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MEDICAL REPORT OF THE 
 
 Society of the Lying-In Hospital 
 
 OF THE CITY OF NEW YORK 
 
 INCORPORATED MARGE 1, 1799 
 
 I^EW YORK 
 D. APPLETON & COMPANY 
 
 1897 
 
Press of J. J. Little & Co. 
 Astor Place, New York 
 
PREFACE 
 
 In presenting the following Report, the Medical Board wishes again to 
 call attention to the fact that this Hospital is an institution the purpose of 
 which is to teach obstetrics quite as much as to conduct a work of charity. 
 
 It has, therefore, seemed proper to describe at some length the methods 
 of instruction in use at the Hospital, and also the system of taking histo- 
 ries and recording statistics. 
 
 The clinical basis of this Eeport is derived entirely from the outdoor 
 service of the Hospital. 
 
 Following the articles on methods of instruction is a statistical synopsis 
 which covers a period of six years, from the beginning of the present sys- 
 tem in the Midwifery Dispensary at Sli Broome Street, to April 1, 1896. 
 
 This statistical synopsis includes the figures in the two Reports of the 
 Midwifeiy Dispensary issued in 1891 and 1892, and also the figures of a 
 similar s3mopsis published by this Society in a medical report in 1893. 
 
 There are also presented here articles based upon the cases in the ser- 
 vice of the Hospital, by members of the Medical Board. 
 
 In addition, articles have been contributed by the heads of the special 
 departments, and by the assistant attending physicians. 
 
 Regarding the articles contributed by ofiicers who are not members of 
 the Medical Board, it may be said that the opinions therein stated are the 
 opinions of the individual writers, and are not necessarily endorsed by the 
 Medical Board. Such articles have been more or less carefully supervised, 
 but there has been no attempt to influence or restrain the opinions of the 
 authors. 
 
 It will be noted that there is no report from the OphthalmQlogist, the 
 IsTeuroloo-ist, or the Dermatoloo^ist. This is due to the fact that the mate- 
 rial at present collected does not warrant a report from those departments. 
 
 In anticipation of an obvious criticism that many subjects of interest 
 which must have been found in so large a series of cases have not been 
 reported, the Board wishes to say that these subjects have been reserved 
 for a future Report. 
 
Digitized by the Internet Archive 
 
 in 2010 with funding from 
 
 Open Knowledge Commons 
 
 http://www.archive.org/details/medicalreportofsOOsoci 
 
CONTENTS 
 
 PAGE 
 
 Preface, iii 
 
 Governors, vii 
 
 Officers, vii 
 
 Medical Board, vii 
 
 Assistant Attending Physicians, viii 
 
 Special Departments, viii 
 
 1. 
 
 2. 
 
 3. 
 4. 
 
 5. 
 
 6. 
 
 7. 
 
 8. 
 
 9. 
 10. 
 11. 
 12. 
 13. 
 14. 
 15. 
 16. 
 17. 
 18. 
 19. 
 20. 
 21. 
 
 Medical Records and the Preparation of Statistics, 
 Practical Instruction Given by this Hospital to Graduate and 
 Undergraduate Pupils, 
 
 Theoretical Lectures.— Demonstrations— Recitations, 
 
 The Instruction of Nurses, 
 
 Statistical Synopsis, . . . . . H. McM. Painter, 
 
 Students of the Hospital, 
 
 Statistical Report of Forceps Operations, Austin Flint, Jr., 
 The Premature Interruption of Pregnancy, James Clifton Edgar, 
 
 Asepsis, Morbidity, and Mortality, 
 Congenital Cystic Kidneys, 
 Deformed Pelves, 
 Case of Cesarean Section, 
 Case of Alexander's Operation, 
 
 Version, 
 
 Fractures in the New-Born, . 
 Placenta Previa. 
 
 Report of Curator, 
 
 Report of Orthop.^dic Surgeon, 
 Report of Embryologist, 
 Report of Pathologist, 
 Report of Bacteriologist, 
 
 Samuel W. Lambert, 
 Martha Wollstein, 
 Austin Flint, Jr., 
 James W. MarJcoe, 
 James W. Markoe, 
 Austin Flint, Jr., 
 Churchill Carmalt, 
 George R. WJiite, 
 
 James W. Markoe and Martha Wollstein, 
 
 T. Halsted Myers, 
 George S. Huntington, 
 Farquhar Ferguson, 
 Martha Wollstein, . 
 
 52 
 65 
 71 
 79 
 106 
 108 
 114 
 219 
 253 
 258 
 272 
 274 
 275 
 283 
 308 
 317 
 320 
 324 
 351 
 352 
 
GOVERNORS. 
 
 Egeeton L. Winthrop, George G. Williams, 
 
 Frederic Bronson, Williajvi Greenough, 
 
 William A. Duer, F. Delano Weekes, 
 
 Edmund L. Baylies, Henry A. C. Taylor, 
 
 Egerton L, Winthrop, Jr., Francis S. Bangs, 
 
 Thomas I^ewbold, Edward W. Lajvibert, M.D. 
 
 OFFICERS. 
 
 President. 
 William A. Duer, 
 
 115 Broadivay. 
 Vice-President. 
 
 George G. Williams, 
 
 Chemical National Bank. 
 Treasurer. 
 
 Frederic Bronson, 
 
 76 Wall Street. 
 
 Secretary. 
 F. Delano Weekes, 
 
 58 Wall Street. 
 
 MEDICAL BOARD. 
 
 Consulting Physicians. 
 
 Edward W. Lambert, M.D., William M. Polk, M.D., 
 
 Thomas M. Maekoe, M.D., William T. Lusk, M.D. 
 
 Attending- Physicians. 
 
 James W. Maekoe, M.D., H. McM. Painter, M.D., 
 
 Samuel W. Lambert, M.D., J. Clifton Edgar, M.D., 
 
 Austin Flint, Jr., M.D. 
 
ASSISTANT ATTENDING PHYSICIANS. 
 
 Asa B. Davis, M.D., Geokge R. AVhite, M.D., 
 
 Churchill Carmalt, M.D., R. C. James, M.D., 
 
 ^y. E. Studdiford, M.D. 
 
 SPECIAL DEPARTMENTS. 
 
 Orthopaedic Surgeon. 
 
 T. Halsted Myers, M.D. 
 
 Embryologist. 
 
 George S. Huntington, M.D. 
 
 Neurologist. 
 
 C. A. IIektkk, M.D. 
 
 Pathologist. 
 
 Farquiiak Ferguson, M.D. 
 
 Ophthalmologist. 
 
 J. L. Adams, M.D. 
 
 Bacteriologist. 
 
 Martha Wollstein, M.D. 
 
 Dermatologist. 
 James Johnston, M.D. 
 
 Assistant Registrar. 
 
 Asa B. Davis, M.D. 
 
 Assistant Curator. 
 
 Martha Wollstein, M.D. 
 
 Chief Clerk. 
 
 Charles Ford. 
 
 Chief Nurse. 
 
 Miss E. Miller. 
 
 Assistant Nurse. 
 
 Miss Margaret M. McCarthy. 
 
 Registrar's Clerk. 
 
 Helen F. Nugent. 
 
 hospital. 
 Second Avenue and Seventeenth Street. 
 
 SUB-STATION. 
 
 Ko. 314 Broome Street. 
 
 DIET KITCHEN. 
 
 No. rJU JiuooMK Strkkt. 
 
MEDICAL REPORT 
 
 OP THE 
 
 SOCIETY OF THE LYING-IN HOSPITAL 
 
 MEDICAL EECOKDS AND THE PKEPARATION OF STATISTICS. 
 
 SYNOPSIS. 
 I. Introduction. 
 
 II. The Nature op the Statistics. 
 
 a. Indoor Service. 
 
 b. Outdoor Service. 
 
 c. The Student Observer. 
 
 1. His Inexperience. 
 
 2. His Entliusiasm. 
 
 d. The Checks on the Student. 
 
 1. Fixing- Responsibility for Written Recoixls. 
 
 2. Written Reports to Transfer Responsibility from Student to House 
 
 Staff. 
 
 3. Personal Investigation of Abnormalities by Trained Assistants. — 
 
 Abnormality Book. 
 
 4. Personal Inspection of the Records at the Bedside by Trained 
 
 Assistants. 
 
 5. Daily Rotation on the Postpartum Cases. 
 
 6. Time-clock Stamp. 
 
 III. The Histories. 
 
 a. The Blanks. 
 
 1. Their Development. 
 
 2. The Forms in Present Use. 
 
 X. Medical. 
 
 y. Administrative for Students. 
 
 z. Administrative for Patients. 
 
 b. The Writing of the Records. 
 
 1. The Student. 
 
 2. The Assistant Resident Physician. 
 
 3. The Discharge of Patients. 
 
 c. The Checks on the Histories. 
 
 1. The Attendance Book. 
 
 2. The Attendance Cards. 
 
 3. The Operation Book. 
 
REPORT OF THE SOCIETY OF THE LYING-IN HOSPITAL. 
 
 TV. The Registrar's Office. 
 a. The Registrar. 
 
 1. General Oversig:lit. 
 
 2. Annual Statistical Report. 
 h. The Assistiint Registrar. 
 
 1. Nunihering the Histories. 
 
 2. Siunmarizing the Diagnoses. 
 c. The Registrar's Clerk. 
 
 1. The Lai'ge Statistic Book. 
 
 X. Special Arrangement. 
 y. Summarizing Pages. 
 z. Clieck on this Book. 
 
 2. The Card Index. 
 
 u". The Individual Cards. 
 y. The Checks on the Cards. 
 
 V. Conclusion. 
 
 I. iNTRODrCTION. 
 
 It is the practice of every hos]ntal to demand of its resident medical 
 staff that a more or less complete medical history be kept of eveiy patient 
 in its wards. These histories are bound in volmnes, and are stored away 
 to be referred to, perhaps, by some members of tlie Medical Board who may 
 desire to investigate a special subject, or to be produced as evidence in a 
 court of law. It is unusual, in this country at least, that any systematic 
 use should be made of the valuable records thus filed away every year. 
 The Johns Hopkins Hospital is the one preeminent exception to this gen- 
 eral rule, and the reports of that institution are unsurpassed by any similar 
 I'eports pul>li.shed in this country or abroad. The first reports recently 
 published from the Children's Hospital in Boston, and the Presbj^terian 
 Hos{)ita] in Xew York, must be added to this list. 
 
 The Society of the Lying-in Hospital has made three previous publica- 
 tions of this nature, and it is the purjiose of this article to present its 
 method of recording its oljservations and of prei)aring its statistics for ref- 
 erence and use. There is no new principle involved, but perhaps a knowl- 
 e<lge of some working system may be of service to othci's avIio may desire 
 to establish a series of re])orts. The sy.stem liere developed deals only Avitli 
 obstetrical cases, and it is not complicated, except where it encounters the 
 ])ossible coni])lications of ))regnancy, labor, and the iMicrjx'i'al state. The 
 neces.sary elasticity is given to this part of the system Ijy the use of the 
 card-index system, so generally employed in library catalogues. 
 
 TT. Thk Natuke ok thk SrATrsTics. 
 
 The obstetrical service of the Society of tlie Lying-in Hospital furnishes 
 two distinct kinds of statistics: tliose of the indoor and those of the out- 
 door service. The indoor .service was estalilished in January, 1805, and 
 
THE MEDICAL RECORDS AND THE PREPARATION OF STATISTICS. 3 
 
 consists at present of seventeen beds. The histories are written by the 
 resident medical staff, and are accurate records of the observed facts. 
 This small plant has furnished 411 cases at the present time, October 1, 
 1896. These histories have been bound in volumes of one hundred, and 
 the statistics have been kept separate from those derived from the out- 
 door ser\ice. 
 
 The outdoor service was organized on its present basis, but under 
 another name (see previous Reports) in January, 1890, and has furnished 
 11, -492 cases up to the present date, October 1, 1896. These histories are 
 written by the pupils of the Hospital from observations made by them. 
 The pupils are obtained from various sources : from the ranks of practising 
 physicians, from the undergraduate classes in our Medical Schools, and from 
 the graduates of nurses' training schools. Of these, the medical student 
 forms a very large majority. All the facts demanded by the history blanks 
 of the outdoor service are recorded, with few exceptions, by undergraduate 
 medical students. 
 
 This unqualified statement would lead to a very erroneous estimate of 
 the scientific value of these statistics, were there not added to it a detailed 
 account of the various checks emplo3^ed to make the student do his work 
 in a careful and reliable manner. As to the fitness of the medical student 
 to do such work, it is the opinion of the Medical Board of this Hospital, 
 that, unassisted and unchecked, his inexperience would be an absolute bar 
 to his employment. But we believe, under careful oversight, the medical 
 undergraduate can become an accurate observer and recorder of facts. 
 The inability of medical students to make clinical observations, it is 
 believed by the Medical Board, is due to the faulty system of instruction in 
 our Medical Schools, in which the old theoretical lectures still hold the 
 prominent place to the exclusion of classroom work, and indi^i[dual, 
 clinical instruction of the student at the bedside. 
 
 This Hospital accepts as pupils any student, male or female, who has 
 finished a two years' course of study in any medical school. Many students 
 have received their first clinical experience here, and it must be said that, 
 as a class, they have been most enthusiastic in their desire to learn, and 
 energetic in their work. They have shown a feeling of responsibility 
 toward our patients which has insured the latter a considerate and careful 
 treatment. A perusal of the subsequent articles on the teaching of students 
 will show how we prepare the raw material, and so instruct the student 
 that we may use him in the capacity of combined nurse and midwife. 
 
 A further study of the following sj^stem of checks upon his work will 
 show the means we employ to keep the student in the straight path of 
 scientific accuracy in spite of his inexperience, or of an exceptional desire 
 of some individual to shirk. 
 
 First. — The responsibility of every written record is fixed, by requiring 
 the student to sign his name to the patients' histories, to the records of 
 daily visits, and to every other written chart which the details of the 
 service demand of him. 
 
 Second. — The student is required by these charts and blanks to make 
 
4 REPORT OF THE SOCIETY OF THE LYING-IN HOSPITAL. 
 
 written reports, at least every two hours, .concerning the condition of all 
 cases of labor while in ])voiiress. A final written rojun't of each case deliv- 
 ered is tilled out upon his return to the Hospital, utul he must make an 
 oral report of all ol)servations when he returns from his daily ])ost])artuni 
 visits. In these ways tlie res})onsibility for every observation is immedi- 
 ately shiftetl from the student to the physicians on the house staff. 
 
 T/tlr<L — "Whenever one of these reports indicates the existence of any 
 abnormal or unusual condition, one of the resident staff of ])hysicians is 
 sent to corroborate the unusual occurrence or to investigate the complica- 
 tion. The reports of the house staff upon these visits are written in a l)ook 
 known as the "Abnormality Book." These reports are subsequently 
 copied into the daily record upon the history chart of the patient, by the 
 office clerk on night duty. 
 
 jFoif/'t/i. — The students are visited while they are in attendance at their 
 cases by the assistant physicians of the staff. The records of the cases are 
 ins]iected by the physicians during these visits, while they are being written, 
 and any eri'ors can be corrected. 
 
 Fifth. — The postpartum cases are redistributed among the students 
 every twenty -four hours, in order that each student may have as convenient 
 a route as possible through the tenements. This custom insures also a cor- 
 rection, by a more careful student, of any possible oversight made by a 
 fellow-student on the previous day. 
 
