
{BriL Med. Jo urn., ii. for 1885, p. 9G3), hy T. David.soii (ihuL, i. for
188(), ]i. 12), hy Stui)ii)f (Arch./. Gijnack., xxviii. 472, 188G), hv
.Saii>,a"r (jhiil.. xxviii. 47:!, 188G), by Dolirii (Cnitrlhl. f. (iynak., x. 1 1:'..
188G), hy U. Keis {Arch. f. Gynaek., xlvi. 384, 1894), hy M. Laii-c
{CentrlU. f. Gyndk. , x\ii\. 1217, 1894), by N. S. Kaiuiegisera {Joum.
akoush. i jensk. boliez., ix. ol, 1895), by Steiuhiicliel (Wicu. imil.
Wchnsrhr., xlv. 370, 434, 474, 1895), by B. Jones {Lamcl, ii. for 1895,
]). 1020), and by Knorr (Cen/rlbl. f. Gyndk.,xx. 40, 1896). In several
of these eases, the dead and rigid infant was removed from the uterus
by Ciesarean section, i)roving conehisively that rigur mortis may
occur in the uterine cavity. In most of the cases the labours were
alinormal (placenta pi'icvia, accidental haauoirhage, eclampsia, pelvic
contraction, etc.), and the fo-tal death must he ascrilied thereto ;
proljaldy the rigor mortis which follows death before labour has com-
menced will seldom, if ever, be seen, unless indeed delivery occur
very ra])idly and very soon thereafter.
The rigidity in some of the reported cases was well marked and
widespread; practically, it always alfected tlie limbs and generally
also the muscles of the jaws and neck. It jiassed oil' in times varying
from one hour to thirty hours after birth, and the post-mortem
examination usually revealed simply the signs of premature respira-
tion. There is nothing in the intrauterine environment to prevent the j
occurrence of rigor mortis ; and J. Tissot {Arch, phyaiol. norm, ct path., i
5 s., vi. 860, 1894) has shown that it takes place in fietal kittens;
possibly it may be slightly marked, and may come on sooner and pass
ott' earlier than in postnatal death, but even of these dill'erences tliere (
is not much proof. Of course every case of congenital rigidity is not
necessarily an instance of rigor mortis {e.cj. Gibb's case. Lancet, ii. for
1858, p. 497). The rarity with which it has been observed, or at any
rate recorded, may be explained by several circumstances : the non-
coincidence of fcetal death and expulsion from the uterus, the :
absorption of the obstetrician in liis duties to the mother, the
characters of foetal rigor mortis, and perhaps the use of the Schultze !
swinging movements in attempted resuscitation. Nevertheless the '
proof of the occurrence of antenatal cadaveric rigidity is, I think, i
complete, at least in the cases where death occurs during or >
immediately before the supervention of labour pains ; iiud it may be :
met with in immature as well as in mature ftetuses. lV)ssil>ly, in
cases of ftntal death occurring slowly in utero from c;iuses not ■
associated with delivery, the gradually ceasing fietal circulation and i
the long-drawn-out manner in wiiich vitality disappears may impresB
special cliaracters on the rigor nuntis which then supervenes.
Clinical History and Symptomatology of FcEtal Death.
In cases of tVetal death, it is not unconnnon to be able to elicit '
the history of the previous occurrence of the same fatality in the
mother's i-c]irodiu'tive record. When this so-called " habit of giving
i
I'd'/I'AL DEATH 415
birth to ilead infants" is met with in any case, it is coiiimou to liiid
inilieations of some distinct maternal disease. For instance, there
may be the history of syphilitic manifestations ([ip. 246, 254), anrl
according to some authorities the " habitual " fu^tal death may itself
be the manifestation and the sole manifestation of that disease. But
there may, in other instances, be a record of long continued ana-mia,
of malaria, of alcoholism, of lead poisoning, of heart disease, or of
renal disease with albuminuria ; again, it may be gathered that the
mother had for a long time suffered from endometritis, or uterine
displacement, or disease of the placenta. Home of tlie conditions
which have been named may be dependent upon each other, as for
example placental alterations upon maternal albuminuria. Finally,
in some instances, there may be no very evident cause for the
recurring fu^tal deaths either in the mother or in the father. Very
curious cases are those in' which every alternate pregnancy ended in
the birth of a dead hptus, or in which all the infants of one sex were
born dead and all those of the other alive.
When the past history of the mother yields no information which
has any obvious bearing on the death of the unborn infant, the record
of the present pregnancy ma\' do so. Thus the mother may have
been the subject of a serious traumatism, or have been the prey of
violent emotion, although it must be at once admitted that not in-
frequently even very serious accidents, and very considerable per-
turbations, may be followed by the birth of a healthy living infant
at the full term. Again, the mother may have suffered from an acute
illness in her pregnancy, such as pneumonia, cholera, or smallpox ;
or she may have become infected with syphilis, or have de\'eloped
cardiac or renal disease. Yet again, there may have been no acci-
dent or disease during gestation to give an indication of the possible
condition of the fretus; when a dead foetus is born after such a
pregnancy, we are led to infer that the death must be due to condi-
tions arising in utero, in the placenta or fcetus, independent of the
maternal health. These cases present most puzzling problems ; and
for most of them no hypothetical explanation even is forthcoming.
Of course, I do not here refer to instances of intranatal death due
to the many lethal influences which may then come into play.
The symptomatology of ftetal death abounds in phenomena which
suggest the possibility, or even the probability, of the occurrence of
this disaster, but is lacking entirely in positive indications thereof.
When it is borne in mind that the symptoms of intrauterine death
are in great measure the negation of the symptoms of pregnancy,
their indefinite character will be appreciated. Further, since preg-
nancy may cause no symptoms which can be regarded as absolutely
diagnostic, so fcetal death, in a still more marked degree, may yield
no certain indications. The mother may fear that her infant is
dead ; her fears may be justified, but, on the other hand, they may
not. All obstetricians must have met with cases in which they were
assured by anxious pregnant women that the child in the womb
was dead, and yet at the full term a living and healthy infant was
born. At the same time there are some symptoms of fLutal death
416 ANTRN'ATAI, I'A rH()I.()(;V AND HYdlF.NK
which liavo a certain ilcijree <if diai^nostio vahiu and iniportance.
They arc of 1,'reater vahie if tiiey supinveue iijioii well-marked
syinptiiiiis (if ])regnaiu'y. They coiisisl, in the first ])lare, in various
ill-defined feelings of the mother, such as headache, loss of appetite,
sensations of heat and cold, tinnitus aurium, general malaise, epi-
gastric ]min, a feeling of weight in the abdomen, and rectal and
vesical uneasiness. In the second place, there may occur a profuse
p(!rspiration or a sudden diarrhtea, and there may be reason to
believe that this symptom was synchrijiious with tlie death of the
infant. In the third ]ilace, there is the ilisap])earance of various
symptoms of pregnancy, such as morning sickness, special tyjies of
neuralgia, salivation, and the like. In the fourth place, there is the
cessation of foetal movements, and, if these movements have
pi'eviously been clearly recognised by the patient, it cannot be denied
that this symptom, negative although it is, lias a very considerable
value. Further, its value is increased if the cessation has followed
upon a series of very violent and disorderly movements, more
especially if these in their turn have been preceded by some recog-
nisable cause of fcetal death, such as a severe blow on the abdomen,
a sudden emotion, etc. It need not, at the same time, be pointed
out that for the purpose of diagnosis this symptom may be vei'v
fallacious, for there are times when the foetus is quiescent, and
conditions under which the active fcetal movements cjinnot be dis-
tinguished ; again, the patient may have made a mistake in thinking
that she felt quickening at all, and so also her ojiinion that quicken-
ing had ceased may be erroneous. Sometimes a sensation of passive
fcetal movements has been described by women carrying a dead
foetus, movements elicited by sudden changes in position ; liut the
value of this symptom is problematical. Finally, there are the
indications of the death of the fo-tus derived from the retrogression
of the mammary changes ; the woman may note that the glands are
not so tender and have not the swollen feeling which they had, and
that these changes have succeeded a time when the tenseness and
sensitiveness were greatly increased.
All these symptoms have a greatly augmented importance and .
diagnostic value when the patient has in one or more previous
pregnancies experienced similar sensations, and has found mit by
sad demonstration that they meant intrauterine death.
Diagnosis of Fcetal Death.
It is doubtful whether the antenatal diagnosis of fu?tal ilealh can
ever be made with alisolute security ; it can never be affirmed with
the same certainty as one affirms the presence of fcetal life after hear-
ing the fci'tal heart : but a very strong ])rovisional diagnosis can be
formed. This provisional opinion is founded upon th(> jiast history
of the patient, the consideration of her symptoms, and the physical
examination which the obstetrician makes. To the past clinical
history and to the symi)tonuitology I have already referred : I must
now consider in detail the physical examination.
F(ETAL DEATH 417
In the first place, the inspection and palpation of the niamniary
glands may yield indications of the death of the fcetus. Intrauterine
death would seem to have the same effect upon the mamniie as the
birth of the cliild, but this primary effect soon passes off. At first
the glands show increased sweUing and tenderness, the cutaneous
veins become more evident, and the secretion first of colostrum and
later of true milk becomes acti\'e. In a few days, however, these
phenomena pass off", and the glands gradually pass into a quiescent
state. When, ultimately, the dead ftptus is expelled from the uterus,
it has been noticed that the usual mammary engorgement which
follows birth is wanting. E. Tridondani (Ann. di ostet. c gincc, xxi.
71, 1899) draws special attention to the value of these mammary
changes, and indicates that perhaps in the microscopical and chemical
characters of the milk may be found additional indications of the
death of the foetus (disappearance of colostrum corpuscles, diminution
in the amount of sugar and fat, etc.).
In the second place, the careful examination of the abdomen has
a very considerable diagnostic value by reason of the change in the
physical signs there apparent. The abdomen ceases to have the
appearances corresponding to the ascertained or estimated date of
pregnancy : it seems, and probably is really, smaller than it was ; it
loses the marked globular projection in the middle line, and becomes
more expanded in the flanks, suggesting ascites ; the uml lilicus is no
longer projecting ; there is absence of the firmness and resistance of
the uterus containing a living foBtus, in fact, it becomes difficult to
map out the uterus by palpation at all ; no muscular contractions can
be felt sweeping over its surface ; and the whole uterus on account of
its flaccidity tends to sink into the pelvic brim and to lose its normal
shape and relations. The pigmentary and vascular developments in
the abdominal walls undergo involution, and it may be added here
that the \'ulvar and vaginal dusky red discoloration (Jacquemier's
sign of pregnancy) gradually disappears. When the attempt is made
to map out the various parts of the foetus, it usually fails, at any rate
when intrauterine death has taken place a week or more previously.
The hard glolie of the head cannot be detected, and there is a general
loss of the feeling of resistance in the fcetal tissues, so that the dead
infant is more or less completely moulded to the containing uterus.
A special sensation of crackling (scroscio), due to the looseness of the
bones of the head, has been described by Negri (Ann. di ostet. c qincc.,
V. 82, 1883 ; vii. 223, 1885). The head often ceases to be the pre-
senting part. The most careful palpation fails to elicit active foetal
movements, and no foetal heart is heard on auscultation ; but these
negative signs have, of course, only a limited value in forming a
diagnosis, for over and over again a living infant has been born, and
yet the obstetrician had neither heard its heart nor felt its move-
ments after the most rigorous examination. The uterine souffle may
be heard after the death of the foetus, but it has been stated that its
quality is changed. Apparently it has little value as a sign of foetal
death, and the same remark applies to the sounds due to intrauterine
decomposition which have been referred to by some authors. In the
27
418 ANTIA Al'AI. I'M IIOI.lX.'i AND IIYCIKNE
rare cases, however, in which antenatal jnitrefaetion is set up (usually
after rupture of the monibranes), the accumulation of gases leads to
the development of a tympanitic note on percussion over the uterus.
In the tliird place, the vaginal and bimanual examinations may
bring out a few additional facts (of no great diagnostic value) re-
garding ftetal death. If the death has been recent, no appreciable
diiferences may be detected ; l)ut if it has taken place ten or fourteen
days previously, it may be found that tlie cervix and lower uterine
segment have already lost the softness jjcculiar to pregnancy with a
living foetus, and that the pulsating artery in the anterior fornix is
no longer to be easily felt. It will be dillicult to distinguish the
presenting part. Sometimes it may bt; found that a fluid is dis-
charged at intervals of time from the uterus ; it may be clear like
serum or it may l)e blood-stained, or liave a dirty brownish colour.
This escape of fluid (Injdrorrluea (jracidaruin) has sometimes been
associated with fo'tal death. It must, however, l^e borne in mind
that it may occur with a living child also ; it has, for instance, been
noted in those curious cases in which the membranes rupture in utero
and the fcetus goes on developing outside them in an extra-anmiotic
or extra-membranous fashion, as in K. lieifi'erscheid's observation
{Centrlhl.f. Gi/ndk., x\\: 1143, IDOl). On the supposition that the
intrauterine temperature falls after firtal death, it has been proposed
to introduce a thermometer between the uterine walls and the mem-
branes for the purposes of diagnosis ; but the procedure cannot lie
commended.
In the fourth place, the death of the fcrtus may lead to the dis-
appearance of certain signs of pregnancy of a pathological nature,
and their disappearance may thus come to have a diagnostic \'alue.
In this way, for instance, varicose veins, dropsical swelling of the
lower limbs and vulva, and alliuminuria (A. H. F. Barljour, Ediiib.
Med. Journ., xxx. 901, 1SS4-5) may lessen very evidently, even if
they do not entirely disappear. The same remark applies to several
morbid symptoms of pregnancy, such as persistent vomiting, gra\ e
dyspno?a, etc.
In the fifth place, fcetal death may be followed by certain changes
of a chemical kind in the maternal excretions. It has from time to
time been somewhat confidently affirmed that in the presence of some
unusual substance in the urine is the certain test of intrauterine
death. Thei-e can ha little doubt that with tiie decease of the foetus
a current begins to pass from the uterus and its contents into the
general maternal circulation ; this current will contain the results ol
the involution of the uterine muscular fibres, as well as little known
substances from the liquor amnii, fietus, and placenta. Possilily tlie
immediate result of post-mortem changes in utero is a marked in-
crease in the total amount of urine secreted ; of this there is some
evidence. Witli regard, however, to the value of acetonuria as a
sign of f(Ptal deatii tlicre has lieen much diflerence of opinion. The
presence of acetone in the urine of the pregnant w^unan was stated
by G. VicarelU {Prag. mcd. Wchnschr., xviii.'403, 428, 1893) to be a
new sign of the decease of the fcetus before birth, other causes being
F(ETAL DEATH 410
excluded. Eesearclies were made by others (L. M. Bosai, Ann. di ostct.
C!)inc<:, xvi. 276, 1894; L. Knapp, CcntrlU.f. Gyncih, xxi. 417, 1897;
H. Lambinon, Journ. d'accouch. (Liege), xix. 70, 1898 ; E. Bidone.
L'acdonuria (jravidica, Bologna, 1898; Lop, Gas. d. hop., Ixxii. 519,
1899), and Vicarelli himself returned to the subject {liiv. di osfet., ii.
o68, 1897). The fact that acetonuria was found by Bossi {Arch, di
ostct. c gincc, iv. 193, 1897) in cases in which fibroid tumours of the
uterus were in process of absorption, formed a piece of continnative
evidence, and seemed to suggest that the acetone was due to the
breaking down of muscular tissue. A. Couvelaire {Ann. dc gyndc, li.
417, 1899) is of opinion that acetouuria in the puerperium is due to
the neuro-muscular fatigue of labour, the auto-intoxication of the
fatigue of the confinemeut being added to the auto-intoxication of
pregnancy; it does not indicate fcetal death with any certainty. It
cannot yet be determined what value acetonuria has as a sign of fcetal
death ; it is probably not developed immediately after the death of
the infant, and it may of course lie due to other causes, but it is un-
doubtedly of some importance ; and future oliservations will more
clearly define its sphere of diagnostic usefulness. It would seem to
be frecpiently associated with eclampsia and syphilis.
Another possible indication of intrauterine death is peptonuria.
A. Kcettnitz {Deutsche mcd. Wchnschr., xiv. 613, 1888) met with this
condition in four cases of fcetal death, and ascribed to it considerable
diagnostic importance. The fact that peptoiruria is often met with
in the puerperium, and after the application of electricity to fibroid
tmnom-s, supports the above view, indicating that the peptone comes
from the involution of the muscular organisation of the uterus. After
the death of the foetus, the uterus is practically in the puerperium,
although its contents are not yet expelled. Further, the belief is
strengthened by the observation, made liy Truzzi {Ann. univ. di mcd.,
cclxxi. 409 ; cclxxiii. 415, 1885), that peptonuria is absent in the period
following the expulsion of a macerated fcetus, the explanation being
that here the puerperium has already run its course before the empty-
ing of the uterus takes place. The experience of other obstetricians
has not, however, come to support the opinion of Kcettnitz, for P.
Caviglia {Stud, di ostct. c gincc, 379, 1890) and some others have
obtained negative results ; again, peptonuria has been repeatedly
foimd in cases in which the fcetus was alive. It has sometimes Ijeen
supposed that one might find traces in the maternal urine of other
products of macerative decomposition of the tissues of the dead
fcetus, such as htemoglobin, bile pigments, glucose, creatinin, and
urea ; but nothing has yet been discovered of real diagnostic value.
It is perfectly clear, fi-om what has been said, that the diagnosis
of foetal death must always be a matter of considerable difficulty.
When a multiparous woman passes through a severe illness and
affirms that she feels sure that her unborn infant is dead, and when
her medical attendant now fails to hear the ffftal heart whicli he
had previously heard with ease, the probabilities of intrauterine
death rise to a high level ; they are also great when previous ex-
perience has proved the existence of " habitual " foetal death ; but
420 ANTENATAL 1' A IlIOl.OdY AND IIYCIKNK
under other circumstances no confident diagnosis should l>e made,
and the obstetrician should be prepared for surprises. Wiieii actual
putrefaction of tlie uterine contents takes place, the condition is
different, for then the discharge of sanious evil-smelling tluid and
malodorous gases from the uterus, along with tympanitic distension
of that organ (physomelra) and grave signs of maternal lilood-jKuson-
ing, will reveal the nature of the processes going on in utero (E.
Chatelain, Thtsc, Paris, 1883). Putrefaction, however, is a very rare
consequence of f(t'tal death, and its ])resence nearly always means
that the membranes liave ruptured, and that air has gained access to
the uterine interior from the vagina.
There are certain conditions wliich, when present, greatly increase
the difficulty of diagnosing antenatal dcatii. These are the existence
of twins in utero or of an extrauterine gestation. It is almost im-
possible to give anything approaching a confident answer to the
question whether one firtus in a plural pregnancy lias succumbed,
and the hopes of determining whether the extrauterine infant \v.\>
died are scarcely greater. In tliese cases, as in all tiie less dillicult
ones, an important factor in clearing up tlie diagnosis is time ; the
repeated examination, especially by mensuration, of the abdomen will
in the long run throw light upon the problem, and by and by the
occurrence of labour will remove all doubt. Insteiid of true labour
there may be a false or spurious one, resultless as regards the ex-
pulsion of any uterine contents, but with a certain diagnostic value
nevertheless.
Even during labour some dubiety may still exist as to tiie life ov
death of the fcetus passing through the birth canals. When tiie
head presents it may l:ie possible by palpation to detect tlu; soft-
ness of the presenting part and tlie crackling sensation of the easily
displaced cranial bones ; the liquor amnii may be tinged green with
meconium, or may contain flakes of desquamated epidermis ; and any
prolapsed part (liand, foot, etc.) may show signs of maceration.
When these conditions are present, the diagnosis of fo>tal death
may be made ; but it is noteworthy that the presence of meconiiuu
in the amniotic fluid is not a certain sign (E. Eossa, Arch./. Gynad:,
xlvi. 303, 1894). Further, a swelling may be found on the presenting
part of a dead fcetus, not distinguishable by touch from the caput
succedaneum which is formed in ordinary labour. Death during
labom- will be diagnosed l)y the occurrence of some evident cause,
by cessation of the fo'tal lieart and of pulsation in the cord or other
palpable part, and by tlie ]iremature escape of meconium. 1 1' doubt
exist, it will soon be set at rest by the complete expulsion of the
infant, alive or dead.
Pathology of Fcetal Death.
I have already indicated the changes which, in all probability,
immediately follow upon the cessation of the life of the fetus (sub-
pleural ecchymoses, rigor mortis, etc.) ; liut it is now necessary to
consider the less immediate post-mortem alterations which occur in
PATHOLOGY OF F(ETAL DEATH 421
the dead unbin'ii infant and in its environment. The subject is com-
phcated by tlie difticnlty of separating the true post-mortem changes
from those due to ante-mortem disease, and by the lack of reliable
descriptions of the changes at various definitely ascertained dates
after death.
Four varieties of pathological change are usually enumerated in
connection with antenatal death, viz., dissolution, mummification,
maceration, and putrefaction. With regard to dissolution or the
gradual disappearance of all traces of tlie embryo in the liquor
amnii, it may be fairly confidently affirmed that it can occur only
in the embryonic period of antenatal life as a result of early death
of the new organism ; it is not, therefore, to l)e reckoned as one of
the post-mortem changes incident upon ftctal death. Mummification
is a peculiar drying up of the fu'tal tissues which occurs only under
special circumstances ; to it reference will be made ere long. Putre-
faction probably occurs only after the rupture of the membranes has
taken place and air has gained access to the uterus. Maceration,
therefore, remains as the commonest and most typical of the post-
mortem changes which follow fcetal death.
All the stages of maceration, a,^ it affects the frotus and its
annexa, are unfortunately not known. The immediate consequences
of intrauterine death and those which are found about a fortnight
later have been fairly well ascertained ; but of the changes which
develop between these times our knowledge is very imperfect. For
it is common for the foetus to lie expelled very soon after its death
or not till ten or fourteen days have elapsed, but rare for it to be
born at intermediate dates. If the death of the fcetus is not accom-
panied by its expulsion, it is common for a sort of spurious laboiir to
occur ; this is apparently without result, and the dead fa?tus is re-
tained for a fortnight or so. During these fourteen days, various
changes have been occurring in the uterus which usually are met
with in the first fortnight of the puerperium. Save, indeed, for the
fact that it is not empty, the uterus is practically a puerperal organ,
and by the end of fourteen days or thereabout the dead foetus inside
it is a foreign body. This is probalily one reason for the commonly
observed fortnight's retention. At the same time, much longer
periods of retention have been recorded. I have myself observed
a case (215) of missed abortion, in which the fretus died at the third
month and was retained tQl the ninth, being ultimately expelled
upon what would probalily have been the date of confinement had
the foetus lived ; and many such observations have been made. It
would seem to be much rarer for the dead fwtus to be retained for
some weeks or months after the full term of gestation ; and most of
the cases in which it was stated that the infant was discharged or
discovered after a sojourn of seven, ten, twenty, and even forty years
in the mother's body, are to be regarded as instances of extrauterine
or interstitial pregnancy. B. F. Baer, however, reports an extra-
ordinary case (Amcr. Journ. Obst., xv. 229, 1882), in which there was
a punctured wound of the uterus, partial escape of the foetus into the
abdominal cavity, and retention of it for five years. From what has
422 ANIKNATAI. PA TllOl.OdY AND IlYCIl-.NK
been said, it will Ije (n'iileiiL that most of our knowledge regavdiiig
maceration applies to the maceration found about a fortnight after
intrauterine death.
The external appearances and the internal alterations of the
macerated fretus vary with tlie period which has elapsed since death.
They have been specially studied by A. Lenipereur {T/ihc, Paris,
1867), by L. Sente.x {Mrm. ct hull. Soc. med.-chir. d. luq^. dc Jiordcaux,
ii. 486-572, 18G7), by O. Hourlier {Thtsc, Paris, 1880), and by others.
The process consists in a gradual softening of tiie tissues of the body
without the development of putrefactive gases or the presence of
microbes ; it is an aseptic change. It used to be termed " putre-
faction " by the older authors, but that name ought to be restricted
to the cases in wliicli putrefactive germs have gained access to tlic
interior of the uterus and s(!t up true putrefaction.
In the Jirst stage of maceration, which corresponds with the fir.«t
ten or twelve days following intrauterine deatii, the e.xternal form
of the foetus is hardly modified, and the parts retain their lirmness.
The epidermis here and there (limbs, neck, etc.) is raised u]> into
Itlebs containing blood-stained serum ; some of these may have burst
and their contents passed into the liquor amnii to mix witii it and with
tiie meconium in it. In the body cavities there is found a more or
less clear serum, and the organs are somewhat soft; the subcutaneous
tissue is infiltrated with serum, and the braiii siiows some softening,
especially in the grey matter. In the second stage, tenth day to
fortieth (Lempereur), the macerative changes have become very
marked. They are represented as they appear in a frozen section
in Plate XIV. This foetus, a male, came into my hands for ex-
amination in 1893, and 1 made sections of it after freezing in order
to bring out certain peculiarities not easily recognised by other
methods. It had been dead for fully a fortnight. At this stage
the whole fo'tus is somewhat swollen, but on account of its softness
tends to flatten out on any liard surface upon which it may be laid.
The abdomen, in particular, flattens out, as does the head in au
antero-posterior direction. The epidermis is absent over nearly the
whole surface of the body, leaving the dull red underlying skin fully
exposed. On the scalp, however, it is still attached. Tlie cranial
bones move freely oil each other, and the scalp tissues are swollen
and infiltrated with sero-sanguinolent fluid, w4iich may accumulate,
especially at the vertex, and produce a spurious caput (Plate XIV.).
Everywhere there is found this sero-sanguinolent fluid — in the sub-
cutaneous tissue, between the muscles, in the abdomen, in the
thorax ; so constant and so copious is it, that C. Euge gave the
name hydroi^s sanginnolcntus to the fcetus in this stage of maceration
{ZtscJir. f. Gehurtsh. u. Gymik., i. 57, 1877), and the name was quite
warrinited, although it came erroneously io be regarded as equivalent
to the syphilitic dead fietus. All the internal organs show softening,
and the brain is quite difliuent, only maintaining its form by the
help of the surrounding membranes. The heart, the liver, the spleen,
and the lungs are all more or less altered in shape on account of
their softness ; they may be pale in colour, or stained to a greater or
Blood- st a irud
subcutaneous
and tnuscufar
tissue.
i_. „su,.
Cap'ng mouth.
{^^^/n/.nor maxilla
th tooth in socket.
PATHOLOCY OF FCETAL DEATH 423
less degree with blood. Under the microscope, the epithelial ele-
ments of the tissues can be recognised as swollen and granular or
fatty in appearance; the changes in the stroma of the organs are
little known : and the blood corpuscles may be found swollen and
paler in colour than normal, or else shrivelled and broken up into
granular masses. The colouring matter of the blood is dissolved in
the fluids of the body cavities, or lies as small crystals in the tissues.
During the second stage of maceration the histological elements of
most of the organs and tissues become unrecognisable. In the third
stage, which last.s, according to Lempereur (o^j. cit.), from the fortieth
to the sixtieth day of intrauterine retention, the cellular elements
of even the lungs are unrecognisable. The absence of the epidermis
is now complete, and is seen even on the hairy scalp ; the softening
of the liody is very marked ; the internal organs rest in a collapsed
state upon the vertebral column ; and the lirain is simply an " emul-
sion of nerve tissues."
The post-mortem changes which ensue when the foetus is retained
in the uterus longer than two months, are not well known. Some-
times the maceration proceeds, and the body breaks up and is expelled
in fragments at various times ; sometimes true putrefaction is set up,
necessitating the artificial clearing out of the uterus ; sometimes pos-
sibly all that remains in the uterine cavity may lie the dry skeleton
of the fcetus: and possibly also petrification or saponifiaition may
occur. It is difficult, however, to determine whether the results
above named occur save in cases of extrauterine gestation in which
the fcetus has died.
There is also a great lack of knowledge respecting the changes
which occur in the fcetal annexa after the death of the unborn infant.
The placenta may show various alterations, e.g., fibrous degeneration,
fatty changes ; but it is always very difficult to exclude the pos.si-
bility of ante-mortem disease of the organ. Even in twin cases in
which one foetus is dead, and in which the part of the placenta from
wliich it derived no\irishment is affected with fibrous or fatty change,
it is still an open question whether the changes are the results or the
causes of the fotal death. I have several times been impressed by
the fact (as indeed I suppose all obstetricians have been) that the
placenta may have an almost normal appearance, and yet be expelled
along with a fcetus which has evidently been dead for some time ; on
the other hand, I have noted tlie conversion of a large part of the
placenta into fibrous tissue with functional destruction of a great
number of villi, and yet the infant has been born alive and well
nourished. Evidently the placenta has a certain degree of vital
independence as regards the fretus ; evidently also the pilacenta
always contains many more villi than are absolutely necessary for
the conservation of fcetal life and health. Nature plans with no
niggard hand. When the fcetus has been born dead and markedly
macerated, I have found villi in the placenta containing apparently
normal blood-cells, and I do not regard it as an impossibiUty that the
placenta may increase somewhat in size after the decease of the
unborn infant. As a rule, however, the cessation of the circulation
424 ANTHNATAF. I' A TllOLOdY AND HYCHKNE
tliroui;li the placouUi is ]]i(il)iiljly fnlloWL'd l)y the riinnalinn of
thrombi in the vessels of tlie villi, and by the development of filn-in
in their neighbourhood, and there may be signs of iiiHanimatory
processes i-ound them. Winkler {Dissert., Wurzburg, 1895), at any
rate, describes perivascular inflammation and obliteration of vessels
of the villi as signs of fietal death ; but Otto von Fraiique {Ztsc/ir.f.
Gcburtsh. u. Gyndlc, xxxvii. 277, 1897) is very guarded in drawing
conclusions. Changes of various kinds have been met with in the
umbilical cord (gelatinous infiltration, vascular inilammation), in the
chorion and amnion (loss of transparency, thickening, so - called
choriitis and amuionitis), in the liquor amuii (al)sorption, increase
in quantity), and in the decidual membranes; but what has been
already said regarding the placental alterations in structure may
be liere repeated — it is very doubtful whether they precede or
follow the fcetal death. It is quite possible that there may be a
much greater degree of independence between the vitality of the
fcetus and that of its annexa than has been hitherto supposed, and
that when the cause of fcetal death resides in the fiL'tus itself the
life of the placenta may to a certain extent be continued. When, on
the other hand, the fo'tus dies because the placenta is practically
dead, the dependence will be more manifest. We think of the semi-
parasitism of the ftPtus as regards the motlier ; we may liave to think
of the semi-parasitism of tlie placenta both as regards tlie mother and
the foetus.
As has been already stated, mummification is a peculiar result of
fcfital death, perhaps similar to the preserving of a fruit in a liqueur
or the pickling of meat in brine. It would seem to occur specially
in early fcetal and in neofrctal death (third or fourth montli) : and
it is characterised by a drying up or tanning of the fietal tissues, by
the alisence of the liquor amnii, or by the presence of some drops of
muddy Hnid representing it, and by the close contact which exists
between the fu:'tus and its enveloping membi-anes. This desiccative
process produces its most striking result when one of twin fcetuses
dies in utero and is pressed upon by the other, wliich continues to
live and grow. Then the so-called fcetiiA comprcssus scti jiajii/raceus is
produced ; in it there is tiattening as well as desiccation, and tlie
result is not imlike the gingerbread figures sold at fairs (" des
Ijonshommes de pain d'cpice "). I have met with several specimens
of the foetus compressus (159, 180, 190), and in all of them the
flattened twin liad its own placenta ; in all of them fa^tal death had
occurred about the second or third month, but the dead fictus had
not been expelled till the full term along with the living infant.
There may, how^ever, be a common placenta, as in H. J. Ilott's
specimen (Trans. Ohst. Soc. Lond., xxxvii. 16, 1895).
When tlie dead ficlus lies in an dtrautcrine f/csfatio7i sac, it
may undergo tlie post-mortem changes of maceration and desiccation
which have been described above ; it may also putrefy. The other
changes wliich are of doubtful occurrence in intrauterine death niostr
certainly occur in the ectopic pregnancy. TIius tlie ftctus may br
converted into adipocere (sa])oiiitication) or into a lithopa'dion (calci-
ABORTION 425
fication, petrifaction). Sometimes the deposit of lime salts affects
only the fa'tal membranes, sometimes it would seem as if the vernix
easeosa had been changed into a calcareous shell, and sometimes the
lime is distributed throughout the foHus itself (true lithop;udion).
The mode of formation of the adipocere and lithopffidion are not
understood. A good account of tlie microscopical appearances of the
lithop;edion was given by Inez-Gaches Sarraute (Arch, de tocoL, xii.
237, 1S85) ; and J. G. Clark {£u!l. Johns Hopkins ffosj}., viii. 221,
1897) has furnished a long bibliographical list, bringing F. Kiichen-
meister's record {Arch. f. Gri/naeL, xvii. 153, 1881) up to date. J. C.
Webster {Ectopic Pregnancy, p. 102, 1895) lias referred to the occur-
rence of h;emorrhages m the placenta after the death of the foetus in
ectopic gestation.
Upon the whole subject of the morbid anatomy of foetal death,
W. 0. Priestley's Lunileian lectures {Pathology of Intrauterine Death,
London, 1887) may be consulted with great profit.
AVhile tlip changes which have been described above are going on
in the fcetus and its annexa, the uterus is passing through a sort of
puerperium. So far as is possible in its iniemptied state, the womb
undergoes involution. Tlie muscular and vascular hypertrophy in
its walls disappears, and, if we may draw conclusions from Orloff's
case {Frag. mcd. IVchnschr., xx. 232, 1895), the mucous membrane is
restored when the retention is long continued. But, as every
obstetrician knows, the usual result of ftetal death is abortion or
premature laliour, and not prolonged retention of the products of
conception. Let us, therefore, consider abortion from this stand-
point.
Abortion and Premature Labour.
It is not my intention to describe in any fulness the causes,
mechanism, diagnosis, and treatment of abortion and premature
labour ; these matters are dealt with in all text-books of luidwifeiy.
I sliall here consider only aboition and premature labour in so far as
they concern foetal death.
In the first place, abortion does not always follow fwtal death
immediately, neither does prematiu-e labour. As has been pointed
out above, the dead fcetus may be, and often is, retained for a varying
period in utero. This is proved by the more or less advanced signs
of post-mortem change so often found in it when it is expelled. Can
this be explained ? I think it may possibly be due to several causes.
First, there is reason to believe that there are special dates in preg-
nancy at which it is more likely that the uterus will empty itself
than at others. That these dates correspond to what would have
been menstrual periods if pregnancy had not occurred, is very prob-
able, as indeed L. M. Bossi {Ann. cli ostet. e ginec, xxi. 445, 1899)
has pomted out. ' It is cjmte rational to think that if foetal death
occur just before one of these dates, with perhaps its recurrent pehic
congestion, the expulsion of the uterine contents will follow immedi-
ately; whereas if it take place midway between two periods, the
426 AXTF.NATAI. I'A 11 1()I,()(!V AND 1 1^( 11 K.NF,
uterus may not eniply till tin- next date. It may lie that at these
times there is an (rstious toxin which, circulating in the blood,
increases uterine excitability. Second, there is the transition time
of neoftt'tal life, which is a period wlien there is a special lialiility to
the occurrence of abortion. At this time a delicate readjustment of
intrauterine atlairs is taking place, for tlie general choriimic-decidual
attaclunents are loosening, and the placental ones are not yet fully
formed and secure ; fa-tal death or any otiier disturbing cause arising
now will be much more likely to cause the emptying of the uterus
than at other times.
In tlie second place, neither abortion nor ])remature laliour by
any means always implies preceding fcctal death. Fo'tal death is
only one of many possible causes of abortion and premature labour.
It is true that most of the cau.ses of intrauterine death may be also
causes of a])ortion ; but it is not very rare to find a living fo/tus in
an abortion sac, and prematurely born babies are of course frequently
born alive. A certain cause may produce abortion without killing
the foetus, just as another cause may kill the f(Ptus without leading
to its expulsion. What, then, are the causes wiiich lioth kill the
fcetus and produce abortion or premature laliour ? Theoretically, we
maj' suppose that they are those which attack in a special way the
placenta ; and, practically, there is some reascm to believe that this
conclusion is justified. Certainly syphilis, which produces marked
placental changes, is a very frequent cause of both fcetal death and
abortion or premature lal)our. As a matter of fact, it would seem
that the life of the placenta (or at least its functional integrity) is
more necessary for the maintenance of the intrauterine statim quo
than that of the fcetus itself. I'l-obabl)' this i.s one reason why in a
given case the slightest cause will lead to the emjitying of the uterus,
while in another case serious injury and the most provocative
abortifacients will not suffice. In the one the placenta i.s prone
to disease or is already morbid, in the other it is not. No doubt
there is also that curious and variable factor, utei'ine irritability, to
which I have referred in a recent lecture on " Abortions " (12Gi).
The abortinfi coefficient is to be arrived at by the consideration of the
cause in action plus the uterine irritability. If tiie total stimidus be
represented by 100, then in some cases the exciting cause may be 45
and the uterine irritability will require to be 55 in order to lead
to abortion ; in other cases the uterine irritability will be 95, then
an exciting cause represented by 5 will be sufficient to produce
the .same effect. Of course, neither factor can be fixed exactly, but
when we are deaUng with patients we soon begin to know those with
a high degree of uterine irritability, and to take altogether dill'erent
means to prevent miscarriage with them. Sjiecially nuist the
aborting coeilicicnt be borne in mind in cases of recurrent abortion.
Wlien we study the mechanism of abortion more fully, it becomes
clear that, in the early fcetal period at any rate, the expulsion of the
uterine contents is dependent more upon the state of the decidual
membranes than u]ion tiie life or death of the foitus. As has lieen
demonstrated by D. P>erry Ilart (Trans. Edinh. Ohst. Soc., xvi. 20,
CAUSES OF F(ETAL DEATH 427
1891), in " normal and complete" abortion, the decidua is first separ-
ated over the lower uterine segment and later over the wliole
interior above the lower segment, with consequent expidsion of the
whole mass ; or else the part of tlie ovum covered by retlexa is driven
down into the cervical canal before the complete separation of the
part covered by the vera. In " abnormal" forms, the separation may
occur in other planes; the foetus and liquor amuii alone may he
expelled, or the whole chorionic sac and its contents may be driven
down imcovered by the deciduic, or the foetal sac in the decidua
reflexa may be separated fii-st from the vera and later from the
serotiiia. Various parts of the products of conception may thus be
retaiued, constituting incomplete abortion. Possibly the life or death
of the ftetus may explain some of these varieties of abortion, but
manifestly the state of attachment of the decidual and fa?tal mem-
branes will be a very important, perhaps a dominating factor.
In the case of premature labour, it will be admitted that tlie death
of the fcetus has a more immediate bearing upon the supervention of
labour than in abortion. Yet, even here, as clinical records show,
the dead fcetus may be retaiued for some days in utero. This delay
is by no means unfavourable for the mother, whom perhaps it saves
from infection by allowing the involutiouary processes in the uterine
walls to be to some extent completed before the separation of the
placenta and membranes takes place. If the cause which has led to
the foetal death do not at once produce also premature labour, then
the uterine contents remain in situ till the occurrence of changes in
the uterine walls converts the foetus and its anuexa into a " foreign
body," .so far as the containing organ is concerned.
Causes of Foetal Death.