 Sirfh. — A time-clock stamp is in use in both the central office of the 
 Ilosjiital in Seventeenth Street, and also in the office of the sub-station in 
 Broome Street. These clocks stamp upon the original woi'king blanks of 
 the Hospital the date, hour, and minute of the reception of the calls, 
 orders, departure and return of students to and from cases, etc. In this 
 way an absolutely accurate time record is kept of the Hospital business, 
 and there is insured prompt service and an economical expenditure of time 
 on the i)art of the student. 
 
 HI. Tin: Histories. 
 
 TIk' Itlanks used for the recording of the olDStetrical histories liave 
 been developed U-om a study of similar charts used in other institutions, 
 and fi-oin tlic personal views of the members of the Medical Board. 
 Tlie Hospital owns two scra])-l)ooks : in one is kept a sam])lc of every 
 kind of stationery that has been print ('«1 U)V its own use; in the other, 
 copies i){ tlie nuMlical and administrative blanks of other hospitals are 
 collected. From time to time the charts have l)een revised, ;tnd the 
 present fonn is the result of six years' use and experience. The i-egular 
 Ithudis of the indoor and outdoor service are identical, exce])t in size. 
 The in<loor history blank is thirteen and one-half inches Avide by fourteen 
 ;in(l one-half inches long; that of the outdoor service, eleven inches wide 
 by seventeen inches long. The indoor service recjnires a tem])erature chart 
 and a blank iov bedside notes, which ai'e not used in the outdoor service. 
 The regular blanks are, a single-sheet "Pregnancy" chart, and two 
 
THE MEDICAL RECORDS AND THE PREPARATION OF STATISTICS. 5 
 
 double-sheet charts stj^led "Labor" and "Child," Special blanks, also, 
 for recording postpartum observations extending over periods longer than 
 ten days, and also for special pathological or operative work, and a special 
 form for cases of albuminuria, are in use in both services. Reproductions 
 of the regular blanks and of the special albuminuria blank are presented 
 below; the others present no features not included in these. It will be 
 noticed that the charts call for a very complete series of observations upon 
 the phenomena of pregnancy, labor, and the puerperium. They may 
 seem unnecessarily full, but it is the opinion of the Medical Board that 
 only by insisting upon such minute observations during the period of 
 instruction can the young physician be taught the necessity of attention to 
 detail; onlv thus can the habit of careful observation be inculcated, and 
 only thus can the ability to obtain an accurate, comprehensive impression 
 of a patient's condition be acquired. Such a chart serves also as a guide 
 to the student in his outdoor work during the absence of his instructor. 
 The studeut takes a miniature set of these charts to every case of labor, 
 and notes the required facts at the time of their occurrence. These records 
 are subsequently copied upon the full-sized blanks. 
 
6 REPORT OF THE SOCIETY OF THE LYIXG-IX HOSPITAL. 
 
 PREGNANCY. -OUT-DOOR SERVICE. 
 
 CONFINEMENT No APPLICATION No. 
 
 SOCIETY OF THE LYING-IN HOSPITAL 
 
 (No. of Cards ' OF THE CITY OF NEW YORK, 
 
 1 7th Street and Second Avenue, 
 NEW YORK. 
 
 PREGNANCY. 
 
 Name of Applicant,. 
 Address, 
 
 Date of Application iS 
 
 Room 
 
 House, Floor 
 
 eld patient, 
 
 i' old patient, \ 
 
 \ City Mission, I 
 
 » •■ »• J 1. »u.«..~u Eastern DisKnsary, \ 
 
 Application made by through ^ y^^ y^,,./. 25,s*,.„5l,o', i 
 
 i Hebrew Chanties, \ 
 
 \ previously confined, ] 
 
 Birthplace, Married Single, Widow, Age, Para,. 
 
 Diseases of Childhood, { rirst ituilkeui) 
 
 First Menstruation, {age) Character of Menstruation, 
 
 rregtilar, \ 
 egi'lar, 
 
 refuse, ly 
 
 sea nly^ 
 
 duration, 
 
 Pain, 
 
 Diseases of Puberty, . 
 
 Husband's History, 
 
 Family History 
 
 Character of Previous Pregnancies, Labors, Puerperiums {miscarriages) 
 
 ( duration, ) 
 First Labor, {date) Last Labor, (date) Last Menstruation, .' date, 
 
 quantity. 
 Quickening, {date) Condition in Present Pregnancy. 
 
 Bowels 
 
 DATE OF EXPECTED LABOR, 189... 
 
 SUBSEQUENT OBSERVATIONS. 
 
 Date 
 
 (Pathological Examinations.) 
 
 EXAMINATION OF URINE. 
 
 Date 
 
 
 
 Date 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Abnormality 
 
THE MEDICAL RECORDS AND THE PREPARATION OF STATISTICS. 
 
 A. EXTERNAL EXAMINATION. 
 
 (/ace) {attitude) 
 
 General Appearance,- 
 
 'HEIGHT OF PATIENT FT. ...IN. WEIGHT OF PATIENT ...LBS. 
 
 {size) {sensibility) 
 
 \(consistency) (veins) 
 
 Mammary Glands, ^(siriee) (areolce) 
 
 ' (papilla:) (nipple) 
 
 ^ (secretion) 
 
 (form) (pigmentation) ... 
 
 I {striie) {umbilicus) 
 
 Abdomen, -< , , , . , . ^, (intermittent \ 
 
 I (abdominal fat) \tUerine contractions ) 
 
 \ (Jiiictztation) {abd. ballottement) 
 
 „ . , ^ r o ., • -i (/««a'2«.s-) (ensi/orm) 
 
 Height from Symphysis of-( 
 
 ( (i{ inbilicus) 
 
 (rapidity) (regularity) . 
 
 Foetal Heart, 
 
 (position) (inore than one) . 
 
 Foetal Movements, (position) (character) 
 
 ,.^ . „ J \ (uterine murmur) (umbilical murmur) . 
 
 Uterine Sounds, < 
 
 ( (other sounds) 
 
 Uterus, '^''''^ ^-^"'"^ 
 
 {position) 
 
 {dorsal plane) {small parts) 
 
 Foetus, -J {head) (movements) 
 
 (size) 
 
 Circumference of (abdoi/ien at timbilicus) [pelvis) 
 
 DISTANCE BETWEEN SPINES, DISTANCE BETWEEN CRESTS,. 
 
 \R 
 
 EXTERNAL OBLIQUE, < TROCHANTERS, 
 
 (From post, sup. spine of one side to ant. sup. spine of opposite side.) 
 
 EXTERNAL CONJUGATE, 
 
 Lower Extremities, (adema) 
 
 B. INTERNAL EXAMINATION. 
 
 J (pigmentation) {secretion) 
 
 External Genitals, 
 
 ( (veins) ... (perineujn) 
 
 ! (length) {size) 
 
 Vagina, -J (secretion) {temperature) 
 
 \ (sensibility) {^nucous inejnbrane) . 
 
 ( (position) (size) 
 
 Cervix, -j [softening) (laceration). 
 
 ' (external os) {internal os) 
 
 i (shape) {consistency) 
 (situation) (mobility) 
 (presenting part) {ballottement) 
 
 PUBIC ARCH DEPTH OF SYMPHYSIS,... 
 
 DIAGONAL CONJUGATE, 
 
 TRUE CONJUGATE 
 
 TRANSVERSE DIAMETER OF OUTLET, 
 
 ANTERO-POSTERIOR DIAMETER OF OUTLET, 
 
 f (specific gravity) (reactioii) 
 
 .%) 
 
 \ (microscope). 
 Examined by , 
 
S REPORT OF THE SOCIETY OF THE LYIXG-IX HOSPITAL. 
 
 RECORD OF LABOR. -OUT-DOOR SERVICE. 
 DIAGNOSIS. SOCIETY OF" THE CONFINEMENT No 
 
 LYING=IN HOSPITAL, application no 
 
 OF THE CITY OF NEW YORK 
 
 1 7th Street and Second Avenue, (No. of Cards ) 
 
 NEW YORK. 
 
 RECORD OF LABOR. 
 
 Name ofApplicant, Date of Application, 189 
 
 Address, House, Floor, Room, 
 
 / Old Patient, 
 \ City Mission, 
 
 Eastern Dispensary, 
 
 Application made by through 
 
 ^ A «ti York liispensary, 1 
 I Hebrew Chanties, \ 
 
 \ Previously Confined, ) 
 
 Birthplace Married, Single, Widow, Age, Para,. 
 
 Diseases of Childhood, (first walked) 
 
 / irregular, 
 \ regu: 
 
 First Menstruation, (age) Character of Menstruation, - ^'^''•'' 
 
 egular, \ 
 
 regular, j 
 
 profuse, I 
 
 "\ scanty, / 
 
 t duration, V 
 
 \ pain, J 
 
 Diseases of Puberty, . 
 
 Family History 
 
 Character of Previous Pregnancies, Labors, Puerperiums (miscarriages) 
 
 ( duration, ) 
 First Labor, ((/rt/t-) Last Labor, (a'a/^) Last Menstruation, - rfa<<^. t 
 
 ( quantity, ) 
 
 Quickening, (date) Condition in Present Pregnancy 
 
 ( normal, ^ 
 
 Month of Gestation, Urine, < ^"""""' r Bowels, 
 
 \ amountf ) 
 
 PREPARATORY STAGE. 
 
 Date, (began) 189 , hour M. 
 
 Sinking of Uterus, (effect upon abdomen) 
 
 (upon chest) (upon bladder) (upon rectum) 
 
 Cervix, (shortening) (secretion) 
 
 Internal Os, (amount of dilatation) (presenting part) 
 
 Uterine Contractions, (pain ) (frequency) 
 
 Foetal Heart, (rapidity) (^regularity) (position) 
 
 Show, (date of onset) (character) (amount) 
 
 Duration, hours minutes. Date, (terminated) 189 , hour M. 
 
 FIRST STAGE. 
 
 Date, (-Ji-^aw) ^ "f^^^'"'^', ,^,. '- 189 , hour M. 
 
 ' ^ * '1 statement of patient, \ ^ ' 
 
 UTERINE CONTRACTIONS, (effect on Os) (frequency) 
 
 FOETAL HEART, (rapidity) (regularity) (position) 
 
 CERVIX, (amount of dilatation) (position) 
 
 Ciualking, ) 
 Temperature Pulse Position of Parturient, < dorsal, V 
 
 / lateral, \ 
 MEMBRANES, (intact) (spontaneous rupture) 
 
 (ariificial rupture, by whom) VAGINAL SECRETION, 
 
 Vaginal Examination*, (made by) (nu tuber) 
 
 Visited by (attending physician) (staff) 
 
 Pelvi* Soft Parti BLADDER RECTUM 
 
 Preience of Attendant, (time of arrival) :,.. 
 
 PRESENTATION POSITION Diet, 
 
 Haemorrhage, (character) (treatment) 
 
 Medication 
 
 Duration hourt, minutci. Date, (terminated) 189 , hour M. 
 
 from beginning of labor.) 
 
THE MEIJICAL RFX'OKD.S AND THE TRKPAKATK ).\ OF STATTSTICS. 
 SECOND STAGE. 
 
 Date, (lit'san) 189 , hour 
 
 UTERINE CONTRACTIONS, (i-j/cci on progress) i^/requcncy) 
 
 FOETAL HEART, (.rapidity) {regularity) (position) 
 
 CERVIX, {oedeinatous, Ineerated, incarcerated) 
 
 Position of Parturient -^f^'"'.?' 
 
 Temperature, Pulse, ^ ^. r . ,- < dorsal, 
 
 at time of delivery, \ lat^-nl, 
 
 MEMBRANES, (intact) (spontaneous rupture, and time) 
 
 (arti/icial rupture, by luhom and time) Vaginal Secretion, 
 
 Vaginal Examinations, {made by) (number) 
 
 Pelvis, Soft Parts, Bladder, Rectum, 
 
 Presence of Attendant, {time oj" arrival) 
 
 Visited by (attendino physician) " (staff") 
 
 PRESENTATION, POSITION, Diet, 
 
 Preservation of Perineum, (method) 
 
 Cord about Neck, (number 0/ coils) (treatment) 
 
 Haemorrhage, (character) (treatment) 
 
 Duration, hours, minutes. Date, (terminated) 189 , hour M. 
 
 THIRD STAGE. 
 
 Date, (began) i8g , hour M. 
 
 Uterine Contractions, (frequency) (effect on uterus) 
 
 ( sitting, ) 
 Temperature, Pulse, Position of Parturient, -s dorsal. 
 
 , -s dors 
 ( lateral. 
 
 Vaginal Examinations, {made by) (number) 
 
 INTRA-UTERINE MANIPULATIONS, 
 
 Presence of Attendant, (time 0/ arrival) - . . 
 
 Visited by (attending physician) (staff) 
 
 Haemorrhage, (character) (treattnent) 
 
 PLACENTAL DELIVERY, (time) (method) 
 
 Uterus, (condition) (management) 
 
 Duration, hours, minutes. Date, (terminated) i8g , hour. 
 
 PERI 
 
 ( intact, ) 
 
 N E U M , -^ lacerated, V . 
 { operation, ) 
 
 HEIGHT OF FUNDUS ABOVE SYMPHYSIS. 
 
 At end of third stage inches. 
 
 10 minutes after " " inches. 
 
 20 " " " " inches. 
 
 30 " " " " inches. 
 
 I hour " " " inches. 
 
 SUMMARY OF LABOR. 
 
 (began, date, hour,. ..M. i8g ) 
 
 First Stage 1 .Duration, hours, ... .minutes, 
 
 terminated, " " ....M. " ' 
 
 (began, " " M. " ) 
 
 Second Stage-. .■ " " ' 
 
 terminated, " " ....M. " ' 
 
 Third Stage j 
 
 (began, " " M. " , ^^ ^^ ^^ 
 
 terminated, " " ....M. " ) 
 
 Total Duration of Labor, " " 
 
 Temperature, Pulse Height of Fundus above Symphysis, inches. 
 
 (Observed one hour after completion of labor.) 
 
 Delivered by 
 
 Assistant 
 
10 RErOHT OF THE SOCIErY OF TIIE L^'IXG-IX HOSPITAL. 
 
 COMPLICATIONS, OPERATIONS, 
 
 Pathological Examinations. 
 
 SUBSEQUENT RECORD. 
 
 Date, 189 Day. 
 
 I. Countenance, 2. Tongue, 3. Bladder, 
 
 4. Bowels, 5. Sleep, 5. Stomach, (Dift) 
 
 7. Temperature, A.M. . .P.M .. . 8. Pulse, A.M. .. P.M. . . 9. Breasls, (coiu/iiioti). . .{secreting or fiot). 
 10. Uterus, {/ii-i^ht). Acondition). . 11. Genitals, (;////iVj) 
 
 Lochia, h/i(arititj) {c ha racier) (oi/or) 
 
 Treatment and Remarks : 
 
 Signature, 
 
 Datu, 189 Day. 
 
 I. Countenance, 2. Tongue, 3. Bladder, 
 
 4. Bowels 5. Sleep, 6. Stomach, (Dii-t) 
 
 7. Temperature, A.M. . .P.M. . . 8. Pulse, A.M .. .P.M .. . 9. 'BTe&sX.s, {conifition). . .{si'<^re/i>!g^or not) 
 
 10. Uterus, Oit-ight)..{conditionj . . 11. Genitals, {itipples) 
 
 la. Lochia, (quantity) (character) Km/nr) . 
 
 13. Treatment and Remarks : 
 
 Signature, 
 
 Date 189 Day. 
 
 I. Countenance, 2. Tongue, 3. Bladder, 
 
 4. Bowels, 5. Sleep 6. Stomach, {Dirt) 
 
 7. Temperature, A.M.. .P.M. .. 8. Pulse, A.M .. .P.M .. . 9. Breasts, {co/tc/it/on). . .(sc-crc-t/nj; or not). 
 10. Uterus, i/i.ig/if). .(condition).. 11. Genitals (.nipples) 
 
 12. Lochia, (quantity) (character) (odor) 
 
 13. Treatment and Remarks : 
 
 Signature, 
 
 Date, 189 Day. 
 
 I. Countenance a. Tongue, 3. Bladder, 
 
 4. Bowels 5. Sleep 6. Stomach, (Diet) 
 
 7. Temperature, A.M. ..P.M... 8. Pulse, A.M ... P.M .. . 9. Breasts, (condition) .. .(secreting or not). 
 
 10. Uterus, l/irighl). .(condition). . 11. Genitals, (,nip/>l,-s) 
 
 12. Lochia, (quantity) (character) (odor) 
 
 13. Treatment and Remarks : 
 
 Signature, 
 
THE MEDICAL RECORUS AXD THE PREPAliATJuX OF STATISTICS. 11 
 
 SUBSEQUENT RECORD. 
 
 Date, 189 Day. 
 
 I. Countenance, 2. Tongue, 3. Bladder, 
 
 4. Bowels, 5. Sleep, 6. Stomach, (/)/V/) 
 
 7. Temperature, A.M. ..P.M. . . 8. Pulse, A.M. . .P.M. . . 9. '&xe.2,%\.%, (condition). . .(secreting oi- not) 
 
 10. Uterus, {/icight) . .{condition) . . 11. Genitals, (nippies) 
 
 12. Lochia, (quantity) (cliaractei-) (odor) 
 
 13. Treatment and Remarks : 
 
 Signature, 
 
 Date, i8g Day. 
 
 I. Countenance, 2. Tongue, 3. Bladder, 
 
 4. Bowels, 5. Sleep, 6. Stomach, (/J'/t/) 
 
 7. Temperature, A.M. . .P.M. . . 8. Pulse, A. M . . .P.M . . . g. 'Breasts, (condition). . .{secreting or not) 
 10. Uterus, {height) . .{condition) . . 11. Genitals, {nippies) 
 
 12. Lochia, (gzinntity) {character) (odor) 
 
 13. Treatment and Remarks : 
 
 Signature, 
 
 Date, 189 Day. 
 
 1. Countenance 2. Tongue, 3. Bladder, 
 
 4. Bowels, 5. Sleep 6. Stomach, (Diet) 
 
 7. Temperature, A.M.. .P.M... 8. Pulse, A.M .. .P.M .. . 9. BreasXs, (condition) .. .{secreting or not). 
 10. Uterus, {/ui\^ht). .(condition). . 11. Genitals, (nippies) 
 
 12. Lochia, ujKantiiy) (character) (odor) , . . 
 
 13. Treatment and Remarks : 
 
 Signature, 
 
 Date, 189 Day. 
 
 I. Countenance, 2. Tongue, 3. Bladder, 
 
 4. Bowels, 5. Sleep, 6. Stomach, (Diet) 
 
 7. Temperature, A.M. ..P.M.. . 8. Pulse, A.M. . .P.M. . . 9. 'Br&asis, (co7idition) .. .(secreting or not). 
 10. Uterus, (height), .(condition). . 11. Genitals, {nipples) 
 
 12. Lochia, dpcantity) {character) (odo?-) 
 
 13. Treatment and Remarks : 
 
 Signature, 
 
 Date 189 Day. 
 
 I. Countenance, 2. Tongue, 3. Bladder, 
 
 4. Bowels, 5. Sleep 6. Stomach, {Diet) 
 
 7. Temperature, A.M. . .P.M. . . 8. Pulse, A.M. . .P.M .. . 9. BTeasts, {co7tdition) .. .{secreting or not). 
 
 10. Uterus, (height), .(condition). . II. Genitals, (nipples) : 
 
 12. Lochia, (quantity) {character) (odor) 
 
 13. Treatment and Remarks : 
 
 Signature, 
 
 Date, i8g Day. 
 
 1. Countenance, 2. Tongue, 3. Bladder, 
 
 4. Bowels, 5. Sleep, 6. Stomach, (Diet) 
 
 7. Temperature, A.M. . .P.M. . . 8. Pulse, A.M .. .P.M .. . 9. Breasts, {ccnditioti).. .{secreting or not). 
 10. Uterus, (height), .(condition). . II. Genitals, (nipples) 
 
 12. Lochia, {quantity) {charactet ) (odoi 
 
 13. Treatment and Remarks : 
 
 Signature, 
 
 PHYSICAL EXAMINATION ON DAY AFTER LABOR. 
 
 Heart, Lungs Breasts, Nipples, 
 
 Perineum, Cervix Quantity and character ofLochia, 
 
 Position, sensitiveness and mobility of Uterus, 
 
 Condition of Internal Os, 
 
 Parametria, Discharged 189 , on day after labor. 
 
 Transferred 189.., to Hospital on day after labor. 
 
 Signature, 
 
12 
 
 REPORT OF THE SOCIETY OF THE LYING-IX HOSPITAL. 
 
 RECORD OF CHILD. -OUT-DOOR SERVICE. 
 CONFINEMENT No APPLICATION No 
 
 SOCIETY OF THE LYING-IN HOSPITAL 
 
 OF THE CITY OF NEW YORK, 
 
 1 7th Street and Second Avenue, (No. of Cards ) 
 
 NEW VORK. 
 
 RECORD OF CHILD. 
 
 Date of Birth, 
 
 Name of Mother 
 
 Present Condition of Mother,.. 
 Previous Condition of Mother,. 
 
 . .i8g 
 Address, 
 
 Sex, , 
 
 Para,. 
 
 Time of Gestation mo. 
 
 Caput Succedaneum, {location, sizc\). . 
 Cephalohaematoma, (location, size,). . . 
 
 \ . .<-vr. / 
 
 Labor, - /. .I'l.'.is. 
 
 { ii!S!'UJ'untal. ) 
 
 Presentation, 
 
 Position, 
 
 Umbilical Cord,. 
 
 Duration, hours, minutes. 
 
 OBSERVATION TO BE MADE AT TIME OF BIRTH. 
 
 Primary Respirations, 
 
 Capillary Circulation, -; congested, - 
 ( anaemic, ) 
 
 nonitat, \ 
 
 at sent. I 
 
 delayed. \_ 
 
 « superficial. i" 
 
 (if delayed. Iio-J! long,) \ 
 
 how restored, ] 
 
 Temperature, 
 
 ( Taken ill rcctuiit for five ininuics iiiniicdiatcly after Inrth.) 
 
 TOTAL LENGTH OF CHILD INCHES. 
 
 VERTEX-COCCYGEAL LENGTH INCHES. WEIGHT LBS. 
 
 PLACENTA. 
 
 Complete, 
 
 Shape, 
 
 V^eight 
 
 Size, 
 
 Form 
 
 Thickni;ss, 
 
 Alterations (appo- 
 plcxy, cysts, etc.) 
 
 MEMBRANES. 
 
 Complete, 
 
 Opening, 
 
 Umbilical vesicle,. 
 Peculiarities, 
 
 CORD. 
 
 Length, 
 
 Insertion, 
 
 Volume, 
 
 Peculiarities,. 
 
 DIAMETERS OF CHILD. 
 
 Occipito-mental, in. 
 
 Occipito-frontal, in. 
 
 Suboccipito-bregmatic, . . .in. 
 
 Fronto-mental, in. 
 
 Trachelo-bregmatic, in. 
 
 Bi parietal, in. 
 
 Bitemporal, in. 
 
 Bimastoid, ....in. 
 
 Bimalar, in. 
 
 Bisacromial, in. 
 
 Dorso-sternal, in. 
 
 Bistrochanteric, in. 
 
 Sacro-pubic, in. 
 
 CIRCUMFERENCES 
 OF CHILD. 
 
 Occipito-mental, 
 
 Suboccipito-bregmatic,. 
 
 Occipito-frontal, 
 
 Bisacromial, 
 
 Bistrochanteric, in. 
 
 GENERAL CONDITION. 
 
 Still born, Macerated, 
 
 Vernix caseosa, Lanugo, 
 
 Skin Anus, Genitals Subcutaneous fat. 
 
 Eyes, Mouth Umbilicus, 
 
 Cry,-].,ua/e, - 
 
 ( absent, ) 
 Development of Cranial Bones, (sutures, size of fontanelles,) 
 
 Living, 
 
 Development, 
 
 Breasts, 
 
 Noac, 
 
 Urine, 
 
 Sacrum, (tirpth of indentation.) 
 
 (In plural llrths Irhif; /■l.icntiu- to K,si,i,iit fliysicia n .) 
 
 CONGENITAL ANOMALIES. 
 
 ATTENDED BY. 
 
 GENERAL REMARKS. 
 
THE MEDICAL KECOKDS AND THE PREPARATION OF STATISTICS. 
 
 13 
 
 SUBSEQUENT RECORD. 
 
 Cord separated on. . 
 
 
 day 
 
 
 
 Umbilicus cicatrized 
 
 on 
 
 
 . day. 
 
 WEIGHT OF CHILD. 
 
 TEMPERATURE OF CHILD. 
 
 (Ta/ceii in rectuiu /or fi-'e ittiinitcs.) 
 
 LBS. ] OZ. 
 
 At birth I i 
 
 6th day... 
 
 LHS. 
 
 OZ. 
 
 At birth... 
 
 A. M. j V. M. 
 
 1 
 
 6th day 
 
 A. M. 
 
 p. M. 
 
 ist day j 
 
 7th day 
 
 
 
 1st day 
 
 
 
 7th day 
 
 
 
 2d day , 
 
 8th day 
 
 
 
 2d day 
 
 
 
 8th day 
 
 
 
 3d day i 
 
 gth day. . . 
 
 
 
 3d day 
 
 
 
 gth day 
 
 
 
 4th day 
 
 
 loth day 
 
 
 
 4th day . . 
 
 
 
 loth day 
 
 
 
 5th day 
 
 
 nth day . . 
 
 
 
 5th day.... 
 
 
 
 nth day 
 
 
 
 Date, iSg Day. 
 
 1. Sleep, 2. Eyes, 3. Nursing, 
 
 4. Cry, 5. Nose, 5. Vomiting, 
 
 7. Breasts, 8. Mouth g. Urine 
 
 10. Umbilicus, {cord off j>tis) 11. Skin, {color^ eruption) 12. Stools, {mtinber, color) 
 
 13. Genitals, 14. Weight, ibs oz. 15. Temperature, A.M. ..P.M. 
 
 Remarks 
 
 Signature, 
 
 Date, 
 
 I. Sleep, 
 
 4- Cry, 
 
 7. Breasts, 
 
 10. Umbilicus, {cord off pus) . 
 
 13. Genitals, 
 
 Remarks 
 
 2. Eyes, 3. 
 
 5. Nose 6. 
 
 8. Mouth, g, 
 
 II. SViin, {color, eruption) 12. 
 
 14. Weight, lis oz. 15. 
 
 Day. 
 
 Nursing, 
 
 Vomiting, 
 
 Urine, 
 
 Stools, {number, coloj-) 
 
 Temperature, A.M. . .P.M. 
 
 Signature, 
 
 Date, 
 
 1. Sleep, 
 
 4. Cry 
 
 7. Breasts, 
 
 10. Umbilicus, {cord off pus). 
 
 13. Genitals, 
 
 Remarks 
 
 2. Eyes, 
 
 5. Nose, 
 
 8. Mouth, 
 
 II. Skin, {color, eruption) . 
 14. Weight, lbs.. . 
 
 .Day. 
 
 3. Nursing, 
 
 6. Vomiting, 
 
 g. Urine, 
 
 12. Stools, {number, color) 
 
 15. Temperature,... A.M. ..P.M. 
 
 Date, 
 
 I. Sleep, 
 
 4- Cry, 
 
 7. Breasts, 
 
 10. Umbilicus, {cord off pus). 
 
 13. Genitals, 
 
 Remarks 
 
 .Day. 
 
 2. Eyes, 
 
 5. Nose, 
 
 8. Mouth, 
 
 II. Skin, {color, eruption) . 
 14. Weight lbs.. . 
 
 -3. Nursing,. 
 
 6. Vomiting, 
 
 g. Urine, 
 
 12. Stools, {member, color) 
 
 15. Temperature, A.M. ..P.M. 
 
 Signature, 
 
 Date 
 
 I. Sleep, 
 
 4- Cry, 
 
 7. Breasts, 
 
 10. Umbilicus, {cord off pus) . 
 
 13. Genitals, 
 
 Remarks 
 
 2. Eyes, 
 
 5. Nose, 
 
 8. Mouth, 
 
 II. Skin, (color, eruption) 
 14. Weight, lbs 
 
 Day. 
 
 3. Nursing, 
 
 5. Vomiting, 
 
 g. Urine, 
 
 12. Stools, [number, color) 
 
 15. Temperature, A.M. ..P.M. 
 
 Date, 
 
 I. Sleep, 
 
 4- Cry, 
 
 7. Breasts, 
 
 10. \irc\\A\\c.'as, {cord off pus). 
 
 13. Genitals, 
 
 Remarks 
 
 2. Eyes, 
 
 5. Nose, 
 
 8. Mouth 
 
 II. Skin, {color, eruption) 
 14. Weight, lbs.. 
 
 Day. 
 
 3. Nursing, 
 
 6. Vomiting, 
 
 g. Urine, 
 
 12. Stools, (number, color) 
 
 15. Temperature, A.M. ..P.M. 
 
u 
 
 KEFORT OF THF: SOCIETY OF TUn LYINcMX HOSPITAL. 
 
 SUBSEQUENT RECORD. 
 
 Date, 189 Day. 
 
 I. Sleep, 2. Eyes, 3. Nursing, 
 
 4. Cry 5. Nose, 6. Vomiting, 
 
 7. Breasts 8. Mouth, 9. Urine 
 
 10. Umbilicus, (r:'r(i'<>^/«j) 11. Skin, i< i>/<?r, tv«///('«) 12. Stools, {/ill t/i/'cr, co/or) . 
 
 13. Genitals, 14. Weight, /is <>=. 15. Temperature, A.M.. 
 
 Remarks 
 
 Signature, 
 
 Date, 
 
 I. Sleep, 
 
 4- Cry, 
 
 7. Breasts 
 
 10. Umbilicus, ((.vri/^i^/z/i). 
 
 13. Genitals, 
 
 Remarks 
 
 .Day. 
 
 2. Eyes, ... 3. Nursing, 
 
 5. Nose 6. Vomiting, 
 
 8. Mouth 9. Urine, 
 
 II. Skin, (((VV;-, tv-/////()«) 12. Stools, («;c;///'tv, <()/(v) 
 
 14. Weight, //'i I'z. 15. Temperature,.. A.M. ..P.M. 
 
 Signature, 
 
 Da: 
 
 .Day. 
 