From what has been said, the reader will now be prepared to
recognise that the long lists of causes of fa-tal death given in the
text-books are in some senses unnecessary. They are not repeated
here, for, as I have tried to point out as each chapter of the work was
written, all the various pathological states of the fcetus and its aunexa
may lie causes of death, just as the various morbid states of postnatal
existence may also produce a fatal issue. They do not always or with
certainty do so, for there are several factors to be taken into account,
such as severity and extent of the pathological process, power of
I'esistance of the organism, degree of placental permeability, etc.
One certain cause of foetal death is the premature expulsion of the
fretus from the uterus before the sixth month ; strictly speaking,
this is not intrauterine death, but fcetal death, due to a too early
entrance into extrauterine existence. Possibly as the means for
rearing premature infants are perfected, even this certain cause of
fu'tal death may become less sure, and the date of viabihtybe puslied
further back than it is at present.
428 ANTKNATAI. I'A TilOI.OCY AND HYCilENE
Treatment.
Foetal doalh is conft'sscilly a failure and a (li.sa])])()iiitiiicnt, and
the treatment it calls for is provciilion. To prevent fo'tal death
means, of course, to abrogate the causes thereof, and in process of
time we sJiall doubtless be better able to do so than at i)resent. The
eUmination of certain notorious causal conditions, such as syphilis
alcoholism, and lead-poisoninc;, would reduce in a sLartling fashion
the mortality of intrauterine life ; but much must lie accduiplished
before any one of these well-known causes can be got rid of or
rendered innocuous. Failing the j)ower of eliminating Ihe causes of
fo_^tal death, it has been proposed, in cases in which the hetus
" habitually " perishes in the last month of intrauteiine life, to
induce premature labour so as to send the hetus forth alive. If the
cause of death reside in the placenta, this plan may pcnchance
succeed ; if in the fo'tus itself, the result will be most problematical.
In cases in which the fu'tus dies in labour on account of too
advanced ossification of the head, the idea of the induction of labour
is well founded and may prove successful ; but of couise it is always
difficult to exclude the fallacy arising from simple coincidence ; for
the pregnancy in which induction was performed might have
terminated in the birth of a living infant.
If there be reason to suppose that the foetus is dead in utero, the
question of obstetric interference will arise. If the membranes are
intact, the expectant plan is to be followed, for during the next week-
changes will occur in the ])lacenta, membranes, and uterine wall
which will greatly diminish the risks of sepsis and luemorrhage in
labour. When uterine contractions supervene, the exj)ulsion of the
foetus and annexa will not, in most case.s, be delayed, and the
recovery may be expected to be rapid. If, however, the membranes
rupture, and yet no signs of labour occur, the question of inter-
vention is more difficult to decide. There is now the risk of putre-
faction in utero with all its attendant dangers. On the whole,
perhaps, it will be best, in the absence of signs of maternal infection,
to await the onset of uterine contractions; but iu the jiresence t>f
such signs and symptoms it will become imperative to empty the
uterus expeditiously, and to use all the means in our power to
diminish the septic absorption. A very important factor in giuding
our conduct in all such cases is the difficulty of determining with
anything like certainty the actual occurrence of foetal death. When
everything seems to point to the foHus being dead, the obstetrician
may be surprised to find a living infant expelled. In the jiresence
of this uncertainty, the intervention of the medical attendant may
serve no good purpose, and may, indeed, produce evil eh'ccts and
precipitate dangers. The use of antejiartum antiseptic douches may
be permitted, but they must be administered with caution. What
has been said as to expectancy in treatment applies to f<etal death
lioth iu the early and in the later months of pregnancy. It must,
further, be borne in mind that when the olistetriciaii has to empty a
uterus h(> will find that his most valuable allv is the uterus itself;
TREATMENT OF F(KTAL DEATH 429
in other words, uterine contractions make the operation very easy,
their absence malces it one of the most difficult of tasks.
There is much yet to be learned regarding foital deatli, regarding
its mechanism, its symptoms and signs, its diagnosis, its pathology,
its causes, and most of all regarding its preventive treatment. But
every advance in our knowledge of the various departments of
Antenatal Pathology will in the long run tend to diminish the
frequency of intrauterine death. In the meantime, it must be said
sadly that the fcetus has indeed the gift of antenatal life accom-
panied by the risk of antenatal death.
" L'teuf fcconde jouit de la vie, sujet par consequent aux maladies,
a la mort." " Ad mortem maturi omnes sumus, etiam antequam
nati." To these, from other lands, I may add the words of Sir Thomas
Browne {Letter to a Friend) : " Nothing is more common with infants
than to die on the day of their nativity, to behold the worldly hours
and but the fractions thereof ; and even to perish before their
nativity in the hidden world of the womb, and before their good
angel is conceived to vuidertake them."
CllAI'TKi; XXV
Diagnosis of Futal Morbirl States : Ditlicullics and Scope ; Antenatal Diaj^osis,
Maternal, Medical, and Reiuoductive History, Paternal and Family
History, Maternal Syniptuniatoldi^y and Pliysical Exandnation, Physical
Exaininaliuu of tlic Fnlus ; intranalal and Postnatal Diagnosis.
ITeke and there tlirrmghout thi.s work, allusions liave been made to
the diagnosis of antenatal morbid states atl'ecting tlie fcrtus ; thus
under variola (p. 19:!), malaria (p. 202), sypiiilis (jx 237), general
dropsy (p. 296), endocarditis (p. 372), hydramnios (p. 402), and i'(Ptal
death (p. 416), some space has been given to the subject. Now,
however, it is necessary to draw together into one chajiter these
scattered allusions, and to attemjtt to juvsent in a more systematic
fashion the means at our disposal for the makhig of an antenatal
diagnosis.
Diagnosis implies diftictdty. The making of a successful
diagnosis implies the overcoming of a considerable dilliculty. It is
true that by the elaboration of mechanical aids, and liy the long
training of the senses, it is possible to reduce the making of a
diagnosis under certain circumstances to a very simjile and a \cry
rapid process. Then, however, it can scarcely any longer be called
diagnosis ; it has become recognition, and requires very little, if any,
mental effort. In dealing with antenatal morbid states, it is diagnosis
in its true and best and most interesting sense that is needed. There
is no immediate risk that any one w^ill olitain such facility in the
discovery of intrauterine conditions as to convert antenatal diagnosis
into a dull and featureless and supremely easy procedure. It ought,
therefore, for a long time yet to retain a special attraction for the
diagnostician who rejoices in the meeting and overcoming of
difficulties, and he is no true scientific physician who does not
welcome with the relish of the epicure the truly intricate and
obscure prolilems of his professional work. There is a feast ready for
him in Antenatal I'athology.
Medical and surgical diagnosis l)egaii witli the separation one
from another of the external morl)id states and of the injuries of tiic
limbs ; after many centuries, it passed to the investigation of the
pathological conditions of the organs contained in tlie three body
cavities ; and while some still alive can look Imck to the elaboration
of the diagnosis of intrathoracic and of intra-abdominal diseases and
injtiries, many of us who have not yet become old in the profession
regard with almost personal pride the development of intracranial
diagnosis. All these advanci's Iiavc meant the overcoming of many
ditticultics, some of them not inconsiderable, some of them at first
ANTENATAL DIAGNOSIS 431
sight insuperable, but all of tiieui yielding before the active brain of
man. The brain itself has been the last to yield up its secrets. It
is now full time that an energetic and sustained effort be made to
carry the diagnosis of intra-abdominal pathological states further
than it has ever been yet taken. The task is difficult, for we have
to investigate the condition of things in a cavity within a cavity ; we
liave to diagnose not merely intra-abdominal morbid states, but
intrauterine intra-abdominal morbid states. The difficulty ought to
be, indeed it is all the stimulus we need.
It is often concluded that liy antenatal diagnosis is meant the
recognition of antenatal morbid states during antenatal life or
intrauterine existence — this and nothing more. The definition of
antenatal diagnosis, however, is a wider one than that ; for by it are
understood the recognition and the separation one from another of
all the pathological conditions which are produced during antenatal
life, not only while that period of existence is still in progress, Ijut
also after the product of its pathology has been expelled from the
uterus, and even during the time it is passing through the vagina on
its way to the exterior. The birth of a diseased or malformed infant
does not remove the necessity for a diagnosis of its particular disease
or malformation, nor does it always clear away the difficulty in
making it ; even if the child be already dead, it will be for the
advantage of future treatment that the medical man make out the
cause of death. It must, therefore, be kept constantly in mind that
the diagnosis of antenatal pathological states may be made at three
times — during antenatal life while the fo?tus is still in utero, during
the act of parturition or intranatally, and after birth or in postnatal
existence. It is, of course, easier to make the diagnosis intranatally
than antenatally, and much easier to do so postnatally; but with
decrease in difficulty has come decrease in value, and the chance of
successful treatment may have passed away. It is necessary,
therefore, to give the first place to the discussion of antenatal
diagnosis made dm-iug antenatal life, as well on account of its
ditticiUty as of its value.
Antenatal Diagnosis.
Emphasis has already Ijeen laid upon the difficulties of diagnosing
morbid states while the sulsject of them is still in utero, and it is
true that while the facilities are few the difficulties are many ; liut it
must not be forgotten that after all they are not more than impedi-
ments, they are not insuperable obstacles to the making of a diagnosis
of intrauterine diseases. Further, can the medical man declare upon
" soul and conscience " that he makes in every case of pregnancy that
comes under his care a full and searching effort to remove these
obstacles ? It is not that he does nothing ; he listens for the fietal
heart, he notes the growth of the uterine tumour, he asks about the
foetal movements, and he examines the maternal urine for alliumen,
not once, if he be wise, but several times. But he is content with
little; he is satisfied with far less from his examination of the
432 ANTRNATAI. I'A'IIIOI.OCV AM) IIVCIKNE
pregnant woman's alulonii'ii tliaii he wmiM lie, for insliint'L', from the
investigation of licr Inisljaiiil's clicsl. In the casu of an obscure lung
com])laint in Uie jircgnant woman herself, this same medieal man
would doubtless pereuss and auscultate and palpate the thorax till
he had cleared up tlie diagnosis, and would feel not a little guilty
and ill at ease if he failed to do so ; but I fancy there are few
])ractitiouers who would pay the same amount of attention to the
examination of the abdomen and uterus if the patient com])lained
of unusually active, or unusually inactive, foetal movements, or of
acute jiain in the hypogastric region. In surgery and in medicine
the most careful and searciiing abdominal palpation is not infre-
quently made, and with good diagnostic efiect ; but for some reason
a similar procedure has not yet become common in obstetric practice.
Yet it is precisely in obstetric practice that it is most called for.
There can be no doubt that in antenatal diagnosis the means of
clinical investigation at our disposal are seldom made full use of,
and are too often nearly completely neglected. It may lie urged
that the medical man has little or no oppoi-tunity of examining
pregnant women in such a manner as would enable him to form an
opinion on the health or disease of their unborn infants ; and it may
further be stated that patients do not offer themselves for such an
exhaustive examination, and even refuse to allow it when it is pressed
upon them. Now, for this state of affairs the meilical jirofession is
largely responsible ; it has not demonstrated the xoluv of such a
procedure, and it cannot be expected that the pulilic will follow
where the profession does not lead. I doubt not the willingness of
the pregnant woman to sulimit to examination, even to suffer to
some extent in so doing, if it can be shown to her that she is thereby
ensuring her own welfare and that of her unborn infant.
It must constantly be l)orne in mind that the antenatal diagnosis
of fretal diseases and other morbid states does not stand on the same
platform, so to speak, with the recognition of the maladies of the
adult. There is something special in it and peculiar to it. In many
respects it resembles rather the diagnosis of disease in the new-born
infant than in the child or adult. Neonatal diagnosis is, in fact, a
sort of transition between antenatal and postnatal diagnosis. In it,
as in antenatal diagnosis, the medical attendant has to learn many of
the facts on which he forms his opinion from the statements of the
mother or nurse, and in his jihysical examination of the infant he
pays special attention to its movements, attitude, and appearance,
and relies much upon palimtion and auscultation. He does not
expect to get any answers from the infant of the verbal sort, and
such articulate replies as he elicits may hinder rather than help. So
it is, only in a more marked form, with antenatal diagnosis. Only
now the inspection of the infant is impossible, and the physician is
thrown back still more >ipon the symptoms of tlie mother and the
palpation of the foetus still in her uterus. The first tiling he ought
to do is to form in his mind the visual image of what the fotus in
utero is at the ascertained or conjectured date of pregnancy. At first
he will Hnd it difiicult thus to imagine his little unseen patient, but
ANTENATAL DIAGNOSIS 4:'.3
practice will do much, and he will eve long have in his mind the
pictures of the t'(etus at the dittbrent months of intrauterine life,
and be able to call them up, as it were, at will. He will find it ;■
great help to read over a description of the outstanding features of
the foetus at the different stages of development and growth, such as
is given him on ])ages 80 to 92. He will doubtless sympathise not a
little with the Western physician who is expected to diagnose and
treat his Eastern female patients by the feeling of the pulse alone.
Having formed the visual image of his patient, he must next make
up his mmd to give more weight to past events in the estimation of
present conditions ; in other words, he must trust to the tendency
there is in antenatal disease to repeat itself. He must be preparetl
to emphasise factors in antenatal wliich are little dwelt upon in
postnatal diagnosis ; and altogether he must be ready to make use of
every scrap of evidence which he can obtain. He will be dis-
appointed in the results obtained, but he must not be discouraged.
Finally, he must remendjer that the morbid state in utero may be
the result of the pathology of the period jireceding the fcetal ; it may
be a monstrosity or malformation which has been carried from the
embryonic into the foetal epoch. I shall not here specially describe
the diagnosis of monstrosities, but I must, of course, make passing
references to it. Antenatal diagnosis includes the discovery of
normal pregnancy and of plural pregnancy, of foetal death, of diseases
and monstrosities of the foetus, of hydramnios, and of morbid conditions
of the placenta. All these matters must be kept in mind in examining
a patient who may be pregnant ; and in all of them there is at any rate
an increasing probability that the diagnosis may be thoroughly well
estalilished under favouraljle circumstances and with care and skill.
The making of the diagnosis of the antenatal morbid state during
antenatal life will best be accomplished by taking up the following
lines of investigation in order. First, the previous medical history
of the woman, both general and sexual, must be inquired into, for
there are certain circumstances which may be regarded as commonly
preceding the development of morbid states in pregnancy ; secondly,
the past history and present state of the father, and the family
history on both sides ought to be taken into account, for there are
foetal diseases and embryonic deformities which appear to be
hereditarily transmitted ; thirdly, the maternal symptomatology
during the pregnancy which is in progress must be carefully
investigated ; fourthly, a very complete physical examination ought
to be made of the maternal organs, and especially of the abdominal
viscera ; fifthly, the foetus should be fully examined by the liands, by
the ear, by the cephalometer, by the Eiintgen rays, and liy any other
means of exact research that may yet be invented; a,nd, fi,7ially, the
maternal urine and blood should be subjected to chemical and micro-
scopical investigation, as it is beginning to be realised that the con-
dition of the foetus in utero is to some extent reflected in the
composition and characters of the maternal excretions. The rest of
this chapter will be devoted to the consideration of some of the
diagnostic possibilities suggested by these lines of research.
28
434 ANTENATAL I'Al'l lOl.OdV AND HYGIENE
Maternal Medical History.
Tlic iiivesti;j;ati(iii of the clinical history of the mother of a still-
born or (lead-boru or diseased or deformed infant must, in the first
place, deal with certain purely medical questions. The hearing of
these questions upon antenatal morbid ])rocesses may not, in the
meantime, he very evident ; but it is of importance in a subject of
such comj)le.\ity that all available information should be secured, and
in other branches of medical diagnosis the physician is every day
learning that details, at one time considered of no value in the
etiology of maladies, sometimes take on a sudden and preponderating
importance — for example, the pre-cancerous phenomena. Reference
is now made to the medical conditions of the mother existing prior to
and apart from her sexual and obstetrical history, and the question
that has to he solved is whether there are maternal medical states
which predispose to, or at any rate precede, the morbid occurrences
of reproductive life. Are there any facts which shall enable us to
predict that in a given case the future will show either morbiparity
or monstriparity or mortinatality ? Can, in other words, a typical
past medical history be looked for in the mother who gives birth to
diseased, deformed, or dead infants ? A priori it may be exjx'cted
that women who have had a healthy childhood and girlhood, who
have suffered not at all or but slightly from the maladies of early
life, who show no signs of rickets or of congenital syphilis or of
anaemia, and who are not the victims of evident cardiac, pulmonary,
hepatic, renal, or nervous disorders, will give Ijirth to health)' infants.
On the other hand, it may be expected that women with a past
medical history the very reverse of the foregoing will produce oil-
spring dead, or dying, or diseased, or deformed. Now, it is not
difficult to find cases which apparently contradict or disappoint these
expectations, for perfectly healthy mothers who have not suffered
from severe illnesses in early life give birth occasionally to deformed
offspring, and delicate and diseased mothers sometimes astonish
every one Ijy bringing forth strong and well-formed infants : lint such
instances do not altogether prove that the past medical history nf
the mother is of no importance as a premonition of future repro-
ductive irregularities ; they simply remind the investigator that there
is a second factor to be taken into accouut — the state of health of
the father. But, even admitting the occurrence of contradictions to
the expectation that a woman who has been previously healthy iu
other ways will be healthy also in the matter of reproduction, the
past maternal medical history ought to be inquired into. 1 have
been struck on several occasions by the frequency with which women
who have had disastrous obstetrical histories have also suftered
previously from neuroses of various kinds, from tubercle, from
alcoholism, from syphilis, from kidney trouble, from rheumatism and
gout. It does not necessarily follow that these medical conditions of
the mother prior to her pregnancy have so altered the ova in her
ovaries as to make them incajialile of healthy development, nor does
it even prove that her whole system has been so altered as to be
luii
MATERNAL HISTORY 435
unable to react in a healthy fashion ou the contents of her uterus.
It may be taken as supporting the idea that both the morbiparity
and the bad medical history of the mother are results of a common
cause ; that they are both hereditarily transmitted to her ; and this Is,
I think, the more correct way of looking at the question. Further,
it gains support from the fact that the degenerative conditions, such
as nervous diseases, insanity, arthritic developments, some neoplasms,
tubercidous predisposition, and the tendency to take alcohol and
other toxic agents to excess, are apparently governed by the same
laws as to transmission, etc., as preside over malformations, morbi-
parity, mortinatality, pluriparity, abortions, congenital deljility, and
the other numerous phenomena of antenatal pathology. They show
family prevalence very markedly, and they exhibit the form of
hereditj' which has been called dissimilar. This association between
the insanities, the nervous diseases, the arthritisms, the tumours, and
the morbid phenomena of antenatal life has been strongly insisted
upon by Fere in his most suggestive work, La Famillc Ncrrojiuth iqt'c, to
wiiich reference has already been made more than once in these pages.
It will, therefore, be of the greatest importance for the progress
of antenatal pathology for observers to investigate the medical
history of the morbiparous and monstriparous mothers along the
lines which have been suggested. So far as my own observations
have proceeded, they tend to show the existence in the mothers of
congenitally malformed or diseased infants of more than the ordmary
amount of manifestation of nervous disease and even of insanity, of
arthritic manifestations, and of tubercle, and syphilis, and alcoholism.
It must be repeated, however, that it by no means follows that all
these medical states are the causes of the morbid phenomena of
antenatal Hfe. Some of them may be so ; but others will be the asso-
ciated manifestations of a common cause or causes which appear most
e\'ideiitly in the form of impaired nutrition of the tissues. Neverthe-
le,ss their presence has a diagnostic value if it can be fully established
that they are met with more often in women who give birth to dead
or still-born infants, to diseased or malformed foetuses, to twins, or to
congenitally weak children.
Maternal Reproductive History.
The mother's pre\'ious reproductive history is of much more
immediate value in the diagnosis of antenatal morbid states than
is her purely medical record. Here the phenomena are closely
associated ; they are to a certain extent manifestations of the activity,
physiological or pathological, of the same organs. There is a close
connection between menstruation and ovidation and pregnancy ; and
there is a very close connection between successive pregnancies ; for
although it may not be correct to say " ab uno disce omnes," yet there
can l^e no doubt that the occurrence of one alinormal gestation greatly
increases the chances of the supervention of others. The inquiry
into the maternal reproductive history may be made along the
following lines : —
436 ANII'.NAIAl. I'ArilOI.OCV AM) I n( ;i I'.N I'.
1. The menstrual habit and type ouglit to be aseertaineil, unci auy
abnormal conditions, such as excessive or diminislied How, ])aiii, etc.,
noted, for from such information something may l)e learned of the
state of the genital organs and their fitness for the discharge of the
reproductive functions. It will be of special importance to elicit tiie
presence of symptoms pointing to the e.xistence of endometritis, for
it is well known that a diseased uterine mucous membrane predis-
poses to various forms of antenatal deviation from tlie normal.
2. The condition of the mother as to inarriaf/r must be inquired
into. It will be well to ascertain whether she married at a very
early age or late in life, for in neither of these circumstances are her
pregnantdes likely to be normal. Further, the fact that she lias
married a relative such as a cousin, and much more an uncle, must
be referred to, for although the marriage of first cousins need not of
itself lead to abnormal developments during ])regnancy unless the
heredity and individual health on both sides be bad, yet the fact is of
importance ; and certainly the marriage of relatives nearer than
cousins — for e.Kample, uncle and niece, aunt and nephew, would
seem to produce pathological results.
3. The history of the previous pregnancies of the patient may
yield information of the very greatest value in the making of a
diagnosis. As case after case of antenatal disease or disorder has
come under my notice, I have been more and more impressed by tlie
tendency of abnormalities in pregnancy to repeat. I do Udt mean
that a given f(Etal disease or embyronic monstrosity will occur
several times in succession in the uterus of the same jKitient,
although that also has Ijcen observed, and I have myself noted its
occurrence in foetal dropsy, in anencephaly, in Polydactyly, in tylosis
palm;e et plauta?, in absence of the radius, etc. ; but I refer rather to
the very commonly noted fact tliat pregnancies that are pathological —
although not pathological in tlie same way — are abuost certain to be
associated. Over and ov'cr again there is the liistory of aljortions,
fietal deatli, fietal disease, still-birth, congenital debility, twins,
hydramnios, malformations, and possibly also monstrosities, in the
same mother, who may on this accoimt be called morbiparous.
Necessarily, these phenomena do not often all occur in one patient's
history, but the appearance of any one of them ought to prepare us
for tlie possible supervention of any other of them in a future preg-
nancy. Further, other ])at]iological events of rarer occurrence iniglit
be added to the list, sucli as the hydatid mole and extraulerine and
extra-amniotic pregnancy. Yet, again, it is wrong to think that
syphilis is the only morbid state that determuies this long series of
morbid developments. Alcoholism at least does so also, and possibly
tuberculosis, lead-poisoning, and other infective and toxic and toxi-
cological states. Syphilis and alcoholism oiler a striking contrast, in
that, while the antenatal plienomena of the former tend to dimiiiisli
in virulence as the reproductive liistory of the woman jirogiesses,
tliose of the latter morbid condition sliow a marked tendency lowartls
intensification. Enougli lias been said to sliow tiie sui)renie imjiort-
ance of a knowledge of the mother's previous obstetric history in
PATKRXAL HISroUV 4o7
forming an estimate of the probable character of the gestations (jf
the future, and it is unnecessary to do more than refer to the diag-
nostic aid that may be received from the record of previous conKuc-
ments in which the size of the f(etus or its malformed or diseased
state caused delay or danger, or both, or in which it was noted that
the placenta or membranes were abnormal in any way. So well
recognised is this tendency to repeat in antenatal pathology, that
the terms " habitual abortion," " habitual premature labour," and
" habitual fu'tal death " have, as has been said, been used to express
it; but a more correct nomenclature would be ''repeating abortion,"
etc., for the idea of habit is scarcely what is meant ; and we ought
to look not so much for the repetition of identical morbid phenomena
as for the repetition of gestations abnormal in some way, Ijut not
necessarily in the same way.
Paternal Medical and Reproductive History.
In most records of foetal disease and monstrosity, little is found
.stated with regard to the health of the father. This is unfortunate,
for it seems to be probable that paternal morbid states acting through
the spermatozoa are potent in inducing antenatal pathological con-
ditions. It is a striking comment upon this line of inquiry, that
cases ha^'e been reported in which women have given birth to
healthy infants by one husband and to diseased offspring by a second
consort. I have myself seen several cases in which I l:)elieve I was
justified in tracing to the father the origin of the antenatal malady
or deformity of the infant ; further, the condition of the father was
not invariably syphilitic, although it is true that more is known of
the paternal factor in syphilis than in any other morbid state which
is capable of transmission to the ftetus. It is, therefore, necessary to
take note of the age of the father when he begets his child, of his
age in relation to that of his wife, of his habits especially in respect
to alcohol, of his state of development, and of certain diseases, such as
syphilis, nephritis, diabetes, cancer, tubercle, malaria, lead-poisoning,
mental disorder, etc., from which he may be suffering or have suffered,
for there is good reason to believe that any of these pathological
state.? may have a direct and injurious effect upon the offspring
engendered by him. It may also be that the morbid paternal influ-
ence is transmitted directly to the foetus without the mother suffering
from it save secondarily through the foetus ; this is believed in
respect to syphilis {vide p. 249), and there is some evidence that it
holds also for malaria (vide p. 203), and probaljly for other diseases.
The influence of paternal alcoholism has not yet been fully worked
out ; but one of the striking results obtained from Sullivan's contri-
bution, already referred to, was that total abstinence on the part of
the father did little, if anything, to improve the prospects of the
unborn infant so long as there was still maternal alcoholism.
438 AN'n.NATAl, I' ATlIOLOCiV AND HYCilENE
Family Medical History.
In rorining a iliagnosis of antenatal morbid states, the c)l)server
cannot allord to neglect the family medical and obstetrical history,
for such conditions are not infrequently hereditary. The heredity,
further, may not always be of the same kind. Direct and similar
heredity is sometimes met with, and when it occurs it is so striking
tliat it seldom passes unnoted ; thus, in the case recorded by the late
Dr. (!. Klder and myself, tylosis palma- et plant;u had been handed
dowu from mother to daughter and then to granddaughter antl great-
granddaughter with such regidaritj', that it was expected and looked
for at once when a female infant was born into the family {vide p.
318). The same thing has Ijeen noticed in anomalies of the fingers
and toes, and especially in Polydactyly, iu congenital cataract, in
retinitis pigmentosa, in hare-lip, in cleft palate, in fistuliu of the lower
lip, in n;cvi materni, iu microphthalmus, iu aural fistuLc, and in a
very large number of other anomalies and congenital diseases. In
other phenomena of antenatal pathology the same tendency is
evident. I have, for instance, given striking statistics illustrating
the heredity of twin-bearing and of large families (96), and the
heredity of triplets has also been established by various records. Tlie
following case I cite from the contribution made to the Ediulnirgh
Obstetrical Society to whicli I have ju.st referred, ilrs. I. was one
of a family of seventeen children, and one of her sisters has had
twins, while another sister has had triplets. She herself has had
twenty-two children in eighteen confinements, four tiiues twins and
fourteen single births. The first contiuement produced a boy dead-
born ; the second, twin boys at the si.xtli month, both dead ; the
third, a boy, dead-born ; the fourth, a girl, wlio lived six weeks ; tlie
fifth, a boy at tlie eighth montli, who died in ten days from umbilical
hffimorrhage ; the sLxth, a boy and girl at the sixtii month, dead-born ;
the seventh, a boy, dead-born ; the eighth, a boy, still alive ; the ninth,
a boy, died in sixteen days from umbilical haanorrhage ; the tenth, a
girl, still living, aged ten years ; the eleventh, a girl at full term, died
shortly from convulsions ; the twelfth, a boy, who died at the age of
one year from wasting; the thirteenth, a boy, who died at six weeks
from wasting ; the fourteenth, a girl, who died at eighteen months
from whooping cough; tlie fifteenth, a boy, still living; the sixteenth,
twin boys at the sixth month, one of whom alone survived his liirtli,
and that only for twenty-four hours ; the seventeenth, twins, a boy
and girl, of whom the girl soon died from wasting; and tlie
eighteenth, a boy, who died at the age of six weeks.
Of course, teratological states which are incompatible with extra-
uterine life cannot be transmitted by direct and similar heredity;
Imt dissimilar heredity niay and dues occur, and occasionally a jiarcnt
with a luiuiir malformation whicli iienuits the continuance of pro-
longed postnatal life, procreates a feetus with a monstrous condition
which renders it quite non-viable. I have elsewliere (117) referred
to a woman with malformed thumbs, the daughter of a woman
similarly deformed, who gave birth lo infants with ancnceplialy.
FAMILY HISTORY 439
hydrocephaly, and absence of radius and thumbs, a case in which
there was both similar and dissimilar heredity. Dissimilar heredity
also is very common in antenatal jjathology, and in estimating its
presence it is necessary constantly to bear in mind that the pheno-
mena of antenatal pathology are not confined to one group of con-
ditions such as malformations or ftctal diseases, but include also
abortions, twin births, mortinatality, congenital debiKty, extrauterine
pregnancy, and placental and membranous abnormalities. It has
sometimes been said paradoxically tliat sterility is hereditary, and the
statement is true if it be meant tliat a woman or a man in whose
ascendants (for example, in aunts or uncles) sterility has been
common, will also run a great risk of being sterile.
In the family history of niorbiparous and monstriparous mothers,
it is not uncommon to find a morbid predisposition to various diseases
developed postnatally, but in all probability present potentially before
birtli ; in this group the neuroses find a prominent place, as do also
susceptibilities to be acted on abnormally by such toxic agencies as
alcoliol, morphine, and tobacco.
Maternal Symptomatology.
In making an antenatal diagnosis of morbid intrauterine condi-
tions, the closest scrutiny must be given to all the details of the
pregnancy. It ought to be our object to elicit from the mother
all that she can remember of her symptoms during both the early
and the later months of her gestation ; too often we repress such
information, partly because we do not wish to make the patient
nervous about herself, and partly because we do not desire to hear
long tales about maternal impressions. Therein doubtless we err ; for
although the mother's s^^eculations regarding her sensations may be
worthless, and worse than worthless, for the formation of a diagnosis,
the same cannot be said of tlie definite information slie gives as
to the occurrence of her sensations. Her theoretical opinions may
be of no value, but her statement of facts is of great imi^ortance ;
we must, therefore, endeavour to direct her flow of information along
the line of facts, and not in the current of theories.
In the first place, we inquire into the symptomatology of preg-
nancy itself, for it is not altogether a truism that before we can
diagnose an abnormal i^regnancy we must diagnose that there is
a pregnancy. Further, the very ease with which we recognise that
there is the normal symptomatology of gestation, is indirect evidence
tliat intrauterine aSairs are progressing in a natural way ; for it is
the abnormal gestation that is difficult to separate from conditions
which are not connected with the presence of a foetus in utero. The
very fact that the diagnosis of pregnancy is not easily made, is pre-
sunipti\e evidence that tliere is an abnormal pregnancy. If, then,
it Ije found that in the history of the case the symptoms upon which
we rely in diagnosis, such as suppression of the menses, morning
sickness, frequency of micturition, quickening, mammary fulness,
nervous phenomena of a reflex type, abdominal enlargement, etc.,
440 AMI.N AIM, I'AllIOI.OC^ AM) ll^(;ll.^l■.
isliiiw ilfvi:ilit)iis which make us dmilit Lho existence of pregnancy,
we may ahiiost unconscidusly haxc made the first steji in the diag-
nosis of a case of antenatal moiliid change. The jiatient herself will
often sum up the symiitomatology for us in the remark that she does
not feel in this pregnancy as she did in pievious ones ; that, in fact,
she doubts if she is really " in the family way " at all. By this she
generally means that one or several of the symptoms u])on which she
has learnetl to rely for the detection of pregnancy have deviated so
nnich froiu the usual, tliat lier o]iinion has been sliaken, while tlie
presence of other of these symptoms in a natural way lias prevented
her altogetlier abandoning the notion that she is jircgnant.
Some of the symptomatological deviations which are met with
may be referred to. There is, for instance, the occurrence of more
or less regular and more or less sauguinolent discharges from the
vagina — the persistence of menstruation in an erratic form. In the
early months this may indicate a threatened abortion or a hydatid
mole, and in the later months it may ])oint to a low implantation of
the placenta, or to premature Separation of the afterbirth. It may
also ])oint to the existence of an antenatal morbid condition of the
uterus itself, such as a bicornate or septate organ, (jr t(j the presence of
a tubal or tubo-abdominal pregnancy. Along with the.se lutmorrhages,
however, there is a continuance of the other phenomena of pregnancy,
and the patient becomes alarmed about her dubious condition.
It may be stated generally that we do not yet know the exact
significance of irregular menstrual discharges during pregnancy, and
the same remark applies with still greater force to the occurrence
of hydrorrhoea gravidarum. P. C. T. van der Hoeven {Monaisschr.f.
Geburtsli. u. Gyniik., x. 329, 1899) has given details of three cases of
hydrorrhcEa in pregnancy, in all of which the infants were born alive
and liealthy, but premature, and from the chemical and microscopical
examination of the Huid it did not appear that it was either liquor
anmii or a transudation tlirough the membranes from the liqufir
amnii. J. A. Macdougall in 1885 gave details of seven cases of marked
hydrorrhoea gravidarum, and I note that in at least five of them tiie
fcctus was small, puny, and poorly develo]ied {Edinh. Med. Journ.,
xx.x. 691, 1885).
Again, the patient may complain of deviations from the noinial
in the symptomatology of quickenuig. The fa?tal movements may
have been felt very early or unusually late in pregnancy, or tliey
may have been very strong or very weak, or tiiey may have been
very frequent or have occurred only at long intervals, or, finally,
they may have shown different deviations at different epochs in the
gestation. Sometimes fa'tal death has been indicated by unusual
activity of the ftetal movements, followed by complete cessation of
them. In cases of maternal malaria, the mother has occasionally
described attacks of foHal quivering and shaking either synchronous
with the ague; fits in herself, or occurring at otlier but at regular
times (ride p. 202); it has been concluded that there was fo'tal
malaria, but not always of the same ty])e as the maternal. Folal
moNcments of a kintl very different from the normal have been
I
MATKHNAl. SYMl'I'OMA TOLOCY 441
described under tiie name of foetal singultus. The details of a case
of this sort were communicated to me some time ago by my friend
Dr. T. B. Darling. It was that of a woman, 29 years of age, a
4-para, who had in each of her four pregnancies, and always about
the seventh month, suffered from convulsive movements of the fcetus
which were (juite imlike the usual "kicking" sensations. They
were regarded bj' her as due to hiccough of the unborn infant, and
they occurred most markedly at night. Her belief received con-
siderable support from the fact that all her infants suffered from
hiccough for a few days after birth, and that the movements were
very similar. It is interesting to note that in tlie first two preg-
nancies the vertex presented in the L.O.P. position, that is, with the
fcetal abdomen anterior ; in the third and fourth gestations, however,
the position was the E.O.A. It has recently been affirmed that these
peculiar movements are not very rare, although it is likely that they
are not often so marked as to attract special attention from the
mother ; liut this point will be referred to again under the head of
the physical examination of the abdomen in pregnancy.
Tlie symptomatology of morljid pregnancy has also to do with
abnormalities in the degree and rate of abdominal enlargement, in
the mammary sensations, and in moining sickness, dysuria, headache,
neuralgia, etc. The patient may, for instance, assert that she is
larger or smaller than she ought to be for the supposed date of
pregnancy, circumstances which may, on the one hand, indicate
hydramnios, hydatid mole, twins, a dropsical foetus, a double monster :
and, on the otiier hand, oligohydramnion, poorly developed ftetus or
monstrosity by defect, such as anencephaly. Of course, it may mean
nothing more than that she has made an error in her estimate of
the age of her pregnancy. Again, she may state that she has a
sensation of weight or of coldness in the lower part of the alxlomen,
that the al;idominal enlargement has ceased to grow, that the breasts
have stopped swelling, and that certain neuralgias or other reflex
phenomena which she has come to ass(jciate with tlie continuance of
gestation, have ceased ; and from these symptoms she may draw tlie
conclusions that the fa3tus in utero has died, and it may very well l)e
that she is quite right {vide p. 416).
In the second place, we must inquire into the spuptoms which
have been present in pregnancy which have nothing to do with
pregnancy as pregnancy. For instance, she may have suffered from
an infectious fever, and have had its typical symptoms, or she may
simply have been exposed to the infection without herself showing
its manifestations. It does not, of course, follow that the diagnosis
of foetal infection can be certainly made under such circumstances ;
but it makes it a probabilitj', and it ought also to make the observer
think of foetal death, of premature labour, and of congenital weak-
ness, or other indication of toxinic poisoning of the unborn infant.
Fm-ther, there is evidence that an infectious condition in the mother
may be connected with an apparently entirely different morbid state
in the foetus, as in Bidone's case of erysipelas in the mother with
streptococcic endocarcUtis in the fcetus {vide p. 198), or in Moucorvo's
442 ANTEXATAI. I'ATIIOLOCY AM) I1Y(.11:NR
record of repeated lyiiipliaiiiiilis in the niutlier a.s tlie result of trau-
matism, with infection and congenital eleiihaiitiasis in the infant f
(vide p. :>02). Although aijjjarently unconnected, the fictal state !•
may nevertheless be the result of the maternal infection, for allow- ;•
ances must be made for differences in environment and in idiysiology, 1
Reference may here be made to the occurrence of traumatism in ^
pregnancy : this should always be noted, for it may have a direct \
bearing upon fietal injuries, death, and even deformities. Here also it j:
may be well that maternal imjiressions Ijc rei'orded, and their nature \
and the date of gestation at which they took jilace noted, if for no '
other purpose than to disprove the efficacy of these imjjressions in
the jH'oduction of monstrosities. Further, the fact that the nu)tluT
during her pregnancy has had for any reason to take powerful or
poisonous drugs ought to be referred to in the formation of a diag- 4
uosis of fa?tal disease or death ; the toxicology of intrauterine life is a ||
large and as yet almost unworked field (cidc ]>. Ii58). The commence- '
ment or continuance of habits of intemperance during the gestation .
must 1)6 noted ; and, finally, the supervention of symptoms of disorder
in any of the great systems, such as the circulatory, resjiiratory,
digestive, urinary, cutaneous, or nervous, must not be passed over, ^
for such may throw light, often quite unexpectedly, upon morbid
intrauterine states.
It may be that in this enumeration of the symptoms of morbid
gestation I have referred to conditions which have little apparent
diagnostic value, but the antenatal pathologist is not yet in a position
to say what is and what is not of importance in this matter. It is
only by the careful recording of all such circumstances that he can
ever hope to build up a system of fcetal symptomatology. If the
truth be told, it is not excess of zeal in recording the phenomena
of morbid pregnancies that is to be deplored or feared, liut the
reverse.
Maternal Physical Examination.
After the history and symptomatology of the pregnancy have
been ascertained, it will be necessary to proceed to an exhaustive
physical examination of the maternal and fietal organisms, and iu
the case of the mother it will be important to examine not only the
reproductive (jrgaus, but also the other bodily systems.
1. Physical examination of the maternal circulatory, respiratory,
and other systems (except the reproductive). The discovery of a
serious diseased condition of any of the maternal systems does not,
of course, enal)le the observer to declare that the fietus is suHeriug
in the same organ, and in the same wa}-. Antenatal diagnosis
is not so easy as that. At the same time, it makes it possible,
and with some maladies even probable, that the fcrtus is affected
with the same pathological change as the niollicr. .iiid it nearly
always enables the observer to predict that tlic infant unlnun is
suHering in some way or other, and that the jircgnancy will
be in some way lU' other abnormal. The structures in the uterus
do not retlect, as in a mirror, the state of the maternal organs;
MATERNAL PHYSICAL EXAMLXATION 443
but it is (loulitful whether there can he anything far wrong with the
mother's economy without the tVetus or embryo sutt'ering in one way
or another, and it occasionally happens that it sutlers in the same
way. For instance, the discovery of grave maternal cardiac disease
(namely, a state of mitral incompetence anil stenosis of recent origin
and without compensation) will be an undoubted warning that
aliortion, or prematnre labour, or fcctal death may be looked for;
and it may, especially when the maternal valvular lesions can be
traced to acute rheumatism, mean that the infant will be born witli
a malformed heart, and possibly with a murmur caused thereby.