 I. Sleep, 
 
 4- Cry, 
 
 7. Breasts, 
 
 10. Umbilicus, (iDrrt'^^/«j). 
 
 13. Genitals, 
 
 Remarks 
 
 2. Eyes, 3. Nursing, ... 
 
 5. Nose, 5. Vomiting, 
 
 8. Mouth, 9. Urine, 
 
 II. Skin, (coiof, f>tiJ>tio)i) 12. Stools, (iitiiiilicr, color) 
 
 14. Weight, lbs o'^. 15. Temperature,... A.M. ..P.M. 
 
 Signature, 
 
 Date, 
 
 I. Sleep 
 
 4- Cry 
 
 7. Breasts, 
 
 10. M mh'xWcus, {co7-ii oJ/'/iis). 
 
 13. Genitals, 
 
 Remarks 
 
 189 Day. 
 
 2. Eyes, 3. Nursing, 
 
 5. Nose, 6. Vomiting, 
 
 8. Mouth, 9. Urine, 
 
 II. SV.\n, (color, crii/'tion) 12. Stools, (iniiiibcr, coloi) 
 
 14. Weight, ll's.. oz. 15. Temperature, A.M. ..P.M. 
 
 Signature, 
 
 Dale 
 
 1. Sleep, 
 
 4- Cry 
 
 7. Breasts, 
 
 10. XJmh'xl'xcMS, {cord oJjT pus). 
 
 13. Genitals 
 
 Remarks 
 
 .Day. 
 
 2. Eyes, 3. Nursing, 
 
 5. Nose, 6. Vomiting, 
 
 8. Mouth, 9. Urine, 
 
 II. Skin, (color, eruption) 12. Stools, (iiuiiilcr, color) 
 
 14. Weight, lis (':.. 15. Temperature, A.M. ..P.M. 
 
 Signature, 
 
 DaU, 
 
 .Day. 
 
 I . Sleep, 
 
 4- Cry 
 
 7. Breasts, 
 
 10. Umbilicus, (f(»»-//<j^/»//). 
 
 13. Genitals, .. . 
 
 Remarks 
 
 2. Eyes, 3. Nursing, 
 
 5. Nose 6. Vomiting, 
 
 8. Mouth, g. Urine, 
 
 II. Skin, {< olor, criiplioii) 12. Stools, (iiiiiiibcr, color) 
 
 14. Weight, lbs o:;. 15. Temperature, A.M. 
 
 Signature, 
 
 Date, 
 
 I. Sleep, ... 
 
 4- Cry, 
 
 7. Breasts 
 
 10. Umbitlcut, (cord off Jiui). 
 
 13. Genitals, 
 
 Remarks 
 
 .Day. 
 
 2. Eyes, 3. Nursing,. ... 
 
 5. Nose, 6. Vomiting, .... 
 
 8. Mouth g. Urine, 
 
 II. S\i'\n, (color, eruption) 12. Stools, (;/;/«//'(■ 
 
 14. Weight lbs oz. 15. Temperature,. 
 
 color) 
 .A.M. 
 
 .P.M. 
 
 Signature, 
 
THE MEDICAL RECOKDS AND THE PKEPARATIOX OF STATISTICS. 15 
 
 SUBSEQUENT RECORD. 
 
 Date, 189 Day. 
 
 I. Sleep, 2. Eyes, 3. Nursing, 
 
 4. Cry, 5. Nose, 6. Vomiting, 
 
 7. Breasts, 8. Mouth, 9. Urine, 
 
 10. 'Umhi\icus, {cvr,/ off" /ii/s) II. Skin, (c'o/or, i'ru///i>/i) 12. Stools, (im/uic-r, co/ar) 
 
 13. Genitals, 14. Weight, Ihs.... oz. 15. Temperature, ... A.M .. .P.M. 
 
 Remarks 
 
 Signature, 
 
 Date, 189 Day. 
 
 I. Sleep, .. . 2. Eyes, 3. Nursing, 
 
 4. Cry, 5. Nose, 5. Vomiting, 
 
 7. Breasts, 8. Mouth, 9. Urine, 
 
 10. \i mhiWcMS, (cord off /> us) 11. SVXn, {color, crtiptioii) 12. S\,oo\%, (number, color) 
 
 13. Genitals, 14. Weight, lbs oz. 15. Temperature, A.M. ..P.M. 
 
 Remarks. 
 
 Signature, 
 
 Date, i8g Day. 
 
 I. Sleep, 2. Eyes, 3. Nursing, 
 
 4. Cry, 5. Nose, 5. Vomiting, 
 
 7. Breasts, 8. Mouth, 9. Urine, 
 
 10. MmhWizMS, (cord off J>us) 11. Skin, (color, eruption) 32. Stools, (innnbcr, color) 
 
 13. Genitals, 14. Weight, lbs 0:. 15. Temperature,. . . A.M. . .P.M. 
 
 Remarks. 
 
 Signature, 
 
 Date, 189 Day. 
 
 I. Sleep, 2. Eyes, 3. Nursing, 
 
 4. Cry 5. Nose, 6. Vomiting, 
 
 7. Breasts, 8. Mouth, g. Urine, 
 
 10. Umbilicus, (<:();-</ c_^/«i-) II. Skin, (coloj-, eruptio?i) 12. Stools, (nu7nbcr, color) 
 
 13. Genitals, 14. Weight, lbs oz. 15. Temperature, A.M. ..P.M. 
 
 Remarks. 
 
 Siarnature, 
 
 Date, 189 Day. 
 
 I. Sleep, 2. Eyes, 3. Nursing, 
 
 4. Cry, 5. Nose, 6. Vomiting, 
 
 7. Breasts, 8. Mouth, 9. Urine, 
 
 TO. Umbilicus, (cord off /> us) 11. Skin, (color, eruJ>tio)i) 12. Stools, (number, coloi-) . 
 
 13. Genitals, 14. Weight, lbs oz. 15. Temperature A.M.. 
 
 Remarks, r 
 
 Signature, 
 
 Date, 189 Day. 
 
 I. Sleep, ... 2. Eyes, 3- Nursing, 
 
 4. Cry, 5. Nose 6. Vomiting, 
 
 7. Breasts, 8. Mouth, 9- Urine, 
 
 10. \Jmhilicus, (cord off pus) 11. Skin, (color, eriipiion) 12. Stools, (nmnber, color) 
 
 13. Genitals, 14. Weight, lbs.. oz. 15. Temperature, A.M. 
 
 Remarks 
 
 Signature, 
 
 PHYSICAL EXAMINATION ON DAY AFTER LABOR. 
 
 Nose, Mouth, Skin, 
 
 Umbilicus, W^eight, 
 
 Discharged 189 , on day after labor. 
 
 Transferred to Hospital on day after labor. 
 
 Signature, 
 
IG ~ REPORT OF THE SOCIETY OP' THE LVING-IN HOSPITAL. 
 
 ALBUMINURIA. -OUT-DOOR SERVICE. 
 CONFINEMENT No APPLICATION No 
 
 BLANK FOR ALBUMINURIA. 
 
 PREVIOUS RENAL HISTORY 
 
 With especial reference to presence and duration oT any of following symptoms 
 (If any of these date from present pregnancy, state from which month.) 
 
 Dropsy 
 
 Quantity of Urine, i/arg-,- or swall) 
 
 Bloody Urine 
 
 Albuminuria, 
 
 Pain over Kidneys, , 
 
 Habitual Condition of Skin, (/rt-e or scatity J>crsf>iratio>i) 
 
 Headache, {frontal, veriicah occipital) 
 
 Failure of Vision, 
 
 Vomiting or Diarrhoea, 
 
 Anorexia 
 
 Marked Anaemia, 
 
 Convulsions, Stupor or Coma, 
 
 Mental Symptoms 
 
 History of any Infectious Disease, \ f^" '^r^'i/^.'''), '''■^^"'^''r rheumatism, \ ^^^ ^^ ^\^o^o\ 
 
 •' •' ' \ tyhoid, syphtltSypneunioma, phthisis, ) ' 
 
 PRESENT RENAL HISTORY 
 
 Dropsy, (distribution, degree) 
 
 Pain over Kidneys, 
 
 Headache, {position, degree, time of day when most marked). 
 
 Impairment of Vision, t,/ei;ree, rapidity o/ development; one or both eyes; retinitis). 
 
 Vomiting, Diarrhoea, Anorexia, 
 
 Anaemia 
 
 Pulse, i frequency, regularity, large or small, tension. Is Tessel thickened ?). 
 
 Heart. \ "f- 'if'l/hyP'rtrophy or dilatation or both, I , ^ distinctly feeble 
 
 { accentuation of aortic or pulmonic id sound . ( ■' 
 
 LungB, (<•//. expansion, signs of consolitialion or of emphysema or of oedema) . 
 
 Convulaions : Time of ist Seizure, {month of pregnancy, stage of labor, post part um) . .. 
 
 Frequency of Seizures Length of Seizures and Duration of Intervals, 
 
 Seat of Commencement Mode of Spreading,. 
 
THE MEDICAL KECORDS AND THE PREPARATION' OF STATISTICS. 17 
 
 ALBUMINURIA. 
 
 Convulsions ^Cont.), Deviation of Head or Eyes, 
 
 Usual Position of Arms, 
 
 Paralysis, {one-sided or bilateral ) 
 
 Rigidity, [local or general ) 
 
 Fibrillary Twitching during Intervals, ('Mhere located) 
 
 Reflexes {esp. knce-jcrks). Are they obtainable during Intervals? 
 
 Condition of Pulse, Temperature and Respiration during and after Seizures,. 
 
 Pupils, size, reaction to light. 
 
 Coma, Duration and Onset, 
 
 Can Patient be Roused ? 
 
 Pupils, size, equality, reaction to light, reaction on pinching skin of neck,. 
 
 Mental Symptoms, (csp. maniacal excitement'). 
 
 Treatment of Convulsions, (<5/tv^//«^, transfusion^ saline enema^ mo7-J>/iine, veratrum^ 7iitro-glycerine, chloral). 
 
 Effect of Treatment on Pulse, Temperature, Respiration, Convulsions, Coma, Urine,. 
 
 URINARY EXAMINATION. 
 
 Date of 
 Examination 
 
 Vol- 
 ume in 
 
 24 
 Hours 
 
 Sp. Gr. 
 
 *Albumen, 
 
 ( Trace., Moderate., 
 Abundant) 
 
 Albumen, 
 
 •Quantity by 
 
 Esbach 
 
 Casts, Kind. 
 
 [Few or Many) 
 
 Blood, Pus or 
 other Sediment 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 ■ Use folio-wing- tests— (x) Heat and Nitric Acid. (2) Cold Nitric Acid {ring test). 
 
18 REPORT OF THE SOCIETY OF THE LYING-IN HOSPITAL. 
 
 The practical ajiplication of the various checks on the student, used in 
 the outdoor service, requires a set of blanks which may be called " Adminis- 
 trative Blanks for Students." The frequent reports sent by the student 
 from his labor cases are always made upon th<? following- printed form, 
 which must be tilled out in detail each time, without regard to previous 
 re})orts from the same case : 
 
 SOCIETY OF THE LYIXG-IK HOSPITAL OF THE CITY OF 
 
 XEW YORK, 
 
 251 East ITtu St., New York City. 
 
 "When sending to the Hospital for assistance, students must in all cases 
 
 use and fill out this blank. 
 
 New York, o'clock, M. 
 
 Patient's Kame, 
 
 Address, 
 
 House, Floor, Room, 
 
 Number of Pregnancy, 
 
 Month of Gestation, 
 
 Duration of 1st Stage, 
 
 " 2d " 
 
 Foetus 
 
 by abdominal 
 
 palpation. 
 
 Pulse, Temp. , 
 
 Foetal Heart (frequency), position,.. 
 
 Dorsal plane, 
 
 Head, 
 
 Small parts, 
 
 ^ Movements, 
 
 Presentation, Position, 
 
 Os uteri (size), condition, 
 
 Memljranes, 
 
 ' Above brim, 
 
 r> ,.• _4. En'^ag'cd, 
 
 Presentmg part, -' . , 
 
 On Perineum, : 
 
 ('li;ir;uti r :iii(l trc(juency of labor pains, 
 
 (iencijil ( onditions and remarks: 
 
 Attendant. 
 
THE MEDICAL RECORDS AND THE PREPARATION OF STATISTICS. 1'.) 
 
 We insert next a page from the "Attendance Book." Each page of 
 this book is devoted to a single case, and it is filled out by the student 
 immediately upon his return from the completion of his case: 
 
 SOCIETY OF THE LYING-IN HOSPITAL 
 
 OF THE CITY OF NEW YORK, 
 
 SECOND AVENUE AND 17th STREET, N. Y. 
 
 Application JVb Bag Jfo Confinement J^o 
 
 Arrival at Case 189 (Time) a. p. m. 
 
 JVame 
 
 Address House Floor Room 
 
 Month of Gestation Presentation Position 
 
 Child delivered at a. p. m 189 
 
 Placenta delivered at a. p. m 189 
 
 Returned to Hospital at a, p. m. 189 
 
 Operation :. 
 
 Delivered hy 
 
 Attending Physician. 
 
 Staff 
 
 Pupils 
 
 Operator 
 
 Staff 
 
 Assistants 
 
 Pupils. 
 
 RemarTcs 
 
20 
 
 REPORT OF THE SOCIETY OF THE LYING-IN HOSPITAL. 
 
 The oral re])orts of the students, concerning the daily condition of the 
 postpartum cases, are made from notes written at the bedside. These 
 reports are received by the resident physician or his representative, and 
 are written bv him on a slate, arranged in the following manner: 
 
 Headings of PosTPARTU>r Slate. 
 
 
 •A 
 
 LOCATION 
 
 IX TENEMENT HOUSE. 
 
 
 
 
 
 
 
 
 
 
 
 
 o 
 
 9 
 
 
 
 
 
 
 
 
 f3 
 
 u 
 
 ^ 
 
 
 Co 
 
 
 
 
 
 +3 
 
 < 
 
 or Ke 
 ding. 
 
 
 1— < 
 
 
 o 
 
 f3 
 o XT' 
 
 rA 
 
 3 
 m 
 
 j2 
 .2 
 
 c"3 
 
 o 
 
 o 
 
 
 liight 
 Doo 
 
 II 
 
 B^ 
 
 
 This slate serves as an index to postpartum complications Avhich require 
 subsequent investigation by the house staff. The assistant resident physi- 
 cians record the result of their investigations of such com})lications in a 
 l>lank book called the " Abnormality Book." 
 
 The subsequent transcription of these records and the use by the 
 student of the small ro])rints of tlie medical histories at the bedside have 
 been alrea<ly described. 
 
 Both the outdoor and the indoor services require a set of " Adminis- 
 tnition Blanks for Patients." These blanks serve to keep a reliable record 
 of tlie patients and their respective histories. Each set of blanks is a 
 <Uq)licate of tlie otlier, although slight differences in detail will Ix' noted in 
 tlio following /y'-v^////!-,'. An " A])i)lication ]>ook " is Iccpt, in \vliich every 
 applicant for treatment is recorded, and given a nmiilx^r in secpKnice of 
 a])plicalion, known as the "Application Nund^er." 
 