Again, the existence of pulmonary tuberculosis does not often carry
with it phthisis of the fa?tus, or even evident tuberculous changes in
any of the organs or in the placenta ; but it may and often does carry
■with it deviations from the normal progress of gestation, such as
premature delivery, and the infant may, as has been pointed out by
Hanot and others, show malformations — for example, stenosis of the
pulmonary artery {vide p. 215). Septic pneumonia of the mother
may occasionally produce septic pneumonia of the fo?tus ; it cannot
be doubted that it nearly always interferes in some way with the
pregnancy which it compUcates. Similarly renal mischief in the
motiier produces changes in the fa?tal tissues, which are sometimes
localised in the kidneys, but more often are found in the other
organs, and very often in the placenta, which is, after all, the kidney
of the unliorn infant. Marked maternal dropsy often means simply
placental lesions and a puny, badly -nourished fa-tus ; Init sometimes the
t'cEtus when Ijorn sliows general anasarca ; out of 06 cases of marked
fietal dropsy there was also maternal dropsy in 16 (vide p. 290).
After ha-\-ing examined the maternal circulatory, respiratory, and
urinary systems (I omit for the present a reference to the testing of
the urhie), the observer should turn his attention now to the other
systems. Tiie osseous and locomotor structures should be examined,
for women with achondroplasia have given birth to achondroplasiac
infants ; and congenital rheumatism, although rarely recognised, has
now and again been noted in the offspring of mothers who have
suffered from rheumatic fever in pregnancy. Nervous diseases, in
addition to being distinctly hereditary, produce effects in other ways
upon the products of conception. Goitre in the mother has some-
times been found in her foetus, and Demme of Berne found that in
53 cases of congenital goitre 37 had mothers suffering from the same
malady {ride \>. 376).
The physical examination of the mother must include the search
for congenital anomalies in herself, such as uajvi, minor malformations,
and muscular peculiarities, for such are now and again to be expected
in lier infant. It must include the taking of her temperature and
the inspection of the skin, for in nearly all the infectious maladies,
such as smallpox, scarlet fever, typhoid, measles, varicella, and ery-
sipelas, the possibility, and indeed the strong probability, is that
there is a transmission of the morljid agency thi'ough the placenta
to the ftetus, with results which may not always exactly resemble
those existing in the mother, but which are, nevertheless, due to
444 ANll'.NAl'AI, I' AlllOI.OdV AM) 1 n(.l I'.N]'.
LliL'iii. Jiuiiiilicc ill iiiotliuL- and fcctus has been noted, so has hiunior-
rliagir purimia, so has epidemic cerebro-spinal meningitis. Even if
the fd'tus esc.ai)e the disease in its oidiiiaiy manifestations, it may
fall a victim to the increased maternal temperature ; or the toxins
arriving in the placenta may cause disease of that structure, or may
pass on to the fu-tus and cause pathological changes in it.
Tiiere is another aspect to this subject. It is possible, and indeed
probable, tiiat morbid states in the fcetus may cause changes in the
maternal organs which are capable of being recognised liy the observer.
P\ctal death, for instance, may be followed liy tiie disappearance of
varicose veins, by shrinking of tlie thyroid enlargement, and liy a
freer condition of respiration ; when the hrtal death is accompanied
by putrefactive changes in utero, maternal vomiting, hectic, high
temperature, and other signs of lilood-poisoning will occur. It is
also very probable that a diseased fcetus may react u])on the maternal
system; but this is a matter upon which we have little information,
and the cases which might teach us something about it — such as
instances of fcetal small^jox in an immune mother — are very rarely
noted. At the same time, there is reason to believe that a high tem-
perature in the fcetus, with excess of waste products passing to the
placenta, and so into the mother's system, may sometimes determine
eclampsia, or albuminuria at least.
2. Physical examination of the maternal reproductive system. It
goes almost without saying that in diagnosing intrauterine conditions
it must be from the examination of the uterus and its contents that
the facts of the greatest value will be obtained. The examinaticjn of
the maternal organs of generation now falls to be considered.
The insiiection and palpation of the mammary glands may reveal
retrogressive changes wliich point to fcetal death; so may the fading
of the purple discoloration of the vulva and vagina. The ins])C"C'tion
of the abdomen may show at a glance that it is larger or smaller than
tlie calculated age of the pregnancy warrants it being, and this obser-
vation may be corrected and confirmed by careful mensuiatidii.
Periodic mensurations may show that the alxlomen is not enlarging
in a steady fashion, or is not enlarging at all. Palpation may dis-
cover a uterus more cystic in feeling than is normal in gestation, a
circumstance which will suggest hydramnios, or may, indeed, cast
grave doubts upon the existence of pregnancy at all. Here it may
again be said that when we are in doubt about the existence of
])regnaney, it will be well for us to suspect the existence of an
abnormal pregnancy. I'ercussion of the aljdomen may serve to mark
out more clearly the uterine outlines and to eliminate pseudocye.sis
from the diagnostic possibilities ; and auscultation may make known
irregularities of the uterine .so^/Z/c, iwinting to anomalies in the growth
of the uteru.s.
Physical Examination of the FcEtus in Utero.
The physical examination of the imborn infant can hardly he
separated from that of the mother's uterus and vagina, either iu
I'fnSUAI. EXAMINATION OF Till', Fd'.TLTS 445
tlieory or practice. As a matter of fact, the two procedures are
carried on simultaneously.
Abdominal iuspection can scarcely do more than suggest that tlie
foetus is very large or very small, or not alone in utero; abdominal
palpation, on the other hand, may be made a diagnostic means of the
greatest importance and value. Nowadays, when so much stress is
laid upon the recognition of presentations and positions by abdominal
without vaginal manipulation, it must follow that obstetricians will
feel better able to appreciate deviations from the normal in the size
and form of tlie tVetus. Further, the widening of practice in the
sphere of alidominal sixrgery must have given most of us a more dis-
tinctly erudite touch than we ever possessed before. It is largely, I
believe, want of utilisation of our powers in this respect that has
interfered with the more frequent making of an antenatal diagnosis.
Let us examine the abdomen of the gravid woman with the same
care that we would employ if we were anticipating the performance
of an o\'ariotomy or a hysterectomy. Further, let us not forget to
use both hands, either both outside the abdomen, or one outside and
the other inside the vagina, in order to get the help which the
bimanual method always gives. Antesthesia may yield as valuable
results in the examination of the foetus in utero as in any other
department of medical practice ; and there are some emergencies in
antenatal pathology which fully justify us in putting the mother
under chloroform.
By abdominal palpation, either with or without anrestbesia, it
may be possible to make out the irregular foetal outhnes and the
indistinct crepitus associated by Negri {Aim. di ostct. e f/inec, v. 82,
1883 ; vii. 223, 1885) with fcetal death, to diagnose provisionally that
there are twins in utero or a double monstrosity, to ascertain the
presence of excess or of scantiness of liquor aumii. and possibly also
to hazard the speculation that the fiptus is small, or large, or grossly
malformed. Peculiarities in the fcetal movements, such as their
great strength, or frequency, or character (for example, singultus),
may be detected by the hands, and tiie difficulty or ease with whicli
laliottcmcnt can be elicited has a diagnostic value. In cases of
hydramnios, where it is usually very difficult to palpate the fcctus,
and where it is particularly important to be alale to do so, it has been
recommended to put the patient in the genu-pectoral position, so as
to allow the foetus to gravitate towards the abdominal i)art of tlie
utei'us, where it can be better felt ; but care must be taken that the
mother does not faint or have very grave dyspncea during the pro-
cess, and I fancy the same result in aiding palpation will be obtained
by putting the patient on the side or in the .semi-prone position.
An unusually cystic feeling in uterus, with the existence of tiie other
symptoms and signs of jiregnancy, ought to make the observer suspect
hydramnios, and along with it a monstrous condition of the uterine
contents or the presence of twins ; for if there is one fact in antenatal
pathology that is well established, it is the association of teratological
conditions, twinning, and hydramnios. The scarcity of the hquor
amnii is also a sign of intrauterine morbid changes, especially of
446 ANTI'.N Al'AI, I'MIIOLOC^' AM) IIV(iIENE
lauUiplc malformations, congenital dislocations, fractures, and anky-
loses. Doubtless in tlie future the palpation of the foetus in utero
will be much more widely ])ractiseil than it has Ijeen in the past.
Auscultation of the abdomen to detect the presence of tlie fcetal
heart is a common, indeed a constant, jn-actice with the careful )
obstetrician, but there seems to be no doubt that the ol)servant ear ■
ought to be able to make out more from tliis method of investigation
than the diagnosis of pregnancy. Some years ago, a colleague .showed
me some daily estimations of the f(i>tal heart-rate taken by liimself
in the case of Ids pregnant wife: he liad made them with the liope
of arriving at a conclusion regarding the sex of his unborn child, and
hia method had been to make d(jts with a pencil on paper as he
listened over the abdomen with the stethoscope for a period of half a
minute or a minute, as determined for him by the patient. The pro-
cedure was a little difficult, but it struck me at the time tliat it had
possibilities in it which could scarcely lie overestimated ; it might,
for instance, be valuable in giving warning both of disease and of
impending death in the fietus, and it migiit be i;sed as a clinical
means of determining what drugs, when given to the mother, pa.ssed
through the placenta and produced a pharmacologicid effect ujion the
infant in utero. In a recent case of pregnancy which was under my
charge during 1899, I was impressed by the fact tliat the mother, a
primipara, who had not lieen strong during girlhood (threatened hip-
joint disease), during the latter half of gestation rajiidly juit on flesh
and weight ; synchronous with this improvement in the maternal
condition, there was a markeil slackening in the growth of the fcetus
and a weakening and slowing of the fcetal heart, with an almost
entire absence of fn:>tal movements ; it seemed, to put it into ordinary
language, as if the mother were being nourished at the expense of
the offspring. At any rate, I diagnosed a small infant with very
little liquor amnii and possible placental changes. I'he event proved
me to be right, for tlie infant — a male- — was puny and had a senile
appearance, was In'ought tlu'ough the first weeks of life only with the
greatest care ; and the placenta was small, of the marginate variety,
and diseased ; there was scarcely any liquor amnii.
The character of the foetal heart sounds may also give diagnostic
indications, and the number of cases in which fwtal heart disease or
malformation was found out before birth is every year lieing added
to. Within the past few years, liellot, Padgett, Nazarofl', and Hall
have all diagnosed fu'tal heart mtu'murs, and confirmed the diagnosis
after the infant was born (vide p. 372). Hall in his cmnnnuiication
gave details of cases by Earth, Hennig, and Christopher; in tlie
example reported by himself, the lesion seemed to have been a
roughening of the lining membrane of the ductus arteriosus, for the
murmur which affected tlic tirst sound disappeared ten days after
birth. It has been affirmed liy Giglio {Ann. di osfet. c i/mec, xix. 333,
1897) that the presence of an anencephalic fcetus in utero may be
suspected from the weak, uncertain, distant, and frequent lieat of the
heart, characters winch may be due to the absence of cerebral and
spinal centres having to do witli the innervation of the heart. In
PHYSICAL EXAMINATION OF THE FOETUS 447
such cases, and on account of the above-named peculiarities of the
fcotal heart-beat, it is often supposed to he absent unless very care-
fully listened for ; this apparent absence, when associated with active
ftctal movements (and with signs of hydramnios), may point, there-
fore, to anencephaly.
The absence of the foetal heart sounds, especially in a case where
they have been previously well heard, and in which their disappearance
has been preceded by a slowing of them, points strongly to foi'tal
death ; but it must always be remembered that absence of the fcetal
heart is a negative sign, and therefore never of the same diagnostic
importance as, for instance, presence of it is in the estimation of
pregnancy and fretal life (vide p. 417).
Other sounds in utero detected by the stethoscope have been
referred to by authors. Thus bubbling sounds due to intrauterine
decomposition, and alterations- in the uterine or placental souffle have
been described in cases of ftetal death ; but their diagnostic value is
most problematical. It seems, however, that the early fcetal move-
ments may be heard even Ijefore they are felt.
Mensuration of the fwtus in utero is a well-known means of
forming an idea of the age of the pregnancy, especially in connection
with the induction of premature labour ; but it is a method which
seems to have been Uttle, if at all, employed in the diagnosis of
anomalies in the size and form of the unborn. It may be carried out
with the aid of a pair of callipers, or, better, with the special modi-
fication of them known as the eephalometer of Bndin and Perret
{L'Ohstdtnquc, iv. 542, 1899); by means of this instrument, which I have
employed by preference, certain of the fcetal cranial diameters have
been determined with a degree of error rai'ely amounting to more than
5 mm. There is no reason why this instrument should not be used for
the detection of abnormalities in head and body measurements.
The graphic representation of the foetal movements is another way
in which mechanical methods may be made to help the obstretrician
in his attempt to find out the state of the unborn infant. Fa?tal
movements are chiefly of four kinds : revolutionary ; extensions and
flexions of the limbs ; extension and flexion of the spine, especially of
the cervical part of it ; and rhythmical movements of the trunk, and
particularly of the thorax, which have been ascribed to fo?tal
singultus, to swallowing, and to intrauterine respiration {vide p. 169).
These movements, as also the fcetal heart-beat, maybe represented as
tracings by the ordinary, although slightly modified, apparatus known
as the cardiograph. Pestalozza, in a case of twins, succeeded in
getting a tracing of the foetal heart, but the conditions were
peculiarly favourable, and not likely soon to occur again {vide p. 137).
Ferroni, however, has shown that it is quite feasible to get good
tracings of the two kinds of rhythmical movements which have been
ascribed to fcetal singultus and to respiration, the former being
abrupt, with an apex, and of a rate of from fifteen to thirty-four
per minute, the latter being undulatory, without interruptions, and
at a rate of from forty to seventy per minute {vide p. 144). Ferroni
also got fcetal tracings in a case of maternal typhoid and in another
448 ANTl'.N A TAI. I'A 11 1( )!,()( I") AM) IHCIKXE
of malaria. There is some justiticatioii for the liope and expectation
that ere long this method of investigation of the infant in utero may
be expanded and made of use. Wlien it is home in mind how much
we can learn from the movements and attitude of the new-horn and
young infant, there is surely reason for trying to learn something
about these same movements and attitude in the IVrtus. It is a fact,
but not perhaps a recognised fact, that the symptoms and signs of
disease in the fu'tus will more closely resemble those of the infant
than those of tlie adult or child.
Skiagraphy will no doidjt also play a part, perhaps not an
unimportant part, in tlie antenatal diagnosis of the future, but in the
meantime the results obtained by Varnier (Ann. de gyiu'c, li. 278,
1 899) have been exceedingly unsatisfactory as regards tlie foetus. For
this failure various riiasons are forthcoming. Among these may be
named the deep shadow thrown by the mother's iielvis and sjiinal
column, the imperfectly ossified f<i'tal skeleton, the thickness of the
maternal structures, the imiiossibility of getting the sensitive plate
in the same relation to the abdominal and pelvic part of the pregnant
uterus, and perhaps the respiratory maternal and the irregular fo>tal
movements. To meet some of these difficulties, Varnier has proposed
to take a skiagram with the patient in the lateral and another
with her in tlie ventral posture, but he has not overcome the technical
obstacles in the way.
There is yet another means of diagnosis of fcctal conditions which
has scarcely at all been employed, and which might yet be made use
of. I mean the detection of changes in the chemical composition of
the maternal excretions {vide p. 418), and in the microsco])ical
appearances of the blood. Progress in this direction is in the mean-
time hindered by the fact that so little is definitely known about
the physiological chemistry of pregnancy, and still less about its
pathological chemistry. What a wide field of research, and not
difficult research, there lies open in connection with such questions
as the occurrence of albuminuria, of peptonuria, of acetonnria, of
glycosuria, of liiBmoglobinuria, and of urobilinuria in pregnancy.
Some of these changes in the urine li.ive been supposed to indicate
the occurrence of fcctal death, but none of them can as j'et be
regarded as an infallible test, and in one case at least— namely, in
albuminuria — the disappearance of the morbid product, and not
its appearance, may point to fcctal death. Further, we know little
of the effect of illness (sliort of death) of the foetus upon the
maternal excretions and blood. There are many problems. Why,
for instance, should the ingestion of from 60 to 120 grm-s. of
glucose by the pregnant woman produce alimentary glycosuria,
while the non-pregnant woman requires to take from 140 to
ISO grms. to bring aliout the same eilcct ? Why should the
toxicity of tlie maternal urine diminish during pregnancy .' Why
sliould I'lunge's law (the ashes of the fu'tus closely resemlilc the
ashes of tiic milk of the mother animal) not apply to tiie human
fcEtus and mother's millv? Whatever the answers to these
and to other problems may be, there can be little doubt that
INTRANATAL DIAGNOSIS 449
from tlie clieiuical side will yet come diagnostic aids uf no small
importance.
Intranatal Diagnosis.
Even when labour has commenced, and is in progress, it is of
importance to diagnose morbid states in the foetus on its way through
the maternal passages. It may be all-important to recognise, for
instance, causes of delay in labour due to enlargement of the foetal
body or head, so that they may be dealt with ere the delay has
become a danger; it may be well for the peace of mind of the
obstetrician that the diagnosis of the presentation be made, and it
will be an advantage for him to be able to forewarn at least the
relatives of the mother of the arrival of a monstrosity or a dead
foetus, for it will at any rate save him from some of the reproach
associated with the unexpected appearance of such an unwelcome
little stranger.
The symptomatology of the labour must, therefore, be taken into
account, and deviations from the iioi-mal noted, such as excess of
liquor amnii, or dryness of the labour, the absence of firtal move-
ments, and the like. Again, the most careful abdominal and vaginal
examinations must be made. It will now be more easy to palpate
the fcetus through the abdominal walls, for the liquor amnii will, in
part at least, have drained away, and the vaginal palpation will be
facilitated by the opening up of the os and the exposure of the
presenting part. It may be taken as a common occurrence for the
malformed part of a monstrous fcetus to present at the os uteri — for
example, the intestinal coils in exomphalos and the basis cranii in
anencep)haly. If the (actus, eruditus fail to make out the presenta-
tion with ease, the erudite mind ought to think of a monstrosity. It
is a good plan for the obstetrician, when he gets a chance, to palpate
the deformed part of a malformed foetus, so that he may recognise
it again if he feels it coming down the birth canal. The escape of
meconium-stained liquor generally, but not always, forewarns of
foetal death ; the feeling of the hydrocephalic head is characteristic,
islands of bone in a sea of membrane ; and the introduction of the
hand well into the passages ought to detect the coming down of a
distended fcetal abdomen (as in ascites), or the presence in utero of
united twins. An interesting case of hydrocephalus, with intestinal
atresia diagnosed during laliour, was put on record by Salus (Frag,
med. iVehnschr., xxi. 529, 1896) ; it was that of a breech presentation,
in which delay occurred after the birth of the body from the large
size of the head ; whilst the trunk was thus protruding from the
maternal parts, meconium of an earthy colour and devoid of bile was
passed from the anus, and it was concluded that there existed an
imperforate condition of the bowel in some jiart of its extent ; the
i conclusion was confirmed after birth by post-mortem examination.
I Foetal ichthyosis may also be recognised during labour. The presence
I of a hairy mole on the shoulder in, say, a transverse presentation,
I might prove misleading to a man who thought that hair only grew
on the foetal scalp. There are many other matters which might be
29
450 ANTKNAIAI. I'A TI lOI.OC'i' AND inCIF.NK
referred to under iuUiUialal diagnosis, sucli as llie detection of fo'tal
anasarca, or of fcetal rickets, from the inspection and ]iali)ation of a
limb or limbs lying in the vagina, or the feeling of tlie 1 tones of
the cranium of a dead fcrtus; hut enough lias been said to show
the possibilities.
Postnatal Diagnosis.
After the morbid or dead fcrtus is born, the necessity for the
formation of a diagnosis does not disappear ; for, if the infant be
dead, it will be essential to discover the cause, so as to take measures
to prevent its recurrence in a future pregnancy ; and if it be dis-
eased or malformed, it will be needful to make a diagnosis in order
to institute the proper treatment. Now, however, the diagnosis will
not differ in its details from that canied out by the pediatric or
general ijhysician, and it will liave lost much of its difficulty. The
disease or the deformity may lie external, and need little more than
recognition ; on the other hand, it may be internal, for example, con-
genital heart disease or pyloric stenosis or diaphragmatic hernia, and
necessitate the most careful application of all our diagnostic methods.
Finally, the placenta and membranes and cord ought always to be
scrutinised, and, when possilile, submitted to microscopical and
bacteriological examination.
I may summarise this long description of diagnostic methods and
means in a case-taking scheme, which differs only in some details
from one published in 1892 (53).
I. Antenatal.
1. Clinical History. c
A. Maternal. j
(1) General Medical. ;
(2) Reproductive. f
n. Paternal. |
C. Family. |
2. Symptomatology.
3. Physical Examination.
A. Maternal.
(1) Circulatory, Respiratory, and other Sj-stems.
(2) Reproductive System.
B. Foetal.
(1) Alnlominal Palpation and Auscultation.
(2) IMensiU'ation by Cephalometer, Callipers, etc.
(3) Skiagrapliy.
C. Chemical and Microscopical Examination of Excretions and
Secretion.'*.
II. Intranatal.
III. Postnatal.
t
CHAPTER XXVI
Therapeutics of Fn'tal Diseases : Erroneous 0]iinioi)s ; Value of Fcetal Life,
Estimation, Appreciation ; Therapeutic Fci'ticide ; Possibilities of Antenatal
Tlierapeutics ; Postnatal Treatment of Antenatal Morbid States ; Intranatal
Hygiene and Treatment.
The goal of the medical man's ambition, and the limits of his iisefnl-
ness to his patient, are not reached when the diagnosis of the malady
from which the latter is suffering has been made. The most exact
diagnosis is unsatisfactory if unaccompanied by effective treatment.
The end and aim of all medical practice is prevention ; and, failing
that, cin-e ; and, failing that, amelioration. A manual of Antenatal
Pathology which contained no reference to antenatal hygiene and
treatment might be of great scientific value, but it would lack practical
interest. It is the treatment of antenatal morbid states, rather it is
the hygiene of antenatal life, that is in the mind of the inquirer into
the phenomena of antenatal disease and death as he prosecutes his
research. He knows by this time enough of tlie subject to expect
httle ; but he has hope, even although it be feebly nourished. Let
us see whether his confidence is in any degree justified.
The medical profession stands upon the threshold of antenatal
therapeutics. It has been standing there so long that even the un-
biassed onlooker must have begun to wonder when it intended to
enter in, whether, indeed, it did not mean to turn away again from
the open portal. Not but that there has been some entering in, of a
retiring kind, unobtrusive, stealthy, passing unobserved by the spec-
tator who is growing weary of watching. High time is it that an
estimate be formed of the probabilities and possibilities of antenatal
therapeutics. Even if the possibilities turn out to be small, vanish-
ing almost, it will yet be better to know than to remain ignorant.
Omne ignotum jjro magnifico will not serve as a cloak ; for the un-
biassed onlooker (already referred to) is hardly prepared to admit
the existence of an omne, notum or ignotum. It is, of course, every-
where admitted that much may be done after labour, even in labour,
to cure or at least to ameliorate morbid states arising during ante-
natal life ; but this is not usually regarded as antenatal therapeutics
in the strict sense of the term. It may be claimed, however, that it
is an integral part of the subject, and I look upon the claim as one
that must be yielded. In this way the field is greatly widened ; and
the subject at once becomes one of great practical importance. Even
in that part which deals with the treatment of the foetus still in
utero (and which is regarded by many as constituting the whole of
antenatal therapeutics), it wiU be found that advances have been
452 ANTKNATAI. 1' VIIIOI.OCV AND llVdlKNK
iiuitle and victories won. Tlie suljject is not so liopeless, although
neglected, as is generally su]i]iosed.
Erroneous Opinions on Antenatal Therapeutics.
During the last few years I have been honoured by inquiries
from nieniliers of the profession as to individual problems in ante-
natal tlierajieutics, and l)y suggestitms as to tiie extension of our
therapeulir resources in dealing with morbid states during fatal life.
A consideration of these suggestions and inquiries has led me to
believe that many medical men hold erroneous views as to the
necessity of treating the unborn child, and that some are inclined
to institute unfair comparisons between this and other departments
of therapeutics.
In the fird place, let me again state that the possibility of
influencing morbid states that affect the infant while in utero does
not cease with its birth. Many malformations produced antenatally
can, of course, be corrected postnatally, and some congenital diseases
can be alleviated, if not cured, by therapeutic measures instituted
after birth. The treatment of antenatal morbid conditions is not,
therefore, exclusively antenatal; it may be, in part, postnatal,
and its effects must of necessity be largely postnatal in their
manifestation.
In the second place, it may be pointed out that most physicians,
if they think about it at all, compare the therapeutics of the diseases
of the foetus with the treatment of disorders of the adult, doubtless
much to tlie prejudice of the former. They contrast the many
medicines which can be administered to the more or less wilUng
adult, with very definite result, with the very few drugs which can be
given, with almost unknown results, to the foetus in utero (always
presupposing that its passive resistance to being drugged at all can
be overcome, — that, in other words, the placental barriers can be
passed). But in so arguing they are not acting quite fairly. Why
should comparison be made between the therapeutics of the foetus
and that of the adult ? We do not contrast the tiierapeutics of the
new-born infant with that of the adult, but with that of the infant
and child. Let us, therefore, contrast antenatal therapeutics with
neonatal therapeutics. I think I am right in supposing that few
medical men commonly administer more than two or three drugs to
the new-born infant ; that few feel altogether at home in its manage-
ment, medicinal or otherwise : and that few can boast of brilliant
results and assured triumphs in tlie domain of neonatal therapeutics.
In comparing neonatal with antenatal therapeutics, we compare
similar things ; the one is divided from the other, it is true, by that
epoch-making occurrence, birth, yet thej' are in many respects
similar. A little reflection will make it clear that, after all, antenatal
tiiiTapeutics in its scope and utility is little, if at all, behind neonatal
tlun-apeutics. Let us see.
Few drugs are needed by, or commonly administered to, the new-
born child, and even those are of doubtful utility : castor-oil to do
ANTENATAL AND NEONATAL TREATMENT 453
what the colostrum does equally well or bettei', and dill water to
undo the evil effects of unnecessarily filling tlie infant's stomacli witli
sugar and water. The first draught of the mother's milk thoroughly
clears the bowel of meconium. The infant does not come into the
world in a state of starvation ; his tissues are not crying out for
pabulum ; it is doubtful if, after birth, he ever again receives so full,
complete, and well-adaj)ted a meal as is provided for him while still
in 'utero ; he requires nothing more for eight hours after birtli, by
wliich time the mother's breast begins to supply his wants. Some
physicians add hydrargyrum cum creta to the drugs given to the
new-born, presumably on tlie principle that mercury for infants is
certaiii to do good, and cannot, at any rate, do harm ; but is it not
somewhat of a reflection upon every one concerned, that it sliould be
deemed necessary to start every child upon his postnatal career with
the specific for sj'philis, always supposing that he is free from that
disease? The most rational plan of giving medicines to the new-
born infant is through the mother's milk or by inunction through the
skin, wliich at this time of life absorbs freely ; but not many new-
born infants require drugs at all. Now, the same general principles
apply to antenatal therapeutics. The unborn, like the new-born,
infant requires drugs seldom, and he can best receive them through
the mother, i.e., through the placenta, which, after all, is in its foetal
part an extension of the fa?tal skin, or ectoderm. In this way arsenic
and mercury, and doubtless many other remedies, may be admin-
istered. As has been shown, there is much ignorance as to the
conditions which favour or obstruct the passage of these drugs to and
from the foetus ; but all is not by any means known regarding the
transmission of medicines through the milk.
In the third place, it is an error (although not so common an
error as it once was) to think only of medicinal treatment. There
are other means of infiuencing beneficially the maladies of all periods
of life. In this respect, also, neonatal and antenatal therapeutics
may be compared. When an infant is born into the world in a weak,
puny, or delicate state, or when it develops weakness or ilhress soon
after birth, the best line of treatment will often consist in attempting
to return it to its antenatal surroundings, in re-establishing the
status quo ante partuni. In its most complete development this
attempt finds expression and visible embodiment in the couveuse, or
incubator, which has become so important an addition to the thera-
peutic armamentarium of the maternity liospital. The treatment of
the new-born is then environmental rather than medicinal ; so, I
maintain, should be the treatment of the unborn. Tlie foetus, when
healthy, requires no external help, and, when ill, no more than is
given to the ailing new-born infant liy the pediatric or obstetric
physician. Indeed, it requires considerably less, for Nature has
already carried out a lai'ge part of the treatment by providing the
best possible coureusc ; for a fluid medium of constant temperature is
better than an atmospheric one, even when artificially warmed and
carefully sterilised. When an adult is ill, we order him to keep his
bed in a room of even temperature : when a fcetus is ill, we are glad
454 ANTKNATAI. I'ATl lOI.OfJV AM) HYCUKNE
to know tliat he is, so to say, keciiiu;;' Iiis room. We are euibaiiassed
only if lie leave it, for to he prematurely horn is a serious matter for
a diseased fietus; and if this should happen, all we can do is to pro-
vide another " room," which very imperfectly resembles the uterus,
namel}', the incubator. But it may bo asked. Can we in any way aid
in keeping the iietus in utero? I thiidv we can. We can keej) down
the maternal temperature and prevent a sudden rise, whicli would
loosen the intrauUnine connections ; we can assist llie inotlicr's
excretory organs (skin, kidneys, intestine) to act vigorously, and
throw olf the effete products which pass in large quantity into tlie
maternal from the fietal economy, for maternal toxamia wiU tend to
set up uterine action and bring on labour; and, finally, we can do
something towards maintaining tlie structural and functional integrity
of the placenta, for chlorate of potash would seem to act as a
placental tonic. How it acts, whether on the placenta directly, or
indirectly by keeping the maternal blood in good condition, does not
so mucli matter; in my experience and in that of otliers it prolongs
intrauterine life, it maintains the placental functions, and so saves
the foetus from the dangers of ])reniature exposure to an extrauterine
environment.
In the fourth place, it has been often sujiposed that the causes of
antenatal morbid states were special, peculiar, and indeed unknown
in their nature, and that therefore the treatment must be also (piite
peculiar or perhaps nil. Thcrapia nulla has been too quickly written
as an epitaph over antenatal therapeutics. There is good reason to
believe that the same causes are at work in the antenatal as in the
postnatal period of life. The reader will have learned from the pre-
ceding pages that the agencies which, when acting upon infantile
and adult organisms, produce pathogenic and toxic eflects, are those
which lead to pathogenic and toxic effects when acting upon the
foetus. Further, in the part of tliis work which is to deal with the
morbid states of the embryo and germ, it will be shown tliat ]irt)bably
these same causes are again in action in producing malformations and
monstrosities. The results of their action are very various — sterility,
single and double monstrosities, abortions, still-births, mortinatality,
twinning, fcctal disease, many tumours, congenital debility, and
tendencies dissolving heredity and leading to the later development
of tubercle, rheumatism, gout, and many neuropathic disorders — these,
and not fcctal diseases and deformities only, are the protean jihenomena
of Antenatal I'atiiology. So there is good reason to believe that the
morbid causes also are not one but manj', and that all the toxic and
pathogenic agents whose action in postnatal life is known, may act
before birth upon the developing organism. In this way the poisons,
such as alcohol, lead, morphine, nicotine, and the rest, and the
microbes and their toxins, such as those of tubercle and the ex-
antliemata, and to some extent traumatism, enter into the arena of
antenatal etiology, and have to lie taken into account in the investi-
gation of every instance of Antenatal I'athology. So far as has been
discovered, one and the same morbid cause may produce in one
instance a fcetal disease, in another an embryonic monstrosity, and in
VALUE OF F(ETAL LIFE 455
auotlier a tendency to the breaking of normal heredity in the develop-
ment of a proneness to certain maladies of body and mind in later
life. Yet again, this same cause may produce sterility, emliryonic or
fietal death, possibly twinning, and certainly abortion and premature
labour. In syphilis and tubercle and alcoholism are to be found
three morbid causes which may produce the protean effects which
have been enmnerated. Further, similar effects may be produced by
different causes, the results depending apparently not so much upon
tlie nature of the morbid agent, as upon the time of its action and the
condition of the organism acted upon. It is quite likely that if it were
possible to reduce these morbid actions to their ultimate factor, it
would be found to be the common one of interference with nutrition,
and probably chemical in its nature.
If these views, then, be correct, it follows that the medicines and
plans of treatment which are appUcable in postnatal life may, with
certain restrictions, prove useful in antenatal life also. If the pheno-
mena of Antenatal Tathology are not due to some occult and myste-
rious special cause, then their prevention, or even their cure, may
be less hopelessly looked for in the tlierapeutic measures which are
known.
Having considered these erroneous ideas regarding the treatment of
antenatal morbid states, we are now, I think, better able to approacli
that great problem, and are less likely to be either disappointed or
startled with tlie results. There is, however, yet one other pre-
liminary matter to be discussed before we can take up in detail the
possibilities of antenatal therapeutics ; I refer to the value of fatal
life.
The Value of Fcetal Life.
Closely bound up with the problem of the value of fa^tal life is
tlie question of the amount of fretal death. What is the antenatal
death-roll ? No estimate has ever been formed of the loss of life
which takes place immediately after birth as the direct result of
birth, during birth from the traumatism of labour, in the fu^tal period,
in the embryonic epoch, and during germinal life. Mortality tables
tell something of the frequency of death during the first months of
life, obstetricians know something of the many times that they have
to deal with premature labours, still-birtlis, and abortions ; but I doubt
whether the most pessimistic has an adequate conception of the loss
of life in tlie earlier periods of antenatal existence. Even if we
neglect all deaths occurring before tlie second month of intrauterine
life, the result is nevertheless appaUing. The frequency of abortions
lias been regarded by Tarnier and Budin {Traitd dc I'art des accoiichc-
ments, ii. 47-4, 1886) as something like one to every three or four
pregnancies ; since abortions are equivalent to frotal deaths (in their
ultimate results), this means that the fo'tus, at the beginning of the
fcetal period of intrauterine life, has a 25 per cent, or a 20 per cent,
risk of never reaching the time of viability.
In maternity hospital practice, ])remature births occur to the
extent of about 16 per cent. (C. Hahn, Dcs ■primaturis, p. 46, Paris,
4r)(i AXTI'.NAl'AI, I'ArilOI.OdV AM) IIYdll'.NK
1901), if we re^'aiil all the infants weighing less tiiau 2500 gnus,
as prematurely horn ; but it' iiOOO grms. be taken as indicating pre-
maturity, then the percentage rises to 41'r>. For practical purpijses,
the frequency of premature labours in maternity iiospitals may be
put at 20 per cent. ; but, of course, this does not enable us to
estimate the percentage in general obstetric practice. Further,
premature birth does not necessarily mean fcctal deatli ; some prc-
luaturely-boru infants are dead when born, and some die very soon
afterwards, but a certain number survive. The number of the
survivors will vary with the age in fictal life arrived at when birth
took place, with the means employed to keep the infant alive, with
the season of the year, etc. The variation will be within wide limits ;
it is not difficult to find statistics of mortality among premature
infants showing any percentage between 90 and 10. It is true that
recent reports show a most gratifying fall to little more than a G'5 per
cent, mortality (C. Maygrier, L'Ohstctrique, vi. 497, 1901) ; Init if a wide
view be takeu, it is probaUe that 50 per cent, or 40 per cent, must
still be regarded as not uncommon. I'erhaps, then, it may be said
that if a f(i;tiis reach a viable age, and is then born before the full
term, he will have a 30 or 40 per cent, risk of early postnatal death.
Of course, it must be added that some fu'tuses go to tlie full term,
and are then born dead ; they are not nearly so numerous, but
statistics are difficult to obtain, for some of the deaths are no doubt
due to obstetric difficulties, and not to truly antenatal causes. It
will be seen, from what has been stated, that it is very difficult to
obtain any idea of the fatal death-rate, for it is almost impossible to
exclude the intranatal deaths due to purely intranatal cau.ses, and it
is far from easy to estimate the mortality due to premature labours
and abortions. One conclusion maj' perhaps be safely drawn :
through improved obstetric methods, and the elaboratiou of the means
for keeping premature infants in life, and possibly also l)y the
amelioration of the condition of the pregnant woman-worker, the
fcEtal death-rate is percejjtibly less than it was, say, fifty years ago.
It is very doubtful, however, whether it can be said that this fall in
the fretal death-rate has done anything towards altering the economic
value of foetal life, for, as will now be shown, another and a far more
important factor has been at work : I refer to the fall in the birth-rate.
From a strict and rigid utilitarian standpoint, it may not matter
much that there is a high fictal death-rate, so long as there is also a
high birth-rate, so long as the po])ulation is going up by leajis and
Ixiunds. ]5ut if not, what tlien ? Tiie social economist of the country
whose population is stationary or receding will soon be forced to take
an interest in the f(ctal death-rate ; in liis mind the value of fictal
life will undergo ap])reciation. He will, of course, consider first the
cause or causes of the diminished birth-rate; if he find that they are
removable, l)e will hope to see them removed by legislation or some
other means; but if he find that they are not removable, he will lie
forced back to the plan of trying to increase the nundier of living
full-time infants born. His idea of the value of foetal life will have
changed. Now, there can be no doubt that in most civilised countries
VALUE OF F(];TAI, LlFl': 457
there is a drop iu the l)irth-rate, iieitlier can there be any doiiht tliat
it is due to causes whicli are practically unreniovaWe. These causes
are chietiy the voluntary prevention of concepti(.in and the procuring
of early abortion in order to pre\'ent large families, and behind these
causes lies the " wish for ease and material enjoyment." It is doubtful
whether a greater .dissemination of educational opportunities among
the masses will lessen this tendency ; at any rate, there is reason to
fear that it will be long before it does so. The fall in the birth-rate
in France has been well known for years : liut in the United Kingdom
we find a still more startling, because more rapid, fall from a birth-
rate of 35 per 1000 in 1875 to one of 29 per 1000 in 1900 1 This
means in each year, and with the present population of 41 J millions,
a deficiency of a quarter of a million infants. In the face of this
deficiency, a slight improvement in the fcetal death-rate is soon
counterbalanced. Tlie effect, however, is to increase the value of
foetal life, for if the abortions and premature labours could be
diminished, and if the diseases of fcetal life could be prevented or
cured, something at least might be accomplished to check the down-
ward trend of the population. There is, of course, no increase in the
intrinsic value of the life before birth ; it is simply an accidental
appreciation.