 TIm' antepartum cases arc known by their aj)})lication number, until 
 after theii- lielivej-y. when they receive a second, or " ("onlinenient A'um- 
 Ijer." The apjtlicatioii iiuinbei- also serves, at tlie liinc of delivery, to 
 tnice the |»re<rnancy cliai-l which has be(.'n on fih^ since tlu; (lat(i of applica- 
 lirm. Tlnse apj)li<;atiou hooks are posted daily by the ollice clerk. 
 
THE mp:dical records and thk preparation of statistics. 
 
 21 
 
 Headings of Indoor Service Application Book. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 © 
 
 
 
 
 t 
 
 
 © 
 
 o 
 
 
 
 
 
 
 
 
 .(^ 
 
 7!\ 
 
 
 r-i 
 
 
 
 
 g 
 
 r^ 
 
 _-i-i 
 
 XJl 
 
 c3 
 
 
 3 
 
 
 
 
 C3 
 
 
 ~ 
 
 Q 
 
 
 ^ 
 
 
 
 , 
 
 q-4 
 
 ,^ 
 
 •"^ 
 
 ••; 
 
 
 
 
 t>. 
 
 '^ 
 
 ^ 
 
 ^^ 
 
 ^ 
 
 
 rj 
 
 
 
 r^ 
 
 P^ 
 
 13 
 
 ^ 
 
 ^ 
 
 
 .2 
 
 c5 
 
 
 
 ned 
 
 O 
 
 
 s 
 
 
 
 _o 
 
 
 
 •r-H 
 
 ^ 
 
 © 
 
 -|3 
 
 *M 
 
 6 
 
 r — 1 
 
 
 g 
 
 ^ 
 
 s 
 
 O 
 
 o 
 
 -t-3 
 
 E- 
 
 
 
 
 
 
 +J 
 
 .2 
 
 1— ! 
 
 o3 
 ft 
 
 < 
 
 1 
 
 < 
 
 
 
 ^ 
 
 r" 
 
 
 Headings of Outdoor Service Application Book. 
 
 
 
 
 
 
 
 fH 
 
 
 
 
 
 
 ^ 
 
 
 
 
 
 ® 
 
 
 
 
 
 
 o 
 
 
 
 
 
 ,£2 
 
 © 
 
 
 c 
 
 
 
 ,J^ 
 
 
 
 
 
 r-i 
 
 
 ® 
 
 o 
 
 
 
 ^ 
 
 
 
 t=^ 
 
 
 3 
 
 -4-3 
 
 s 
 
 
 ~l-3 
 
 
 
 ri 
 
 
 
 ^ 
 
 fl 
 
 o 
 
 g 
 S 
 
 -1-3 
 
 tn 
 
 o 
 
 
 
 O 
 
 
 02 
 
 a) 
 
 © 
 
 
 s 
 
 O 
 
 aj 
 
 ^ V 
 
 -(J 
 
 o 
 
 •l-H 
 
 O 
 g 
 
 
 c3- 
 
 '"O 
 0) 
 
 f3 
 
 O 
 
 O 
 
 O 
 -1-3 
 
 '+3 
 
 ci 
 
 ee 
 
 P, 
 
 -ce 
 
 n^! 
 
 XI 
 
 ■+^ 
 
 o 
 
 c3 
 
 
 o 
 
 O) 
 
 P 
 
 ^ 
 
 ^ 
 
 <1 
 
 H 
 
 <1 
 
 O 
 
 i-ri 
 
 h-i 
 
 ^ 
 
 « 
 
 A card bearing the address of the Hospital, the name and address of 
 the patient, and her application number, is given to every woman at the 
 time of her application. These cards are to be returned to the Hospital 
 whenever the patient needs attendance. The}^ serve as an index to the 
 application numbers, and insure the selection of the proper history blank. 
 A record of the progress of the outdoor labors is kept on the three blanli 
 spaces on the face of the cards, by the use of the time-clock stamp. All 
 the cards of j^atients in labor are kept on a reference file on the office desk. 
 The obverse and reverse of these cards are reproduced here : the reverse is 
 Avholly for the information of the patient. The different districts of the 
 city are designated by varying the color of the card. 
 
22 REPORT OF THE SOCIETY OF THE LYING-IN HOSPITAL. 
 
 Patient's Cakd fok Indoor Service. 
 
 Society of the Lying=ln Hospital, 
 
 SECOND AVENUE AND 17th STREET, 
 
 New York City. 
 
 Krrlicktion Ckrd. 
 
 Application JVo Date 189 
 
 JVuDIP '. 
 
 Address House Floor Eoovi 
 
 Return with this card for admission to Hospital 
 
 189 
 
 // taken with labor pains before above date, come to Hospital at once, 
 bringing this card luith you. 
 
 (SEE OTHER SIDE) 
 
 PATIENTS COMING TO HOSPITAL FOR ADMISSION SHOULD BRING 
 WITH THEM A SET OF BABY CLOTHES. 
 
 Application for admission to Hospital for care in childbed 
 should be made between the hours of i and 2 P. M. 
 Emergency cases will receive attention at any time. 
 
 IF NECESSARY AN AMBULANCE WILL BE FURNISHED TO BRING 
 PATIENTS TO THE HOSPITAL 
 
 Visitors will not be allowed to see patients, but ina\' inrjuirc 
 about them as often as they desire. 
 
 Women without homes will be referred to some suitable 
 charitable institution upon leaving the Ilfxspital. 
 
THE MEDICAL RECORDS AND THE PREPARATION OF STATISTICS. 23 
 
 Patient's Cakd for Outdoor Service — Main Hospital. 
 
 Date 189 
 
 A. JV'.. 
 
 SOCIETY OF THE 
 
 Lyinq=In Hospital, 
 
 « 
 
 2d Ave. & ITthi St., 
 
 NEW YORK CITY. 
 
 JSfame 
 
 Address House Moor Boom.,. 
 
 (SEE OTHER SIDE) 
 
 Free medical attendance in childbed will be furnished at their homes 
 to women who are unable to pay for such services. 
 
 Applications for attendance should be made at the HOSPITAL, 2nd 
 AVENUE & 17th STREET, between the hours of I and 2 P. M. 
 
 Emergency cases will receive attention at any time. 
 
 In casi di parto, si prestano gratuitamente cure mediche at domi- 
 cilio delle parturienti, quando questo siano povere e non abbiano i 
 mezzi per pagani. 
 
 Le richieste per attenere queste cure gratuite devono essere fatte 
 al OSPEDALE, 2da AVENUE e STRADA 17, nelle ore prescritte cive 
 dalle I alle 2 P. M. 
 
 Nei casi urgenti si provederei immediatamente a qualunque or^a. 
 
 Unentgelbltd^e (irstltcfte 3Sefianbtnng tion 2Bocf)nerinuen ober graiim, treldje ibre 
 'Jfieberfunft erwarten, fallg fie iud;t fiir bte SSe^anbluug jablen fi5nnen. 
 
 Tim melbe fidj im §of»)ital, 2. ^be. unti IT. Stc, i\v\\&)Q\\ 1 unb 2 
 U&r 9?ac^mtttag§. 
 
 Sringeitbe gcitte icerben ju jeber ^fit be^anbelt. 
 
 ^n^-it3D yni7 nj'-x rjyiiy yn3 ^xto^siDxn j\s \vhv^:) Tin 'i?^^ |yo 
 •lyn^yo :3"^ nyny^ iv T]n lyo \v? '\r]i^^Vi^ ly^^nj x px |yn 
 
•H 
 
 REl'OKT OF THE SOCIETY OF THE LYING-IN IIOSPJTAL. 
 
 AVhen a patient is admitted to the indoor service, the following- admission 
 blank is tilled out and ke})t on tile in the office. The admission card, also 
 ])resented below, is projierly tilled out and is sent to the wards with the 
 ]>atient. The reverse of the card is wi-itten when the child is born. The 
 facts recordetl on these two blanks enable the Kesident Physician to fill out 
 the birth certificate or other blanks required by the City Bureau of Yital 
 Statistics. 
 
 SQGielY 0f the liYing-ln Hsspital, 
 
 Second Avenue and 17th Street, 
 
 NEW YORK CITY. 
 
 ADMISSION BLANK 
 
 On .lihnis.sitm, Stiniiji ii'itii Time Clock, 
 
 Name . 
 
 How admitted 
 
 Address House Floor Room 
 
 Age Color.. Single — Married — Widow. 
 
 Occupation Birthplace 
 
 How long in U. S In City 
 
 Father's name Birthplace 
 
 Mother's name Birthplace 
 
 Friend's name 
 
 Address 
 
 Number of previous children Number now living. 
 
 Father of child, name 
 
 Age Address 
 
 Birthplace Occupation 
 
 Remarks 
 
 Stamp taith Time Clock here. 
 
^JHE MEDICAL EECORDS AND THE PREPARATION OF STATISTICS. 25 
 
 SOCIETY OF THE LYING-IN HOSPITAL 
 
 2d AVENUE &. 17th ST., NEW YORK CITY. 
 CARD OF ADMISSION TO WARD. 
 
 Application No Confinement No. 
 
 Admit 
 
 to Ward 
 
 Date of Admission i8g 
 
 Diagnosis 
 
 Date of Discharge 1 89 
 
 Cause of Discharge 
 
 - M. D. 
 
 (SEE OTHER SIDE) 
 
 CHILD. 
 
 Date of Birth 
 
 Name 
 
 Sex Color. 
 
 Presentation 
 
 Position 
 
 Period of Gestation 
 
 Operation 
 
 Confined by. 
 
 The office clerk copies from the attendance book, which is filled out by 
 the student, the facts demanded by the ' ' Attendance Cards. ' ' These cards 
 contain fifty lines, and the cases are entered in the order of their confine- 
 ment. Cards are used to duplicate this part of the attendance book, 
 because they are more compact, and the different pages of the attendance 
 book must often be used by various officers and clerks at the same time ; a 
 
26 
 
 REPORT OF THK SOCIETY OF THE LYING-IN HOSPITAL. 
 
 book does not permit this eas}' reference. These cards form an index to 
 the confinement numbers of tlie cases, and to the histories. The same 
 form of card is used to record the cases in both services. 
 
 Headings from the Attendance Cards. 
 
 
 
 
 
 
 
 rt 
 
 
 
 
 
 
 
 
 
 
 
 o 
 
 
 ;-i 
 
 
 
 
 
 §3 
 
 
 
 
 
 fl 
 
 0) 
 
 
 
 
 
 rO 
 
 
 
 C 
 
 o 
 
 d 
 
 
 
 
 
 2 
 
 
 
 o 
 
 :^ 
 
 O 
 
 
 11 
 
 a* 
 
 
 
 
 o 
 
 
 g 
 
 
 
 
 Ph 
 
 02 
 
 o 
 
 (-1 
 
 
 
 
 6 
 
 
 03 
 
 1:3 
 
 o 
 d 
 
 03 
 
 o 
 
 50 
 
 .o 
 
 0) 
 
 c 
 d 
 
 5; 
 d 
 
 d 
 
 
 ^ 
 
 c5 
 
 ^^ 
 
 ce 
 
 13 
 
 •l-H 
 
 •r-( 
 
 o 
 
 o 
 
 o 
 
 ® 
 
 ^ 
 
 ft 
 
 < 
 
 ^ 
 
 <1 
 
 ft 
 
 P 
 
 ^ 
 
 O 
 
 O 
 
 P^ 
 
 The Resident Phj'sician writes a brief resume of all operations done by 
 any members of the medical staff, or by one of the Attending Physicians, 
 in a special book, the " Operation Book." 
 
 Headings of Operation Book. 
 
 
 
 
 
 
 
 ANiESTHETlO. 
 
 
 
 
 s 
 
 
 
 
 
 
 
 -t-j 
 
 
 
 
 . 
 
 ^ 
 
 
 
 
 
 
 
 ^ 
 
 
 
 
 Oi 
 
 a 
 
 d 
 
 
 
 
 
 
 
 o 
 
 
 
 
 B 
 
 
 
 
 
 
 
 -t-i 
 '^ bb 
 
 
 
 
 ^ 
 
 ■s 
 
 
 
 
 
 
 
 'Sg 
 
 ^ 
 
 
 
 d 
 
 ® 
 
 M 
 
 r^ 
 
 
 d 
 
 . 
 
 
 dft 
 
 •43 
 
 
 
 o 
 
 i 
 
 d 
 
 O 
 
 .2 
 
 '+3 
 
 o 
 
 
 d 
 o 
 
 .2 ^ 
 
 ^ 
 
 -^ 
 
 s 
 
 g 
 
 §D 
 
 
 CD 
 
 be 
 
 
 
 "^ r^ 
 
 8i 
 
 c3 
 S 
 
 a 
 
 
 o 
 
 • ^ 
 
 sx 
 
 2- 
 
 u 
 
 d 
 
 d 
 
 o ^ 
 
 d 
 
 (D 
 
 O 
 
 O 
 
 O 
 
 p— 1 
 
 O 
 
 o 
 
 P 
 
 O* 
 
 ft 
 
 Q 
 
 -< 
 
 Ph 
 
 The following'- l)l:nil< is used to record any coiiiplicjition discovered 
 among the ant<'partuni ap[)li(:ants. Tliese " Abnoi-inality lilanks " for the 
 cases of both services are made out by the Assistant llesident Physicians, 
 and Jire kejit on a roforoncc file in th(; ()ffic<\ Hioy arc c-arofully scrutinized 
 
THE MEDICAL RECORDS AND THE PREPARATION OF STATISTICS. 27 
 
 by eacli Attending- Ph3^sician immediately upon assuming control of the 
 Hospital, in order that he may have in mind any abnormal cases falling 
 due during his service. 
 
 ABNORMALBTY BLANK. 
 
 Application J^o Date, 189 
 
 J^ame, Para, 
 
 Address, House, Floor, Room 
 
 DATE OF EXPECTED LABOR, 189 
 
 History of Previous Labors 
 
 MENSURATION. 
 
 Between Spince, Right Oblique, Depth of Symphysis, 
 
 Betiueen Cristce, Left Oblique, Pubic Arch, 
 
 Conjugata Externa COjYJ. DIAGOJfALIS, COMJ. VERA, 
 
 Transverse of Outlet, Antero- Posterior of Outlet, 
 
 URINANALYSIS. 
 
 Specific Gravity, Reaction,. 
 
 Sugar, Urea, 
 
 Albumen, 
 
 Microscope, 
 
 REMARKS. 
 
 
 
 Exainined in Service of Attending Physician 
 
 Examined by 
 
 DATE. 
 
 SUBSEQUENT OBSERVATIONS. 
 
 
 
 
 
 
 
 
 
 
 
 The student's first duty upon returning to the Hospital after an}- service, 
 is to report to the Resident House Physician or his representative. After 
 making this report, he must record upon the History Charts the observa- 
 
28 REPORT OF THE SOCIETV OF THE LYING-IX HOSPITAL. 
 
 tions be has made, and attach his signature thereto. These records are 
 inspected each evening by one of the Assistant Resident Physicians, for the 
 ])ur]X)se of detecting anil correcting inconsistencies and errors. AVhen a 
 cjise lias been discharged, and the history has been signed by the Resident 
 riiysician. it is turned over to the Registrar's office. 
 
 Tlie checks on the loss or disa.p])ea.rance of any history are furnished by 
 a reference to the attendance book or to the attendance cards. The check 
 on the c<)ni])leteness of a history is furnished by a comparison with the 
 attendance book and with the oi)eration book. 
 
 lY. The Registrar's Office. 
 
 This department is a feature in hospital organization which, as far 
 as we know, is a new departure. There are three workers in the 
 Registrar's department of this Hospital. They care for the cards, attend 
 to the binding of the histories, and prepare the statistics for reference 
 and pul)lication. The Registrar is a member of the Medical Board, and 
 holds office for one year; he oversees the work of the Assistant Registrar 
 and of the Registrar's clerk. The five Attending Physicians rotate in 
 order in this duty. Each Registrar makes to the Medical Board a complete 
 statistical report on the cases observed during his year of service. The 
 Medical Board subsequently publishes these rej)orts singly or in various 
 combinations, as seems advisable. The Assistant Registrar is also one 
 of the xVssistant Attending Physicians. It is the duty of this officer to 
 number the histories from the attendance cards ; to discover all the points 
 of interest in each history, and to summarize these at the upper left-hand 
 cornel* of the Record of Labor C^hart under " Diagnosis. " He also indicates 
 in the upper right-hand corner of tlie same cluirt the numbei' of cards 
 required for each history. (This will be explained later on, undei- the 
 sul)ject of the Card Index.) The manual labor of com])iling the statistics 
 devolves U])on the Registrar's clerk, who is a ])ermanenf employee of the 
 IIos])ital. 
 
 The statistical material divides itself easily into two main classes: 
 Fi/'xt. Those facts which are common to all the histories, and relate to the 
 nornud processes of pregnancy, labor, and the puerperium. Second. The 
 facts which vary in each history and whicli comprise the complications and 
 abnormalities of an obstetrical service. 
 
 Tin: Ijiiuje Siathttc Booh. — The first set of facts are recorded in iai-ge 
 lK>oks arrangerl so that each history occupies a line, and each kind of 
 obser\'ation a perpendicular column. Eacli ])age contains one hundred 
 lines, and, tliercfoiv, oik^ hiiridi-cd histories. The headings of the fourteen 
 pages which ajc devoted to tlie records of each hundred histories are a 
 repetition, in so far as oi)servations of the fii'st ten ))oslpartiim days are 
 concerned. Postpartum observations which extend Ix^yond tliis |)eriod of 
 ten days are not considered in this book. Such cas(!s are usually coinidi- 
 cated. and reeorded as such in the card system described b(!low. 'i'he record 
 is made by a single mark in the square formed by the crossing of the 
 
THE MEDICAL RECORDS AXD THE PREPARATIOX OF STATISTICS. 
 
 29 
 
 appro])riate lines and columns. The results of each hundred histories are 
 totalized by adding the columns at the foot of the page. In the case of 
 twins, a double mark is placed in the squares of the "Record of Child,'" 
 opposite the history's number. 
 
 The check on the correctness of the column totals on any page is 
 obtained by adding the totals of the subdivision columns under each sub- 
 ject: these must always add up one hundred, i.e., the number of cases 
 on a page. 
 
 The figures obtained by adding the columns of each hundred histories 
 are transcribed to the ])roper columns of a set of pages in this large Sta- 
 tistic Book. In this summary each line represents the totals of one hundred 
 histories, instead of a single history, and the results of one thousand 
 liistories are concentrated into ten lines. 
 
 It is possible to add up at any time the columns of these summarizing 
 pages and prepare a statistical report for any number of cases. This can 
 be done with a minimum of work, and at verv short notice. 
 
 Headings of Laege Statistic Book. 
 Record of Pregnancy. 
 
 
 sorKCE or applica- 
 
 TRIXE. 
 
 BOXY PELVIS. 
 
 
 
 
 TIOX. 
 
 
 
 
 
 
 m 
 
 
 6 .2 
 
 
 
 
 'A M S 
 
 
 ^ >^ 
 
 
 
 
 . o^ =3 
 
 
 . . ^C . ^ 
 
 
 
 
 ai 1^ ;^ .-S '2 
 
 
 -^ — =-M P7' 
 
 
 
 
 Jr o s ^S^ 
 
 '•0 
 
 :^ ^ 5 ^ S 
 
 
 
 
 
 
 • skill's 
 
 -M 
 
 fo 
 
 
 X3 
 
 
 . ^ ">-* m vi. 
 
 ?: 5 ©0 
 
 
 
 d 
 •^ 
 
 
 F ^ ci ^ -, 
 ^ i?. S 
 
 
 
 
 ^ 
 
 HP^-^Cw^pHf:^ 
 
 ^<^on^ 
 
 TXl RLW H hH H P 
 
 Lbs. 
 
 Ft. In. 
 
 Recoi'd of Labor 
 
 
 
 
 
 
 
 
 
 
 
 
 
 CIVIL 
 
 
 
 BIETHPLACE. 
 
 
 
 
 
 
 
 AGE 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 COJSTDITIOX. 
 
 -2 
 
 
 
 F— ' 
 
 
 
 
 
 
 
 
 
 
 
 d 
 
 
 weden. 
 
 \\dtzerlan( 
 
 Gotland. 
 
 d 
 
 
 
 <D 
 
 -^CiTjHOi'^cirJHci'* 
 
 Married. 
 
 Single. 
 
 Widowed. 
 
 © .5 !Z! 
 
 < 
 
 s ©13 c^ 
 
 5 
 
 
 
 
 1 1 M 1 1 1 1 1 
 
 I-O 
 
 »— ' — — 
 
 
 X X :/: 
 
 N-/ 
 
 t— ^ 
 
 " 
 
 C^J CM 
 
 JO 
 
 IC 
 
 "^ 
 
 -tH 10 kO 
 
30 REPORT OF THE SOCIETY OF THE LYINGIX HOSPITAL. 
 
 Becord of Labor. — (Continued.) 
 
 former preg 
 nancies. 
 
 — 
 
 — 
 
 
 — 
 
 3 
 
 
 1. 
 
 — 
 
 
 ~ 
 
 O 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 < 
 
 2_ 
 
 
 X 
 
 '-S 
 
 
 ■r. 
 
 •/■ 
 
 ■f. 
 
 •r. 
 
 -/: 
 
 X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 C 
 
 c 
 
 
 O 
 
 O 
 
 i^ 
 
 
 
 
 
 
 
 > 
 
 >. 
 
 d 
 
 > 
 
 > 
 
 ct 
 
 ?^ 
 
 w 
 
 ^ 
 
 ^ 
 
 P 
 
 h-! 
 
 t-^l^l—lH-lt— !►>>>»—(•— (t—iK.K.(— !»—(>— Ij> 
 I— i r^ y^_ \—{>—{ KNk^i_,t— (K^r'Kl— (I— I 
 
 Mr 
 
 X 
 
 MONTH OF CJKSTATION. 
 
 -t^ r^ 
 
 • iS'Tj-^ _■ r-i" ^ -*-^ rG r^ 
 
 Ttecoi'd of Lahor. — (Continued.) 
 
 CONDITION 
 OF CHILD. 
 
 URINE. 
 
 PRESENTATION. 
 
 DISPLACEMENT OF FOSTAL PARTS. 
 
 
 2 S ^ "H* 
 
 fS Vertex. 
 
 Ear. 
 
 Brow. 
 
 Face. 
 
 Occijuto Posterior 
 
 at Birth. 
 Shoulder. 
 Breech. 
 ISioi Observed. 
 
 Prolapse. 
 
 Extension. 
 
 Placenta 
 Pra3via. 
 
 E 5 
 
 Funis. 
 
 Foot. 
 
 Hand. 
 
 Legs. 
 
 Arms. 
 
 Hands. 
 
 Central. 
 Partial. 
 Marginal. 
 
 Record of Lahor. — (Continued.) 
 First Stage. 
 
 VAOINAL EXAMINATIONS. 
 
 mkdi(;ation. 
 
 HEMORRHAGE. 
 
 dura- 
 tion. 
 
 o 
 
 V>y Attending Physician. 
 
 \W Staff. 
 
 r.y Statf and Pupil. 
 r.y Outside Attendant. 
 Number not Observed. 
 
 N'aginal Douche. 
 
 Whiskey. 
 
 Quinine. 
 
 ^[orphine. 
 
 Chloroform. 
 
 Chloral. 
 
 Slight. 
 
 ^Moderate. 
 
 Profuse. 
 
 Demanded Treatment. 
 
 No Treatment. 
 
 
THE MEDICAL EECORDS AND THE PREPARATION OF STATISTICS. 
 
 31 
 
 Record of Lahor. — (Continued.) 
 Second Stage. 
 
 POSITION AT TIME 
 
 
 
 
 
 MEMBRANES. 
 
 VAGINAL EXAMINATIONS. 
 
 OF DELIVERY. 
 
 
 
 
 
 6 
 
 
 d 
 
 
 6 S 
 
 
 • rt -t^ ti 
 
 
 '^(n 
 
 
 - 5 
 
 
 J ^ 
 
 
 oi . c; t> 
 
 
 ^^ 
 
 
 ^ "Es 53 
 
 
 .^ 1 
 
 
 Ph ^ bM 
 
 '6 
 
 ^"T ^^' 
 
 
 
 (D 
 
 , Z/i \ ZD P 
 
 
 
 > 
 
 
 
 
 •^ s oj 
 
 
 1—1 CD r—- CD O' 
 
 
 
 Dorsal. 
 Lateral. 
 
 Not Obs 
 
 Intact. 
 
 Artificia 
 
 Spontan 
 
 Artificia 
 
 Spontan 
 
 Not Obs 
 
 § § g g 1 ^ >; ^fjD^ rt 
 
 By Atte 
 By Staff 
 By Pupi 
 By Staff 
 By Outs 
 Number 
 
 Record of Lahor. — (Continued.) 
 
 Second Stage. 
 
 MEDICATION. 
 
 CORD ABOUT. 
 
 HEMOR- 
 RHAGE. 
 
 DURA- 
 TION. 
 
 
 Neck. 
 
 Legs. 
 
 Arms. 
 
 Slight. 
 
 Moderate. 
 
 Profuse. 
 
 Demanded Treatment. 
 
 No Treatment. 
 
 
 Vaginal Douche. 
 
 Ergot. 
 
 Morphine. 
 
 Chloroform. 
 
 Chloral. 
 
 Once. 
 Twice. 
 
 Three Times. 
 Four Times. 
 Five Times. 
 
 . <6 
 OH 
 
 . a5 
 
 
 1 ^ 
 
 OH 
 
 to 
 
 Record of Lahor. — (Continued.) 
 Third Stage. 
 
 MEDICATION. 
 
 HEMORRHAGE. 
 
 DELIVERY OF 
 PLACENTA. 
 
 IMPLANTATION 
 OF CORD. 
 
 ce o © 
 
 a '^ = 
 
 © O 05 
 
 Q ^ <o 
 
 S O P2 
 
 ■ ■ O 
 
 .B-Z 
 
 > U ^ W^OQ 
 
 -J— > 
 
 ID OS c| ^3 
 
 ^ S r3 03 cpj>^ 
 
 
 iZ2 
 
 O) o 
 
 c ^ g « 
 
 ic »> c3 f^ 
 
 :e 
 
 
 
 
32 
 
 REPORT OF THE SOCIETY OF THE LYING-IN HOSPITAL. 
 
 Record of Lahor. — (Continued.) 
 
 Third Stage. 
 
 COXDITK»X OF I'LACENTA 
 AXD MEMBRANES. 
 
 TEMPERATURE ONE HOUR 
 AFTER LABOR. 
 
 PULSE ONE HOUR AFTER 
 LABOR. 
 
 -7: ? r: £j ,. :£ -2 
 (^ Q 'J <"'5'£ ^ ^ 
 
 ^7^ '^fi ^^ ^^ '^T' "'T' ^^ ^-J" ^I" ^T* 
 
 1:0 t-^ 00* ci th" (M' CO -*' ^ 
 
 OiOSOiOSOOOOOO 
 
 TH T-H T-t T-H T—l 1—1 
 
 1 1 1 1 1 1 1 1 1 1 
 
 10 t-^ GO oi i-H oi CO -+' 
 
 05 Oi Oi Oi O-. 'O 
 
 CiOiCiOiCiOiiXOjOiOi 
 
 ^lOCOt-COOiOT-HO^CO 
 
 1— ( T— I 1— I rH 
 
 1 1 1 1 1 1 1 1 1 1 
 
 O' 
 
 'TtiOOl— QCOiOT-HOTCO 
 
 1— 1— 1 ^H 1— 1 
 
 Record of Lahor. — (Concluded.) 
 
 Third Stage. 
 
 DURA- 
 
 
 
 TOTAL DURA- 
 
 
 
 
 PERINEUM. 
 
 
 
 DAY OF DISCHARGE. 
 
 TION. 
 
 
 
 TION LABOR. 
 
 1 
 
 
 
 . 
 
 
 
 
 
 <o 
 
 
 O) 
 
 
 
 
 
 > 
 
 
 K" 
 
 «t-H 
 
 
 
 T^ <0 
 
 c 
 
 
 
 
 
 'A 
 
 
 "■+3 
 
 Pi 
 C 
 
 Hours. 
 
 Minutes. 
 Not Obs 
 
 5 
 
 H^ Pl, o:i H P^ P^ X' oi W ^ H 
 
 Daily Record of Mother. 
 
 TEMPERATURE. 
 
 PULSE. 
 
 A.M. 
 
 P.M. 
 
 A.M. 
 
 P.M. 
 
 -f -f -+* 
 
 
 -+■ -r -f 
 
 -t" -t -t 
 
 -t -+•-+<-+• -f -f 
 
 50- 59. 
 
 60- 69. 
 
 70- 79. 
 
 80- 89. 
 
 00- 09. 
 100-109. 
 110-119. 
 
 ci oi 
 
 O'l CO 
 
 1— 1 T-H 
 
 ^ J. 
 
 -ri CO 
 
 T— 1 rH 
 
 
 «j- 'r^ r: 
 
 J[ 1 
 
 ■£ ij- '/> 
 
 i- 9" r 
 
 CO ■j;< »r. 
 
 1— -- 1-4 
 
 ' ; 1 
 
 tr. t". tr. 
 
 -ri CO* -t< 
 
 ceo 
 — — • 1— t 
 
 96.5- 97 
 97.5- 98 
 98.5- 99 
 
 -^ 7 ) CO ;^ 1^ 
 
 1 T 1 1 1 1 
 
 ».0 >C ».0 iC if5 iC 
 
 cv — -' oi CO* -t< 
 
 Ci C C C C 'C 
 
 Oi Oi Oi Oi Oi Oi Oi O".' Oi 
 iO I- CO Ci tH O'l CO 
 
 T-H r-H 1— ( rH 
 
 1 1 1 1 1 1 1 1 1 
 
 00000000-0 
 lO 'X' t^ "Xl Oi rH O'l CO 
 
 T—^ r-i 1—f r—i 
 
THE MEDICAL RECORDS AND THE PREPARATION OF STATISTICS. 
 
 33 
 
 Daily Record of Mother. — (Concluded.) 
 
 BREASTS. 
 
 UTERUS. 
 
 LOCHIA. 
 
 
 Height above Symphysis in Inches. 
 
 Con- 
 dition. 
 
 
 Normal . 
 Caked. 
 
 Lymphangitis. 
 Abscess. 
 Nipples Fis- 
 sured. 
 
 t 
 
 CD 
 
 > . ^ 
 
 tH tH T— ( r-l tH rH 
 
 Firm. 
 