This appreciation in the value of fcetal life has had an evident
effect in another direction; I refer to the c|uestion of the relative
value of maternal and foetal life. This question usually arises in
connection with the performance of some obstetric operation, such as
craniotomy or tlie induction of aljortion or X'l'emature laliour, in
which the life of the foetus is sacrificed or put into jeopardy on
behalf of the mother. Under the title of "Mother versus Child,"
Dr. S. Macvie of Chirnside {Tratis. Edinb. Ohst. Soc, xxiv. 123, 1899)
dealt with this matter in the form in which he met it, namely,
inoperable rectal cancer in a woman pregnant at the sixth month ;
he had to decide whether to induce abortion at the sixth month or
premature labour at the seventh, or do C;T?sarean section at the full
time ; and, in attempting to decide the line of procedure, he found
himself face to face with the problem of the relative value of the life
of a mother with inoperable cancer of the rectum, and that of an
unborn infant at the sixth month of intrauterine life. Which was
the more valuable life ? He was still deliberating upon this matter
when circumstances arose (increase in the mother's sufierings, block-
ing of the rectum, risks of performing C;esareau section in the
country) which led him to induce premature labour ; the child was
born alive and hved five weeks, and the mother recovered fi'om the
effects of the labour, and was able for some time to attend to her
household duties. The problem in this case was a very involved one.
It usually arises in a simpler form in the choice of the alternative
operations in cases of contracted pelvis ; but Macvie's attempt to
arrive at a solution of the problem is so ingenious and interesting,
that it must be considered more in detail.
If we consider the question of life-expectancy, it would seem that
at twenty years of age that of the mother is barely equal to that of
458 AN'ri'-NATAI, I' A 11 lOI.CXiV AM) IIVCllAl-.
her new-born iuranl, and al i-very subsequent prcLjnaney it is less.
Therefore, if at every birth after twenty years of a^e the life-ex-
pectancy is taken as tlie measure of value, the new-born child is the
more valuable life. The "general practice, however, is to regard the
mother's life as the more valualjle, although lier life-e.\peetancy may
be less than that of her child. " It is not diilicult," writes I\Iacvie,
" to find ethical justification for the practice. Life-e.xjiectancy tables
are misleading indices of life values, unless the duration of the ex-
pectancy covers the same series of years. If two lives have an
expectancy of twenty years eacli, reaching from twenty to forty, they
may safely be said to be of equal value. Each individual would have
the same time in wliich to discharge the obligations of life. The
lives of mother and child do not give such synchronous parallelism,
and a life-expectancy of equal duration might give widely uneipial life
values. For example, if a child's life-expectancy covered the first
ten years, and the mother's reached from twenty to thirty years,
there would be no hesitation in giving to the mother's tlie higlier
value. The difficulty lies in determining the figure with which to
multiply it. . . . Ethically regarded, the value of life consists in the
discharge of subjective and altruistic obligations, instinctive or voli-
tional, as the case may be, and with such opportunity or capacity as
the individual possesses. To this may be added the due iierformance
of procreative functions from which the life acquires a racial in
addition to an ethical value. In other words, life ^'alue is composed
of thi-ee elements, personal, social, and racial. At certain periods of
life the discharge of these obligations is an impossibility, and at
such periods life has either not acquired or has lost its highest
value. For example, the foetus in utero is a parasite performing no
function whatever." [This is not quite correct, for there can be no
doubt that its life reacts upon the maternal life in an obscure, even
in a mysterious fashion, either as a stimulus to a high degree of
physiological activity or as a cause of disease ; but the point need not
be insisted upon, and Dr. Macvie's line of argument need not be
broken.] " Its existence involves a physiological loss to the maternal
organism. Unlike an arm or a spleen, it performs no duty in return
for its sustenance. Its actual value could only be expressed by a
minus quantity. Its potential value is equal to its extrauteriue
life-expectancy. If that is, by reason of dangers ahead, reduced to a
life-expectancy muiimum, its potential value may never be realised.
The new-born child is still parasitic, tliough detached ; and, though
it inhales its own oxygen, is still a physiological loss to tlie maternal
organism. The actual value is still a minus quantity, but it lias begun
to realise its potentiality by satisfying the parental instinct, and
contributing to the subjective element of life. The mother, on the
other hand, has realised the potentialities of life. Value after value
has been added to lier existence as consciousness, self-cunsciousness,
and volition developed. Tlie later-added procreative function has
given it a racial value. In the discharge of her manifold functions,
she, living less to herself than any other being, attains a higher self-
sacrificial value. She is directly and indirectly contributory to the
VALUE OF RKTAL LIFE 459
life of her childreu, and her own life, to he accurately estimated,
must be multiplied by some fractional sum of theirs. Thus, while
child-life in its partially developed stages must be represented by a
varying fraction, the maternal life must be represented by an integer
raised to an »"' power equivalent to her manifold functions. There-
fore, unless the life-e.xpectancy of the child covers the years in which
its potentiality is converted into actuality, the relative values of the
maternal and foetal life will be that of actual as against potential."
From all this, and from much more of a like inconclusive, per-
haps even inconsequent, kind, it may be gathered that we cannot
estimate the actual or the I'elative value of fcctal life. The mother's
^ life has a value because she is what she is ; the fcetal life has a value
on account of what it may become. We are not able for want of
data to calculate life-expectancy at either the third or the seventh
month of intrauterine existence, much less at earlier dates. During
the last fifty years tliere has probably been a slight increase in the
chances of a fcetus surviving till the full term ; but against this has
to be put the fact that apparently parents ha\'e decided that there
are to be fewer fcetuses to enjoy this enhanced cliance of life. Pro-
letaneous parents are to Ije rare. When the birth-rate begins to go
down, the value, economic as well as sentimental, of the unborn infant
begins to go up. This, at least, is undoul3ted.
A very practical question meanwhile awaits an answer. Be the
value of foetal life what it may be, has any one the power to ordain
that a foetus shall die ? In whose hands, if in any one's, is the jus vit;e
iieci que ? Pinard {An7i. de gyndc, li. 1, 1899 ; lii. 81, 1899 ; liii. 1,
1900), discusses this matter very seriously, and in view of the various
fceticidal operations still in use it requires serious discussion. Pinard
puts to himself the following question : " A woman in labour cannot
be delivered spontaneously on account of contraction of the pelvis ;
the fretus is at full term and alive, the interference that you regard
as necessary, indispensable, and indicated, is forbidden to you by the
patient herself or by her relatives; another means of treatment is
proposed to you, and it implies the death of the infant : under these
circumstances, what are you to do ? " Pinard examines in turn the
paternal right to decree the death of the offspring, the maternal
right to demand the same thing, the power that the medical attend-
ant has during a confinement to decide whether the infant shall live
or die, and the right of any one else (e.g. the managers of a mater-
nity hospital) to interfere in the matter. The conclusion would
seem legitimately to be that the right of life or death over the infant
belongs to no one, neither to the father nor to the mother, nor to
the medical attendant, nor even to the directors of the hospital.
The infant's right to his life is an imprescriptible and sacred right
which no power can take from him. The right of choosing the
operation to be employed belongs to the medical attendant, and his
duty is to both his patients, to child as well as to mother. If it
seem to be advantageous for the mother, embryotomy or embryulcia
may be i)erformed upon the dead fcetus ; but if the unborn infant be
still alive, the logical and the moral conclusion is that its birth be
460 ANTKNAI'AI, 1>AI'I lOI.OCI^ AND IIVCII'.NK
ellected witliout delibeiately killing it. " Sacrifier I'enfant pour
sauver la mere est une k'geiiile qui doit disparaitre " (C. Zalackas,
Proijrrs mi'd., 3 k., xiii. 421, 1901). JJut if tiu! mother forbid tlie
special operation needed, what then ! Tlie obstetrician is hardly
ready with an answer yet. Fortunately many thinifs are contri-
buting to make the abolition of craniotomy upon the living fo?tus
possil)le : the great fall in the mortality from Ca-sarean section at
the full time, the introduction of symphysiotomy, the improvement of
the forceps, the development of the means for keeping in life the pre-
maturely born infant; these and other advances in the obstetric art
are having a manifest influence upon professional opinion in this
matter. As to therapeutic fu'ticide, or the induction of labour before
the foetus has arrived at a viable age, it is possible for some doubt to
arise, when it seems certain that the mother if undelivered will die,
and if delivered will live. The thinking obstetrician awaits with
impatience the discovery of some alternative means of dealing with
such conditions. Let him, as he thinks, repeat to himself tlie legal
maxim, " (^)ui in utero est, pro jam nato habetur," and extend its
application to matters other than tlie succession to estates. Surely
it will yet be found possible to deal with hyperemesis in pregnancy
in some other way than by terminating pregnancy before the se\'enth
month, and so sacrificing the product of conception.
Possibilities of Antenatal Therapeutics.
In many respects the field of research which has been designated
Antenatal Pathology resemljles a battlefield, rather perhaps a whole
campaign. It is indeed a field thickly strewn with the dead, the
dying, the wounded, the maimed ; for it is not only antenatal death
that has to be taken into account, we have to think of the aute-
natally wounded, crippled, and diseased. Now, in such a campaign,
it will be evident that the individual may require medical treatment
after the battle, during the campaign, or before the wai'. For the
wounded from the battle the Army Medical Department provides
the ambulance corps, the field hospital, and the base hospital : but it
does more, it endeavours to keep the troops healthy and in a healthy
environment during the campaign, and by means of a good water
supply and suitable food sends them into the fight fit to bear the
strain to which they wiU assuredlj' be suljjected. Yet more, liefore
the campaign is begun, the medical inspection of recruits is the
subject of great care, and only such are selected as give promise
of strong and healthy development ; and, when selected, these are
still further trained until they become almost perfect fighting
machines. Like all comparisons, this one may be pushed too far;
but it may be said generally that the postnatal treatment of morbid
states arising during birth, or before birth, corresponds to the field
and base hospitals, being mainly reparative and palliative ; that
intranatal therapeutics and tlie treatment of the fo'tus and embryo
may be likened to the care of the soldier during the battle and in
the whole campaign, being mainly preventive ; and that germinal
POSTNATAL TREATMENT 4G1
therapeutics resembles iu its possibilities the work of the recruiting
sergeant and the drill instructor, being mainly selective and prepar-
atory. The watchwords, then, in both cases, must be repair, i)reveut,
prepare, and select with care. Here we have chiefly to do with the
treatment of foetal maladies during the foetal period, but some re-
ference must also be made to treatment during the later and earlier
periods.
Postnatal Treatment of Antenatal Morbid States.
It may Ije thought to be almost a work of supererogation to enter
into details regarding what may be done, after the birth of the infant,
to remedy the ills with which it comes burdened into its extrauterine
existence, but it is doubtful whether the medical profession realises
how much may be done, and is done, in this direction. Few indeed
are the malformations \\-hicb are comiiatible with the life of the
individual that have not now come under the sway of the surgeon,
and there are several instances in which his skill has made anomalies
that were formeily regarded as certainly lethal no longer so. Now,
the malformations and monstrosities are not, strictly speaking, foetal
in origin, but the opportunity of treating them comes at the same
time, namely, at birth ; they are, therefore, referred to here, although
their fuller consideration will be found in the part of the work which
deals with Teratology. Less immediate and striking beneficial results
have followed the ministrations of the physician and obstetrician;
but hei'c also noteworthy advances have to be reported.
As has been said, it is in the domain of surgery that the postnatal
treatment of antenatal morbid states has secured its most noteworthy
triumphs. Club-foot, cleft palate, hare-lip, phimosis, imperforate
hymen and anus, congenital dislocation of iiip, shoulder, and knee,
torticollis, spina bifida, congenital fistulte, cysts and tumours of
various regions, umliilical and other hernia?, extroversion of the
bladder, atresia of urethra, vulva, or vagina, epispadias, hypospadias,
non-descent of the testicle, vulvar anus, supernumerary digits, syn-
dactyly, congenital absence of tibia, filjula, and radius, and many
other conditions quite as markedly antenatal in origin, are every
day taxing the ingenuity of the surgeon. In the repair of some of
these deformities surgery has been quite successful ; in others, such as
ectopia vesica.', congenital dislocations, and absence of fibula or radius,
only a moderate degree of success has been registered. E^■en in the
latter, however, there has been progress ; attempts to close the bladder
in extroversion of that organ have been abandoned for the implanta-
j tion of the ureters into the rectum, and that in its turn seems likely
I to give way Ijefore the implantation of them into the dorsum penis ;
the so-called bloodless methods of reducing congenital dislocation of
' the hip appear to be gaining ground, as compared with the various
I cutting operations, and so also with other deformities and their treat-
I ment. Further, it cannot be doubted that new triumphs await the
j orthopaedic surgeon in the dealing with such conditions as meningo-
I cele, encephalocele, parasitic or attached fcfituses and united twins
462 ANTF.NATAT, 1'ATI1()I.(X;Y AND IIVCIF.NF.
(Chapot-PrL-vost, Chirurgie den Tt'ratopoffcs, Paris, 1901). Scarcely
any serious attempts have yet been made to correct tiie internal
malformations : and the reparative surgery of congenital diapliragmatic
hernia, of kidney in the pelvis, of intestinal and resopliageal atresia,
and tlie like, has to l)e elaborated.
The results obtained by the pliysician in his treatment of ante-
natal morbid states, although less brilliant than tliose of the surgeon,
have been sufficiently good to encourage further ellbrts. It is un-
necessary to do more than refer to the beneficial effects of medicinal
treatment of the manifestations of congenital syphilis ; and the value
of thyroid feeding in cretinism and infantilism is well known. It
must, however, be confessed that little success has as yet attended
the medical treatment of the congenital skin diseases ; and ichthyosis,
tylosis, sclerema, hypertrichosis, hypotrichosis, na-vus neuroticus, and
congenital elephantiasis must still be looked upon as nearly intract-
able. The ordinary form of jaundice of the new-ljorn yields readily to
treatment of the simplest kind, but the grave ftirm does not yield at
all. Umbilical htenrorrhage usually requires surgical interfeience,
and that of a very active kind, to control it ; congenital heart disease
handicaps the individual for life, and congenital dropsical states are
rarely amenable to the drugs of the physician. There are, however,
hopeful signs in connection with congenital hyi)ertrophy of the
pylorus, fcctal endocarditis, foetal goitre, etc.
On the other hand, wonderful results have been obtained in the
branch of medical practice that deals with congenital defects and
diseases of the nervous system. Witness the effect of medically
regulated educational training upon the congenitally blind, or deaf
and dumb, or idiotic. The combination of medical supervision with
educative methods has almost made the blind to see, the deaf to hear,
the dumb to speak, and the idiot to understand. This is no random
statement, for every one knows what the congenitally lilind, deaf, or
dumb can accomplish, notwithstanding his infirmity. With regard
to idiocy, the following sentence contains a report of the results of
twenty years' work in its alleviation (Shuttleworth in Hack Tuke's
Dkt. Fsycholog. Med., ii. 675, 1892). " Of patients discliarged after full
treatment, 10 per cent, are self-supporting, whilst another 10 per cent,
would he so if they had obtained suitable situations, and about 20
per cent, were reported as useful to their friends at home."
In one direction, however, the treatment of idiocy has not been
altogether encouraging. I refer to craniectomy for the microcephalic
form of it. The operation is not uncommonly followed by evident
and immediate improvement, which continues up to a certain point,
and then all that has been gained is too often steadily lost. The
reason probably is that in primitive microcephaly the arrest in brain
development has occurred before the fourth month of intrauterine
life, and that, therefore, the division of the cranial vault does not
reach the root of the mischief; it is not the cranium liut the lirain
that is at fault. In cases developed later, the o]ieration is theoret-
ically more hopeful. In this relation it may not be out of place
to refer to the treatment of cranial depressions in the new-born
INTRANATAL TREATMENT iG?,
by trephining. Sometimes the natural resiliency of the bones alone,
or aided by manipulation (Munro Kerr, Tram^. Edinh. Ohst. Soc,
xxvi. 42, 1901), restores the normal form of the head, and obviates
symptoms ; but this good result does not always follow. In a case,
of which Dr. D. 1). Jennings {Trans. Edinh. Ohst. Soc, xix. 105,
1894) kindly sent me the notes, the use of forceps had produced a
distinct depression of the left frontal bone ; pneumatic suction was
first tried, and that failing, tlie trephine was employed and the bone
elevated ; the child made an uneventful recovery. It seems to me
that this mode of treating congenital depressions and fractures of the
cranium might l)e extended with advantage.
Part of tlie postnatal treatment of antenatal morbid states falls
into the hands of the obstetrician. He it is who has to deal witli
apnoea neonatorum ; and it will be well if he give heed to the causes
of this morbid state, for it is very certain that all instances of still-
birth are not due to one cause, and are not, therefore, all amenable to
the same treatment. The obstetrician ought to scrutinise each case,
endeavour to ascertain the special cause, and treat accordingly. It
also falls within the province of obstetrics to examine the new-born
for fractures, dislocations, and imperforations, and to remedy them as
far as may be. I need not refer to the incubator and the wet-nurse
in the rearing of premature infants ; l:)ut it may be necessary to
supply to the milk certain minei'als {e.rj. iron) which the foetus gets
through the placenta in the last two months of intrauterine life.
Intranatal Hygiene and Treatment.
Intranatal treatment, under which I include the management of
the infant during labour, both in the uterus and in the vagina, is
entirely in the hands of the obstetrician. It is mainly preventive in
character. In discussing the intranatal factor in neonatal pathology
(vide pp. 44-56), I pointed out some of the risks run by the infant on
his way through the birth canals. There is, for instance, the danger
of septic or gonorrhoeal or syphilitic infection affecting the eyes or
mouth or lungs ; this danger may be almost entirely averted by the
prophylactic vaginal douche during labour, and by the cleansing of
not only the eyes, but also the nose and mouth of the child immedi-
ately after birth. Prophylactic douching in labour for the sake of
the infant is a procedure the full value of which has not, I think,
been fully appreciated as yet. The introduction of air into the uterus
in some cases of labour (breech presentations, prolapse of cord) to
obviate asphyxia has been reconnnended, but it is of doubtful value
(iiapin, Ann. dc gynic, lii. 326, 1899). Again, the obstetrician has it
in his power to prevent tetanus neonatorum by the application of
surgical cleanliness to the dressing of the umbilical cord, and by the
same means it may be confidently anticipated that erysipelas neo-
natorum and omphalitis with defective closure of the umbilical ring
will be banished from practice. Porak (Ann. de [lynec, lii. 122, 1899)
has proposed crushing of the umbilical cord (omphalotripsy) with a
special kind of forceps (omphalotribe) instead of the ordinary ligature
464 AN ri-.NATAI. I'ATI lOI.OC^ AM) I nciKNK
ami section ; and il luiist be admitted tliat the present mode of
allowing the gelatinous stump of the cord to separate by mummifica-
tion does not seem to fulfil the requirements of ase])tic surgery. The
rational treatment fif the physiological l!(j\v f)f milk from the breasts
of the new-born will prevent many of the cases of mannnary abscess
due to the nustaken notion in midwives' minds of the necessity of
" breaking the breast strings." The almost complete banishment of
ergot until after the infant is born, has already, doubtless, saveii many
infantile lives ; and the rapid delivery of the second twin is, I believe,
a step in the right direction.
Further, every improvement in obstetrical instruments and
manipulations is beneficial to the foetus. The better the forceps,
and the more correctly it is applied in the right cases, the greater
will be the infant's chance of being born alive and free from intra-
cranial ha?morrhages and facial paralysis ; and the more thorough
the obstetrician's knowledge of the safe methods of delivery in
contracted brims, in face cases, and in head-last labours, the better
it will be for the child. It may be suggestetl, further, tiiat in cases of
fluid accumulations in tlie foetus, such as hydrocephalus, ascites, and
distended bladder, diagnosed in labour, it may be well to aspirate
instead of widely incising the affected region of the infant ; the
tapping of the spinal canal in breech cases with hydrocephalus ought
to be kept in mind. Ji
It will not be out of place if I here strongly insist upon the '
necessity for the registi'ation of still-births that exists in our country.
Registration, if it were obligatory, would necessitate necropsy, and
necropsy would do much to familiarise the medical practitioner with
the appearances of still-born infants, and would be of enormous value
in elucidating the causes of intrauterine and intranatal death. Tidy
{Legal Medicine, ii. 253, 1883), says :
So notorious is it that a large number of these ileatli.s couM be
averted, that some legislation is urgently needed, requiring that still-borns,
whose bodies weigh, say, not less than 2 lbs. (the average weight about
tlie sixth and seventh months, and at which age children are viable),
should not be buried without registration and a medical examination.
Although it may not be well to insist upon it by law, it would
also be most beneficial to our treatment of antenatal states if fa?tuses
of less than six months were also submitted to post-mortem investi-
gation liy the medical man in whose practice they occurred.
■•'' THE
CHAPTER XXVII
Hygiene and Therapeutics of Ftetal Life : the Hospitalisation of the Pregnant ;
"Plea for a Pre-Maternity Hospital" ; "Sanatoria de grossesse " ; Hygiene
of Pregnancy; Diet, Occupation, Exercise, Dress, etc. ; ^Irdiialion of the
FiL'tus, in Syphilis, Placental Disease, Nervous JMal^idics, I l;riiiophilia ;
Transmission of Immunity; Genuinal Therapeutics; ( 'innlusidu.
Antenatal Hygiene and Treatment.
Hitherto I have referred simply to the treatment which may he
adopted after or during liirth to correct or ameliorate the morhid
changes which are produced before birth. I have not gone into
details, for the measures I have alluded to are all well known or
can be learned from text - books of Medicine, Surgery, and Mid-
wifery. I have now, however, to describe antenatal hygiene and
treatment in the true and strict sense of the word, 1 mean the
antenatal prevention, cure, or amelioration of morbid states arising
in antenatal life. This is a subject which is not found discussed in
the ordinary text - books. I have already pointed out some of the
erroneous opinions that are held about it, and can therefore proceed
at once to set forth what, to my mind at least, can be securely affirmed
concerning it.
It is possible to bring hygienic and medicinal influences to bear
upon the fcetus while still in utero, but it is absolutely necessary that
these shall act first upon the mother ; antenatal treatment is prim-
arily maternal ; it cannot be otherwise. The foetus is immediately
surrounded by the liquor amnii — its hydrosphere ; around that again
are the maternal tissues and placenta which together constitute the
foetal biosphere. For any infiueuce to act upon the foetus, it must
influence it through its environment, through its hydrosphere and
its biosphere. One can produce an effect upon the unborn infant by
altering the condition of its environment or by transmitting medicinal
suljstances to it throvigh its environment. Of these two methods the
former is probably the more important ; theoretically, it is possible
to separate them, but it is doubtful whether in practice this can be
done. The first step, therefore, in the direction of successful treat-
ment of the unborn infant must be successful treatment of the
pregnant mother. Here, on the very threshold of the subject, we
meet with a check ; for, when we come to consider it, we realise
that about the physiology of pregnancy, and more especially about
its pathology, our knowledge is very imperfect. Further, if we set
about to try to remedy this defect in our knowledge, we discover that
there is no hospital wliere we can study the normal and pathological
3°
466 ANTKNATAl. I' A TllOI-OdV AND I lYdlF.NK
plienomeua of pregnancy as we can those of laliour or of the puer-
periuni or of the non-pregnant state. It was this reason among others
that lead me to puliHsli in tlic L'rilisk ^f(■(li(■al Jmiriud of April G,
1901, a " riea for a rro-Maternity Hospital." As the plea ])uts
forth my views on this matter in a concise fashion, I reproduce it
liere, simply altering the word " pro-maternity " into " pre-materuity,"
as jjeing the more correct form.
A Plea for a Pre-Maternity Hospital or Home.
In youlli or early iiiaiilnxHl oiu' plans enter] irisi'.s and huiiefully endjurks
upon projects which in old age are put aside as visionary or Utopian ; no
one blames Youth for so planning and ijvojecting, not even Age. La
jeunesse vit d'espi'rance, la rieiUesse de souvenir. " Youth lives on hojie, and
old age on remembrance " ; and a reversal of the role>! woidd be unfitting,
grotesque even. So in the infancy of the twentieth century it is per-
missible to suggest schemes which in the old age of the nineteenth might
have been characterised as vain or stigmatised as chimerical. The young
century is full of hope, and is not ashamed ; la jetinegse vif d'espi'rance.
The cure of cancer ; the prevention of the preventible (hut not yet pre- '
vented) diseases ; the laying of the spectre of morbid heredity ; the
" suppression of the weeds to give the flowers a chance " : these are some
of the hopes in the beating heart of the twentieth century, and the faint
echoes of " fantastic," " imaginary," " impossible " from the nineteenth do
not cause it to beat less high. As the years roll on, it may be necessary
to confess to partial failure ; it will assuredly be necessary to revise the
plans of procedure — it will probably be found, for instance, to be better
to try to turn the weeds into flowers rather than to suppress them ; but
who shall dare, in full remembrance of what has been accomplished in the
past century, to set linuts to the progress to be achieved in the present?
In the sphere of medicine, one of the most noteworthy and praiseworthy
advances of the nineteenth century was the birth and coming of age of
scientific gynecology; it is difficult to realise that in 1801 ovariotomy was
unknown, and special hospitals for the treatment of gynecological diseases
xmdreamed of, and yet these are solid facts. The advances in the sister
svdsject of obstetrics were also numerous if not so startling : there were im-
provements in the construction of instruments and in the mode of their use,
there was the discovery of the real nature of puerperal fever and of means
for preventing it, and there was the growth of correct views as to the
management and internal arrangements of the maternity hospital conse-
quent upon the recognition of the value of antisepsis and asejisis. But
there was one department of obstetrics in which the same degree of progress
could hardly be reported, — that, namely, of the pathology of pregnancy.
At the end of the jiast century obstetricians were still in doubt as to the ■
real nature of eclampsia gravidarum, of hyperemesis gravidarum, of the
malignant jaundice of pregnancy, of hydramnios, of hydatid mole, and of
most of the idiopathic diseases of the fcetus and of many of the causes of
foetal death ; at the best, they were but slowly seeking after the truth, being
much hampered by the absence of reliable information concerning the
physiology of pregnancy, and more especially the physiological chemistry
of pregnancy. The condition of the urine of the pregnant woman, its
toxicity, the changes in her blood, the modifications in her nervous system,
the state of her thyroid gland, the cause of the phj'siological vomiting of
U
PRE-MATERNITY HOSPITAL 467
prei^'nancy, tlie origin of the liqtior amiiii, tlie unture of the iilacciital inter-
changes, the physiology of the fcetus, the inter-relation of the life of the
mother and the foetus, — these and many other matters were imperfectly
known or merely guessed at in the nineteenth century. Was it strange or
inexplicable that eclampsia and liyperemesis continued to claim their many
victims— mothers and foetuses — and that most obstetricians were in almost
complete ignorance as to the state of matters in the gravid uterus, and
found it safest to make their diagnosis of the health or disease or deformity
of the uterine contents after their expulsion ? Of course, the foetal heart
was listened to, and a few conclusions drawn therefrom, and there was
a certain degree of accuracy attained in the palpation of foetal parts ;
but antenatal diagnosis was far from exact, and it was, indeed, little
attempted.
The question may now be fairly asked, if we, in the twentieth century,
are going to be contented with the knowledge (or ignorance) of the nine-
teenth in these matters of the physiology and pathology of pregnancy, with
the maintenance of the status quo ante ? I suppose obstetricians everywhere
will agree that no such easy contentment is possible or to be thought of,
with the maternal mortality from eclampsia what it is, and with the
number of abortions and antenatal deaths and malformations what it is.
This being so, the next question is, whether, with the methods and material
at our disposal, we are making all the progress that is possible, and whether
any further means can be suggested for the perfection of antenatal diagnosis
and its certain concomitant, the improvement of antenatal therapeutics 1 I
think it must lie admitted that we are not making all possible haste towards
the solution of the many problems of prenatal diagnosis and treatment, and
I think that there is a means of investigation which has not yet been tried,
at least not yet attempted, on a large scale and in a systematised fashion.
Herein lies the plea for the pre-maternity hospital.
The pre-maternity hospital need not be a separate establishment ; it
may quite well be an annexe of the maternity ; in time it may come to be
of equal size with the maternity, but it must be distinct from the maternity ;
it will be for the reception of women who are pregnant, but who are not
yet in labour. In the first place, doubtless, it will be for the reception of
patients who have in past pregnancies suffered from one or other of the
many complications of gestation, or in whose present condition some
anomaly of the pregnant state has been diagnosed ; but in time it may be
taken advantage of by more or less normal ambulants, working women for
example, who ought to rest during the last weeks of pregnancy, but who
are unable from financial reasons to do so, and by the patients who clamour
for admittance to our maternities, but who are told to come back again when
the " pains have begun." It is worth while for us to realise that practically
no provision is made in existing hospitals for pregnant women. In general
hospitals, cases of morbid pregnancy (for example, hyiieremesis gravidarum)
are sometimes received and treated, but mostly under protest, lest there
occur a birth in the wards. In maternities, pregnant women are not
welcome much before the full term of gestation, for obvious or easily
ascertained reasons. Such patients would be received into the pre-maternity ;
it would be their special ho.spital. When labour pains came on, they would
be transferred to the adjoining maternity, and it would therefore be advis-
able that the two buildings communicated, by a covereil way, for example.
A system of linked hospitals !
The idea of a pre-maternity hospital has been forced into my mind by
several circumstances during the last few years, but more particularly by
468 ANTKN.VIAI. I'Al H()I.()(;V AM) inClKNE
i-oiumunio:iti(ins wliicli I have receiveil fruiii inoiliciil men in various parts
(if this country ami tlie United States. Jn tliese CDmrnuiiicatinns tlie par-
ticulars of cases of antenatal disease and deformity were stated, and an
opinion asked for with regard to possiljle plans of tri^atment. Tn some I
was able to give advice, in others I had to confess that I had little or
nothinf; to propose ; hut in all I could not help wishing that I knew of a
hospital where the ease <'oiild be ]>laced and scientifically investigated. The
iir.st case which powerfully imi>ressed me was one nf recurrent abortion, .so-
called habitual miscarriage, in which there was no evident and sulKcicnt
cause for the tendency which the uterus had, on the slightest provocation,
or on really no provocation at all, to exjiel its contents. Had the patient
been in circumstances that would have iiermitted it, I should have recom-
mended her to go into a nursing home for the dangercms period in preg-
nancy, and not only have treatment with chlorate of iiotash, but have also
her various excretions and functions thoroughly investigated, so as, if
possible, to ascertain the cause of the special " uterine irritability." Another
patient who might have benefited by such a hospital as I imagine the pre-
maternity might be, was the subject of hyperemesis gravidarum, which
terminated fatally after twin foetuses had been expelled from the uterus.
I cannot help thinking that the investigation of such cases in the pre-
maternity might lead to the adoption of a more scientific method of
management than the artificial induction of abortion, wdiich, of course,
entails therapeutic foeticide. In fact, one of the principles of the pre-
maternity would be the conservation of fa?tal life, although, of course, not
at the expense of maternal safety ; the residt aimed at would be the con-
tinuance of the pregnancy with safety to the mother ; that would be the
ideal. Then there have been several cases of albuminiiria in pregnancy, all
of which would, 1 am certain, have been fit and pro]ier jiatients fiir the
pre-materuity ; several of them developed eclampsia, and in one of them
albumin appeared in the urine for the first time the night before the con-
vulsions manifested themselves. In a pre-maternity we might be able to
study, with scientific exactness, not only the pre-eclamptic but also the
pre-albuminuric modifications of the urine, and we might also discover the
relationship which exists between the absence of normal thyroirl hypertrophy
and the presence of albumin in the urine. In one of the cases of eclampsia
that I have met with during the last twelve months, the urine kept for
nine mouths without showing any signs of putrefaction, and without giving
any positive results on the ordinary culture media ; this case would have
been a suitable one for such scientific inve.stigation as could have been given
to it in a pre-maternity.
The cases to which I have referred were instances of the pathology of
pregnancy in w-hich the maternal factor was of primary importance, and in
which the treatment aimed at the safety of the mother ; but there were
others in which it was antenatal therapeutics that came uniler consideration.
There was the case of an alcoholic mother who had given birth to an infant
with congenital heart disease (persistence of the patency of the foramen
ovale), and who was again pregnant; the obvious treatment was tot-al
abstinence from alcohol, a treatment which might have been carried out
with some chance of success in a special hospital. There was the luemo-
philic mother who had given birth to two hemophilic male infants, and had
suffered from dangerous jmsf -pari urn hasmorrhage on each occasion, and who
was given calcium chloride during the last three months of the third ] reg-
nancy, in the hope of preventing the j^sf-parti/m bleeding, and perchan, e of
benefiting the foetus. There was the case of the woman who had p ven
PRE-MATERNITV HOSPITAL 469
birth to a series of very large children, dcail-horii on account of their great
size ; in the pre-maternity the effect of variations in the niatorual diet (as
suggested by Prochownick and others) upon the bulk of the fatus might
be carefully tried. The same remark applies to cases of narrow pelvis, in
which a small infant might pass safely, while a larger one would have to be
sacrificed or be extracted prematurely, or born by the Caesarean section at
term. There was the case of the patient who had in previous pregnancies
given birth to imbecile or mentally defective children, and to whom phos-
[ihorus was given with the apparent result that the next infant was normal
in these respects. Finally, there was the case of the woman, truly a
monstripara, who had brought three monstrous fcetuses into the world, and
had had several abortions ; she was willing to do almost anything that
might be recommended, in the hope of having a more satisfactory reproduct-
ive record ; she would undoubtedly have entered the pre-maternity, even if
but little hope of betterment were held out to her.
The number of cases which might be benefited by the systematic and
scientific investigation of the bodilj' functions in pregnancy, might easily be
increased ; but I have cc.intented myself with a reference to the actual
instances which have been brought under my notice recently. I have em-
phasised the scientific value of such a hospital as the pre-maternity might
be ; but the more distinctly economic aspects are not to be lost sight of,
especially if it be found to be true that working women who are able to rest
for the last month or two of pregnancy give birth to larger and more healthy
infants. I have not gone into the question of the management of this as
yet imaginary hospital, nor into the matter of the medical staff ; but from
the scientific standpoint there would have to be every appliance for the
perfection of antenatal diagnosis (skiagraphy, cephalometry), and one
member of the staff would require to be a skilled physiological chemist.
That there will be difficulties in the way may be expected ; that the idea
will be regarded as visionary or chimerical is certain, and will not sur-
prise me, as it has been only by slow degrees that I have come to regard
it as anything else. In the meantime, this communication may be looked
upon as a " ballon d'essai," the whole matter of the pre-maternity being still
in niibihus.
Since I published the plea for a pre-maternity hospital, I have
become still more impressed with the need there is for the hospital-
isation of the iDregnant woman. The idea of a special hospital
attached to each maternity may be chimerical, but there might at
least be a ward or some beds set apart for the special treatment
of diseases of pregnancy. That this would be beneficial for the
maternity hospital itself, I do not doubt. jMany of the fatal cases
which occur in our maternities at present are due to complications of
pregnancy {e.g., eclampsia, albuminuria) which have arisen before the
admission of the patients. There can be no doubt, further, that a
patient who has passed through a morbid pregnancy will be more
liable to a bad labour than one in whom the changes of the wonderful
gestation period have been accomplished in a physiological fashion.
Even when the pregnancy has been fairly normal, some preparation
for the fast approaching labour and puerperium would not be amiss.
Pregnancy is a great strain upon the resources, anatomical and
pi ysiological, of the body ; and labour is the crowning test of a
woman's strength; yet in too many cases the parturient patient
470 ANll'.NAI'AI. I'ATHOI.OCV AND I l^(;i I'.XK
comes to the liiitli with little or no prei)aiciti<iii at all. A pre-
niateniity hosjiital or a ward in the maternity fur the diseases of
pregnancy would make it possible for a woman who was ill during
gestation to get the Ijest treatment, and so to fall in lahdur under
better conditions than could otherwise have been obtained for her.
More would soon be learned regarding both the pathology and the
physiology of pregnancy ; and u gratifying fall in the mortality lists
of the hospital could scarcely fail to follow. The maternity hospital
might then hope to attain more nearly to its ideal state, that of a
hospital with two patients, mother and infant, to each bed. Sepsis is
admittedly one of the great causes of hospital deaths, and it is clear
that there would be less risk of it if patients were admitted before the
labour was in thi^ second stage, and while, therefore, there was still
the opportunity of thoroughly cleansing the genitals.
Since Novemlier 1, 1901, through the liberality of an anonymous
donor, a bed has been endowed in the Edinburgh lloyal Maternity
and Simpson Memorial Hospital for the study of the diseases of
pregnant women ; there have already (Deceml:>er) been in it (under
the care of I'rofessor A. E. Simpson and myself) several interesting
cases of disease in pregnancy, including one of hydramnios and twins,
another of hyperemesis gravidarum with retrottectiun of the uterus,
and another of peculiar convulsions, regarded as of the nature of petit
mal, with hysteroid sequelte. We have been able to analyse the
urine in these cases accurately, to take sphygmographic tracings, to
count the fcetal heart-beats, to test reflexes, to use the cephalometer,
etc., in a way that was before dilHcult or impossible. I believe the
" Hamilton bed," as it has been called, will very soon practically
demonstrate its value, if it has not already done so.
At the time when 1 was writing my plea fur a pre-niater-
nity hospital,^ other obstetricians were approaching the idea of
the hospitalisation of pregnant women from other standpoints.
I'rofessor J. A. C. Kynoch of Dimdee {Brit. Med. Journ., i. for 1901,
p. 929) has pointed out that homes for the reception of pregnant
women exist in large towns, and it is true that there are such : but
they are often of the nature of reformatories or asylums rather than
of hospitals in which the medical care of the patients is put first.
L. Bouchacourt (/,« Grosscssc ; jvicricidtxirc intra-utrrinc, I'aris, 1901)
has traced the history of the various establishments in France and
Austria for the reception of pregnant women, and has argued
strenuously for the creation of numerous " sanatoriums de grossesse."
The " Secret ^laternity " of Prague seems to have been the first of
these "sanatoriums," for it was founded in 1789, but it was veiy
different from what is understood by the " sanaturium de grossesse"
of the present day. Into it pregnant women were received on the
payment of a fee, and neither their religion nor their social position
nor their nationality were inquired into. In I'aris, also, there were
beds for needy pregnant women in connection with some of the
obstetric clinics ; but they were too often occupied by strong and
' I liad ]iievioii.sly mooted the subject in a tentative fiisliion euilv in 1900 {SaiU.
Med. and Surg. Juani., vi. i76, 1900).
I HYGIENE OF I'lU'.ClNANCY 471
liealth)' young women wlio could render service as cooks and waslier-
wonien. In 1885 the " asile de nuit de la rue Saint-Jac(jues " was
increased by the addition of a ward containing sixteen beds for
pregnant women, and similar institutions are to be found both in
I'aris and in other large towns ; but they are often of the nature of
reformatories or " maisons de correction," and their sanitary condition
lius seldom given satisfaction. In Paris the first " sanatorium de
grossesse," in the proper sense of the word, was not founded till
1892; it was called the "Eefuge de I'avenue du Maine," and it
received thirty-six pregnant women who required to rest. Since
then several other sanatoriunis of the same kind have beeii estab-
lished (" asile public pour femmes enceintes," " asile maternel," " asile
.Sainte-Madeleine," etc.). These institutions have done good service,
especially in the case of working women, who were thus enabled to
rest during the last month of pregnancy; and Pinard {Ann. dc gynt'c,
1. 81, 1898) has shown that the infants of these patients weighed
more than those of pregnant women who had to work for their living
up to the onset of labour pains. All these facts are very interesting,
but in the idea of the pre-maternity hospital I aim at something more
than is accomplished by any of these existing institutions. I look
forward to a specially set apart hospital for the treatment of diseases
of pregnancy, with a medical stafl' capable of carrying on all kinds of
research, and with all the known means of diagnosing and treating
both the pregnant woman and her unborn child. I am fully con-
vinced that the only way to establish, on a sure foundation, the pre-
ventive treatment of the diseases of pregnancy and of the unborn
infant, is by the institution of pre-maternity hospitals or pre-
maternity wards in maternity hospitals. Under the title " la defense
do I'cnfant" Ollive and Schmitt {Gaz. hehd. d. sc. med., xxii. 478, 1901)
enumerate many ways in which the health of the new-born is to be
preserved ; among these the pre-maternity hospital must surely find
a place. " La defense de I'enfant est a I'ordre du jour," writes
]\Iaygrier {L'Ohstcii-iqiie, yi. 481, 1901); but it is necessary to begin
with " la defense du fcetus."
Hygiene of Pregnancy.
As has already been pointed out, treatment of the fa?tus must
be primarily maternal ; so, to maintain the hygiene of antenatal life
one must maintain the hygiene of pregnancy. This is the true
environmental treatment of the unborn infant ; this is one aspect of
puericulture. Most of the text-books of Obstetrics give a chapter or
part of a chapter to the management of pregnancy ; but in many of
them the advice consists laigely in the recommendation that all the
laws of health which applj^ to the non-pregnant condition should be
specially enforced in the pregnant state. This is, of course, quite
true ; but it is too often interpreted by the profession and the public
as permission to the pregnant woman to continue disregarding many
of the laws of health just as she did when non-pregnant. As I have
said already, pregnancy is a severe strain upon the whole system.
472 ANTKXAT.M. I'AIIIOI.OdV AND I I^C.IKNK
and weaknesses wliich were unrevealed nr unnoliceil, as a result <>(
hygienic errors jnior Ui gestation, may give rise to gia\e dangers in
pregnancy. For instance, the kidneys may he somewhat: (hseased,
and yet cause the woman no inconvenience ; hut under the strain of
their increased activity in pregnancy, with perliaps the special tax of
a full meal of proteids, they may fail, and eclampsia l>e induced.
Constipation, which may apparently cause no ill effects in the non-
pregnant state, may set uj) a toxaemia in pregnancy. The result of
all this is that, while we occasionally meet with a normal jiregnancy,
we too often have sadly to admit that pregnancy frequently is not
strictly physiological. It ought to he so, hut it is not. Tliat the
fo'tus suffers no more than it does, is probably due to the wonderful
regulating mechanism which tends to counteract errors and to
prevent ill etlects.
As a matter of fact, the profession does not understand the
physiological changes of pregnancy, possibly does not believe in their
existence or in their inip(jrtance. There are, however, popular
notions on the subject, and these overshadow the scientific ideas and
cover them as with a mantle of fog, through which some few well-
ascertained facts loom forth dimly to be discerned. Thus, the
popular mind has opinions on diet in pregnancy, on the power of
maternal impressions, on exercise, on sea-bathing, etc., and these are
often far from correct, but pass as truth because the profession does
not very actively contradict them or replace them. Of late, however,
there have been some signs of lifting of the fog curtain, and here and
there some things are coming into sight, and others are losing tliat
unnatural magnitude which fog-shrouded objects often show. There
is a freshening breeze of scientific investigation, and the mists are
rolling slowly away. The light that may come from the pre-
maternities of the future may wonderfully dissipate these fogs.
Diet in Pregnancy.
,^ Let us take a few examples of these popular beliefs. Tiicre is,
nBinstance, the question of diet in pregnancy. The popular advice
to the pregnant woman is to eat " enough for two," and, as generally
and confidently interpreted, this means to eat double the usual
amount ; and it may be safely said that, if this injunction be carried
out, too much is eaten. Even supposing for a moment that the
dietetic dilliculties of pregnancy could thus he got over in this
arithmetical fashion, to be logical, the jiopular advice ought to be to
eat enough for one and a varying fraction of one, namely, at the mid-
term of pregnancy, enough for one and one-hundred-and-twelfth of one.
Since, however, most healthy persons habitually eat more than enough
for one, it may reasonably be concluded that the pregnant woman
who eats heartily consumes quite sufficient food to supply tlie wants
of herself and her fraction. That there is a real and not a visionary
danger in the application of such popular advice, is borne out by
cases like that reported by liarton Cooke Hirst ( Tiji-Boolc of OhftMrics,
p. 189, 1900), in whicli a woman took two quarts of nnlk a day between
DIET IN PREGNANCY 473
meals, ami was confined (with difficulty) of a child weighing 11 i| lbs. ;
and by the results of experiments u])on the lower animals. D. Noel
I'aton has found that, in the case of well-fed pregnant guinea-pigs,
each gnu. of mother's weight produced from O'-l to 0o5 grm. of
young, while in the case of an under-fed animal, each grm. of the
mother only produced 0-22 grm. of young.
With regard to the quality of her food, the popular belief as to the
pregnant woman is that she must get what she " longs for," otherwise
her unborn infant will suffer. Now, it is quite possible that under-
lying the " longings " of pregnant women for certain articles of food
(sometimes neither nutritious nor nice), there is a true physiological
need which thus finds expression (a sort of inarticulate crying out of
the tissue for acids or alkalies), yet in the great majority of cases no
such dietetic necessity lies patent or latent. Further, there is no
valid scientific evidence that the refusal of " longed-for " snacks, con-
sisting of peppercorns and raw oatmeal, or other dietetic eccentricities,
will result disastrouslv to the unborn infant (A. (liles, Trans. Obst.
Soc. Loiul, XXXV. 242, 1893).
Within recent years, signs have not been wanting that popular
beliefs as to the cj^uautity and quality of the food of the pregnant
woman were to be soon replaced by scientific views. Apparently,
many obstetricians are afraid of giving an opinion on such matters ;
but L. I'rochownick of Hamburg (Ccntrlhl.f. Gynilh., xiii. 577, 1889 ;
Thcraj}. MonafsL, xv., Hft. 8, 9, 1901) and others (H. Florschiitz,
A. Hoflraann, J. Eeijenga, J. Haspels, v. Swiecicki, Josephson,
J. F. W. Donath, Hegele, Leusser, G. Beck, F. Horn, E. Fraeukel,
E. Preiss, and Meurer) have gone much further, and have modified
the diet of pregnant women in such a way as to produce definite
effects both upon the mother and the fcetus. Prochownick and his
followers believe that by altering the diet in pregnancy it is possible
to infiuence the character of the confinement, of the puerperium, and
of lactation, as well as the state of development of the foetus. Thus,
by dieting aniemic, chlorotic, or fat and weak women, it has been
found possible to give them more normal obstetric experiences, and
to give them back the power (which they had lost) of nursing their
infants. But it is specially with the effect of diet upon the foetus
that we are here concerned. In cases of pelvic contraction between
3] and 4 inches, Prochownick shows, by a series of forty-eight cases
representing sixty-two confinements, that maternal diet can so
influence the size, weight, and osseous development of the foetus, as
to make it possible for it to be born normally at the full term,
whereas, in previous pregnancies, instrumental means or the induction
of premature labour were necessary. The cases included seventeen
of Prochowuick's own, and thirty-one under the care of Haspels,
v. Swiecicki, Eeijenga, and the others mentioned above. The recom-
mendation was that the mother take during the last two or three
months of her pregnancy the following diet : — For breakfast, a small
cup of coftee (100 c.c), about 25 grms. of biscuit or bread with some
butter. For dinner, any kind of meat, an egg, fish with a little
sauce, green vegetables prepared in fat, salad, cheese. Supper, the
II
474 AN ri'.N.Vr.M. I'MIIOLOCII- AM) Il^dll'.NF.
same as for dinner, with 40 to 50 i,'rnis. of liread and butler at
pleasure. Water, soups, potatoes, puddings, suj,'ar, and beer are quite
forbidden; from .'iOO to 400 c.c. of red wine or moselle is to be drunk.
Slight alterations were permitted to suit individual tastes, such as
the sulistitution of small quantities of milk and water for the alcohol,
along with fresh fruit. Further, a small cujj of tea or cottee may be
taken in the afternoon, with 15 to 20 grms. of bread or one egg.
The total daily quantity of iluid was not to exceed 500 c.c.
So far this dietetic treatment has been used for the definite pur-
pose of diminishing the bulk of tlie foetus and delaying the ossifica-
tion of the cranial bones, so as to allow its passage through a narrow
pelvis ; but its range of applicability is not limited to these cases.
It might conceivably be useful in women who, with normal pelves,
had gi\-en birth repeatedly to infants so large and well developed as
to die in birth simply on account of tlieir bulk and advanced ossifica-
tion. It might also be valualile in instances of prolonged pregnancies
with post-mature fuetuses, as well as in cases of fcetal disease and
congenital debility.
Having enumerated these po.ssible therapeutic extensions of the
dietetic treatment, I must, however, point out certain difiiculties
which lie in the way. There is, first of all, the question whether it
is possible to slacken nutrition in the ftttus without delaying develop-
ment. In other words, are the infants born at the full term mature
in every respect save size and weight, or do their internal organs, etc.,
show the characters of the sixth or seventh month of antenatal life ?
Are they full time babies save in size, or premature infants except in
age ? Then there is, second, the difficult problem of ftetal nutrition
upon which I have already written at some length (ride pp. 152-159).
There is evidence to show that in the later months of pregnancy,
at any rate, the fa>to-maternal metabolism is of a most intricate kind,
and that the placenta is far from being the simple transmitter of
pai'ticles (nutritious or excrementitious) as has in the past been
believed. There is sufficient proof forthcoming of the selective
powers of the placental epithelium to enable us to state that the
transplacental interchanges are not governed solely l)y the laws of
osmosis as they are understood by the jihysicist. The fietus, also, has
a metabolism which is, to some extent, independent of that of the
mother : its tissues are assimilating and functioning at a different
rate, and perhaps even in different ways, from the homologous tissues
in the mother. To put it in somewhat more popular language, the
imborn infant may have a better or a worse digestion than his mother.
Taking all tliese matters into account, as well as others to which
reference has been already made [ride pp. 152-159), the question of
f(etal nutrition becomes very obscure, and its relation to the diet of
the pregnant woman cannot be simple. We cannot by overfeeding a
woman make sure that she will give birth to a large, fat child ; at
the same time, there must be a relation between fcetal and maternal
nutrition, and the state of the maternal health must have an influence,
determined by laws, albeit undiscovered laws, upon the size and
development of tlie fatus. In the meantime, there is no need to
OCCUPATION IX I'REONANCY 475
suspend all attempts to influence the development of the unborn
infant by modifying the maternal diet; rrochownick's treatment
must lie tried and its results tested ; we cannot afford to wait
till we understand all the details of the action of renredies or other
therapeutic measures; if they give good results, we use them empiric-
ally, hoping later to clear up, in a scientific way, the rationale of
their employment. Further, we must surely rejoice that there is
some slight but perceptible lifting of the fog curtain hanging over the
subject of diet in pregnancy ; nevertheless, we must hasten slowly,
for with such a fog and that continual lee-shore of the unknown
physiological reaction of the foetus so close at hand, it will be well if
our theories carry very little sail.
Occupation, Exercise, etc., in Pregnancy.
Another means of maintaining the mother's health in pregnancy,
and so of mauitaining also the foetal well-being, is to regulate the
occupations in which the pregnant woman may engage. This matter
has been already referred to in Chapter XV. in connection with foetal
poisoning with lead, mercury, phosphorus, etc., and it is now fairly
well recognised that there are trades which are so dangerous that
expecting mothers ought not to be allowed to engage in them
(Brit. Med. Journ., i. for 1900, p. 718). Further, it is doubtful
whether women who are within a month of their confinement should
be allowed to do hai'd manual laliour of any kind ; it ought to be
obligatory upon them to rest in the last four weeks of gestation (in
Switzerland this is insisted on by law), and there should be provision
made for them (" uue indemnito' de grossesse "). A pregnant woman
ought to take sufficient exercise to keep her body in health ; but
excessive exertion, whether in the form of bicycling (24), or of walk-
ing, or of golfing, or of dancing, or of household work, should be
forbidden. The clothing should be hygienic, and abdominal com-
pression should be prevented ; for there is some evidence, although it
is not very strong, that coi'set-pressure may act injuriously upon the
foBtus in utero. The pregnant woman ought to be encouraged to
think lightly of the possil)le effects of so-called " maternal impres-
sions," and to be strengthened by the assurance that there is no real
scientific evidence of their potency to deform her infant. This sub-
ject, however, wiU be dealt with in detail when I come to describe
malformations and monstrosities (Pathology of the Embryo). The
question of permitting tooth-extraction, long railway journeys, small
surgical operations, and sexual connection during pregnancy, usually
arises in relation to the production of abortion or premature labour.
In attempting to give an answer, each case must largely be decided
on its own merits ; for, as I have already shown, some women will
abort on the slightest possible provocation, having a high degree of
" uterine irritability " ; others may be subjected to severe accidents
without the interruption of pregnancy. But, apart from the produc-
tion of abortion or premature labour, it is sometimes a.sked whether
much travelling or regular sexual intercourse during pregnancy will
476 AXTKXATAI. I'ATHOI.OdV AND inCll'.NK
have any iiijuridus ellbcls upon tlie fd'tus. Tt is difHcult to give
answer to this; and in the present state of our knowledge it is safest
to confess our ignorance, and to take precautions erring on the side
of safety.
The use of certain medicines is to be prohibited to pregnant
women ; among these are ergot, quinine, and all the direct aborti-
facients, as well as powerful purgatives, especially of the saline kind.
Further, alcohol in excess must be forbidden, and all habits, such as
the craving for morphia or cocain, sternly coml)ated. Finally, all
pathological states of the mother arising during pregnancy should be
treated in accordance with the Ijest i)rinciples of therapeutics ; in
order that this may be done, they must first, of course, be recognised,
and for this purpose the regular testing of the urine for albumin is
one very necessary precaution. The more smoothly and normally
tlie pregnancy runs its course, the more chance tiie foetus will have
of coming into the world healthy and well nourished, always suppos-
ing, of course, that it came into tlie fujtal period of antenatal life out
of a normal embryonic and germinal existence. Unfortunately, that
cannot always be assured.
Enough, howevei', has been said of the value of caring for the
foetus by caring for the mother. I must now pass from the environ-
mental treatment of the f(Ptus to the direct and immediate.
Medication of the Foetus.
Many misconceptions have gathered round the subject of the
medicinal ti'eatment of the infant still in utero ; and while some have
greatly exaggerated the possibilities, others have greatly minimised
them. From some of the statements that have been made by
enthusiastic antenatal therapeutists, it might be imagined that drugs
could be passed directly into the unborn infant as one pours a liquid
from one bottle into another. On the other hand, it would seem as
if those who are sceptical regarding antenatal treatment had come to
believe that the foetal economy was absolutely separate from and
independent of the maternal. Now, as is so often the case, the truth
lies somewhere between these two extremes.
Just as some diseases can be transmitted through the mother to
the fcetus, so some drugs can be admmistered to the fcetus by admin-
istering them to the mother. Just as some diseases sometimes fail to
affect the fcetus although they aifect the mother, so some drugs some-
times fail to reach the ftetus although they circulate freely in the
mother. Into both subjects the placental factor (ride p. 179) enters
with most perplexing results. All tliis, and much more, the reader lias
doubtless already gathered from the perusal of Chapters X. and X^^ ;
but I may here summarise our knowledge of the passage of medicines
from mother to ftetus in tiie following few words : — There is evidence
(clinical and experimental) that not only do the chemical substances
which make up the fo'tal body pass from the woman to her unborn
infant, but that also certain substances, foreign to the constitution of
the fretus, sometimes, and under certain circumstances, pass through
TREATMENT OK Fd'/IAL SYPHILIS 477
tlie placental barriers. Among these last may lie mentioned arsenic,
lithium, mercury, alcohol, chloroform, ether, morphin, autipyriu,
carbolic acid, quinine, and the salicylates. We do not know in what
form and in what special combination any of these substances
(whether those, such as phosphorus, calcium, soda, or potash, which
exist normally in the foetus, or those such as mercury and morphin,
which are foreign to it) pass through the placenta, for the chemistry
of the freto-maternal interchanges is an unworked (almost unwork-
able) field of research. Of fatal pharmacodynamics, or the jihysio-
logical action of drugs on the healthy foetus, we also know exceed-
ingly little. We must be content in the meantime with the know-
ledge that some medicines pass to the fo'tus.
At this point it may be well to emphasise the fact that it is not
necessaiy for the drug to reach the intracorporeal tissues of the
foetus in order to influence it. It may, by improving the mother's
health, beneficially affect the fa3tus. That, of course, is quite clear.
But, further, if it reach tlie placenta, it is already in touch with the
foetus, it is indeed in one of the foetal organs ; for the placenta is
part foetal as well as part maternal. Possibly it is in this manner
that mercury and chlorate of potash act upon foetal disease. The
presence of the drug in the placenta may produce its beneficial effect
simply by prolonging pregnancy to its natural term ; the placental
integrity is maintained, and abortion or premature labour avoided.
Or it may increase the bactericidal or resisting or selective powers
of the placental tissues, and so influence for good the foetus which is
so dependent upon the placenta for life and health. At any rate, it
is very necessary to keep this fact in mind in judging of clinical
evidence or experimental results.
It may be well now to consider some specific cases of foetal
therapeutics by medicinal substances. The treatment of foetal
variola, malaria, general dropsy, and one or two other morbid states,
has been referred to already, and will not be given here.
Treatment of Foetal Syphilis.
The treatment of the foetus for syphilis may be necessary in
several possible circumstances. In the first place, the pregnant
woman may herself show evident signs of syphilis ; in the second
place, the father of her foetus may be syphilitic, but she herself may
show no sign of it ; and, in the third place, the condition of the
father may be doubtful or unknown, and the only signs of syphilis in
the mother may have been tlie previous occurrence of a series of
abortions, or premature labours, or dead-births. In all these cases
the rule is to treat the foetus through the mother with antisyphilitic
medicines, for in all of them the foetus or the placenta, or both the
foetus and the placenta, are very probably syphilitic. The earlier in
pregnancy the ti'eatment is begun the better, and it ought to be
continued to the end, and then its place taken by direct treatment of
the new-born infant. All writers are not agreed upon tlie second
and third indications for antisyphilitic treatment referred to above,
478 ANTKXATAI, I'A Tl lOI.OC'i' AM) IIVCII-.NK
and the risks of adininisteriug much mercury to a healthy mother
and fa-tus liave been brought forward ; but, according to A. Fournier
{L'HMdiW SfipMlitiquc , p. 368, 1891), these are not great. The
results to be expected are the prevention of abortion and premature
labour, of dead-birtii, of placental disease and hydramnios, of syphilis
in the infant at birth or soon thereafter, and of congenital debility.
E. Fournier (Sfif/mafrti iJi/sh-o/i/iiqucs di- l'IT('ir)lo-Si//i/iilis, p. 365,
1898) claims also that a possible result may be the prevention of the
dysti'ophies as well as of the other manifestations of antenatal
syphilis ; but this, altiiough quite possilde, almost implies the com-
mencement of treatment at the very beginning of tlie fietal period
(second month of intrauterine life).
The medicine to lie used is, of course, mercury, either alone or
in combination witli iodide of potassium, but ])referably alone so
far as its effect on the fa'tus is concerned. Tlie preparation may
be that of hydrargyrum cum creta in one-grain doses; and one
of these powders may be given twice or thrice daily. Tlie mer-
cury may also l)e administered as the iodide, and combined with
iodide of potassium ; but the advantages of the iodides are somewhat
problematical. We cannot tell what proportion of the dose given
reaches the placenta and the fa-tus, but it is generally believed that
only small quantities are necessary for the fietus. As, however,
mercury is proverbially well borne by the infant, no great anxiety
need be felt regardmg the exact amount to be transmitted to the
placenta. Eecently, the local treatment of fietal syphilis with mer-
cury has been tested by Riehl (JVicm. klin. Wchnsrhr., xiv. 627,
1901), and with apparently good results. Thirty-three cases of
pregnancy in women with recently acquired s}-philis were treated
with vaginal pessaries containing 1 grm. of the German unguentum
cinereum with 1 or 2 grms. of oleum theobromatis. The pessaries
were introduced as far as the vaginal roof, and kept in position with
a tampon soaked in glycerine of tannin. It should be remarked that
mercury was also given by inunctions or injections. In the tliirty-
tiiree cases there were only one abortion (3 per cent.) and three
premature labours (9 per cent.) in the eighth and ninth month, wliile
aboi'tions occurred in 22 per cent, of the cases treated in the ordinary
way given in Fournier's statistics. The number uf still-liirths was
two, or only 6 per cent., and the total number of children (alive
or dead) who showed signs of syphilis was seven, or 21 per cent.
It will be interesting to learn if Iliehl's local treatment prove
equally effective where the ftutal syphiUs is apparently due to the
father alone.
It need hardly be added that the mercurial treatment of tlie
infant after birth is absolutely necessary, and thai the treatment of
the mother should be continued in view of the occurrence of another
pregnancy, and in order that mercury may reach the child also
tlirougli the milk. These measures, however, do not fall under the
heading of fa>tal therapeutics strictly so called.
TREATMENT OE I'LACENTAL DISl'.ASE 470
Treatment of .Recurrent Placental Disease.
The treatment of recurrent placental disease, with its frequent
concomitants, premature labour, still-birth, or dead-birth, is not so
well established as is that of fu?tal syphilis. Of course, I refer here to
the cases of placental disease in which syphilis can be excluded.
As Prof. A. R. Simpson has pointed out {Trans. Amcr. Gyncc. Soc,
xiii. 413, 1888), Sir James Y. Simpson, in a clinical lecture published
in 1845 {Lond. and Edin. Month. Journ. Med. Sc, v. 119), stated that
he had kept patients constantly on small doses of alkaline salts, such
as chloiate of potassa, in cases where they had lost the children of
previous pregnancies from disease of the placenta, and " apparently
with perfect success." His explanation was that the salt rendered the
blood more arterial and facilitated the interchange of gases in the
feeble placenta. Sir James Simpson states that he treated in this
way " a great nmnber of cases," but towards the end of his life he
admitted that the drug sometimes failed. T. F. Grimsdale (Lirerjiool
Mcd.-Chir. Journ., i. 248, 1857) also obtained good results, as did
Bruce {Edinh. Med. Journ., xi. 669, 1865-6), A. IngUs, Cairns, J.
Moir, and Keillor {ibid., p. 671), Cuthbert {ibid., xv. 85, 1870), J.
Thorburn {Liverpool and, Manchester Med. and Surg. Ecp., iii. 1, 1875),
and A. E. Simpson {loc. cit.). I have used it in several cases ; in one
the success (as .judged by the post lioc argument) was complete, a
living healthy child being born not only not prematurely, but a
month beyond the full term ; in another (a case of recurrent fa^tal
dropsy) the pregnancy lasted longer, but the infant was still drop-
sical ; and in two others (recurrent fa;tal death), the effect seemed
to be nil. I have given it both alone and combined with iron. The
dose is twenty grains thrice daily. It would appear to be specially
valuable in the cases in which there are traces of placental hasnior-
rhages. The results to be expected are continuation of the pregnancy
to the full term, and the birth of a living infant ; and the drug may
perhaps be described as a placental tonic. E. Lomer {Ztsclir. f.
Gcbiirtsh. n. Gyndh:, xlvi., 306, 1901) gives iodide of potassium and
iron for the same purpose.
Treatment of Foetal Nervous Maladies,
There is some small amount of evidence to show that phosphorus
given to the mother in pregnancy may have a beneficial effect upon
the fui'tus. Nourse and W. Fleming Phillips {Brit. Med. Journ., i. for
1899, p. 1062) have written on this subject. The latter records the
case of Mrs. L., who had had six children, one of whom was idiotic,
three were rickety, and the youngest died of hydrocephalus within
a year of birth. In the next pregnancy, Phillips gave a mixture
containing 2 grs. of calcium hypophosphite and 4 grs. of sodium
hypophosphite for a dose during six months ; the child was healthy.
Two years later the same treatment was followed in another gestation,
and again the infant was healthy. The general hygiene of preg-
nancy was also attended to ; but Phillips gives most of the credit
480 ANI'I'.NA'I'AI. I'AIIIOI.OCY AM) I I'l ( 11 1'.XI'.
to the medicine. Of course, in this as in all antenatal treatment,
one is conijielled til judjie hy consequences, or rather hy ]ihenomena
wliich may or may not be consequences. This, however, is a limita-
tion inseparalile from tlie siiliject : it a]>]ilies niarkeilly to the treat-
ment of ha'nio]ihilia, of wiiich I must now sjieak.
Antenatal Treatment of Haemophilia.
As has been said, it is tlitlieult to judge of tlie effects of antenatal
treatment because of the absence of means of accurate antenatal
diagnosis. The cases in wliich, therefore, such treatment can be
tested are few and far between. The well-known tendency of
morbid fcetal states to repeat tliemselves more than once in the
reproductive history of the same mother, gives, however, a possible
opi)ortunity of trying to influence beneficially the healtli of the
unborn infant : further, the hereditary character of some of the
maladies wliich thus tend to repeat themselves, increases the ])ro-
bability of the antenatal diagnosis, although it must be confessed
that it diminishes, or appears to diminish, tlie cliances of successful
therapeutics. Hiemophilia is a malady which fulfils the conditions
which have been stated above : it is very clearly and persistently
hereditary, and it also shows family prevalence. As a test case, then,
it has advantages : given a woman who comes of a ha?mophilic stock,
who has a hemophilic father or ha?mophilic brothers, there is a pro-
bability that her male offspring will be h;emophilic ; and the pro-
bability is greatly increased if she have already given birth to one or
more hemophilic male children. There is a presumptive diagnosis,
then, of antenatal htemophilia when such a woman is pregnant of
a male infant. But as a test case it has also disadvantages ; hemo-
philia is a very intractable disease, and it may be urged that, if it
cannot be cured after birth, there can be little hope of curing it
before birth. The latter statement, however, is merely an opinion ;
it may also be urged that it may be easier to affect beneficially a
morbid state before birth, i.e., in the foetus, than after birth ; but of
this more anon. Let me now narrate the history of the following
case, which was published by W. X. B. Brook (Lincoln) in the Uritish
Medical Journal (i. for 1901, p. 957), and by myself (126«). On
June 25, 1900, I received from Dr. Brook a letter in which he stated
the facts of a case of hemophilia complicating pregnancy and
laliour which he had in his practice ; and he closed his letter with
the iiK^uiry, whether in my opinion the administration of chloride of
calcium to the mother in pregnancy would prevent the child from
being the suliject of hemophilia. The case was as follows : —
Mrs. C, o4 years of age, pregnant for the third time, is a tall,
well-built woman, ratlier spare, with black hair and a sallow com-
plexion ; she has always lost much blood at her menstrual periods,
and had post-partum hemorrhage after both confinements. She
last menstruated on December 25, 1899, and expected her confine-
ment in October 1900. Her family history was interesting : her
mother w'as healthy, but her uncle (mother's brother) died at the age
TREATMENT OF HAEMOPHILIA 481
of eleven from bleeding ; she herself has had four brothers and four
sisters, and one of the brothers died at the age of twelve from
bleeding ; the other brothers are alive and healthy ; the four sisters are
healthy, and their male children are also healthy. Her first preg-
nancy ended in 1891 in the birth of a male child; there was a con-
siderable amount of hiemorrhage, which left the mother weak ; tlie
child at birth was white and ana-mic ; the infant survived birth, and
is still alive, but is a marked " bleeder," and bruises easily, and has
suffered from haemorrhages into the joints and from the gums during
the shedding of the first teeth. In fact, he nearly succumbed several
times from great bleeding during the casting of the milk teeth. The
second pregnancy like^vise ended in the birth of a male infant (in
1894) : there was again j^ost-partum haemorrhage : the infant showed
haemorrhage from the umbilical cord at birth, bruised easily, and
died at the age of twelve months during dentition, the cause of death
being returned as cerebral haemorrhage. The mother is now pregnant
for the third time, and has reached the sixth month.
Such were the facts upon which I was asked to form an opinion as
to the prospects of successful antenatal treatment. I replied to Dr.
Brook without much enthusiasm, pointing out the difficulty of being
sure that the fcetus in utero was hemophilic, the uncertainty of the
sex of that infant even, and the hereditary nature of haemophilia.
Hsemophilia, I remarked, was not in the same category as the diseases
such as syphilis and smallpox and typhoid fever, which the mother
transmits to her tVetus in utero ; being so distinctly and persistently
hereditary, it was hardly to be expected that antenatal medication,
begun at the sixth month of pregnancy, would greatly aff'ect it. At
the same time, I gave it as my opinion that chloride of calcimn might
safely be given to the mother, and that it would pass through the
placenta and reach the foetal tissues. I advised that the treatment with
the chloride be commenced, although theoretically the hopes of success
were small; and I also suggested that iron, arsenic, and strychnin be
also administered in order to improve the general health, and jaos-
sibly to increase the tone of the uterine musculature, and so lessen
the risk of post-partum hfemoi-rhage.
Dr. Brook immediately accepted my suggestions, and put the
patient upon a mixture containing 10 grs. of chloride of calcium
thrice daily; this was continued till her confinement on October 3,
1900. He also gave her a pill of arseniate of iron with strychnin
thrice daily till September 17, when it was replaced by the syrup of
the phosphate of iron. I had also referred to the possible benefit
that might follow the administration of thyroid extract, especially
if the mother did not show the normal thyroid hypertrophy of
pregnancy ; but, as a matter of fact, thyroid extract was not given, as it
was difficult to say whether the thyroid gland was normal in size or not,
and it was thought best not to complicate the treatment. During three
months, therefore, this woman received the above-mentioned drugs.
On October 3, 1900, the confinement took place, and again the
child was a male. On this occasion, however, the infant, instead of
being white and anremic in appearance, was red and mottled, and was,
482 ANTKNATAI. I'ATHOLOGY AND HYCilENE
indeed, in all respects a normal cliild. There was no hremorrliage
from the umbilical cord as there had Ijcen in the previous case.
Further, for the first time in the mother's obstetric liistory, there was
no post-partum hiumorrhage. The patient was able to nurse lier
infant, but Dr. Brook advised that this sliould not be attempted. The
labour was easy, the vertex presented, and the whole process did not
occupy more than six hours. It should lie added that the cord was
not tied for five minutes after the infant was Ijorn. Since October,
Dr. Brook has kept me acquainted with the progress of the case,
which has been quite satisfactory all the time. The infant never had
any bleeding, and did not bruise like his brothers ; during dentition
there was no luemorrhage. It may be noted as of some interest that
his eldest brother still shows the bleeding tendency very markedly ;
during February he had severe haanaturia, which was uninfluenced
by turpentine, but rapidly stopped under chloride of calcium and
thyroid e.xtract.
What are we to say about this case ? Here is a woman with a
distinct hereditary history of htemophilia, handed down to her
apparently through her mother, and showing itself in the form of
post-partum hemorrhage and profuse menstruation, and in the pro-
creation of hiemophilic male infants ; under chloride of calcium, and
iron, arsenic, and strychnin, she passes through her third pregnancy,
is confined without ])0st-partum htemorrhage of a male infant without
hfemophilia ! The treatment, let it be noted, is only begun at the
sixth month of pregnancy. Is it nothing more than a coincidence,
a remarkable one, no doubt, but still a coincidence, and nothing more ?
At first thought we are inclined, knowing what we know and have
been taught to believe regarding the intractable nature of hereditary
maladies, to accept the conclusion that it was a coincidence. If we
accept the other view, that the healthy, non-h;emoiihilic state of this
woman's third son was due to chloride of calcium administered during
the third trimester of pregnancy, we are face to face with the con-
elusion that it is possible, by medicinal substances given to the
mother in the last three months of gestation, to cure the unborn
infant of a malady which no medicines in after life are capable of
curing. Here I am tempted to leave the question. Certainly it is
far easier to take it that, just as this woman had four brothers only
one of whom was a bleeder, so of her three sons two were bleeders
and the third was not a bleeder ; even with the most hereditary com-
plaints some members of a family escape. It was merely a coincidence
that antenatal treatment was instituted in the case in which the heredi-
tary influence was going to fail. But there are some circumstances
which encourage me to express the opinion that, after all, there is a
chance that the treatment in this case may have something more than
a coincidental relation to the healthy state of the third infant.
In the first place, it may be taken from what is known of the
physiology of the fcetus, and more particularly of jilacental trans-
mission, that the chloride of calcium given to the mother reached
the fu'tal tissues : there is no reason to doubt that the iron, arsenic,
and strychnin did so also. In the second place, there is evidence that
TRANSMISSION OF IMMUNITY 483
chloride of calcium is beneficial in luumophilia after Ijirth, and there
is also evidence that haemophilia if jjersistently treated in postnatal
life shows a certain amelioration. In tlie third place, there is in the
extraordinary power of recovery possessed by the fcetus, a factor which
nnist not be left out of account in dealing with all questions of ante-
natal treatment. When we remember the marvellous power of
growth and tissue-building which the fcetus displays, a power so
great that in one niontli of intrauterine life the body-weight is
quadrupled, we are led to ask ourselves whether this wonder of con-
struction may not be accompanied by an equally great wonder of
reparative energy ? If there be a greatly exaggerated %ns medicatrix
naturcc in the fwtus, is it not possible that even the hereditary
maladies may, if properly influenced, show a tendency to cure during
antenatal life ? May it not be that medicines acting upon the organs
and tissues while these are still in the stage of construction, may be
more efficacious than when they act upon structures which are, as it
were, sc( either for health or disease ?
This prolilem, like many others in antenatal pathology and
hygiene, must be left unsolved ; wo?i liquef must again be the verdict.
Of course, we cannot be too careful about post hoc arguments ; but
unfortunately they are all that we have to trust to in antenatal
therapeutics, and that they are untrustworthy is only too evident. In
this connection I may refer to the carbonic acid bath treatment for
the prevention of monstrosities. The foreign correspondent of the
Medical Times and Gazette (vol. i. for 1861, p. 209), writing from
Driburg, states that tlie carbonic acid Ijaths of that place produced a
marvellous ettect upon females disposed to give Ijirth to monsters.
Dr. Briick had under his care a lady whose general health was ex-
cellent, but whose first pregnancy had ended in the birth of a micro-
cephalus ; she took the baths in her second pregnancy, and had a
normal infant: in her third, she neglected them and had again a
microcephalus ; in her fourth pregnancy tlie baths were resumed, and
another normal infant was laorn ; in her fifth pregnancy, it is said that,
" incredible though it may seem," she again neglected the baths and
had another microcephalus ; but, finally, in her sixth gestation she
returned to Driburg and had another normal child. Here we have
the post hoc argument in its most specious and convincing form, and
yet, I fancy, few of my readers will feel convinced.
Transmission of Immunity to the Foetus.
Just as diseases and drugs may be transmitted to the fcetus in
utero, so, it may be concluded, may innnuuities. At any rate, some
evidence of this passage of immunising materials has been found in
the vaccination of pregnant women {ciilc p. 194). The subject need
not be returned to here. It is a most complicated one, but it is a
matter in which progress of a real kind may yet be reported. It is
conceivable that either there may be a transmission to the foetus of
the antitoxin prepared in the mother's body, or that there may be a
transmission to the fcetal tissues of the property of manufacturing
484 ANTKNA'l'AI. I'ATIIOLOGY AND IIYGIEN'E
the antitoxin. 0]\ tliis and allied questions, the works of Ehrlicli
{Ztsrhr. f. llijij. u. Jiifaiionti-Kranlcli., xii. 183, 1892), of Charrin and
Gley {Arch, cle plij/siol. norm, et 'path., 5 s., viii. 225, 1896), and of
many others, may be consulted.
Tn yet other directions tliere may be expansions of tlie tlierapeuties
of the fu'tus in utero. We do not, for instance, know whether in
cases of morbiparous mothers the administration of the thymus or of
the thyroid extract would produce any Ijeneficial effects upon tiie
oiTspring ; but there is evidence that the thynms is a very imi)ortant
organ in the fa-tus, just as the thyroid is very active in tlie infant.
Perhaps the tliymus may check excess of growth and formation, for
it has been found to lie small in the large foetus, as in 15. Wolifs
case (Ccntrlbl. f. Gynulc, xxv. ."181, 1901). We do not as yet know
any drugs, unless it be chlorate of potash, wliich have a special
effect (good or bad) upon the placenta, but there may Ije such.
There is, however, one line of treatment which has sometimes been
advocated (I refer to the induction of premature labour at the
eighth month when the mother is suffering from some infectious
malady), which must be regarded as of very doubtful utility ; it is
very uncertain if by so doing one diminishes the chances of the fcctus
being infected by the mother, while it is quite certain that one
increases the risks of the infant succumbing to that or some other
infection. I believe that a foetus suffering from a disease will
recover more satisfactorily in the uterus than out of it, and I do not
regard the chances of the mother as lessened l)y the presence of
such a fcetus in her womb ; but even if her chances of recovery are
slightly less good on that accomit, the risks of a premature labour will
more than countervail.
Germinal Therapeutics.
Therapeutics in the earliest period of antenatal life (the germinal),
when the future organism is represented by two specialised cells
(sperm and ovum), must of necessity be both paternal and maternal,
and it must be mainly prejiaratory and selective. With its considera-
tion I have not in this volume to do, for it belongs to the pathology
and hygiene of the embryo and germ, and calls for special dis-
cussion along with monstrosities- and malformations and morbid
heredities; but I may very briefly indicate some of its salient
points.
It will l3e concerned, in the first place, with the health of the
parents after marriage, but before impregnation has occurred, or
between successive pregnancies. With a view to the procreation of
healthy infants, it will be pointed out that diseases m the parents
ought to be combated, such as syphilis, alcoholism, and tubercle in
the father, and endometritis, renal mischief, syphilis, and alcoholism
in the mother. In the case of habitual abortion or of recurrent
monstriparity, as in the family history narrated by myself some time
ago (117), it may be wise and right to recommend curettage of the
II
\
i
GERMINAL THERAPEUTICS 485
uterus prior to a new pregnancy ; and persistence in antisyphilitic
remedies in the intervals between successive gestations is, of course,
dc riji'cur.
In the second place, it will have to do with marriage and with the
restriction of the marriages of the unfit, and there can be no doubt
that there is wide room for action along such lines. At the same
time, I think that all attempts to regulate marriage by law in the way
that has been so often suggested, of having a sort of bureau of inspec-
tion of candidates for matrimony, must be regarded as premature at
least, if not founded actually on a wrong principle. At present, it
must be confessed that public opinion judges of the suitability or un-
suitability of a proposed marriage very much by the amount of money
the young couple will have to live upon. It would be better if a
basis of health were to take the place of a basis of wealth in the
public mind. The young contracting parties often say they are
marrying for love, and that is right enough so long as the love is of
the right kind ; but with them, also, it is to be feared that physical
and mental and moral health does not take the high place it ought to
do in determining the union.
It has l-ieeu said by a writer iu an American journal (B. 0. Flower,
in the Arena), that " if 100 young men and women in this land,
realising tlie solemn import of this question, enter the marriage
relation attracted by pure love, untainted by base or sordid considera-
tions, and recognising the great moral responsibility they assume to
the society of to-morrow, no less than the sacred obligation they owe
to the unborn, we shovdd have from these true, pure, and ideal unions
children who would, I believe, inaugurate an ethical reformation that
would awaken the moral energies of civilisation, and lead to a higher
and truer order of life." Francis Galton, in his HiLxley Memorial
Lecture (October 29, 1001), lias advocated something akin to this
for the possible " improvement of the human breed," and has pro-
posed a system of dowries to make possible the early marriage of
girls of a favoured stock as regards health ; but, of course, there are big
problems in the way.