 Flabby. 
 
 Not Observed. 
 
 Absent. 
 
 Sanguineous. 
 
 Sero-sanguineous. 
 
 Serous. 
 
 Sweet. 
 
 Foul. 
 
 Daily Record of Child. 
 
 w'gt. 
 
 TEMPERATURE. 
 
 CORD. 
 
 EYES. 
 
 
 A.M. 
 
 P.M. 
 
 
 
 
 ^T^ ^ji 'Tji ^^ ^^ ^^ ^^1 ^^ ^^ ^fi 
 
 ^^ ^^ ^T" ^^ ^^i ^7" ^'T' ^T" ^^' '^^ 
 
 Normal. 
 Suppurating. 
 
 
 J2 02 
 
 cicia:>OiOO'OOOo 
 
 tH rH r-( T— I 1—1 T-( 
 1 1 1 1 1 1 1 1 1 1 
 
 lOOiOiOiOiOiOiOiOiO 
 
 CCt-GOCiOr-IOTCC-+IO 
 
 CSCSCiOiOOOOOO 
 
 1— 1 rH rH rH r-l rH 
 
 1 1 1 1 1 1 1 1 1 1 
 
 1 — 1 03 
 
 H 
 
 o ^ 
 
 O^^Ct^GOCiOr-ICJCO'* 
 
 IC O -t- QO Oi O rH CM Oti ^ 
 
 CI Ci Ci Ci CI O' O O O O 
 
 r-H rH rH rH rH 
 
 
 Record of Child. 
 
 SEX. 
 
 
 
 
 
 WEIGHT AT 
 
 BIRTH. 
 
 
 
 
 
 
 c» 
 
 
 
 
 
 
 
 
 
 cc 
 
 S 
 
 
 
 
 
 
 
 oted. 
 on. 
 
 OJ 
 
 0) 
 O 
 
 in 
 
 ;3 
 
 O 
 
 
 
 
 
 
 
 
 c 
 
 i«t:s 
 
 UI^'SS 
 
 \sit^ 
 
 icjo icjo ois; inf© injto 
 
 irriO ic:f» ir$^ 
 
 irsfo i^':o 
 
 \ri^ \r.fs if:(» 
 
 «« 
 
 
 H-H 
 
 -H 
 
 -H 
 
 H'^ H^ HtH H^ H'-* 
 
 ■r^■^ H-H --M 
 
 H-H H-i 
 
 H-* -M --H 
 
 
 lo 
 
 t-i 
 
 CM 
 
 OO 
 
 -^ UO CO J::- GO 
 
 Ci O tH 
 
 (>T CO 
 
 '^ lO CO 
 
 O .JO as 
 
 T->. 
 
 
 
 
 
 T-i r-{ 
 
 rH rH 
 
 rH 1— 1 rH 
 
 ^<1^ 
 
 1 
 
 rH 
 
 1 
 
 rH 
 
 fM 
 
 1 
 
 CO 
 
 1 1 1 1 1 
 
 -H lO O t^ OO 
 
 1 1 1 
 
 C: O' rH 
 
 1 1 
 G^ CO 
 
 1 1 1 
 
 -^ lO CO 
 
 
 
 
 
 
 
 
 •r^ rH 
 
 •r-\ T^ 
 
 T^ •'-^ T^ 
 
34 
 
 REPORT OF THE SOCIETV OF THE LYING-IN HOSPITAL. 
 
 liecm'd of Child, — (Continued.) 
 
 VERTEX — COCCYGEAL LENGTH AT BIKTII. TOTAL LENGTH AT BIRTH. 
 
 
 
 ■A 
 
 xH' kH' sH =5*^ «H =eH' «t* kH «^* kH kH mH- kH «H 
 
 — 1 (M rt -+ o cc^ t- 00 C5 c: T-i CM Of 4i lo CO J^- CO 
 
 T— IT— It— (tHt— It— It— It— It— 1 
 1 1 1 1 1 1 1 1 1 1 1 1 1 I 1 1 1 1 
 
 -tssyi CO -<ti o w t-^ 00 05 o T— 1 (M Of ^ lo <:o t- GO 
 
 1— 1 
 
 ccH* kHi mH mH" <=^ =^ <=«H ^H ==H* etH* '^ =^ '=^* ^ 
 T— 1 CM Of tJH IQ O t^ OO 05 O' T-l Ol Of -4l 
 
 T— ^ T-H T— 1 T— 1 T— ^ 
 
 1 1 1 1 1 1 1 1 1 1 1 1 1 1 
 
 "l<^>(^^ Of rti Kf <:o i,— c/: cr. C: t— l Ol of -rH 
 
 T— ( tH 1—1 T—l T—l 
 
 Record of Child. — (Continued.) 
 
 TOTAL LENGTH AT BIRTH. 
 
 JCT^ sc^-t St-* sth* sH":H"^ kH seH" 
 J--: --Z I- X Ci C: -^ Ol CO 
 
 — I .^ .r-l -^ r^ CM ^1 CM (M 
 
 I I I I I I I I 
 
 . -. V: I - CO CI O ■^ '?! CO 
 — ' ^ T-l T-l (M CM (>5 <M 
 
 TEMPERATURE AT BIRTH. 
 
 -t--+i-H-H-H-H-+i-H-+i 
 
 
 1— 
 
 C5 
 
 CO 
 C5 
 
 CI 
 
 T-l 
 
 T^ 
 
 (M Of -+I 
 
 o o o 
 
 ^^ T—l 1—1 
 
 >o 
 
 Vfj 
 
 lO 
 
 vo 
 
 lO 
 
 UO 
 
 lO lO 
 
 Kf 
 
 IC CO 1- CX> 05 O T— I OT CO 
 
 C:' CI C^) CI Ci O O O' O' 
 
 CORD DETACHED ON. 
 
 
 
 
 Record of Child. — (Concluded.) 
 
 £Y£8 AT 
 
 BIBTH. 
 
 DAY DISCHARGED. 
 
 DICATH OF CHILD. 
 
 
 
 
 
 s« v* 
 
 ^ 
 
 ^ -^ 
 
 "Z J=. 1^^ 
 
 
 fi^ 
 
 ^ r— *- r^ "Z: _ri _i=l 
 
 J^ (^ Ph 
 
 9x C g 5r-5'S o^^t:; 
 
 '^.i: ^..2 o'TZ i:j c^ •""•--' S 
 
 h-5fj-ic/iHfiHPiHCC!c^w;2;EH 
 
THE MEDICAL KECORDS AND THE PREPARATION OF STATISTICS. 35 
 
 The Card Index. — The card system of keeping records is too well 
 known and too nniversally used to need any description here. We have 
 applied it to the recording of the complications and the exceptional phe- 
 nomena of our obstetrical service. This system is more elastic and more 
 flexible than any record book. It allows also of additions and subtractions 
 without mutilation, and it permits the handling and the arrangement of 
 the records into various groups, as a book cannot. The cards used are five 
 and one-half inches by six and three-quarter inches in size. They are 
 printed on one side, and after being filled out are stored in boxes, each 
 kind of card having its own box. These boxes are kept in a cabinet built 
 for the purpose. Each important subject has a special card, and there is a 
 general card for miscellaneous subjects. These cards are reproduced in 
 reduced size. 
 
 ABORTION. 
 
 Application No Confinement No. 
 
 BIRTHPLACE, AGE,.... PARA, .... MONTE OF GESTATION, 
 
 LABOR, 
 
 i Dispensary. 
 
 DELIVERED By) MMwile ^^^'''''''"' 
 
 PRESENTATION, POSITION, ( Unattended, 
 
 Symptoms, 
 
 Complications, 
 
 Treatment, 
 
 Result,. 
 
36 
 
 KEPORT OF THE SOCIETY OF THE LYING-IX HOSPITAL. 
 
 Application No. 
 
 ACCOUCHEMENT FORCE. 
 
 Confinement No, 
 
 Birthplace,- 
 Labor, 
 
 Presentation,. 
 
 _Age,.. 
 
 .:Para, Month of Gestation,. 
 
 f 
 
 Position,. 
 
 Dispensary. 
 
 .Delivered by \ Z""!''^! Physician. 
 
 Midwife. 
 _ Unattended. 
 
 Foetal Heart,.. 
 Indication, 
 
 Compfications, 
 
 Perineum,.... 
 Treatment,.. 
 
 Cervix, 
 
 Result,. 
 
 ALBUMINURIA. 
 
 ANTE-PARTUM. DURING LABOR. POST- PARTUM. 
 Application No Confinement No.. . . 
 
 /i/Ii rilPLA CK. \0K PA It A MONTH OF (I EST. 1 TlON 
 
 LABOR i Dispensary. 
 
 DELIVERED by) ^[^^^J/^'^''"'""- 
 
 I'RESEXTA TION, POSITION. ( rimlt.'ii.Ud. 
 
 Symptoms,. 
 
 Previous Renal History, 
 
 Urine, 
 
 Complications, 
 Treatment, 
 
 Result, 
 
TJIE MEDICAL KECORDS AND THE PREPARATION OF STATISTICS. 37 
 
 BREECH PRESENTATION. 
 
 Application No, Confinement No 
 
 Birthplace, Age Para, Month of Gestation, 
 
 Labor, r Dispensary. 
 
 DELIVERED BVJ 0,^;i^!|;/'<>--- 
 
 Presentation Position, I Unattended. 
 
 Pelvis,. 
 
 Soft Parts, 
 
 Complications, 
 Treatment, 
 
 Result, 
 
 BREECH EXTRACTION. 
 
 Application No Confinement No. 
 
 BIRTHPLACE, AGE,.... PARA, .... 210 NTH OF GESTA TION, . 
 
 LABOR, r Dispensary. 
 
 T^TTT TT^TPVjpT^ z? X- ) Out-sidc Pliyslcian. 
 DELUERED B14 Midwife. 
 
 PRESENTA TION, POSITION, ( Unattended. 
 
 i Arms, 
 Position of^ 
 
 ( Legs, . 
 
 Foetal heart, 
 
 Funis, 
 
 Complications (after-coming head), 
 
 Treatment, 
 
 Result, 
 
38 KEPORT OF THE SOCIETY OF THE LYINU-IN HOSPITAL. 
 
 BREECH EXTRACTION, AFTER VERSION 
 
 Application No Confinement No 
 
 Birthplace Age Para ]\[oxtii of Gestation,. 
 
 • • • [ Dispen 
 BY -J ?,'.'S' 
 
 Pkeskxtation'. Position, 
 
 Labor C Dispensary. 
 
 -r-k ^ ,,,, ) Outside Physician. 
 Delivered bW ^^.^^^.^^ • 
 
 ( Unattended. 
 
 Presentation before version, Position before version,. 
 
 \ Arras, 
 
 / Leijs 
 
 Position of 
 
 Foetal heart, 
 Funis, 
 
 ^ 1- i.- \ extended arras. 
 
 Complications , ^fter-coraing head. 
 
 Treatment (methods used,) 
 
 Result, 
 
 CURETTING. 
 
 Application No Confinement No. 
 
 BIRTHPLACE, AGE, .... PARA, .... MONTH OF GESTATION, 
 
 LABOR, 
 
 DELIVERED B 
 
 PRESE.XTA TTOX, POSITION. 
 
 ■ ( Dispensary. 
 Y ] Out-side Physi 
 
 „ sician. 
 Midwife. 
 Unatleiided. 
 
 Indication, 
 
 Technique, . — 
 Complications, 
 
 Treatment, 
 
 Result, 
 
THE MEDICAL EECORUS AND THE PREPARATION OF STATISTICS. 39 
 
 DEATH OF CHILD. 
 
 Application No Confinement No 
 
 BIRTHPLACE, AGE, .... FAB A, .... MONTR OF GESTATION, 
 
 LABOR, 
 
 ( Dispensary. 
 
 DELIVERED By) ^l^^^^^^^^'"'^^'^- 
 
 PRESENTATION, POSITION [ Unattended. 
 
 Age of Child, 
 
 Heart, Lungs,. 
 
 Umbilical Stump, 
 
 Symptoms, 
 
 Autopsy, 
 
 DEATH OF MOTHER. 
 
 Application No Confinement No. 
 
 BIRTHPLACE, AGE, .... PARA, .... 3I0NTH OF GESTATION, . 
 
 LABOR, 
 
 I Dispensary. 
 
 DELIVERED by) nJawiie. ■^^^'''"''"" 
 
 PRESENTA TION, POSITION, I Unattended. 
 
 Complications before delivery, 
 
 Operations or manipulations, 
 
 Complications after delivery,. 
 
 ( antepartum, 
 
 Day of Death, \ 
 
 ( postpartum, 
 
 Autopsy, 
 
 Cause of Death, 
 
4,0 KEPOKT OF THE SOCIEIY OF TIJK JA'IXG-IN HOSPITAL. 
 
 DEFORMED PELVIS. 
 
 Application No Confinement No. 
 
 Birthplace, Age, Paka Month of Gestation,, 
 
 Labok, [ Hospital. 
 
 T^iiivn^vi^ Tiv ' Outside Physician. 
 DlLINEKED B\. Midwife. 
 
 I'KESr.NTATlON PoSITIOX ' l^'i'i<tended. 
 
 Result, 
 
 DISPLACEMENT OF FOETAL PARTS. 
 
 HANDS, FEET, FUNIS. 
 Application No Confinement No 
 
 /y/A' 77/ /'LA ( '/■: Adl-J PARA, .... MONTH OF GESTA TION, 
 
 LABOR, 
 
 DELIVERED BY 
 
 /'li/:s/:XTA T/OX, /'OSTT/ON. 
 
 ■ ( Dispensary. 
 
 y ) Out-side i'liy: 
 
 "i Midwife. 
 
 ( Unattended. 
 
 sician. 
 
 Hands, 
 
 Feet, 
 
 Funis, 
 
 Foetal heart,. . . 
 Complications, 
 
 Treatnnent, 
 Result, 
 
THE MEDICAL RECOEDS AND THE PREPARATIOX OF STATISTICS. 41 
 
 EXTRACTION.) MEMBRANES. 
 
 Application No Confinement No 
 
 BIRTIIPLA CE, AGE,.... PARA, .... MONTH OF GESTA TION, 
 
 LABOR, [ r^. 
 
 I Dispensary. 
 
 DELIVERED By\ ^^"V'-J'' P'^y^^^'*^"' 
 
 1 Muhvife. 
 
 PRESENTATION, POSITION, '. Unattended. 
 
 Hemorrhage, 
 
 Condition of Placenta, 
 
 Complications, 
 
 Treatment, 
 
 Result, 
 
 FACE PRESENTATION. 
 BROW PRESENTATION. 
 
 Application No Confinement No. 
 
 BIRTHPLACE, AGE,.... PARA, .... 210 NTH OF GESTATION, 
 
 LABOR, 
 
 PRESENTA TION, POSITION, 
 
 Dispensary. 
 DELIVERED By) ^^^^^^ Physician. 
 I Unattended. 
 
 Pelvis, 
 
 Soft Parts, 
 
 Complications, 
 
 Treatment, (manual rectification.). 
 
 Result, 
 
42 
 
 REPORT OF THE SOCIETY OP" THE LYING-IN HOSPITAL. 
 
 FEVER. 
 
 Application No. 
 
 Confinement No. 
 