All this may be brought about ultimately ; but in the meantime,
and before it can be hoped that it may lie accomplished, it is necessary
that a healthy public opinion on what constitutes a good marriage be
built up, and in the building up of this opinion the profession is ex-
pected to act as a guide and leader. What, for instance, has the
profession to teach the public on the question of marriages of con-
sanguinity ? This matter has been rendered most uncertain by the
confusion which has been introduced through the mixing up of two
very different states — namely, the marriage of near kin or incest, and
marriage of consanguinity or of cousins. In the former case there
can be no doubt of the eil'ects, and every breeder of domestic animals
will support this assertion ; but the marriage of cousins is a different
matter. It has been stated that such marriages result in sterility,
abortions, congenital deaf- dumbness, idiocy, retinitis pigmentosa,
albinism, and such malformations as Polydactyly and ectrodactyly.
Now, it does not seem that consanguinity i2)so facto — that is, without
486 ANTKNATAL I'ATllOLOCJV AND IIYCUENR
the existence of traces of pre-existing degeneracy in tlie contracting
parties — increases the risk of these diseases and anomalies. Fere
goes furtlier, and says that in good families it is to be sought for,
nut avoided ; but tlie medical man will be well advised if lie be very
careful in the advice that lie oilers.
The chief point in all this matter is that the ])rofession and public
should reiuiiin no longer thoughtless about it. Donald T. Massou has
pointed out what " breedmg our manhood from the shots" has led
to and is leading to (Caledonian Mid. Journ., October 1898) ; and
many others have iidduced evidence of the heredity of degeneracy.
Various legislative measures have been brought forward in the United
States of America dealing with the jjroblem of marriage restriction
and regulation {vide C. W. Parker, Journ. Amcr. Med. Assoc, xxxiv.
521, 1900 ; D. R Brower, ibid., p. 52:! ; A. H. Burr, ihid., p. 524 ;
and A. Lee Moque, ihid., p. 526); but I maintain that the lirst thing
to be accomplished is the education of public opinion on all such
matters by the medical profession.
In the third jilace, germinal therapeutics will have to face the
problems of morbid heredity; and that they are problems of the
gravest kind, every one will readily and sadly admit. Morbid heredity
in these days stalks spectre-like through the laud. It is heard in the
pulpit, it is much discussed in current periodical literature, it is found
in the popular novel, and it looks at you from the stage. There are
some — they constitute the minority, I think — w'ho treat this matter
lightly. For them the question has no terrors ; every man has his
chance.
" Years roll'J on years successive glide,
Since lirst llie world liegan,
And on tlie tide of time still floats,
Secure, the bark of man."
But there are others, and their number is great, to wlioin nmrbid
heredity is a spectre that w'ill not be laid. They see it in evervlhing.
An unreasoning terror seizes them.
If, however, they will only think, they who are so fearful of
morbid heredity will soon begin to realise that the most hereditary
thing in the world is the normal, not the abnormal ; that health
is transmitted as well as disease : that even where the past history
of the family is bad, the clean livers have handed something to their
children that is better than what was handed on to them.
It begins to be evident that inherited diseases and anomalies are
rather signs of the breaking of heredity than instances of the per-
sistence of it. The tendencies of the germ plasm are towards the
formation of normal structures capable of performing their functions
normally ; but they are liable, through the action of iiKU-bid causes,
to dissolution, lluch of the harm that is done to the germ in one
generation may be undone in the next: there is a constant tendency
of the germ plasm to return to right pliysiological paths, if it be
permitted.
But now, again, the terrors of the only half-laid spectre come back.
Of what account is it to the iiidi\i(lual that the breaking of the
HEREDITY 487
normal heredity of health is only temporary, and not of necessity
permanent ? Think of the appalling loss of life and health that is
going on everywhere before the return to the normal {le retour a 1%
nu'diocrite) can be accomplished !
" Are God and Xature then at strife,
That Nature lends such evil dreams ?
So careful of the type she seems,
So careless of the single life."
It can be answered that, in the very nature of the thing, antenatal
pathology and antenatal health cannot be restricted to one generation.
We must take a wider view than that which includes the individual
alone. It may be better for the family, for the race, that the indi-
vidual suffer and die. This, however, the individual never can tell.
Still must he trust, now with a l)lind belief, but yet with a real hope.
Never can he say the possibilities of the vis medicatrix naticrce, of
the vis medkatrix licrcditafis, are ended. Suicide is not the answer
to the sad riddle of inherited pathology, but individual cleanness of
life and a trust in the tendency to return to health, which is also (and
much more) an attribute of the germ plasm.
But it is asked : Why should such things be, what is the meaning
of antenatal death, disease, deformity ?
" The same old liaffling questions ! my friend,
I cannot answer them. In vain I send
My soul into the dark, where never bvu'n
The lamps of science, nor the natural light
Of Reason's sun and stars ! I cannot learn
Tiieir great and solemn meanings, nor discern
The awful secrets of tlie eyes which turn
Evermore on us through the day and night
With silent challenge and a dumb demand,
Proffering the riddles of the dread unknown,
Like the calm Sphinxes, with their eyes of stone,
Questioning the centuries from their veils of sand !
I have no answer for myself or thee
Save that I learned beside my mother's knee ;
'AH is of God that is, and is to be ;
And God is good.' Let this suffice us still,
Resting in cliildlike trust upon His will
Who moves to His great ends unthwarted hv the ill."
I
I
APPENDIX
EEFEREXCE LIST OF THE AUTHOR'S CONTRIBUTIONS TO
MEDICAL LITERATURE FROM 1883 TO 1901, WHICH ARE
REFERRED TO UNDER THEIR NUMBERS IN THE TEXT.
A. Published Works.
1. All Infroduction to the Diseases of Infancy : The Anatomy, Physiolorjij,
and Hi/ffiene of the New-born Infant. Oliver & Boyd, Edinburgli,
1891. Pp. viii, 242. Plate.s, 9 (4 coloured), and Illustrations, 15.
2. The Diseases and Deformities of the Foetus: An Attempt towards a
System of Antenatal Pathology. Oliver & Boyd, Edinburgh, 1892.
Vol. i. pp. xiv, 252. Plates, 13. Subjects considered in this
volume are : The Study of Foetal Pathology, its Scope, Delayed
Progress, Difficulties, etc. (chaps, i., ii.) ; Historical Sketch of the
Diseases of the Foetus (chaps, iii.-vii.) ; Classification of Diseases
of the Foetus (chap, viii.); Oeneral Characters of Foetal Disease
(chap, ix.); General Dropsy of the Foettis (chaps, x.-xiii.); General
Cystic Elephantiasis (chaps, xiv.-xvii.) ; General Foetal Obesity
(chap, xviii.) ; Index of Authors and Index of Subjects.
3. Tlie Structures in the Mesosalpinx : Their Normal and Pathological
Anatomy. (Jointly with the late Dr. J. D. Williams.) Oliver &
Boyd, Edinburgh, 1893. Pp. 52. Illustrations, 12. Subjects
considered in this work are : Anatomy and Histology of the
Fallopian Tubes, including Hypertrophy, Hydro-, Pyo-, and
Hsemato-salpinx, Malformations and Displacements, Tubercle,
Cancer, and Cysts ; Anatomy and Histology of the Organ of
Rosenmiiller or Parovarium ; Homologues of the ]\Iesonephric
Relics in the Mesosalpinx ; Pathology of the Organ of Rosenmiiller,
including Cysts and Cancer ; and Anatomy and Pathology of the
Vessels and Cellular Tissue of the jMesosalpinx.
4. Tlie Diseases and Deformities of the Fwtus. Oliver & Boyd, Edinburgh,
1895. Vol. ii. pp. xii, 264. Illustrations, 8. Subjects con-
sidered in this volume are : Sclerema Neonatorum (chaps, i.-iv.) ;
Atrophy of the Subcutaneous Tissue, Subcutaneous Abscess in the
Foetus, Dermatolysis (cliai). v.) ; Foetal Ichthyosis (chaps, vi.-viii.) ;
Congenital Ichthyosis Hystrix (chap, ix.) ; Tylosis Palmm et
Plantse, etc. (chap, x.); Foetal Keratolysis (chap, xi.); Keratolysis
Neonatorum, etc. (chap, xii.) ; Congenital Cutaneous Affections in
General (chap, xiii.) ; Addenda, Index.
5. Teratogenesis : An Inquiry into the Causes of Monstrosities : History
of the Theories of the Past. Oliver & Boyd, Edinburgh, 1897.
Pp. iv, 62.
489
400 ANTENATAI, I>ATII()L(){;Y AND HYGIENE
/)'. Articles in ENCYCLor.EDiAs of Medicine.
6. " Malformations of the Female Generative Organs," in Allbutt and
I'layfair's Sijsteiii of Gi/mrrulor/t/ hi/ mami writers. JIacmillan &
Co., London, 1896.' Pp. 63-112. Illustration.s 31-39.
7. " Le.s Maladies du Fostus," in Granchcr, Coinby, and Marfan'.s Traiti:
(Jes mdlatiif's <h Venfance. Masson et Cie, Paris, 1898. Vol. v.
pp. 191-215.
8. " Congenital Disorders and Diseases of tlie New-born," in Keating'.s
Cijclopwilia of the DiseaKcn nf Children, Supplementary volume,
pp. 1-17. Lippencott, Philadelphia, 1899. Subject.s included
are : Congenital Anasarca, Elephantiasis, Ascite.s, Fcetal Peritonitis,
Infectious Fevers, Endocarditis, Tuberculosis, Prolapsus Uteri,
Osteogenesis Imperfecta, and Congenital Teeth.
9. "Congenital Skin Diseases," in Keatmg's CyclopcEdia of the Diseases
of Children. Supplementarv volume, pp. 1113-1123. Lippencott,
Philadelphia, 1899.
10. "Cheek, Fissure of,'' in Green's J'Jnri/elojxi-dia Medira, vol. ii. p. 19S,
Edinburgh, 1899.
11. "Curettage, Uterine," in Green's Enajclopaeilia Medica, vol. ii. j). 411,
Edinburgh, 1899.
12. "Anatomy of the Female Organs of Generation." Green's Ennjch-
pirilia Medica, vol. iv. p. 127, 1900.
13. " Arrested Developments of the Female Organs of Generation." Green's
Encydopwdia Medica, vol. iv. p. 1.50, 1900.
14. "Hermaphroditism." Green's Encj/clopo'dia Medica, vol. iv. p. 490,
1900.
15. " ^laternal Impressions." Green's Encycloptpdia Medira, vol. vii.
p. 344, 1901.
15rt. " >Ialformations of Genital Organs." Tieed'n Text-Boo/c of Gi/iiecology,
1901.
15b. "Diseases of the New-born Infant." Green's Enct/clopcedia Medica,
vol. viii. p. 345, 1901.
C. ^Medical .Iournal.
16. Teratologia: A Quarterly Jnitriial of Antenatal Patholo(iy. Williams
& Norgate, London and Etlinburgh, 1894-1895. Vol. i. pp. viii,
238. illustrations, 12. Vol. ii. pp. iv, 344. Illustrations, 21.
D. Contributions to the Medical Journals.
1. Gynecological.
1 7. " Cases of Clinical and Pathological Interest in the Buchanan AVard
under Profe,ssor Simpson." Edinh. Med. Joiirn., xxx. 438, 1884 ;
Trans. Edinh. Obst. Sac, ix. 173, 1884. Illustrations, 4. The
cases recorded in this communication were (1) one of ligation of the
blood supply of the ovaries for dysmonorrhoea, etc. ; (2) one of
removal of a hsematosalpinx ; (3) one of epithelioma of the cervi.x
in a woman 26 years of age ; and (4) one of recurrent fibroid of
the cervix.
18. "Labia Minora and Hymen." Ediidi. Med. Journ., xxxiv. 425, 1888;
Trans. Edinh. Ohst. Soc, xiii. 179, 1888. Illustrations, 5.
^
APPENDIX 491
19. "Histology ami Pathology of tlie Fiilli>iiiaii Tubes." (.Jointly with
Dr. J.' D. AViLLiAJis.) Brit. Med. Journ., i. for 1891, pp. 107, 168.
Illustrations, 7.
20. "Influenza in relation to Gynecological, Ob.stetric, and Pediatric Cases."
Edinh. Med. Journ., xxxix. 615, 1894; Tram. Edinb. Ol/sf. Soc,
xix. 33, 1894.
21. "Uterine Curettage: History, Indications, and Technique." Edinh.
Med. Journ., xli. 787, 908, 1896 ; Trans. Edinb. Obst. Soc, xxi.
69, 1896.
22. "So-called Epispadias in Woman, Avith an Illustrative Case." Edinb.
Hosjj. Rep., iv. 249, 1896.
23. "Congenital Prolapsus Uteri, with two Illustrative Cases." (Jointly
with Dr. J. Thomson.) Jn/. Journ. Obst., xxxv. 161, 1897.
Illustrations, 3.
24. "Bicycling and Gynecology." Scott. Med. and Surr/. Journ., ii. 529,
1898 ; Med. Press and Circ, ii. for 1898, p. 54. ' ^
25. "The Sequelfe, Usual and Uniisual, of Ovariotomy." Infernat. Clin.,
8 s., iv. 266, 1899.
26. "The Present Position of the Pessary in Gynecological Practice."
Scott. Med. and Surg. Journ., iv. 289, 1899; Trans. Edinh. Obst.
Soc, xxiv. 53, 1899.
27. "Digest of Recent Literature on Atresia of the Vagina." Scoff. Med.
and Surg. Journ., iv. 536, 1899.
28. " The Antenatal Factor in Gynecology." American Med. Quart., i. 215,
1900; Trans. Amer. Assoc. Olist. and, Gijiiec, xii. 337, 1900.
2. Obstetrical {including Aiitenatal Pathology).
29. " Sphygmographic Tracings in Puerperal Eclampsia." Eifinfi. Med.
Journ., XXX. 1007, 1885; Trans. Edmb. Obst. Soc, x. 56, 1885.
Illustrations, 35.
30. " Report of the Royal Maternity and Simpson Memorial Hospital for
the Quarter ending 31st January 1885." (Jointly with Dr. T. B.
Darling.) Edinh. Med. Journ., xxxi. 259, 1885; Trans. Edinb.
Of>st. Soc, X. 174, 1885.
31. "Sphygmographic Tracings during Labour." Trans. Edinh. Obst. Soc,
xi. 104, 1886.
32. " Sphygmographic Tracings in Pregnancy, Labour, and the Puerperium."
Brit. Med. Journ., ii! for 1886, p. i094.
33. "Frozen Sections of a New-born Child with General Dropsy." Trans.
Edinb. Obst. Soc, xii. 161, 1887.
34. " Mitral Stenosis in Labour and the Puerperium, with Sphygmographic
Tracings." Edinb. Med. Journ., xxxiii. 796, 1888 ; Trans. Edinb.
Obst. Soc, xiii. 16, 1888. Illu.strations, 21.
35. "Sclerema and Gidema Neonatorum." Brit. Med. Journ., i. for 1890,
p. 403. Illustrations.
36. "Intrauterine Rickets." Edinh. Med. Journ., xxxv. 1111, 1890';
Trans. Edinb. Obst. Soc, xv. 45, 1890. Illustrations, 3.
37. "The Head of the Infant at Birth, Part I." Edinb. Med. Journ.,
xxxvi. 97, 1891 ; Trans. Edinb. Olmt. Soc, xv. 103, 1890. Illus-
trations, 7.
38. "The Relations of the Pelvic Viscera in the Infant." Edinb. Med.
Journ., xxxvi. 313, 1891 ; Trans. Edinb. Obst. Soc, xv. 168, 1890.
Illustrations, 5.
492 ANTENATAL I'ATIIOLOCJY AND IIYCilENE
39. "The Head of Ihc Infant at Birth, Part II." Edinb. Met!. Journ.,
xxxvi. 4-29, 1891 ; Trans. Edinh. Ohst. Soc, xv. 235, 1890. Illu.s-
trations, 2.
40. "Maternal Impressions." Edinh. Med. Journ., xxxvi. G24, 11^91;
Trans. Edinh. Ohst. Soc, xvi. 7, 1891.
41. " JltTniorrhage during Labour due to Vascular Anouialy (if tho Jlcni-
hranes." Edinh. Med. Journ., xxxvi. 1000, 1891 ; Trans. Edinh.
Ohsf. Soc, xvi. 9.5, 1891. Illu.stration.
42. "Relations of the Abdominal Viscera in the Infant." Edinh. Med.
Journ., xxxvii. 45, 1891 ; 'Trans. Edinh. Med.-Chir. Soc, x. 140,
1891. Plates, 4.
4.'5. " ,V Portable Infant- Weigher." Edinh. Med. .Journ., xxxvii. 321, 1891 ;
Trans. Edinh. Ohsf. Soc, xvi. 105, 1891. Illustrations, 2.
44. " Disease in Early Infancy." Jirif. Med. Journ., i. for 1892, p. 321.
45. "The Investigation of EcEtal Disease." Edinh. Med. .Journ., x's.x.vii.
812, 1892; Trans. Edinh. Ohst. Soc, xvii. 53, 1892.
40. "Rupture of the Spleen in a New-born Infant." Arcli. Pediai., ix.
27.5, 1892.
47. "The Spinal Column in the Infant." Edinh. Med. Journ., xxxvii.
913, 1892 ; TraJis. Edinh. Med.-Chir. Soc, xi. 71, 1892. Plate, 1.
48. "Series of Thirteen Cases of Alleged JMaternal Impression." Edinh.
Med. Journ., xxxvii. 102.5, 1892; Trans. Edinh. Obsi. Soc, ^\n.
99, 1892.
49. " Clinical Notes of Four Cases, and De.scription of Two Specimens of
General Dropsy of the Foetus." Edinh. Med. Journ., xxxviii. 57,
142, 1892 ; Trans. Edinh. Ohsf. Soc, xvii. 133, 1892. Plates, 3.
50. " Sectional Anatomy of an Auencephalic Foetus." Journ. Anat. and
IVii/sioL, xxvi. 516, 1892; 7'rans. Edinh. Ohst. Soc, xvii. 228,
1892. Illustrations, 3.
51. "General Dropsy of the Foetus." Edinh. Med. Journ., xxxviii. 147,
224, 1892; Trans. Edinh. Ohsf. Soc, xvii. 148, 1892.
52. " General Dropsy in the Twin-Foetus." Trans. Edinh. Ohsf. Soc, xvii.
177, 1892.
53. " Case-taking Scheme for Foetal Diseases and Deformities." Edinh. Med.
Journ., xxxviii. 434, 1892 ; Trans. Edinh. Ohsf. Soc, xvii. 202, 1892.
54. " An Infant with a Bifid Hand." Edinh. Med. Journ., xxxviii. 623,
1893; Trans. Edinh. Ohsf. Soc, xviii. 1, 1893. Illustration, 1.
55. " Description of a Foetus Paracephalus I)ii)us Acardiacus." Edinh. Med.
Journ., xxxviii. 830, 1893 ; Trans. Edinh. Ohsf. Soc, xviii. 38,
1893. Plates, 2.
56. "Congenital ^leasles, with Notes of a Case." Arch. Pediaf., x. 301,
1893.
57. "Paracephalus Dipus Gardiacus." Edinh. Med. Journ., xxxviii. 1095,
1893; Trails. Edinh. Ohsf. Soe., xviii. 94, 1893. Illustrations, 2.
58. "Congenital Ascites with Retention of Urine." Edinh. Hosp. Rep.,
i. 012, 1893.
59. " Case of Scarlet Fever in Pregnancy, with Infection of the Foetus."
(Jointly with Dr. D. jMilligan.) Edinh. Med. Journ., xxxix. 13,
1893; Trans. Edinh. Ohst. Soc, xviii. 177, 1893.
60. "Notes on Six Cases of Polydactyly." Arrli. Pediaf., x. 573, 1893.
61. "Two Further Cases of General Dropsy of the Foetus." Trans. Edinh.
Ohst. Soc, xviii. 215, 1893.
62. " Paracephalus Dipus Acardiacus." Edinh. Med. Journ., xxxix. 321,
410, 1893; Traw.s-. Edinh. Ohst. Soc, xviii. 201, 1893.
Uo.
APPENDIX
493
Piiraceplialus jNIonopus, iVpu.s, ami PseuJoacormus." Trans. Edinh.
Ohst. Soc, xviii. 257, 1893. Plate, 1.
Two Cases of General Dropsy of the New-born Infant." Arch.
Pediat., xi. 137, 1894.
The Foetus Amorphus." Terafologia, i. 1, 1894. Plates, 3.
Tlie First Monograph on Foetal Disease." Teratoloiiia, i. 37, 1894.
Plate, 1.
Congenital Ichthyosis." Arcli. Pediat., xi. 257, 408, 1894.
Case in which Premature Labour was induced for Contracted Pelvis."
Edinh. Med. Journ., xl. 4-5, 1894; Trans. Edinh. Obsf. Soc, xix.
126, 1894.
Case of Hypospadias in a New-born Infant." Terafologia, i. 9G, 1894.
Teratological Records of Chaldea." Terafologia, i. 127, 1894.
Plate, 1.
Paracephalus Dipus Cardiacus." Terafologia, i. 158, 1894. Plate, 1.
Description of an Anidean Foetus." Trans. Edinh. Obsf. Soc, xix.
41, 1894.
The Fcetus Amorphus Anideus." Trans. Edinb. Obsf. Soc, xix. Gl,
1894.
The Foetus Amorphus ]MyIacephalus." Trans. Edinb. Obsf. Soc, xix.
73, 1894.
Case of Preaiu-icular or Branchial Appendage." Terafologia, ii. 14,
1895. Plate, 1.
Preauricular Appendages." Terafologia, ii. 18, 1895.
Pathogenesis of Preauricular Appendages." Terafologia, ii. 65, 1895.
Iniencephaly." Terafologia, ii. 87, 1895. Plates, 3.
Diphallic Terata." (Jointly with Dr. Scot Skirving.) Terafologia,
ii. 92, 184, 255, 1895. Plates, 2.
Rigor i\Iortis in the Fcetus." Terafologia, ii. 96, 1895 ; Trans.
^Edinh. Obsf. Soc, xx. 20, 1895.
Note on the Literature of the Fretus Amorphus Anideus." Terafo-
logia, ii. 182, 1895.
Dr. Pallares' Dicephalic Fcetus." Terafologia, ii. 210, 1895.
Plate, 1.
Antenatal Pathology in the Hippocratic Writings." Trans. Edinb.
Ohst. Soc, XX. 51, 1895; Terafologia, ii. 275, 1895.
The Biddenden Maids." Trans. Edinh. Ohst. Soc, xx. 128, 1895;
Terafologia, ii. 268, 1895. Plates, 2.
Teratological Types — Iniencephaly." Terafologia, ii. 287, 1895
Plates, 2.
Teratogenesis : Supernatural Causes of Monstrosities." Edinh. Med.
Journ., xli. 593, 1896; Trans. Edinh. Ohst. Soc, xxi. 12, 1896.
Case of Tylosis Palmje et Plantse." (Jointly with the late Dr. George
Elder.) Pediatrics, i. 337, 1896. Illustration, 1.
Congenital Teeth." Edinh. Med. Journ., xli. 1025, 1896; Trans.
Edinh. Ohst. Soc, xxi. 181, 1896. Plate, 1.
Recent Advances in Antenatal Pathology." Pediatrics, i. 455, 1896.
Anomalies in the Form and Position of all the Male Genitals," etc.
Brit. Med. .Journ., i. for 1896, p. 1392.
Teratogenesis : Physical Causes of Monstrosities." Edinh. Med.
Journ., xlii. 1, 1896; Trans. Edinh. Ohst. Soc, xxi. 220, 1896.
Report on Mr. J. Rutherford j\Iorison's Case of Congenital Tumour
on the Face of a Child." Edinh. Med. Journ., xlii. 132, 1896 ;
Trans. Edinb. Ohst. Soc, xxi. 256, 1896. Plates, 2.
494 ANTENATAL PATHOLOGY AND HYGIENE
93. "Note on Dr. M. Gunsbiirg'.s Teratological Ca-ses." Edinh. Med.
Journ., xlii. 139, 1X96'; Trans. Edinh. Obsf. Soc, xxi. 252, 1896.
94. "Teratogciicsis : Mental Influence." Edinh. Med. Jo?/;-?;., xlii. 240,
307, 1.S96; Trans. Edinh. Ubst. Sor., xxi. 258, 1896.
95. " Mana^'einent of Labour complicated by Death or Di.sease of the
Fcetu-s." Iidmtat. Clinics, 6 .«., iv. 262, 1897. Plate, 1.
6. "The Causation of Twin.**, as Illustrated by some Clinical Histories."
Trans. Edinh. Ohst. Soc, xxii. 29, 1897.
97. " Displacement of the Kidnej' in Ob.stetric Practice." Internal. Clinics,
7 s., iii. 312, 1897.
98. " Congenital Growth (iVcanthoma?) of the Hairy Scalp." lirit. .Journ.
Dermal., ix. 421, 1897. Illustrations, 2.
99. "Digest of Recent Literature on Transjiosition of the \'iscera." Scoll.
Med. and Surg. Journ., i. 1020, 1897.
100. "Placenta Proevia : its Dangers and Treatment." Inlernat. Clinics,
8 s., i. 48, 1898.
101. "Pathology of Antenatal Life." CJlasgow Med. Journ., xlix. 241,
1898; Arch. Pediat, xv. 434, 1898.
102. "Occurrence of a Non-Allantoic or A^itelline Placenta in the Human
Subject." Scolt. Med. and Surg. Journ., ii. 296, 385, 1898 ;
Trans. Edinh. Ohst. Soc, xxiii. 54, 1898. Plates, 3.
103. " Three Additional Cases of Congenital Teeth." Trans. Edinh. Ohst.
Soc, xxiii. 112, 1898.
104. "Antenatal Therapeutics." Brit. Med. Journ., i. for 1899, p. 889;
Arch. Pediat., xvi. 513, 1899.
105. " Spontaneous Dislocation Outwards of the Right Knee Joint in
an Infant Eleven Months Old." Arch. Pediat., xvi. 267,
1899.
106. "Pathology of the Foetus." Scott. Med. and Sur<j. Journ., \\ 112,
1899.
107. "Sequel to the Case of Spontaneous Recurrent DLslocation of the
Knee .loint." Arch. Pediat., xvi. 701, 1899.
108. " Some Antenatal Aspects of Tuberculosis." Polyclinic, L 39,
1899.
109. "The Position of Antenatal Pathology." Arc],. Pediat., xvi. 860,
1899.
110. "The Antenatal and Intranatal Factors in Neonatal Pathologj-."
Journ. Avier. Med. Assoc, xxxiii. 1245, 1899.
111. "Pathology of the Embrvo." S<-ott. Med. and Suri]. Journ., v. 481,
1899.^
112. "The Term ' i\loon-calf ' ; a Teratological Note." Brit. Med. Journ.,
i. for 1900, p. 780.
113. " Heredity in Disease." Scott. Med. and Surg. Journ.. vi. 310, 1900 ;
Trans. Med.-Chir. Soc Edinh., xix. 114, 1900.
114. " Chronology of Antenatal Life." Scott. Med. and Surg. Joiirn., vi.
416, 1899. Plates, 2.
115. " Pathologv of the Germinal Period of Antenatal Life." Edinh.
Hosp.'Pep., vi. 36G, 1900.
116. "Case of Vulvar Hrematoma." Scott. Med. and Surq. Journ., vi.
505, 1900.
117. "A Problem in Antenatal Pathology: Recurrent Monstriparity."
Amer. Journ. Ohst., xli. 577, 1900. Illustrations, 3.
118. "Antenatal Diagnosis." Brit. Med. Journ., i. for 1900, pp. 1458,
1525.
APPENDIX 495
119. "Two Cases of Congenital Diaphragmatic Hernia." Pln/siciaii and
Surgeon, i. 891, 1900. Illustrations, 2.
120. "Case of Eclamp.sia at the Sixth Montli of Pregnancy treated by
Saline Infusions and Veratrum Viride." Scott. Med. and Surg.
Journ., vii. 19, 1900.
121. "Therapeutics of the Unborn Infant.'' Internat. Clinica, 10 s., ii.
p. 9, 1900.
122. "Contributions to Antenatal Pathology." Physician and Surqeon, i.
988, 1900.
123. "State of the Spinal Cord in Congenital Absence of a Limb." Intrr-
^taie Med. Journ., vii. 367, 1900.
12-1. "Report on Specimen of Foetus in Foetu." Brit. Med. Journ., ii. for
1900, p. 1428.
125. " Cleidotomy : An Operation accessory to Craniotomy or Lasilysis."
Scott. Med. and Surg. Journ., viii. 48, 1901.
126. " A Plea for a Pro-jNIaternity Hospital." Brit. Med. Journ., i. for
1901, p. 813.
126a. "The Antenatal Treatment of Haemophilia. Journ. Amer. Med.
Assoc, xxxvii. 503, 1901.
126i. "Abortions." Internat. Clinics, 11 s., vol. ii. 231, 1901.
126c. "A Visit to the Wards of the Pro-Maternity Hospital." Amer.
Journ. Ohst., xliii. 593, 1901.
3. General Medicine, etc.
127. " Health Aspects of School Life." Lancet, ii. for 1890, p. 909.
128. " Common Errors in tlie Rearing of Children." Edinh. Health Soc.
Trans., xi. 83, 1891.
129. "Folk-Lore Factor in Medicine." Our Students' Mar/a::ine, viii 119,
1900.
130. "Life and Work of Miss Elizabeth Blackwell (1849-1899)." Med.
Mag., n.s. ix. 117, 1900.
E. Shorter Contributions to the JIedical Journals.
131. " Case of Peritonitis in the New-born Infant." Trans. Edinh. Ohst.
Soc., XV. 56, 1890.
132. " Case' of Antemortem Clot in the Heart of an Infant." Ihid., p. 57,
1890.
133. "Note on Syphilitic Liver in the New-born Infant." Ihid., [i. 91,
1890.
134. "Case of Uterus Bicornis Septus." Ibid., p. 160, 1890.
135. " Case of Foetus with Encephalocele." Edinh. Med. Jojirti., xxxyi.
759, 1891.
136. "Dermoid Tumour expelled per vaginam in Labour." Edinh. Med.
Journ., xxxvii. 750, 1892.
137. " Retarded Development of Embryo." Edinh. Med. Journ., xxxviii.
84, 1893.
138. "Exomphalos and Anencephaly of Fcetus." Edinh. Med. Journ.,
xxxviii. 85, 1893.
139. "Umbilical Hernia in a Foetus." Edinh. Med. Jo?«7j., xxxviii. 85,
1893.
140. " Multiple Deformities in a Fcetus." Edinh. Med. Jonrn., xxxviii. 86,
1893.
49G ANTF.NATAI, I'ATIIOLOCY AM) lIVdlKNT,
141. "Hernia of Umbilical Cnnl in a Fa'tiis." Edinh. Mc<l. Jaurn.,
xxxviii. 87, 1S93.
142. "Fro/en Section.s of Exomjilialic and Anencephalic Ftt'lu.';." Edinh.
Med. ,/ourn., xxxviii. 17G, 1893.
143. "A Knotted Umbilical Cord." Edinh. Med. Journ., xxxviii. 178,
1893.
144. " Yelamentous Insertion of the Umbilical Cord." Edinh. Med. Journ.,
xxxviii. 179, 1893.
145. "Cysts on tlio Fcetal Surfa('e of Placenta." Edinh. Med. Juurn.,
xxxviii. 863, 1893.
146. " Abortion Sac from Case of Habitual .Vlternating Miscarriaj,'!'." Edinh.
Med. Journ., xxxviii. 864, 1893.
147. " Fcetus with Measles." Edinh. Med. Journ., xxxviii. 865, 189."!.
148. "Foetus with General Dropsy." Edinh. Med. Journ., xxxviii. 866,
1893.
149. " Steam Steriliser for Infant Feedins,'." Edinh. Med. Journ., ws.\m.
1059, 1893.
150. "Hydrocephalic Fffitus." Edinh. Med. Journ., xxxviii. 1059, 1893.
151. "Frozen Section of a Macerated Foetus." Edinh. Med. Journ.,
xxxix. 174, 1894.
152. "Frozen Sections of Still-burn Infant." Edinh. Metl. Journ., xxxix.
174, 1894.
153. "Foetus with Retroflexion and Spina Bifida." Ei/inh. Med. Journ.,
xxxix. 175, 1894.
154. " Iniencephalic Foetus." Edinh. Med. Journ., xx.xix. 176, 1894.
155. " Tubo-ovarian Cyst and Ovarian Concretions." Edinh. Med. Journ.,
xxxix. 176, 1894.
156. " Anenceplialic Fo;tus with Cervical Spina liifida." Eilinh. Med.
Journ., x.xxix. 272, 1894.
157. "Further Note on Infant with Bifid Hand." Edinh. Med. Journ.,
xxxi.x. 273, 1894.
158. "Case of Kxternal Subpericranial Cephalhematoma." Arch. Pediat.,
X. 848, 1893.
159. " Foetus Com pressus seu Papyraceus." Edinh. Med. Journ., xxxix.
749, 1894.
160. "Frozen Sections of an Anenceplialic Foetus." Edinh. Med. Journ.,
xxxix. 750, 1894.
IGl. " A Fcetus with General Dropsy." Edinh. Med. Journ., xxxix. 835,
1894.
162. " A Foetus with Imperforate Anus." Edinh. Med. Journ., xxxix. 836,
1894.
IG3. "An Exencephalic Foetus." Edinh. Med. Journ., xxxix. 836, 1894.
164. "A Pseudcncephalic Foetus." Edinb. Med. Journ., xxxix. 837,
1894.
165. "An Abortion Sac and Arrested Embryo." Ediidi. Mod. Journ.,
xxxix. 838, 1894.
166. "Foetus with Exomphalos and Sacral Meningocele." Eiiinh. Med.
Journ., xxxix. 1041, 1894.
1G7. "Frozen Sections of Pelvis of a Female ^lonkey." Edinh. Med.
Journ., xxxix. 1041, 1894.
168. "Foetus with Caudal Appendage." Edinh. Med. Journ., xxxix.
1042, 1894.
169. "Still-born Infant with Intracranial IIa?morrhages." Edinh. Med.
Journ., xxxix. 1042, 1894.
APPENDIX 497
170. " Large Placenta from a Case of Hvdramnios." Edinb. Med. Joitrn.,
xxxix. 1043, 1894.
171. " Fcetus with Anencephalus and Cervical Spina Bifida." Edinb. Med.
Jouim., xx.xix. 1043, 1894.
172. " Monochorionic or Uniovular Twins." Edinb. Med. Joitrn., x\. 78,
1895.
173. "Foetus with Goitre-like Swelling of the Neck." Edinb. Med. Joiirn.,
xl. 78, 1895.
174. "Dead-born Infant." Edinb. Med. ,Jonrn.,x\. 78, 1895.
175. " Foetus with Ketrotlexion of the Spina and Anencephalj'." Edinb.
Med. Jouni., xl. 658, 1895.
1 76. " Case of Dilatation of the Bladder and Ureters, and Hydronephrosis
in a Still-born Infant." Edinb. Med. Journ., xl. 858, 1895.
177. "Balanic Hypospadias in a Child." Teratologia, ii. 119, 1895.
178. "Protracted Gestation and Anencephalus." Teraioloqin, ii. 120,
1895.
179. " Foetu.s with Anencephaly, Spina Bifida, Talipes Calcaneu.s, and a
Malformed Thumb." ~Edinb. Med. Journ., xl. 1029, 1895.
180. " Twin Foetus showing Mummification and Flattening." Edinb. Med.
Journ., xl. 1121, 1895.
181. " Anencephalic Foetus with Double Hare-lip." Edinb. Med. Journ.,
xli. 263, 1896.
182. "Diseases of Infancy and Antenatal Conditions." Brit. Med. .Journ.,
ii. for 1895, p. 712.
183. "Dicephalio Foetus." Edinb. Med. Journ., xli. 760, 1896.
184. " Congenital Elephantiasis." Edinb. Med. Journ., xli. 761, 1896.
185. " Iniencephalic Female Foetus." Edinb. Med. Journ., xli. 857, 1896.
186. "Placenta with Persistent Umbilical Vesicle." Edinb. Med. Journ.,
xli. 858, 1896.
187. "Frozen Sections of Congenital Diaphragmatic Hernia." Edinb.
Med. Journ., xli. 1057," 1896.
188. "Three Anencephalic Foetuses." Edinb. Med. Journ., xli. 1058,
1896.
189. "An Anencephalic Fcetus." Edinb. Med. Journ., xlii. 70, 1897.
190. "A Foetus Papj^raceus or Compressus." Edinb. Med. Journ., xlii.
169, 1897.
191. "Photographs of Infant with True Congenital Prolapsus Uteri."
Trans. Edinb. Obsf. Sac, xxii. 23, 1897.
192. "An Anencephalic Foetus." Trans. Edinb. Obsf. Soc, xxii. 72,
1897.
193. " Congenital Fibroma of Scalp of Xew-born Infant." Trans. Edinb.
dbst. Soc, xxii. 73, 1897.
194. " Photographs of Teratological Specimens." Trans. Edinb. Obsf. Soc,
xxii. 81, 1897.
195 " Foetus with Exomplialos, Sacral jMeningocele, and double Genital
Tubercle." Trans. Edinb. Obst. Soc, xxiii. 36, 1898.
196. " Fcetus with large I^ncephalocele." Trans. Edinb. Obsf. Soc, xxiii.
37, 1898.
197. "Foetus with Ascites and Distended Bladder." Trans. Edinb. Obsf.
Soc, xxiii. 37, 1898.
198. "Placenta with Supernumerary Lobe." Trans. Edinb. Obst. Soc,
xxiii. 38, 1898.
199. "Placenta with Succenturiate Lobe." Trans. Edinb. Obsf. Soc,
xxiii. 38, 1898.
32
498 ANTENATAL I'ATHOLOGY AND HYGIENE
200. "FcEtuswith Retroflexion and Torsion of the Spine." Trans. Kdinh.
Obst. Sor., x.xiii. 53, 1898.
201. " Pliotograph of a Teratological Chick." Trans. Kilinh. Ohst. Soc,
xxiii. .53, 1898.
202. " .tViieucephaly with Diaphragmatic Hernia." Tratts. Edinh. Ohst.
Soc, xxii. 83, 1898.
203. " Case of Fcetal Bone Disease." Tra?is. Edinh. Ohst. Soc, xxiii. 84,
1898.
204. " Photographs of a Limbless Infant," etc. Trans. Edinh. Ohst. Soc,
xxiii. 100, 1898.
205. "Frozen Sections of a Foetus (anencephalic) hardened in Fornml."
Trans. Edinh. Ohst. Soc, xxiv. 16, 1899.
206. " Large IMultilocular Ovarian Cyst." Trans. Edinh. Oh^t. Soc, xxiv.
17, 1899.
207. "Large Unilocular Ovarian Cyst." Trans. Edinh. (ilisl. Sor., xxiv.
17, 1899.
208. "Vulvar Epithelioma." Trans. Edinh. Ohst. Soc, xxiv. IS, 1S99.
209. " Twin Foetus and Placenta, showing the First Stage of Sympodia."
Trans. Edinh. Ohst. Soc, xxiv. 18, 1899.
210. " Secundines from three Cases of Placenta Pr.Tvia." Trans. Edinh.
Obst. Soc, xxiv. 18, 1899.
211. "Cervical Fibroid." Trans. Edinh. 0/jst. Soc, xxiv. -16, 1899.
212. " Siamese Child with large Congenital Growth on the Face." Trans.
Edinh. Obst. Soc, xxiv. 47, 1899.
213. "Abortion Sac." Trans. Edinh. Ohst. Soc, xxiv. 47, 1899.
214. " Secundines from a Case of Central Placenta Praevia." Trans. Edinh.
Ohst. Soc, xxiv. 48, 1899.
215. "Case of Missed Abortion." Trans. Edinh. Ohst. Soc, xxiv. 48,
1899.
216. "Congenital Hypertrophy of the Hands (Macrodactyly)." Trans.
Edinh. Ohst. Soc, xxiv. 49, 1899.
217. "Boaistuau's ' Histoires Prodigieuses.' " Trans. Edinh. Ohst. Soc,
xxiv. 49, 1899.
218. " Frozen Sections and Photographs of Iniencephalic Foetus." Trans.
Edinh. O'jst. Soc, xxiv. 79, 1899.
219. " Frozen Sections and Photographs of Anencephalic Foetus." Trans.
Edin'j. Obst. Soc, xxiv. 79, 1899.
220. " Case of Anencephaly and Retroflexion of the Spine." I'rans. Edinh.
Ohst. Soc, xxiv. 80, 1899.
221. "Case of Foetal Peritonitis." Trans. Edinh. Ohst. Soc, xxiv. 123,
1899.
222. " Teratoma from Abdomen of an Infant." Trans. Edinh. Otji't. Soc,
XXV. 52, 1900.
223. "Foetus with absence of Radii and Deformity of Thumlis." Trans.
Edi?ih. Ohst. Soc, xxv. 70, 1900.
224. "Anencephalic Foetus." Trans. Edinh. Ohst. Soc, xxv. 70, 1900.
225. " Photographs of Historical Teratological Phenomena." Trans. Editd).
Obst Soc,xxv. 71, 1900.
226. "Foetal Iniencephaly." Tra7is. Edinh. Ohst. Soc, xxv. 144, 1900.
227. "Uromelic Sympodial Foetus." Trans. Edi>d>. Obst. Sor., xxv. 144,
1900.
228. "Knot on the Umbilical Cord." Trans. Edinh. Ohst. Soc, xxv. 144,
1900.
INDEX OF AUTHORS
I
Abel, W., 367.
Achalme, P. J., 60.
Achard, C, 200.
Adaclii, Buutaro, 105.
Addinsell, A. W., 407.
Ahlfeld, F., 144, 268, 271, 305, 329,
Allirecht, K., 198.
Aldrovaiidus, U., 323.
Allieri, E., 280.
Allbutt, C, 363.
Andrews, H. R., 386, 387.
Anker, M., 263.
Ansiaux, G., 265.
Apert, 200, 348, 354, 407.
Archambault, P., 303.
Aristotle, 4.
Arlidge, J. T., 262.
Armenteros, F. de, 254.
Ashby, H., 379.
Ashmead, 325.
Aubinais, P., 203. '
Auehe, 189, 208, 212, 213.
Audebert, 230.
Audion, L. P., 61.
Audion, P., 61, 65.
Angagueur, M. V., 328.
Auspitz, H., 315.
Aviragnet, 209.
Bachimoxt, 168.
Baer, B. F., 421.
Baerensprung, F. von, 225.
Bailly, M. 413.
Baker, B., 262.
Ballaiid, J., 260.
Bar, P., 64, 144, 195, 209, 232, 234,
236, .327, 404.
Barbezieux, G., 403.
Barbour, A. H. F., 36, 37, 418.
Birker, Fordyce, 270.
Barkow, H. C. L., 314.
Barling, G., 340.
Barlow, T., 353.
Bartb, 372, 446.
Bastianelli, 204.
Batten, F. E., 366, 367.
Bauraes, 249.
Baumgarten, 212, 213, 214.
Bazin, 203.
Beard, J., 142, 158.
Beatty, W., 328.
Beck, G., 473.
BecK're, 195.
Behm, G., 293.
Behrend, G., 228, 307, 315.
Eeigel, H., 323.
Bellot, 372, 446.
Benicke, F., 271.
Bennewitz, 283.
Beraud, 375.
Bermann, 244.
Bernhardt, M., 47.
Besuard, A., 375.
Betz, F., 375.
Bidone, E., 138, 139, 140, 177, 183, 198,
419, 441.
Billig, A., 375.
Birch-Hirscbfeld, 209. •
Biskamp, A., 348.
Bissell, J. D., 230.
Blackwood, C. M., 381, 382.
Blau, 0., 353.
Blondel, 30.
Blumcr, G., 328.
Blmidell, J., 319.
BIyth, W., 263, 264.
Boeckh, G., 334.
Bode, E., 353.
Bohu, 203.
Bond, 53.
Bonnaire, 217, 407.
Bonnet, R., 327.
Booker, 86.
Bordoni-Uffreduzzi, G., 221.
Borntraeger, J. B., 348.
Borri, L., 265, 266.
Bossi, L. M., 419, 425.
Boucliacourt, 170.
Boucliacourt, L. , 470.
Bouchard, Oh., 186.
Bouchut, 203.
Boulengier, 250.
Bourgeoi.s, L. X., 282.
Bourneville, 164, 276, 305.
Bovero, 155.
Bowen, J. T., 328.
Boxall, R., 414.
Braun, C, 353.
Braun, E. von, 329.
Breslau, 267.
500
ANTENATAL PATHOLOGY AND HYGIENE
Brian, 163.
Biiiidcau, 372.
Brinoai, H., 383.
Brook, W. N. B., 480.
Bro.siu, 376.
Brower, D. R., 486.
Brown, E. S., 219.
Browne, Sir T., 429.
Bruce, 357, 479.
Briick, 483.
Brim, De, 397.
Brunner, C, 326.
Brunzlow, 203.
Bruyn Kops, C. J. de, 354.
Budin, P., 447, 455.
Bugge, J., 209.
Bulkley, L. D., 226.
Buuge, 148.
Burckhardt, L., 383.
Bureau, 271, 203.
Buret, 247.
Burr, A. H., 486.
Butte, L., 159, 160, 279.
Cacace, E., 337, 338.
Caocini, V., 204.
Cairns, 479.
Cameron, J. C, 284.
Campbell, ^Y., 329.
Carbone, T., 310, 313, 314.
Carbonelli, G., 221.
Carita, V., 222, 223.
Carrara, M., 273.
Carriere, G., 216.'
Carstanjen, M., 141.
Carton, A., 353.
Caruso, F., 297, 399.
Caspary, J., 74, 315, 316, 317.
Casper, J. L., 178, 267, 413.
Catliala, 376.
Cathelineau, H., 264.
Cattani, 198.
Caulfield, 323.
Cavazzani, 141.
Caviglia, P., 419.
Cestan, R., 348.
Chamberlain, W. M., 270.
Chambevland, C, 222.
Chand:irelent, 200, 208, 212, 213, 283,
354.
Chantemesse, A., 199.
Chantnniil, 190.
('li:i|i.it-Prevost, 462.
Charrrllay, 199.
Cliaivot, 192, 351.
Charpentier, A., 279.
Charrier, 200, 320.
Charrin, 149, 163, 182, 184, 195, 207, 212,
283, 334, 484.
Charrin, A., 201.
Chatelain, K., 420.
Chaussier, 394, 395.
Cliiarleoni, 29.
Chit'vitz, J. H., 99, 106, 109, 110, 111,
112, 114, 116.
Chowne, 323, 413.
Christopher, 372, 446.
Cima, 1''., 203, 235.
Clark, J. G., 425.
Cless, 192.
Coley, W. B., 303.
Colles, 225, 249, 250.
Collina, M., 167.
Condjemale, 274, 276.
Comby, J., 55, 72.
Corbin, J. E., 201.
Cordes, L., 308.
Cordon, 320.
Corin, G., 265.
Courniont, 358.
Coutts, J. A., 250.
Couvelaire, 382, 383.
Couvelaire, A., 419.
Crandall, F. M., 203, 358.
Crawford, J., 323.
Crichton, R. W., 375.
Crocker, Radclilie, 308, 318.
Crooni, J. H., 29.
Curtze, 413.
Cuthbert, 479.
Dagincourt, E., 414.
Dalziel, 219.
Dana, 20.
Dana, C. L., 390.
Daniel, A. S., 308.
Danyau, 375, 394.
Date, W. H., 318.
d'Aulnay, G. R., 230, 255.
Daunie, 200.
Davidson, 283.
Davidson, T., 414.
Decaisne, 272.
Delamare, 283.
Delestre, M., 221.
Denielin, 72.
Demme, E., 375, 376, 443.
Depaul, 353
Diday, 225.
Diehl, 72.
Diehl, J. C, 219, 220.
Diener, 375.
Dodd, A. H., 326.
Doehle, 244.
Dogliotti, A., 200.
Dohrn, 219, 220, 329, 414.
Dolcris, A., 159, 160, 386.
Dfillken, 103.
Donath, J. F. W., 473.
Doutrelepont, 244.
Drappier, 275.
Drennen, 250.
Drummond, W. B., 373.
Dubrisay, 222.
Duci, 14"4.
Duclert. 182.
Dark, IL, 200.
During, E. von, 250.
Duttel, P. J., 4, 188, 189.
Dumeuil, 353.
Duncan, ,T. Matthews, 184, 274, 283.
Durante, 231, 354, 374.
INDEX OF AUTHORS
501
I
Durozier, 285.
Duval, D. F., 136.
Duval, M., 1S6.
Eberle, 0., 235.
Eberth, C. J., 199, 353.
Eckardt, 230.
Euker, A., 323.
Eden, 38.
Edis, A. W., 320.
Edmunds, W., 166.
Edwards, 32.
Ehrlkdi, 484.
Elder, G., 13S, 140, 141, 318, 438.
Elliot, G. T., 315.
Englisch, J., 353.
Engstrom, E., 28.
Ercolani, G. B., 230.
Era.st, P., 199.
Esmarch, F., 300.
Etienne, G., 200, 201, 272.
Everke, C, 298.
Fabkis, F., 380.
Falk, F., 267.
Fauvelle, 324.
Fede, F., 337, 338.
Feliling, H., 147, 268, 269, 271, 353.
Feis, 0., 414.
Felkin, AV., 203.
Feri', Ch., 20, 46, 170, 272, 274, 276, 435,
486.
Ferguson, J. H., 223.
Ferrari, P. L., 181.
Ferro, R. von, 353. .
Ferroni, 139, 140, 144, 169, 447.
Fienus, T., 322.
Fiexix, 279.
Filipi)i, A., 353.
Filomusi-Guelfi, G., 266.
Finger, 244.
Finizio, 170.
Finkelstein, 62, 366.
Finlay, C, 198.
Fischer, A., 347.
Fischl, R., 228.
Flechsig, 102, 103.
Flemming, C. E. S., 354.
Flensburg, C, 162.
Florschutz, H., 473.
Flower, B. 0., 485.
Foa, P., 221.
Fordyce, AV., 200, 355, 356, 357, 358, 360,
361.
Fo'alis, J., 120.
Fournier, A., 225, 247, 253, 254, 255, 257,
478.
Fournier, E., 240, 241, 243, 276, 478.
Fo.x, G. H., 318.
Fox, Tilbury, 328.
Fraenkel, 200, 317.
Fraenkel, E., 473.
Frankel, E., 230.
Franque, 0. von, 353, 357, 424.
Frascani, V., 199, 380.
Frenkel, 200.
Frerichs, 283.
Freund, 200.
Freund, M. B., 267.
Freund, W. A., 29, 30.
Frieker, E., 400.
Friedlrinder, S., 265.
Friedreich, 391.
Friibelius, 375.
Fuhr, 290, 296.
Furst, L., 324.
Fiirth, 225.
Fussell, M. H., 384-.
G.^RTNER, A., 213.
Gartner, F., 70.
(iallavardin, 200.
Galton, F., 485.
Gauiayre, 262.
Gardini, 138, 139, 140.
Garrod, A. G., 373.
Gascard, A., 230.
Gauthier, G., 164, 166.
Genevet, 376,
Gerard, G., 133.
Gerhardt, 375.
Gessner, 363.
Geyl, 48, 324.
Ghika, C, 164.
Gibb, 414.
Giglio, J., 199, 446.
Giles, A., 473.
Gillespie, A. L., 152.
Gillette, W. R., 270, 271.
Glenn, J. H., 219.
Gley, 195, 334, 484.
Gcickel, C. L., 320.
Goldberger, H., 329.
Goldseheider, A., 328.
Gradwohl, R. B. H., 218, 219.
Graetzer, 173, 202.
Grancher, J., 370.
Grandidier, 65.
Grandis, V., 149, 150.
Gream, G. T., 269.
Gr^haut, N., 268.
Griffith, J. P. Crozer, 49, 200, 340.
Grigg, W. C., 413.
Grinisdale, T. F., 479.
Grindon, J., 198.
Grotthof, F., 354.
Gubler, A., 232, 233.
Gu<;niot, 353.
Guillemet, V., 403.
Guillemonat, 201.
Guinard, L. , 163.
GuUand, G. L., 87, 142.
Gusserow, 153, 163.
Hahn, C., 455.
Hall, 446.
Hall, J. ST., 372.
Hallopeau, 315.
Hallopeau, H., 328.
Hanks, H. T., 320.
Hanot, v., 215, 216, 220, 443.
Hansson, 386, 387.
502
ANTENATAL PATHOLOCiY AND HYGIENE
Harliitz, F., 354.
Hardoiiiu, 362.
Hart, I). B., 397, 426.
Harvey, A., 163.
HusiH'ls, J., 473.
Hans, G. A., 307, 313.
Hayiie, L. li., 365.
Hebra, H. von, 329.
Hecker, 88, 89, 90, 91, 353.
Hecker, R., 236.
Hegele, 473.
Heil, K., 386.
Helme, T. A., 102.
Heniiig, 372, 440.
Heniiig, C, 230, 321.
Henrotin, F., 27.
Herrgott, 210.
Herrgott, A., 354.
Herman, G. K., 285, 361.
Hervey, 234.
Hervieux, E., 230.
Herzog, 27.
Heubner, 225.
Hildebrantlt, 199.
Hildebrandt, H., 340.
Hink, W., 353.
Hippocrates, 4, 201.
Hirst, B. C, 64, 221, 354, 472.
His, 80.
Hochsinger, C, 225, 236, 244.
Hochstetter, 329.
Hochwelker, H., 163.
Hoess, F., 348.
Hoeven, P. C. T. van der, 440.
Hoffa, 50.
Hoti'niann, A., 473.
Hoffmann, F., 5.
Hofmeyer, 268.
Hijgyes, A., 268.
Holmsen, F., 383.
Hiinck, E., 293.
Horn, F., 473.
Houel, 307.
Hourlier, 0., 422.
Hubreclit, 154.
Hue, E., 192.
Hudelo, L., 232, 233.
Hueter, G. F. G., 320.
Hugounenq, L., 142, 147, 148, 149.
Huntingdon, 390.
Husband, A., 283.
Hutchinson, J., 7, 47, 225. 247, 250, 256,
318, 327.
Hutchison, R., 1.38, 140, 141.
Ilott, H. J., 424.
Inglis, A., 479.
Ireland, W. W., 103.
Ithen, 394.
Jackson, G. T., 323.
Jaggard, W. W., 407.
Jahn, J. F., 308, 313.
Jakeseh, "\V., 294.
Jamieson, W. A., 318, 332.
Janiszewski, T., 199.
Jany, C, 358.
Jardine, R., 281.
Jeannel, 397.
Jell'cr.son, 32.
■lenner, E., 193.
Jennings, D. D., 463.
Jilden, 357.
Joaeliimstlial, G., 326.
Johannessen, A., 354.
Jones, B., 414.
Jones, J., 198.
Jones, J. D., 330.
Jopson, J. H., 301.
Joseph, M., 328.
Jo.sephson, 473.
Jullien, 244.
Jungbluth, 404.
Justu.s, 235.
Kader, B., 53, 54.
Kaltenbaeh, K., 197.
Kannegisera, N. S., 414.
Karvonen, J. J., 2.36.
Kassowitz, 225, 244.
Katz, 164.
Kaufmaun, E., 335, 336, 346, 348, 349,
350.
Keane, A. H., 323.
Keber, 266.
Keiller, A., 307, 375, 479.
Keim, G., 216.
Ken-, J. Munro, 463.
Kiderlen, 200, 217.
Killiam, 71.
Kircliberg, A., 353.
Kirchberg, J. A. A. F., 353.
Kirstein, E., 285.
Klebs, 285.
Klein, J. H., 353.
Klem, G., 354.
Knapp, L., 419.
Knorr, 414.
Koekel, 181, 209, 210.
Kiilliker, 160.
Koettnitz, A., 419.
Korm.ann, E., 270.
Kostial, T., 272.
Krause, L., 386, 387.
Krebs, 324.
Kristeller, 380.
Krukcnberg, 152.
Kruska, E., 326.
Kubassof, P., 271.
Kuelienmeister, F., 425.
Kuleukanipir, D., 300.
Kiiss, G., 181, 209, 210.
Kyber, E., 310, 311, 312, 313.
Kynoch, J. A. C, 400, 470.
Lakoxt-Maerox, H.,
Laniadrid, J. J., 271.
Lanibertz, 107, 120.
Lanibinon, H., 419.
Lanii)e, R., 354.
Laneereaux, 276.
Lang, 317.
353.
INDEX OF AUTHORS
V
UNIVERSITIY,
OF
Lange, M., 165, 2S1, 414.
Langeudoi'ft', 160.
Langerhans, 313.
Langhans, 124, 125.
Laimois, 163.
Latis, M. R., 223.
La Tone, F., 168.
Laurens, 190, 191, 192.
Lauro, V., 353.
Laveran, 203.
Lawrence, J. Z., 323.
Leale, 197.
Lebedeff, 197.
Lecard, A. J., 353.
Lecorche, 283.
Lederer, I., 353.
Lefour, 262, 382.
Legrand, H., 260, 263.
Legros, 190.
Legiy, 222.
Lehmann, 181.
Lenipereur, A., 422, 423.
Lepidi, 203.
Leroux, 203.
Leter, L., 276.
LetuUe, 158.
Leusser, 473.
Levaditi, 149, 201, 282.
Levi, 141.
Levy, 200.
Levy, E., 221.
Liebreich, F. K., 314.
Liuck, P., 394, 395, 407.
Lincoln, 262.
Lindfors, A. 0., 298.
Lisi, 223.
Lisle, J. de, 244.
Little, 389, 390, 391.
Livingstone, B., 313.
Lize, A., 263.
Lobsteiu, 145.
Luhlein, H., 29, 375.
Loeffler, 211.
Lombroso, C, 323.
Lomer, R., 479.
Londe, 209.
Lop, 195, 419.
Lorain, P., 59, 60.
Lorenz, 50, 51.
Lovett, R. W., 51.
Lucas, J. C, 198.
Luce, J. B., 326.
Ludwig, H., 152, 223.
Lusk, AV. T., 271.
L'lstgarten, 244.
Luzet, Ch., 220.
Lynn, 189.
M.VCDOFGALL, J. A., 440.
Mace, 231.
Macvie, S., 282, 457.
Magitot, E., 323, 325.
Mainzer, M., 303, 304.
Mairet, 274.
Makins, G. H., 354.
Malgaigne, 375.
Mall, 86. ^^ — ^^-^
Maniurotfski, 198.
Mamby, A. R., 320.
Mansfeld, 353.
Marchand, F., 222, 353.
Margarucci, 0., 354.
Margouliefi', 192, 205.
Marquis, E., 271.
Martel, 285.
Martin, A., 413.
Martin, E., 35S.
Mason, R. 0., 340.
Massa, C, 223.
Masson, D. T., 486.
Mathewson, G., 239.
Mattlies, V. AV., 329.
Mattison, J. B., 270.
Mauriceau, F., 355.
Mayer, L., 375.
Maygrier, C, 456, 471.
Meckel, A., 298, 299.
Mejan, T., 192.
Mekerttsciiiantz, 407.
Melischer, L., 268.
Mercelis, 71.
Merkel, F., 99, 114.
Mermann, 144.
Metteuheimer, H., 99, 107, 113.
Meurer, 473.
Michelson, 315.
Michelson, P., 324.
Miklucho-Maclaj', N., 327.
Milligan, D., 196.
Milroy, 301.
Milton, 410.
Minot, C. S., 55, 80, 85, 87, 120, 121.
Mirto, D., 264.
Miura, I. M., 265.
Moir, J., 479.
Molenes, P. de, 326.
Moncorvo, 174, 198, 203, 301, 303, 304,
441.
Moore, B., 161.
Sloque, A. L., 486.
Moreau, 362.
Mori, E., 353.
Morisani, D., 222.
Morrow, P. A., 304.
Mosse, A., 200, 376.
Mott, F. W., 92.
Moussous, 370.
MraJek, F., 228.
Mueller, A., 380.
Mueller, H., 353.
Mtiller, A., 353.
Midler, L. W., 414.
Midler, S., 336.
Mtiller, W., 375.
Muude, P. F., 270.
Munnicli, A. J., 315.
Nachtigallkr, 289.
Nattan-Larrier, 158, 201.
Nazaroff, 446.
Neelsen, F., 298.
Negri, 417, 445.
504
ANTENATAL I'A'lllOI.OCY AND HYGIENE
Neisser, 244.
Nelson, I). T., 267.
Netter, 221.
Ninigebaiier, F., 134, 135, 323, 386.
Neuliaus, 2.'J0.
Neuhaiiss, R., 199.
Neumann, G. , 348.
Newman, 283. ,
Nicholson, H. 0., 137, 282.
Nicloux, M., 140, 156, 273.
Nissl, 103.
Nonne, M., 301.
Nutting, J. H., 353.
OESTllEllHElt, 307.
Oiiilvii-, (;., 247.
Oliuiann-Diimc-siiil, 314.
Okel, 307.
Ollive, 471.
OUiviei-, P., 218.
Olsliausen, 360, 361.
Onoili, 169.
Opitz, E., 134, 177, 3ri4, 383, 404.
Orlotf, 425.
Oime, 320.
Osier, W., 201, 295, 30-3, 388.
Paal, H., 353.
Paci, 50.
Padgett, H., 372, 446.
Palazzi, (i., 218, 223, 26G, 267, 273,
281, 362, 411.
Palm, H., 194.
Paris, 282.
Parker, C. W.', 186.
Parkinson, C. H. W., 413.
Parreidt, J., 323.
Parrot, J., 225, 238.
Parry, L. A., 326.
Partridge, E. L., 271.
Paterson, 89.
Paterson, R., 285.
Paton, D. Noel, 473.
Paul, C, 260, 261, 262.
Paullini, C. F., 202.
Peasl.-..., 270.
Pe.liiini, M., 230.
Peiser, E., 134.
Pello, P., 354.
Pennato, P., 204.
Penrose, 32.
Perez, JI., 315.
Ferret, 447.
Perrin, E. R., 323.
Perrondto, E., 222, 223.
Peslalozza, 136, 137, 144, 169, 447.
Petersen, E., 228.
Petit, 219.
Petit, L., 236.
Pflui,', 375.
l'liilil>e;uix, 267.
Pliilli|.s, \V. v., 479.
Pi.iscrki, 272.
Piekell, 324.
Pii5ry, 194, 195.
Piuard, 459, 471.
Pinkuss, 354.
Pitres, 354.
Plaiicliu, 200.
Playlair, G. R., 203.
Plottier, A., 264, 266, 271, 273.
Poeoek, F. E., 224.
Pohlius, 322, 325.
I Pollmann, 285.
Polosson, 376.
Porak, 158, 180, 183, 260, 263, 264, 265,
266, 267, 334, 340, 348, 354, 362, 383,
463.
Porta, L., 375.
Pott, R., 293.
Pradel, 272.
Preiss, E., 473.
Preuschen, F. von, 70.
Preyer, W., 126, 143, 145, 146, 147, 163,
170.
Priestley, ^^'. 0., 328, 425.
Proehowniek, L. , 473.
Profeta, 247. 248.
Pulewka, 265.
QvEir.F.L, 217.
Quinquaud, 268.
Qvisling, N., 386.
Radwansky, 386, 387, 388.
Raineri, G., 295.
Ranke, ,T., 323.
Rapin, 463.
Raynaud, L., 397.
Recklinghausen, 1!. von, 326.
Regnanlt, F., 348.
Reher, H., 199.
Reid, \V. L., 58, 283.
Reillerscheid, IC, 418.
Reijenga, J., 473.
Reinbaeh, G., 304.
Remy, S., 386.
Renon, 209.
Rennert, 0., 262, 263.
Resinelli, G., 200, 363, 406.
Restelli, L., 265.
Reuhohi, 144.
Reusing, H., 162.
Ribhert, H., 379.
Riliemont, 113.
Riheniont-De.s.saignes, A., 320.
Richer, P., 351.
Richter, 307.
Ricker, G., 217.
Rieder, 390.
Riehl, 0., 257, 478.
Kisohpler, A., 186.
Hitter, 73, 319.
Robinson, 0., 100.
Roger, H., 164.
Rolleston, H. D., 364, 365.
Romano, S , 222.
Romberg, M., 353.
Roque, F., 262.
Rose, 304.
Rosenblath, W., 222.
Rosinski, 230.
INDEX OF AUTHORS
505
Rossa, E., 161, 223, 420.
Rostowzfw, M. J., 222.
Roth, J. H., 354.
Roiiget, J., 397.
Royer, C, 323.
Ruge, C, 230, 422.
Rumpe, R., 348.
Range, M., «5, 66, 68, 69, 145.
Russel, P., 202, 203.
Saohse, 394.
Saintu, 0., 382.
Salaghi, M., 354.
Salisbury, J. H., 244.
Saliis, 449.
Salvetti, C, 354.
Sanchez-Toledo, 213.
Sangalli, G. , 222.
Sanger, 284, 285, 294, 296, 414.
Sanger, W. M. H., 353.
Sarra, R., 304.
Sarraute, I.-G. 425.
Sartorius, 0. F., 353.
Sarwey, 216.
Satullo, S., 399.
Savory, W. S., 163.
Schaefer, 145, 224.
Sehaeff'er, 0., 386.
Schaffer, 0., 99, 110, 115.
Schaller, L., 162.
Scharfe, H., 133, 235.
Snharlau, 353.
Schatz, ¥., 163.
Sehede, M., 326.
Scheili, 354.
Schenk, 375.
Schiller, H., 407.
Schlesint;er, E., 236.
Sclilidlowsky, E., 353.
Schloss, 0., 303.
Sehmey, F. , 354.
Schmitt, 471.
Schmorl, 181, 209, 210.
Sclincider, A., 348.
Schnitzlei-, J., 304.
Scholz, L., 353.
Selinider, 145.
Sehuhl, 320.
Selmltz, 386.
Schultze, 413.
Schultzc, H. S., 329.
Schulz, G. K. A., 353.
Schiitz, E., 294.
Schiitze, 70.
Schwab, 230.
Schwalbe, 99.
Sehwarz, F., 337, 338.
Schwarzwiiller, G., 353.
Schwendener, B., 354.
Schwyzer, G., 380.
Seegen, 283.
' Seeger, 292.
J Sentex, L., 405, 422.
I Seulen, 290.
I Sevestre, 362.
Seydel, C, 265.
Sfameni, P., 139, 141, 149, 150, 151.
Shuttleworth, 462.
Siebold, C. T. von, 323.
Siefart, 285, 294.
Simon, M., 222.
Simpson, A. R., 3, 352, 375, 479.
Simpson, Sir J. Y., 186, 236, 268, 307,
362, 375, 479.
Sireday, 262.
Skene, 271.
Skirving, A. A. S., 406.
Smitli, M., 353.
Smith, Protheroe, 289.
Smitli, W. R., 313.
Sonntag, E. H., 347.
Souty, 308.
Spannochi, T. , 27.
Sperling, M., 394, 395.
Spiegelberg, 0., 375.
Spietschka, T., 303, 304.
Sj)illmann, L., 348.
Squire, 196.
Squire, Balmanno, 326.
Stef, H., 264.
Stcinbiiehel, 414.
Steinthal, 303.
Steinwirker, H., 298.
St. Florent, V. D. de, 390, 391.
Still, G. F., 366.
Stilling, H., 336, 340.
Stoeltzner, W., 346.
Stokes, C. E., 401.
Storp, J., 348.
Strassmann, 407.
Strassmann, P., 112, 133, 163, 264.
Stratz, 197.
Straube, 309.
Strauch, H., 295.
Straus, I., 222.
Stricht, 0. van der, 142.
Strieker, W., 323, 326.
Stroebe, 236.
Stumpf, 414.
Sullivan, W. C., 274, 275, 276.
Sutton, Bland, 307, 326, 344.
Svehia, K., 164, 166, 167.
Swan, R. L., 394.
Swiecicki, von, 473.
Symington, J., 336, 348, 349, 350.
TAir, Lawson, 293, 295.
Tarnier, 455.
TaruHi, C, 353, 375, 377, 380.
Taylor, W. T., 203.
Thiel, 230.
Thiemich, 147.
Thiercelin, 209.
Thiry, 226.
Thoma, R., 121.
Thomas, H. M., 48.
Thompson, J. A., 413.
Thomsen, 391.
Thomson, A., 87, 117, 118, 119.
Thomson, H. A., 336, 348, 349, 350.
Thomson, J., 25, 347, 348, 353, 363, 365,
367, 373, 384.
506
ANTENATAL PATHOLOGY AND HYGIENE
Thorburn, J., 479.
Thoiner, M., 221.
Thost, 318, 319.
Thuriiam, J., 327.
Tidy, M., 464.
Tissier, 235.
Tissot, J., 169, 414.
Tizzoni, 198.
Tschistowitsch, T., 354.
Tomes, C. S., 323.
Toiirdes, G., 413.
Tourette, G. de la, 237.
Town.send, 0. W., 340.
Tridondaui, E., 417.
Tripier, L., 353.
Trousseau, A., 59, 60.
Tnizzi, E., 358, 419.
Tuke, Hack, 462.
Turner, G. A., 58.
Turner, Sir W., 117.
Unna, p. G., So, 318, 325.
Uriel, H., 353.
Valentin, A., 328.
Vanoye, 244.
Varaldo, 139, 142, 156, 204.
Varnier, 448.
Verneuil, 203.
Viearelli, G., 146, 418, 419.
Vierordt, H., 371.
Villa, F., 348.
Vinay, Ch., 283, 284, 285.
Vircliow, R., 234, 292, 293, 295, 323, 353
357.
Vitanza, R., 198.
Viti, A., 221.
Vrolik, G., 308, 336, 340.
Wagner, 234.
Waitz, 303.
Walker, X., 325.
Wallic'Ii, v., 217, 230.
AVarner, ¥., 315.
Wassmuth, A., 307.
Wasten, 134.
Watelet, 315.
Weber, 144.
Weber, F., 376.
Weber, F. P., 372.
Weber, M. J., 353.
Webster, J. C, 27, 425.
Wegner, G., 237.
Weir, J. J., 323.
Westphal, W., 380.
Widal, 217.
Widal, F., 199.
William.s, J., 283.
Williams, J. D., 211.
Williamson, T., 366.
Wilson, 323.
Winckel, F. von, 64, 65, 100, 283.
Winfield, J. M., 314.
Winkler, 424.
Winkler, N. F., 347.
Winslow, K., 203.
Winter, L., 260, 263.
Wolff, B., 484.
Wurster, 146.
Wyss, 353.
Ygonin, 272.
Young, P. A., 413.
Zaoaki, G., 223.
Zalackas, C., 460.
Ziingerle, 200.
Zanier, G., 140.
Zariquiey, 372.
Ziegenspeek, 112.
Zilles, R., 230.
Zweifel, P., 26S, 269.
INDEX OF SUBJECTS
¥
Abdomen of Fcetus, anatomy
Abortion ....
etiology of .
frequency of .
in fcetal death .
in neofcetal period
Absence of Skin, congenital
Acanthoma of Skin
Accumulation op Microbes and Toxin;
AcETONURiA, in pregnancy
Achondroplasia .
Acromegaly, cause of
Adaptive Mechanism at Birth .
Adrenals in F(etal Syphilis
Age -Incidence of Morbid Processes
Acglutinating Principle in Fcetal Ty
Ainhum(?) IN the Fffifus
Albumoses of the Liquor Amnii
Alcohol, passage from mother to fretus
Alcoholism, effect upon the fcetus
Alimentary Sy.stem, diseases of, in ftetus
Allantoic Placenta
vessels .
Alopecia, congenital
Amnii, liquor
amount
chemical analysis
functions
in fcetal syphilis .
in neofcetal period
meconium in .
nutritive properties
renal origin
sugar .
temperature
transmission of disease througl
Amnioma of Skin
Amnion, anatomy of
Amniotic Adhesions in Fcetal Fractuk
in fcetal wounds
Amniotic Origin of Concenital Ampu
fractures
wounds
Amniotitis
Amputations, congenital .
spontaneous
PAOE
112
425
426
455
425
84
328
330
180
418
334, 347
167
38
236
5
200
397
152
273
272
355
154
121
326
125
3, 89
151
153
231
83
161
153
162
223
146
182
330
125
177
178
397
394
395
405
396
178, 396
508
ANTENATAL I'A'l'IlOLOCY AND HY(;iKNR
rAOB
Anatomy of Fcktus ........ 99
of ncofcctal |ierioil
80
ANKNCEI'HALY AXD FlETAL MOVEMENTS .
. 169
Animals, fcetal iclithycsis iu
. 314
fwtal rickets in . . .
. S.-)!
Annexa, fcetal, di.seases of
1
75, 398
Anteconcei'tionai, Period ok Geuminai. Like
9
Antenatal Diagnosis
. 431
factor in gynecology .
. 22, 23
in neonatal |iatliology.
42
fragility of liones
48
hygiene ....
405
life, divisions ....
6
scheme ....
7, 10
Antenatal Patiiolii(!Y, and anatomy .
17
and general |iathology
17
and psychology
•JO
definition ....
i
emergence ....
3
interest in .
12
journal ....
13
leetureshiii ....
13
literature ....
3
novelty ....
1
practical importanee .
2
relations ....
16, 21
subdivisions ....
12
Antenatal Pempuiuvs
327
prevention ....
14, 19
therapeutics ....
ira, 4
00, 465
Anthrax, fu-.tal ....
222
Aouta ok FfETUs, anatomy of
1
11, 116
" Apoplexies " in the Placenta
398
Appendicular Circulation in the Foetus
131
Appendix .....
489
Appendix Vkrmiformis of Fcetus, anatomy of
115
development of . . .
90
Arsenical Poisoning in the Fcetus
266
Arvthmic Character of Fietal Cardiac Cycl
E
135
Ascites, tVetal ....
355
in syphilis
237
Asphyxia, IVctal .
1
63, 411
neonatorum
75
" Asterion" Region of Skull
104
Asymmetry of F(ETAL Head
101
Ataxia, Friedreich's
391
Atheroma, antenatal
374
Atrophic State of SuiicuTANEOUS Tissue
305
AUTO.MATIC Character of Fietal Cardiac Action
134
Bacillus of Syphilis ....
244
Bacteria, transmi.ssion through the placenta
157
Bacteriology of Fietal Anthrax
222
erysipelas ....
197
pneumonia ....
221
sepsis .....
217
typlioid .....
199
Baumgarten's Theory of Latency
213
BiDLIOGRAPHV OK ANTENATAL KiGOR MoRTIS
413
author's works
489
congenital goitre ....
375
congenital i>rolapsus uti li
386
foetal bone disease ....
353
obliteration of the bile-ducts .
365
Birth, funi'tional changes at
39
readjustment of functions at .
38, 39
^uro^^^
INDEX OF SUBJECTS
Birth — continued.
separation — results of .
traumatism of .
BiRTH-KATE, fall ill
Bladder of Fcetus, anatomy of .
(listension of .
hypertrophy of
BLENORRHffiA NeON ATORFiM
umbilici
Blood, development
distriliution
chemistry
histology
in neofretal period
in syphilis
BOGEXFURCHE
Bone Diseases, fretal
Bones, antenatal fragility of
in fcotal syphilis
Brain of F(etus, anatomy of
changes in, in neoffctal period
development of
Bronohooele, intrauterine
Bronzed H.emath; Disease
Buccal Cavity of Fcetus, anatomy of
secretions in the fcetus
Buhl's Disease .
Bunge's Law
C^CUM OF Fcetus, anatomy of
Calcareous Deposits on Placenta
Cancer, maternal, state of fretus in
Caput Succedaneum
Carbonic Oxide Poisoning in the Fietu;
Cardiac Action in the Fcetus
circulation in fcetus
impulse, jialpation of .
Cardiogram of Fcetus
Cephalhematoma Neonatorum
Cephalometer in Antenatal Diacjnosis
Cerebellum, development of
Cervix Uteri, antenatal laceration
Chaldea, teratological records
Chemical Examination of Excretions in Antenatal
Chemical Substances, transmission through the iilacenti
Chemistry of the Fcetal Liver
urine .
of the fcetus
liquor amnii .
meconium
placenta
veruix caseosa
Chloroform, influence upon the fcetu
Chlorosis and Malformation
Cholera in the Fcetus .
ChONDRODYSTROPHIA FlETALIS
Chorea, congenital .
Chorion, anatomy of
development of
in neofretal iieriod
villi of, structure of .
Circulation in the Fcetus
changes in, at birth
extra-corporeal
intra-corporeal
Circulatory Changes at Birth
system, diseases of
88, 89
509
PAOK
37, 38
35
13, 456
116
u79
381
52, 53
62
86
131
141
139
83
235
86, 87
334
48
237
101
82
91, 92
374
64
103
159
63, 64, 65
148, 448
114
151
282
36, 37
267
133
129, 135
136
137
44, 45
447
89
32
4
448
156, 157
159
162
147
151
161
150
160
268
20
198
335, 347
390
125
124
127
132
127
129
510
ANTENATAL PATHOLOGY AND HYGIENE
Classification of Fo-nAi, Honk Diseases
morbid states .
movements
Clavicle of FtEius, anatomy of .
ossification of .
Cleidotomv
Clinical History of Congenitai, ELKriiANTiAsis
bone disease
congenital hyiiei-tiicliosis
fcetal ascites
death ....
endocarditis
general ffctal dropsy .
hydramnios ...
ichthyosis
malaria
measles
obliteration of the bile-iUu^ts .
variola
Cloaca, development of .
Closure of the Foramen Ovale and D
Clouding of Cornea, congenital .
Coal Gas Poisoning in the F(etus
CoLLEs' Law IX Svi'HiLis.
" Collodion FfETUs "
Colon of Fcetus, anatomy of
hypertrophy of
Comparative Emuryologv
fcetal pathology
histology of placenta .
teratology
Complications of Fcetal Variola
Composition, chemical, of fcetal blood
Congenital Absence of Skin
alopecia
bullous dermatitis
cystic elephantiasis
elephantiasis .
goitre ....
hypertrichosis .
jiemphigus
syphilis
torticollis
Conjunctivitis, gonorrhccal, of new-born
Convolutions ok the Umbilical Cord
Copper, poisoning with, in pregnancy
Cornea, congenital clouding of .
Coronary Sinus of Placenta
Corpuscles, red, in the fcctus
white, in the fcctus
Cranio-Pharyngeal Canal in Fcetus
Craniotabes
Cranium of Fcetus, anatomy of .
development of
Cretin, goitrous .
Cretinism, congenital
Cyanosis, pernicious icteric
Cystic Elephantiasis, congenital
Dasytes ....
Death of Extrauterine F<etus
Death of the Fcetus
pathology of .
Decidual Membranes, anatomy of
development of
in neofcetal period
INDEX OF SUBJECTS
511
Definition of Antenatal Pathology
con<»eiiit!il elephantiasis
congenital goitre
congenital hyiiertrichosis
congenital obliteration of bile-duets
f(_etal ascites
ftetal ichthyosis
fretal keratolysis
genera! iietal dropsy .
hydraninios
tylosis palmie .
Deformities, embryonic in origin
Decexekation, fibro-fatty, of placenta
Dehmatitis, congenital bidlou
exfoliativa neonatorum
Dekmoids in the Fietus .
Desquamation, physiological, in new-lior
Development of Fcetus .
Diabetes, maternal, state of fii.'tu;
DlAl'.ETES MeLLITUS IN F(ETUS
Dia(;nosis, antenatal
of fcx'tal death .
fietal endocarditis
fetal morbid states
general f efcil dropsy .
hydramnios
intranatal
neonatal
oliliteration of the liile-ducts
postnatal
DiAriiKAGM IN FcETUS, anatomy of
development of
Diet in Pregnancy
of mother and chemistry of fretus
Difficulties of Antenatal Diagnosis
Digestion in the Fcetus .
Dicestive Changes at Birth
Digits, development of
DlTLOTERATOLOGT
Diseases, fecial
and malformations
idiopathic
of the fcetal annexa
skeleton
Diseases, transmission of, from fcetus to
through the placenta .
Diseases, transmitted
Dislocations in the Fcetus
in the new-born infant
spontaneous of knee .
Divisions of Antenatal Life
jiathology
Dropsy, general, of the fetus
Ductus Arteriosus, anatomy of
closure of, at birth
Ductus Thyreo-Glossus .
Duodenum of Fcetus, anatomy of
Dy'strophies of Alcoholism
of fcetal syphilis
of fcetal tuberculosis .
Ear of Fcetus, anatomy of
anteversion of .
develojiment of
Eclampsia, maternal, effect on Fi
on placenta
PAGE
2
300
374
321
363
355
306, 315
319
289
400
318
185
399
327
72
174
73
92, 93
283
223
431
416
372
430
296
402
449
432
365
450
108
86
472
147
430
160
40
85
12
173, 188
. 186
175, 288
175, 398
. 334
. 184
156
. 175
. 395
49
. 214
6
12
. 288
111, 112
. 133
83
. 114
243, 276
. 239
214, 243
. 104
85
. 84, 87
. 278
. 281
512
ANTENATAL l>A ril()I.()(;'> AM) HVCIKNK
ECZKMA NkONATORU.M
Effects of F(etai. SvriiiLis
Elastic- Fibrks ix Skin, flevclo]>nieiit of
" Elastic: Skinnki) Mf.x "
Elei'Haxtiasis, cougeiiital
cystic ....
EMnRYOLOOY, comparative
E.MllRYONIC CONTRA.sTKll WIIH F(i;rAr, Lu
factor in fcftal iiatliolupy
]iatholoj;y ...
period of life .
Emergence of Antenatal rATiioLocY
Endarteritis, in fntal .syphilis .
Endocarditis, fiftal
streptococcic, in fo-tus.
tubercular ...
Environment, influence of, upon fntal diseases
intrauterine
Epidemic Cerf-bro-Spinal llENiNorrrs in Fiktf
Ei'iDERMOLY.sis Bullosa Hereditaria
Epitrichiim
ErONYCHIUM
Erroneocs Views regarding Antenai
Eruption, characters of, in fa-tal variola
Erysipelas in the Fcetus
neonatorum
Ery'throblasts in the Fcetus
Ery'throcytes in the Fietus
"Es.\us" ....
Essential Icterus Neonatorum
Ether, influence upon the Fotus .
Etiology of Abortion
congenital goitre
congenital hypertrichosis
cystic elephantiasis
ffietal ascites
fcetal bone disease
foetal death
foetal endocarditis
foetal ichthyosis
foetal keratolysis
tylosis palniiB .
Eustachian Tube of Fcetus, anatnmj- of
EusTACHirs, valve of, in fcetus
Excretions of the Fcetus
Exercise in Pregnancy" .
Exophthalmic Goitre, cause of .
Extrauterine Fcetus, death of
pregnancy
Extremities of Fcetus, anatomy of
Eye, development of
Face, in neofcetjil period .
Face Bones, ossification of
Face of Fcetus, anatomy of
Facial Paraly'sis in New-born .
Factor, embryonic, in fcBtal pathology
environmental, in fn-tal ]iathology
placental, in fcetal jiathology
Fallopian Tubes of Fo:tus, anatomy of
Family History in Antenatal 1)iac:nosis
Family Preyalexce, and ovarian cysts
Fat of the Fcetus, origin of
Father, influence of, in fcetal malaria
upon fn>tal weight
Femur, ossific nucleus in epiphysis of
254
90
305
174, 300
•297
17
r, 10
3
235
369
19S
209
17t)
2\S, 220
74, 327
452
192
. 197
59
139
139
322
67
269
426
376
324
300
366
339, 352
427
371
314, 317
320
31S
104
111
161
475
166
424
27
120
S4, 86
81
82, 85
103
46, 47
1S5
177
179
119
43S
29
89, 147
203
168
91, 92
INDEX OF SUBJECTS
513
Finp.oiDs OF Uteevs, antenatal cause
Filter, placenta as a
FtETAL Ascites
development .
diseases, first work on .
giowth
heart beat in labour pains
ichtIi3'osis, grave fonii
,, mild form .
keratolysis
life, contrasted with enibryt
general characters of
placental influence in
semi-parasitism of .
FtETAL Pathology
classification .
comparative
embryonic factor in
general principles
Fcetal Period of Life .
FtETAI. Peiiitoxitis
rickets
tubercle
FtETlciDE, therapeutic
Fi£TUS, anatomy of
anthrax of
asphyxia of the
cardiac action in the .
chemical composition of
cholera in the .
circulation in .
compressus
cystic elephantiasis of .
death of the
diabetes mellitus of
distension of Ijladder in
elephantiasis of tlie
endocarditis in the
epidemic cerebro-spinal mening
erysipelas in the
excretions of the
general dropsy of tlie .
growth of the .
liypertrophic dilatation of bladder
idiopathic diseases of .
immunisation of
influenza in the
malaria in the .
measles in the .
medication of .
movements of .
nejihritis in the
nutrition of the
papyraeeus
parotitis
pertussis in the
physiology of .
pneumonia of .
position of primary lesions in
jiotential morbidity of
purpura of
rallies of
relapsing fever in the .
respiration in the
rheumatic fever of tlie
scarlet fever iu the
33
90, 91
90. 91
vxor,
27
181
355
92, 93
4
92, 93
13«
306
315
319
79
78
78, 79
78
12
174
17
185
172
7, 10
26, 362
335
206
13, 460
99
222
163
133
147
198
127
78, 424
297
176, 409
223
379
174
369
218, 220
197
161
288
167
381
288
195
198
201
196
476
169, 170
378
145, 152
424
198
198
126
221
182
179
219
223
198
143
223
196
514
ANTENATAL PATHOLOGY AND HYGIENE
FiETUs — continued.
secretions ol' the
sensation in the
HCJlsis of . . .
syiilulis of .
teinjieraturc' of
to.xii'olofjical states of tlie
traiiniatisni in the
tnlii'Viidosis of .
tyjilioiil fever in the
vaeeinia in tlie
vai'icclla in the
j-ellow fever in the
FONTANELLE OF GeIIDY
Foramen Ovale, anatomy of
closnre of, at birth
FKACTURES in the F<ETI'S
in ue\v-1jorn
FRAGILITY OK Bones, antenatal .
Frequency of Fietal Endocarihtis
Friedreiih'.s Ataxia
Functional Changes at Biutii .
Gall-stone, antenatal
Gastric Spasm, congenital
Gastro-intestinal Circulation in the
General Dropsy of the F(etus .
Genital Organs, diseases of, in fietus
malformations ...
Genital TuiiERCLE ...
Germinal Pathology
jieriod of life .
therapeutics
Glucose in Fcetal Blood
Glycosuria in the FiETrs
Goitre, congenital
e.xoiihthahnic, cause of
Granuloma of Umuilicus
Growth of Fcetus
Gummata in Fcetal Syphilis
G^'NECOLOGY, antenatal factor in .
diagnosis
etiology
juris] irudence .
luorliid anatomy
l>rognosis
relation to antenatal ]«ithi)logy
syniiitomatnlogy
therapeutics
Habitual Fietal De.\th .
h.ematemesis neonatorum
H;EMAT0MA OF SteRNO-MASTOIH IN NkW
HjEMATOI'OIESIS in the FffiTUS
H^matozoon of Malaria
Ha:M0GL0MX of the Fcetal Blooh
H.EMOGLOBINURIA NeONATORI'M .
Hj,mophilia, maternal, eti'ect on fetus
of newborn
treatment of .
H,EM0RRHAC;E FROM THE UMBILICUS
H.KMORRIIAGES IN THE PLACENTA
H.EMORRHAGIC SYPHILIS .
Hair, develoiiment of
"Hairy Men"
"Hamilton" Bed in Edinpa-riui Mate
86, 88,
89, 90,
159, 160
. 170
217, 220
225, -177
145
259
393
206
199
194
198
198
4B
111
133
, 393
4S
48
371
391
39
69
365
131
288
384
91, 92,
, 85
12
, 10
484
141
162
374
166
61
167
234
. -'3
28
10, 419
69
53
42, 164
203
140
63
286
63
480
65
398
227
85, 88
322
470
I
INDEX OF SUBJECTS
515
" Haklkijuin FoiTrs "
Hkad of FcETi'S, anatomy of
new-liom infant, anatomy of .
Hkad-movlding, in labour
Hkajit, changes in, in ffrtal syphilis
disease in new-lioin infant
malformations of
maternal, state of futus in
ntofiftal perioil
Heakt of Fcetus, anatomy of
intlaramation of
^tnlcture of .
HEAT-iiE(;ri.ATixt; Mecuani.ssi in Fcett's
Hei'Atic Changes at Bir.TH
circulation in the frctus
Heredity, heteromorphic .
morbid
of uterine fibroids
Heteuomohi'hic Hekeditv
Hexkxmilch
Hihekxatixg Animals axd Human Fcetu:
Hir, congenital dislocation
Hiksuties Adnata
HiisriTAL, pre-maternity .
Hvdi:amnios
elmracter of liijuor amuii in
in f'ctal syphilis
Hydrocephalus, congenital
in fetal syphilis
HyDKONEI'HKOSIS in the FtETUS .
HyDKOPHOBIA in Pr.ECNANCY'
HVDHOPS SAXaUIXOLEXTrS .
Hydp.orrH(ea Gravidakum
Hy(;iene, antenatal
intrauatal
of pregnancy .
Hymen, development of
Hyoid Bone, anatomy of .
Hypersiderosis of Fietus
Hypertrr'hiasis .
Hypertrichosis Congenita
general
local ....
lumbar
Hypertrophic Dilatation of the Bladdei:
Hypertrophy-, congenital, of the colon
Hypophysis Cerebri of Fcetus, anatomy of
function of .
Hyposiderosis of Pregna>xy-
Hypospadias, diagnosis of
Hypotrichosis, congenital
Hystrix, ichthyosis
Huntingdon's Chorea
HUTCHINSONIAN TRIAD OF EFFECTS OF CoNGENIi'AI, SyI
Ichthy'OSIs, fetal .
gi'ave form
mild form
hystrix
syphilitic
Icterus Neonatorum
Idiopathic Diseases of the Fcetus
Idiopathic Icterus Neonatorum
Immunisation, fcetal, mechanism of
Immunity against Sy'philis
vaiiola
307
100
100
36
ti35
83
no
369
111
H6
41
130
215
486
27, 28
215
55
147
49, 50
321
466
400
177
231
389
237
383
223
239, 422
418, 440
465
463
471
88
107
149
322
321
321
326
326
381
367
105
167
149
29
326
318
390
254
177
306
315
318
238
67
195
246
194
51G
ANTENATAL PATHOLOGY AND HVGI?:NE
Immusitv, transmission to fu-tus .
Impkessioxs, niateinal, in fn-tal pathology
InCUBATIOX of l^STAI, Mkaslks .
variola ....
In'KANt, syphilis of the
Infantilism in Wumkn, characters
iNFlXriuN AND Tl!ArMAri-M
neonatal ....
Infixtions, intranatal
LVFI.UENZA in THK l-'lETl'-s
Ix.sriitATiON, first, cause of
IXTKSTINAI. PitOTnVSION INTO UmIULKAI, Coltl)
Intksitne, secretions of, in the fictus
IxTKsriNi'.s OF FtETUs, anatomy of
in f.i-tal .syphilis
Inti:aconcei'tionai, Peuioh of Geuminai, Lifi
InTK.VNATAL CKrHAl.lljKMATOMA .
diagnosis ....
infections ....
life, importance
pathology ....
phy.siology ....
syphilis ....
traumatisms ....
treatment ....
Intrautekink Kvir.oNMF.xr and Disk.\ses
life, changes in . . .
divisions ....
patliology ....
Iodine, ahscnce of, in the fi-tus .
Iron of the Fcetu.s, origin of
iRBEOtTLAlUTY OF FcETAL CARDIAC ACTION
Jaundice, congenital
of the new-born
Joints, development of .
Justus Blood Test IN Sv chilis .
Kek.\tolysis, fretal
neonatorum ....
Keratoma Pl.\ntark
Kidney, in neofu-tal period
Kidneys, anatomy of .
cvstir degeneration of
lutal syphilis ....
intlammatiou of, in fn'tus
Knee, spontaneous dislocation of .
Knots on Umbilical Cord
Knowledge of Fcetal Pathology, limitation
Labia Ma.iora and Minora, .Tuatoniy of
LAiifiui!, effects of, on head of fVctus
hfad-nioulding in .
jiressurc effects of .
Lackratiox, antenatal, of cervix uteri
L.KHMK .....
Lanohan.s' Layer of Villus
Lanugo, development of .
Larval Stage of Congenital Tubeiuli,
L.\RYN.\ IN Fcetus, anatomy of .
Law of Colles ....
of Profeta ....
Lead-Poisoning in the Fiktus .
Length of the F(ETUs, causes of variations
Lesions, placental, lethal cfl'cct
jirimaiy, in the futus .
4S3
174
196
190
225
29
23, 24
t*7
r,i
198
143
81
160
114
236
9
44
449
34
226
44
463
176
84
166
148
13r>
235
319
72
318
82
115
383
236
378
214
121, 400
173
120
101
36
36, 37
32
65
124
89, 90
213
107
249
246
260
168
183
182
INDEX OF SUBJECTS
517
Lin-HAL Kffkct of Placental Lesions
Lei'coiytes, dcvelojiinent in liutus
transmission through the placenta
Lfatoivtusis in the Fcetur
LEUKi;MiA, maternal, state of fcetus in
Life, antenatal, divisions .
scheme
embryonic
ftetal ....
general characters of .
gerr.iinal
neofietal
neonatal
Limbs, in the neofn-tal iieriod
of f'l'tus, anatomy of .
Limitations of Knowledge of Fietal T
liteuatlt.e of antenatal pathology
congenital goitre
congenital prolapsus uteri
fretal lione disease
rigor mortis
LiTHOl'.EDION
Little'.s Disease .
LiVET., anatomy of
changes in, in fn'tal syphilis
chemical composition of
development of
in neofretal jieriod
"Living Skeletons"
Lochia, umhilical .
Long Bones, ossification of
Lungs, anatomy
changes in, in tVetal syphUis
in neof ctal j)eriod
LvMi'HANGiTis OF Umbilicus
Lymi'Hatiis, develojiment of
Lyjiphoi'ytosis in the Fcetus
Macekatiox in Fietal De.4.th
Macrocephaly and Lead-Poisoning
Malaiiia, ftetal
clinical history of
jiathology of .
treatment of .
Malfobmations and Chloeosis
and fetal diseases
in f'ctal sypliilis
in olfspring of tubercular mother
in offspring of women suffering from tj'jihoid
of genital organs
treatment
of the heart
of the nervous system
Malignant Icterus Neonatorum
Mammaby Glands, development of
secretion in the fictus .
Maki!IAGe, legal restriction of
regulation of .
Mastitis Neonatobum
M.ateknal History in Antenatal D
impressions, in Petal pathology
phy.sical examination in antenatil diagn
symptomatology in antenatal diagnosis
temperature, effect upon fetus
Maturity of Foetus
Measles in the Fcetus .
I'AOK
183
142
157
, 140
•2Si
6
7, 10
7, 10
7
78
9, 10
9
7
81
120
173
3
375
386
353
413
425
389
113
232
159
83, 86
83
305
60
82
111
2.34
83
141
178, 421
262
201
202
203
204
20
186
240
215
201
24
31
370
389, 392
69
90
160
14
485
54
434
174
442
439
146
91
196
518
ANTIAATAL PATHOLOGY AM) IIVOIKNK
Mkasuiskmexts of Hkaii of Foctus
Mkchanism ok Ar.uiiTiox .
f.i-tal (U-iith .
imiimiiisiition .
Mkciinii'M, aii]ii'aiancf of .
loinposition of
Mkdicatios, antenatal
Mkwi-inks, jiassaj,'!' thiougli jilacenta
Mki,^;xa Neonatohim
Mi;.mi!i:axes of Kikti's, anatomy of
Mexixoitis, epidemic eereliro-spinal, in fn
Mkxstuuatiox of the New-dokn
Mercurial Poisoxixc; ix the Fietus
Metaiiolism, Petal, regulation of .
in the placenta
Microbes, aecunmlation of, in placenta
transniissioii of, tlirongli placenta
MrCTUKITION Dl'RIXn FtETAI, LiFE
Miliaria, nasal, in intus .
"Missing Links"
MiTTELscHMERZ, cause of .
Modification of F(etal Disease iiv Ex\
" Moles " .
Monstrosities
formation of .
in f'l'tal sypliilis
in tlie ollspring of the phthisical
MoRiiiD Axatomv of Coxgexital Gastric SfAssi
of congenital goitre
of fietal ascites
of fietal lione (lise.isi- .
of fetal ichthyosis
of fu-tal syjihilis
of general futal dropsv
of oliliteiati(.u of the iiilc-ilnets
of oligohyilrainnion
MoRiiii) Hekeditv
MoRBin Processes, age-incidence
MoRRioiTY, potential, of the fietus
Morbus C(eruleu.s
MOKI'HIXE, effect upon the fietus .
Mortality, potential, of the futns
Moulding of the Head ix Laboui;
Mouth, develoiiment of
MoVEMEXTS, fietll
Mui.LERiAX Ducts, changes in
MlMMIFICATIOX IX FlETAL DeATH
Musculature of F(etus .
Myelination of Tracts ix Brain
Myotoxia Coxgexita
Myxedema, congenital
NACKESGKiBE
N^VUS PiLOSUS
Nails, development of
Neck of F<ktus, anatomy of
Neokietal Period ok Life
NeuXATAL DiACiXOSIS
infection
pathology, antenatal factor in
investigation .
nomenclature .
[leriod of life .
readjustments, disturbed
Neoxatal Syphilis
Neoplasms in the Fietus
101
426
411
195
m, 92
1«1
476
476
69
125
21S, 220
54
263
64, 165
184
180
181
162
92
322
26
176
40S
12
1>S5
240
215
366
358
340, 348, 352
308, 315
229
292
364
408
486
5
179
371
270
ISO
36
84
69, 170
82, S6
78, 424
120
102
391
305
81
326
, 89, 91
107
9, SO
432
57
42
33
33
7, 10, 34
66
226, 227
174, 175
INDEX OF SUBJECTS
519
Nepheitis, fa?tal .
Neiivoi's Maladies, fi.-tal, trcatm
Nervous System, diseases of, in ff
in fcetal syphilis
New-bokn Infant, asphyxia
desquamation in
diseases of
dermatitis exfoliativa .
dislocations in
eczema in
erysipelas in
facial jjaralysis
fractures in
hitmatoma of sterno-mastoid
liaemoglobinuria in
hemophilia of .
jaundice
keratolysis
mastitis in
melfena in
menstruation in
ledema in
omphalorrhagia
ophthalmia in .
pemphigus in .
prematurity
puerperal fever
purjmra of the .
sclerema in
sepsis in
sphygmograms of
syphilis of the .
tetanus
NicoTiSM, effect upon the fcetus
NOMENCLATUllE OF FlETAL BONE DISEASE
of neonatal diseases
"Normal" Head of Fcetus
NouitlSHMENT, transmission through the pi
Nuileated Red Corpuscles in the Fcetu
NucLEON IN Fcetal Blood
in the placenta
Nutrition of the Fcetus
Obelio.v, region of cranium
OiiLiTERATioN OF BiLE-DucTs, congenital
Occipito-atlantoid Joint in Fcetus
OciUPATioN in Precjnancy
QiDEMA Neonatorum
(Esophagus op Fcetus, anatomy of
development of
Olicohtdramnion
Omentum of Fcetus, anatomy of .
Omphalitis Neonatorum
O.mphalokrhacjia Neonatorum .
Onychooryphosis in Fcetal Iohthyosi
Ophthalmia Neonatorum
Opium, inliuence upon the fretus .
OllGANOGENESIS
Os Tribasilare
Osmosis in the Placenta
Ossification of the Clavicle .
face bones
long bones
of sternum
vertebrfe
Osteo-chondeitis, syphilitic
PAOE
378
479
388
237
' 75
73
6
72
49
55
59
46
48
53
63
63
43, 67
72
54
74
65
51
74
62, 463
59
219
74
60
138
225
. 57, 58
272
335
33
101
156
139
141
150
145, 152
46
363
106
475
74
112
90
381, 406
113
61, 62
65
51
52, 53
269
7, 10
346, 349
158
81
82
82, 85
82
82, 88
238
520
ANTKNATAI, I'ATl lOI.OdV AND HYdlKNK
OsTEOfiENESIS ImI'EIIKKCTA
OSTEOI'SATHYIIOSIS
OvAKiES OF FcETiTs, aiiatomy of
Palpatiox of F(etal Heart Bej
Panckeas of F(KTU.s, anatomy of
secretions of .
syi)liilis
Paralysis, facial, in now-liorn
Pakasitism of Fietal Life
Para-thyroids, Amition of, in t!
Parotitis in the Fcetus .
Pahs Commvxicaxs of Aoista
Paternal History in Antenat
inlliiencf in fietal malaiiii
in sypliilis
uiiuii the weight of the fo-tus
Pathui:enesis of Acanthoma oi
ceiihalha;matonia
congenital absence of skin
ainimtatioiis
ele]ihantiasis .
congenital gastric spasm
goitre .
hy])ertrichosis .
lirulapsus uteri
PvrHixiENEsis ok Facial Paraly
fietal ascites .
asphyxia
bone disease
fractures
ichthyosis
keratolysis .
sy])hilis
variola
general fietal drops}' .
liyi.Irainnios
liyiiertrojiliy of liladder
obliteration of the bile-ducts
oligoliydramnion
I'laeental htemorrhages
Pathology-, antenatal, and anati
and liotany
and dermatology
and emliryology
and general jiathology
and g_ynecology
and legal medicine
and medicine .
and neonatal ])atliology
and obstetrics .
ami orthojiedics
and ]iediatrics
and jihysiology
and ])svchulogv
and jniblie health
and surgery
Patholooy, antenatal, definition
interest in
journal
lecturesliip
literature
novelty
]iractical importance .
relations
sulidivisions
ic fietu
L DiAi:
Amxu
SIS IN NeW-DORN
40, 334, 340
335, 340
. im
13t;
]14
160
236
46
78
165
IflS
112
437
203
252
168
333
45
329
396
304
366
370
325
387
47
360
412
, 339, 350, 352
394
314, 317
320
243
189
294
404
382
.■!64
407
399
17
17
20
17
17
22, 32
20
19
21
19
20
19
17
20
19
20
12
13
13
3
16, 21
INDEX OF SU13.JECTS
i21
Pathoi.ooy, embryonic
Pathology, tVetal .
classification .
comparative
emliryoDic factor in
limited knowledge of .
placental factor in
principles of .
scu]ie of
PATiiOMKn", germinal
Patiioi.i>i;y, neonatal ; antenatal factor in
investigation .
nomenclatnre .
Pathoi.ooy of Blood in Fcetal S
congenital prolapsus uteri
cystic elephantiasis
fcetal ascites
asphyxia
bone disease
death
endocarditis .
ichthyosis .
malaria
syphilis
tuberculosis .
tyjilioid
general fretal dropsy .
lieart in fetal syphilis
hyriramnios
hypertro]ihy of bladder
obliteration of the bile-ducts
jilacenta in syphilis
placental lisemorrhages
tylosis ]ialm!e .
Pkculiakities of Fcetal Morbid States
Pelvis of Fcetus, anatomy of
development of
Pkmi'Hicus, antenatal
neonatorum
syphilitic
Peptonukia, in pregnancy
Pekiartf.eitis in Fa:TAL Syphilis
Peritonitis, tVetal
Permeability, placental .
Perxicious Icteric Cyanosis
Persistence of Fcetal Cardiac Activi
PERTrssis IN the Fubtus .
Petrification of Dead FiETUf
Phosphates in the Fcetus
Phosphorus in the Placenta
poisoning in the fnetus
Phy'sical Examination in Antenatal
Phy-sical Signs of Hydramnios
Physiological Readjustment at Birth
traumatism of birth
Physiology of the Fcetus
of mother in pregnancy
of neof etal period
of neonatal life
PiLOSISM .
Pituitary Body, functions of, in fcetus
Placenta, allantoic
anatomy of
changes in fcetal death
chemical composition of
circulation in the
337, 339,
PAGK
12
12
174
17
185
173
179
172
172
12
42
33
33
235
385
298
358, 360
. 412
342, 348, 352
176, 420
. 371
308, 315
203
229
212
9, 201
292
235
403
381
364
230
399
318, 319
176
116
87
327
74
227, 238
419
235
236, 362
182
64
134
198
425
149
151
265
442, 444
401
38, 39
35
126
127
80
34
322
167
154
122
423
150
127
522
ANTKN.MAI. I'.VniOLOCIY AND HVCJIKXK
Placenta — cnntln ued.
comparative Iiistology of
connections, in ncolVi-tal iieriotl
developnient of
disease of, tii'atment of
excretion tlirougli tlie .
iiliro-fatty degeneration of
in f(etal anthrax
in fietal sypliilis
in general fotal dro]isy
liaimorrliages in the
lesions of, lethal elfect
life history of .
metabolism in the
nutritive functions of .
pathology of, in cdaniiisia
separation of the
sepsis of . . .
teratology
toxicitj' of .
tuberculosis of
vessels of
vitelline or omphaloidean
PXEVMONIA, fcetal .
in foetal syjiliilis
Poisons, efl'ect of, on the fu-tus
storing up of, in placenfci
Polytrichia
Post-mortem Chaxoes ix the Fcetus
postxatal diagxosis
pathology
treatment of antenatal morbid state
Potential Morbidity of Ixtrauterixe
Pregnancy, diet in
exercise in .
extrauterine
liydropholiia in
hygiene of .
occupation in .
physiolog}' of .
vaccination during
Pregnant Women, hospitals for .
Pre-Materxity Hospital, plea for
Premature Infaxts
Premature Labour
in fretal death .
Pressure Effects of Labour
Prevention, antenatal
Prochownick's Diet in Pregxancy
Profeta, law of .
Prognosis ix Fcetal Exdocarditis
fretal ichthyosis
hydramnios
obliteration of the bile- ducts .
tylosis palniiB .
Projectiox of Antenatal into Postx
Prolapse, congenital, of uterus .
Propuvlaxis of Tubercle
Protection of the Fcetus by the Placi:
" Ptebiox " Regiox of Skull
PlERICULTURE
rfERpKp.AL Fever of the New-borx
Pulmonary Circulation ix the Fcetu
Pulse of Fiktus, characters of
Pupillary Membraxe, development of
Purpura, fa?tal
SS, 89;
90, 91
1S2
84
92, 93
479
163
399
2-J2
230
294
398
183
122
184
155
281
37, 38
217
17
281
181, 209
123
154
221
234
259
180
321
178
450
5
461
179
223
471
475
127
194
470
466
62, 463
455
427
36, 37
14, 19
473
246
373
314
403
365
319
2
25, 384
216
180
104
13, 465
59
130
137
90
219
I
INDEX OF SUBJECTS
523
PvLORUS, congenital li3-iiertrojiliic steuosis of
PvocYAN'io Disease, immunity against .
I'AQB
365
195
QflCKEXIXC.
Rabies, Fovtal
Rachitis Coxgexita
f<etal ....
Rarity of Fietal Tuberci'losis .
Rate of Fcetal Heart Beat
Readjustments, neonatal, distinbed
liliysiological, at liirtli
Rectum of Fcetus, anatomy of .
Kicnioxs OF the Spixe IX the FoiTUS
ReiUstratiox of Still-Biuths .
Rr.i.APsixu Fever ix the Fietus .
RksI'IIIATIOX IX THE FlETl'S
intrauterine
pulmonary, cause of .
ReSI'IRATORY MoVEMEXTS of F(ETUS
Retention of Dead Fletus
Rheumatic Fever in the Fietus
Ribs of Fietus, anatomy of
Rii:iDiTY, congenital spastic
RiGiiR JIoRTis IN the Fcetus
RiTTEu's Disease .
223
335
335
210
135
66
3S, 39
119
106
464
198
143
169
40
144
427
223
109
389
178, 413
. 63, 72
Sacrum of Fcetus, anatomy of
ossification of .
Salivary Glands, clianges in the neofn'tal jieriod
secretion in the fivtus .
Salts ix the Fietal Blooh
"Sanatoria de Geossesse "
Sapoxificatiox of Dead Fcetds
Scapula of Futus, anatomy of
Scarlet Fever in the Fietus
Scheme of Axtexatal Life
Sclerema Neoxatorum .
Scope of Axtexatal Diagnosis
Sebaceous Glaxds, development •
secretion in tlie fcetus .
Secretioxs of the Fcetus
of the placenta
Sensation in the Fcetus .
Separation Results of Birth
Sepsis, fetal
neonatorum
Serous Membranes, secretions of, in tlie foetus
Serum Test for Fcetal Typhoid
Sex, microscopically recognisable in neofcetal period
Sexi'al Glaxds, development of .
Shoulders of Fcetus, measurements of .
Sigmoid Flexure of Fcetus, anatomy of
Sixgultus, fcetal ....
Sixus of Meckel of Placenta .
Skeleton, fetal, diseases of
Skiagraphy ix Axtexatal Diagnosis .
Skix', congenital absence of
development of . . .
in fcetal syphilis
Smallpox ix the Fcetus .
Spasm, gastric, congenital .
Sphygjioorams of New-born Ixfaxt
Spixa Bifida and Coxgexital Uterixe Prolapse
. 117
. 107
82
. 159
. 141
. 470
. 424
. 109
. 196
. 7, 10
74
. 431
88
. 160
159, 160
. 158
. 170
. 37, 38
217, 220
60
. 160
. 200
82
82, 86, 87, 90
. 109
. 115
144, 169, 441
. 123
237, 334
. 448
. 328
85
238
176, 188
. 365
. 138
. 387
524
ANTKNAJAl. I'A TIIOLOC^' AND PnXMENE
'
SriXAl, Coiti) IX I'lKiTs, anatomy of
development of . . .
SriKE OF FiETUs, anatomy of
Si'iiiALiTV, fii'tal, of Falloiiiun tulic.--
Si'l,KEX OF FovTf.s, anatomy of
in syphilis ....
St. Kilda, the .scourge of .
Stexosis of Pylokus, congenital hypiTtiophic
Steiixvm of F(ETr.'i, anatomy of .
ossification of .
Stikkage .....
Stomach ok Fikti'.s, anatomy of .
contents of ....
development of . . .
StouiXG Ul' OK SviWTAXf'ES IX THE Pl.ACEXTA
Stkuma Coxgexita
" suckixg-pabs " ix fcetus
SuDOKiPAEors Glaxds, develojinient of .
Sugar in the Lkjuor Amxii
SuLPHUKK^ Acid, poisoning with, in ])regnancy
SuritA-KEXAL Capsule.s of FtETU.'i, anatomy of
development of
functions of .
in syphilis
Sylviax Fissure .
Symptomatic Icterus Neoxatorum
Sy-mptomatologv of Coxgexitai. Ki.eph.
of congenital gastric spasm
of congenital goitre
of congenital liyjicrtrichosis
of congenital prolapsus uteri .
of f'etal ascites
of ffletal bone disease .
of ffctal death .
of fictal ichthyosis
of fietal keratolysis
of general ffetal drojisy
of hydramnios .
of obliteration of the bile-ducts
of oligohydramnion
of tylosis jialma;
Svxcvtiu.m ok Villus
SYXOXYMs UK CnNKINITAL H VPE RTRICHOS
of f.f^ll irlitllV.isis
of fn/tal li.k.-ts
Syphilis, embryonic
Syphilis, F(Etal, diagnosis
dystrophies
effects ....
limitation of .
morbid anatomy of
nature of causal agent of
]iathogenesis of
placenta
tran.snii.ssion .
treatment
Tail, in the neofiptal jieriod
"Tails" ....
Teeth, development of
formation of, in ncofcital )ieriod
in congenital hypertrichosis .
Telegoxy, mechanism of .
Temperature of the Fcetus
of the liquor amnii
Tekatogexesis
I-AOK
106
$:>, 88
106
30
114
23B
57
365
109
S2
169
113
160
86, 87
158
374
103
88
223
267
115
S6
166
236
S2, 87
67
303
366
376
324
386
357
39, 348
415
307, 315
320
290
401
363
408
319
124
321
7, 315
335
228
238
239
254
225
229
244
243
8. 230
245
7, 477
81
326
89, 91
82
324
185
145
146
17
INDEX OF SUBJEC'IS
Teuatolooical Rkcokiis ok Chaldka
Teratology
comparative
isolated position
of plants
TeR ATOM ATA
TK.r.ATOSCOI'Y
Tes'I'KLe, descent of
in fii'tal sypliilis
Tetanus Neoxatokum
Tiii'.ORV, Bauuigaiten's, of lateucj'
TlIEIlAl'ElTlr FtETRTDE .
Tuekapeutr'S, antenatal .
germinal
of fffital diseases
of malformations of genitals .
Third Generation, syphilis of .
Thomsen's Disease
Thoracic Duct of Fietus, anatomy of
Thorax of Foetus, anatomy of .
Thromdo-arteritis of Umrilicus
Thymus of Fietus, anatomy of .
changes in, in f t-tal syphilis .
development of
function of .
in neofiital period
physiology of .
regulator of growth
Thyroid Gland in Fcetus, anatomy of
development of
enlargement of
function of .
hypertrophy of
in neotVetal period
regulator of metaliolism
Thyro-mucoin in F(etal Thyroid
Tobacco Poisoning, effect upon the fcetui
Tonsils, development of .
Torsion of Umbilical Cord
Torticollis, congenital .
Toxicological States
ToxiNES, transmission through the placenta
Trachea in Fcetus, anatomy of .
development of .
Transition Changes in Neofcetal Pei
organism
traumatic, of 1 lirth
Transmission of Diseases from Fietus
of fVetal malaria
of microbes through the placenta
of substances from fcetus to raotlicr
of syphilis, mode of .
through the liquor amnii
through the placenta .
Trau.matk; Morbid States of the Fietu
Traumatism and Infection
intranatal . .
Treatment of Congenital Dislocation
elephantiasis .
gastric spasm .
hypertrichosis .
fii'tal ascites
death ....
endocarditis
keratolysis
nervous maladies
175, 1
12
17
(i
17
174
i
90, 91
237
57, 58
213
13
14, 15
484
451
30, 31
254
391
112
83, 108
62
109
235
86
164
83
484
164
107, 108
86
374
164
165
83
165
166
272
87
120, 400
53
175, 259
157
107
87
83
80
35
84, 188
203
181
163
244
181
156
5, 393
23, 24
35, 44
50, 51
325
362
428
373
320
479
520
ANJl-.NAl'AI. I'A'llIOl.OdY AM) inciKNK
TitEATMENT— C'/H</)ll(((/.
syi.hilis
fjfiicral fiital ilrojisy .
liii'iiiogiliiliit
liydianiiiios
intranatal, nf fn-tal disease
oliliteratioii of tlie liile-ilucts .
rtcmreiit placental disea.se
tylosis i)ahuic .
TitKMOH, hereditary
TltlliASILAR BOXE IN FlKTAI. KllKETS
Trkhauxis
TltllHOSTASIS
TUBKRCLE, iVetal, bacteriology of .
cases of . . .
characters of .
dystroi)hies of .
eWdencc of existence of
heredity in .
latency of .
malformations in
liathology of .
jirophylaxis of
rarity of
TUBKItCrLOSIS OF THE FfETUS
of the placenta
Tr.Morns hf Fietus
genital organs .
Twis-BEAHIXG, lieredity of
Twins, dilference in tenijierature of
syphilitic infection in .
variola in .
Tylosis Palm^ et Plant.e
Tympanic Cavity of Fietus, anatomy of
Tyi'hoid Fever in the FtETUs
serum test in .
Ui.CEU, congenital .
umbilical
Umbilical Arteries, anatomy of
cord, anatomy of
development of
intestine in .
morbid conditions of
syphilis of .
lochia ....
vesicle, function of
vessels, changes in, at liirtli
Umhilicu.s, blenorrhcca of .
granuloma of .
hajmorrhage from
lymphangitis of
ulcer of . . .
Uracih-s of Fcetus, anatomy of .
Urea in Fcetal Bluod
I'llKIKIl ....
Ureters of Fietvs, anatomy of .
Urethra of Fcetis, anatomy of .
Urinary System, diseases of, in f'ctus
Urine, fretal
clieniical composition of
excretion of .
Uterus, changes in, in IVetal death
congenital jirolapse of the
fietal, anatomy of
pregnant, tenipeiature of
■-'97
. 480
406
. 463
. 365
. 479
. 319
. 300
34t), 349
. 321
. 325
181, 208
207, 208
. 212
. 214
. 207
215
. 213
. 215
. 208
. 216
. 210
. 206
209
. 175
25
. 438
146
. 247
. 190
318
104
. 199
. 200
329
62
116
112. 120
88. 90, 91, 92
81
400
231
60
154
62
62
112
141
82
116
120
378
92
162
161
425
384
119
146
INDEX OF SUBJECTS
A'aCCISATION of the F(ETUS
Yagin'a ok Fcetus, anatomy of
development of
Vaoixal Glands, secretion of, in the fietus
Vacitus UTEraNUs
VALrE OF F(ETAL LiFE, estimation of
relative
Varicella in the Fcetus
VaKIOLA of FtETVS
clinical history
comiilications .
diagnosis
ernption
iuculiation jieriod
jiathogenesis .
prognosis
stages ....
treatment
Veexix Caseosa, composition of .
development of
VEKTEnnAL CoL^■MX OF FtETUs, anatomy of
ossification of .
Vesicle, umbilical
A'essels, changes in, in fretal syphilis
congenital atheroma of
vitelline
Vestibvlah Baxd is F<ETr.s
ViEUSSENS, linilms of
A'illi, changes in structure in pregnancy
chorionic, structure of
Vitelline Cieculation ix Neofietal P
placenta ...
A'OLVi'Lrs, congenital
Wegxkr's Sigx of Fietal Syphilis
Weight of the Fietus, causes of variations
Whaktux's Jelly of Umbilical Cord
V'idal Sekum Test for Typhoid
Winckel's Disease
WoLFFiAX Bodies, development of
■'VouKDS of the Fcetus
XaNTHOCYTES IX' THE FcETUS
Yellow Fever ix the Fcetus
YuLK-sAc, function of
527
I'AUK
193, 194
119
87, 89
160
143
455
457
198
176, 188
189
192
193
192
190
189
193
192
193
160
!9, 91, 92
. 106
', 88, 106
83, 154
. 235
. 374
154, 155
120
111
38
124
83
154
367
237
168
121
200
63, 64
82, 86
178, 395
. 139
. 198
. 154
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