 Birthplace, Age, Para, Month of (jestation,. 
 
 Presentation, Position. 
 
 LaISOIi f Dispensary. 
 
 ^^^^^ ^^^^' ^'^ ^ Midwife. 
 
 f UnuttondtHl. 
 
 Day 
 
 1 
 
 a H. 
 
 E 
 
 
 3 
 
 = 
 
 4 
 
 
 5 
 
 6 
 
 £ 
 
 3 
 
 1 
 
 7 
 
 £ 
 
 C3 
 
 £ 
 
 5 
 
 g 
 c. 
 
 9 
 
 c 
 
 e3 
 
 E 
 s. 
 
 10 
 
 1 
 a 
 
 r 
 
 12 
 
 5 E 
 
 1 
 
 E 
 a 
 
 3 
 
 1 
 £ 
 
 4 
 
 £ 
 
 15 
 
 . .1 . . 
 
 16 
 
 S £ 
 
 17 
 
 Eia 
 
 18 
 
 e'e 
 
 19 
 
 B a 
 
 20 
 
 106° 
 105° 
 104° 
 103° 
 102° 
 I0i° 
 100° 
 99° 
 
 
 
 
 ■•I-- 
 
 y.c. 
 
 
 ' ' 
 
 
 
 
 98= 
 97° 
 
 Pulse 
 Res^pi- 1 
 ratiuii. \ 
 Hei^bt| 
 
 litem- \ 
 
 "l 
 
 
 
 
 
 
 ± 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 '.'l 
 
 
 
 ■■ 
 
 
 
 
 
 
 
 
 Lochia,. 
 Uterus,. 
 
 Breasts,. 
 
 Parametria,. 
 
 Bowels, 
 
 Complications,. 
 
 FCETAL DEFORMITIES. 
 
 Application No. 
 
 Confinement No. 
 
 Birthplace, 
 
 Lai'.oh 
 
 Age, PAii.y. 
 
 Month of (Je.station,, 
 
 Pp.ksentation. 
 
 Position, 
 
 r Dispensary. 
 
 Delivered by -> ^}!f'^' ^'^'y''''' 
 
 j iMidwife. 
 f Unattended. 
 
 Foetal Movements, 
 
 Foetal Heart, 
 
 Complications of Labor,. 
 
 Mother's History, 
 
 (a) Con.stitutional, 
 
 (b) In pregnancy, 
 Father's History, (f.'on.slitutional), ... 
 
 Condition of Placenta, 
 
 Condition of Child, 
 
 A utopsy, 
 
THE MEDICAL RECORDS AND THE PREPARATION OF STATISTICS. 43 
 
 MEDIUM. 
 LOW. 
 
 Application No, Confinement No 
 
 BIRTHPLACE, AGE,.... PARA, .... MONTH OF GESTA TION, 
 
 LABOR 
 
 Dispensary. 
 DELIVERED BY J ^/Jj-^^^ Physician. 
 
 PRESENTATION, POSITION ' Unattended. 
 
 Foetal heart 
 Indications. . 
 
 Complications, 
 
 Cervix Perineum. 
 
 Treatment, 
 
 Result, 
 
 HEMORRHAGE. 
 
 ANTEPARTUM. DURING LABOR. POSTPARTUM. 
 Application No Confinement No... 
 
 BIRTHPLACE, AGE,.... PARA, .... MONTH OF GESTATION, 
 
 LABOR 
 
 1 Dispensary. 
 
 DELIVERED by) MMwife ^^^''''''"' 
 
 PRESENTA TION, POSITION. ( Unattended. 
 
 Antepartum, (how long.), . . . Stage of Labor, Postpartum, (how long,) 
 
 Cause of the hemorrhage, 
 
 Symptoms, 
 
 Placenta implantation. 
 Condition of Placenta, 
 
 Foetal heart, 
 
 Complications, 
 
 Treatment, 
 
 Result, 
 
4-i REPORT OF THE SOCIETY OF THE LYING-IN HOSPITAL. 
 
 ICTERUS NEONATORUM. 
 
 Application No Confinement No. 
 
 lilltTllI'LAlE, A(ii: PaKA, ^loNTll OK (Jl'.STATlOX, 
 
 ^■'■'^l^Oli r Dispensary. 
 
 Delivered by J m'S ^''•'''''''"' 
 
 Presentation Position, v Uiuittended. 
 
 Begun on day after birth, 
 
 Subsided on day after birth, 
 
 Complications, 
 
 Treatment, 
 
 Result, 
 
 MAMMARY ABSCESS | ^q^^^P 
 
 Application No Confinement No.. 
 
 Birthplace, Age, Para, Month of Gestation, 
 
 I^ABOR, r DispciiSHiT. 
 
 Delivered by^ Outside Physician. 
 
 1 JMidwiic. 
 
 |',;i:<i:nt ATfON- Position ' l'""<<ended, 
 
 Symptoms, 
 
 Complications, 
 
 Treatment, 
 
 Result, 
 
THE MEDICAL RECORDS AND THE PREPARATION OF STATISTICS. 45 
 
 OCCIPITO— POSTERIOR POSITION. 
 
 Application No Confinement No 
 
 Birthplace, Age, Para, Month of Gestation,... 
 
 ^-^^^^^ ( Dispensary. 
 
 Delivered by^ nSfe.^^^''"''"' 
 
 Presentation Position, I Unattended. 
 
 Pelvis, 
 
 Soft Parts, 
 
 Complications, 
 
 Treatment (manual rectification), 
 
 Result, 
 
 PERINEORRHAPHY. 
 
 Application No Confinement No.. 
 
 BIRTHPLACE, AGE,.... PARA, .... 310 NTH OF GESTATION, 
 
 LABOR 
 
 1 Dispensary. 
 
 DELIVERED By) ^.^'-side Physician. 
 
 PRESENTA TION, POSITION, 
 
 Midwife. 
 Unattended. 
 
 Laceration, 
 
 Treatment, (Technique.) 
 
 Complications, 
 
 Result, 
 
46 
 
 REPORT OF THE SOCIETY OF THE LYING-IX HOSPITAL. 
 
 Application No, 
 
 PLACENTA PRAEVIA. 
 
 MARGINAL. PARTIAL. CENTRAL. 
 
 Confinement No. 
 
 BIRTHPLACE, AGE,.... I'ARA JIONTII OF OESTA TI(}.\ 
 
 LABOR, 
 
 DELIVERED 
 
 PRESEXTA TIOX. (foetal.) POSITION, (foetal.) .... 
 
 ■ ■ ■ r Dispensary. 
 
 Ti\') Out-sido Physician. 
 
 ^^^ i Midwife. 
 
 I Unattended. 
 
 Foetal heart, 
 Symptoms,. . . 
 
 Complications, 
 
 Treatment, 
 
 Result, 
 
 Application No. 
 
 PLURAL BIRTHS. 
 
 TWINS. TRIPLETS. 
 
 Confinement No. 
 
 BIRTHPLACE, AGE,.... PARA,. 
 
 LABOR, 
 
 MONTH OF GESTATION. 
 
 PRESENT A TION, I . . . TT . . . ITT . . . POSITION. 
 SEN. T II Ill 
 
 ( Dispensary. 
 
 ) Out-.side Physioiii 
 
 - -r -jy -,., I Unattended. 
 
 .DELIVERED BY 
 
 Placenta, 
 
 j single, . 
 ( double, 
 
 one, 1 
 
 Amniotic cavity, ^ two, \ 
 
 three, ) 
 
 Funis, 
 
 Complications of labor,. 
 
 Result, 
 
THE MEDICAL RECORDS AND THE PREPARATION OF STATISTICS. 47 
 
 PNEUMONIA. 
 
 Application No. Confinement No 
 
 BIRTHPLACE, Aiii:, .... PARA, .... 2I0NTH OF GESTATION, 
 
 LABOR, [ r,- 
 
 ' I Dispensary. 
 
 DELIVERED By) Midwife ^*'^'''''"''' 
 
 PRESS NT A TION, POSITION I Unattended. 
 
 Operations, 
 
 Puerperium, 
 
 Pneumonia began on day of puerperium. 
 
 Pneumonia terminated on day of puerperium, (defervescence.) 
 
 Complications, 
 
 Treatment, 
 
 Result, 
 
 SHOULDER PRESENTATION. 
 
 Application No Confinement No. 
 
 Birthplace, Age, Para, Month of Gestation, . 
 
 L-^^O^' ( Dispensary, 
 
 Delivered by J MMtife.^^'"''''''''' 
 
 Presentation, Position, I Unattended. 
 
 Pelvis,. 
 
 iArms, 
 Legs, . 
 
 Funis, 
 
 Complications, 
 
 Treatment, 
 
 Result, 
 
48 REPORT OF THE SOCIETY OF THE LYIXG-IX HOSPITAL. 
 
 STILL BIRTH. 
 
 Application No Confinement No. 
 
 BIllTlIPLACE, AGE,.... PARA, .... MONTH OF GESTATION, 
 
 LABOR 
 
 ( Dispensary. 
 
 DELIVERED By\ mJ^S. ^'''^''^''''"• 
 
 PRESEXTA TIOX. POSITION, \ Unattended. 
 
 Foetal Movements, 
 
 Foetal Heart, 
 
 Complications of Labor, 
 
 i (a) Con.stitutional, 
 Mother's History, -I 
 
 ( (b) In pregnancy, 
 
 Father's History, (Constitutional.) 
 
 Condition of Placenta, 
 
 Condition of Child, (macerated,). 
 Autopsy, 
 
 SUPPURATION OF UMBILICAL STUMP. 
 
 CONJUNCTIVITIS. I bo"eyes. 
 
 Application No. Confinement No 
 
 lilR TIIPLA CE AGE,.... PARA,.... MONTH OF GESTA TION, . 
 
 LA BOR ( Dispensary. 
 
 DELIVERED by) l^^^^^-- 
 
 I'UFSENTA TION, position, ( Unattended 
 
 Begun on day after birth, 
 
 Subsided on day after birth, 
 
 Complications, 
 
 Treatment, 
 
 Result, 
 
THE MEDICAL RECORDS AND THE PREPARATION OF STATISTICS. -19 
 
 VERSION. I -rua- 
 
 Application No Confinement No. 
 
 BIRTHPLACE, AGE,.... PARA, .... 3I0NTH OF GESTA TION, 
 
 LABOR, ( Dispensary. 
 
 Out-side PI: 
 
 Midwife. 
 
 Unattended 
 
 DELIVERED by} Sia'wSe. ^^^'''"''''' 
 
 PRESEXTA TIOX, POSITION, 
 
 Foetal heart, 
 Indications,. - 
 
 Connplications, 
 
 Perineum, Cervix, 
 
 Hand used, 
 
 Treatment, 
 
 Foot seized, , 
 
 Result, 
 
 Application No^ Confinement No. 
 
 Birthplace, Age, Para, Month of Gestation,, 
 
 Labor. . . . .• c Hospital. 
 
 D-^™™ byJ g°«;fh: 
 
 Presentation Position, v Unattended 
 
 Result, 
 
50 
 
 REPORT OF THE SOCIETY OF THE I.VIXC-IX HOSPITAL. 
 
 The checks on these cards are the following: 
 
 1. A cross index of all the other cards belonging to that particular his- 
 tory is -written under " Labor " on the heading of each card. This 
 l)erniits one to compare the cards of any history with one another. 
 
 2. The number of cards demanded by each history is recorded under 
 the column, '' Xumber of Cards," in the large Statistic Book. The total 
 of this column gives the number of cards in every hundred histories. 
 
 o. The number of cards is recorded also in a special Card Tally Sheet, 
 on which each line represents one hundred histories, and the columns 
 represent the kinds of cards (see accompan3dng figure for a sample of such 
 a sheet). The totals of the lines give the number of cards in each hundred 
 histories, and the totals of the columns give the numbers of cards of each 
 kind. 
 
 Sample Card Tali-y Shee;t. 
 
 2 
 
 c o 
 
 3 O 
 
 .2 
 
 o 
 
 i 
 
 .5 
 1 
 
 
 d 
 
 
 a 
 
 
 
 Qi 
 
 
 
 Q 
 «f-i 
 
 
 
 Pi 
 
 S 
 
 
 
 6 
 
 03 
 
 g 
 
 
 
 5001-5100 
 
 4 
 
 1 
 
 1 
 
 6 
 
 8 
 
 1 
 
 2 
 
 
 
 S 
 
 etc. 
 
 52 
 
 51 01 -.5200 
 
 2 
 
 
 
 2 
 
 3 
 
 5 
 
 3 
 
 1 
 
 1 f; 
 
 etc. 
 
 ()2 
 
 etc. 
 
 etc. 
 
 etc. 
 
 etc. 
 
 etc. 
 
 etc. 
 
 etc. 
 
 etc. 
 
 etc. 
 
 etc. 
 
 etc. 
 
 etc. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 "We thus have the total number f)f cai-ds recorded in two places: in tlie 
 large Statistic Book, where it is itemized on the basis of the individual 
 history; and on tlu; tally sluict, where it is itemized on the basis of the 
 individual cards. If any card is not made out, the two totals will not 
 tally. If any card once made out is lost, the number of the remaining 
 
THE MEDICAL RECORDS AND THE PREPARATION OF STATISTICS. 51 
 
 cards will not tally with these totals. The missing card can be located in 
 the proper hundred of histories, and it must then l^e supplied by refer- 
 ence to the histories themselves. 
 
 Such is the method of preparing statistics which is used Ijy the Medical 
 Board of this Society. It means an outlay of a certain sum of money for 
 tlie payment of a permanent clerk and for the necessary stationery. The 
 expense, however, need deter l)ut few, for one thousand dollars will more 
 than cover the annual outlay. By such a system the more routine part of 
 the work can be kept in a condition of constant readiness for publication. 
 Of course there will remain for the members of the Medical Board a large 
 expenditure of time and special work before each report is edited and 
 published. 
 
PRACTICAL IXSTRUCTIOX GIVEN BY THIS HOSPITAL TO 
 GRADUATE AND UNDERGRADUATE PUPILS. 
 
 Practical instruction is divided to-d;iy into five classes, as follows: 
 
 A. A Course of Preliminary Instruction is given to Graduate and Under- 
 
 graduate Pupils alike, which includes : 
 
 a. The Care and Preparation of the Sui'gical Dressings Used in the Service 
 
 of the Hospital. 
 
 b. The Care and Uses of the Contents of the Labor and Postpartum Bags. 
 
 c. The Keeping and Recording of the Histories of Pregnancy, Labor, and 
 
 Child. 
 
 d. The Principles of Asepsis and Antisepsis, especially as Applied to the 
 
 Examining Hand. 
 
 e. And, finally, the Principles in the Treatment of Normal Labor, and 
 
 the Care of the Puerperal Woman and her Child. 
 
 B. Examination of Pregnant Women. 
 
 a. Antepartum Instruction. 
 
 C. The Care of Labor Cases. 
 
 a. Intrapartum IiLstruction. 
 
 D. Treatment of Mother and Child after Confinement. 
 
 a. Postpartum Instruction. 
 
 1. Outdoor or Dispen.sary Service. 
 
 2. Indoor or Ward Service. 
 
 E. Obstetrical Clinics— Normal Labor and Obstetric Surgery. 
 
 A. Preliminary Instruction. 
 
 As far as possil>l(', the M<!dic;d Hoard aim at a graded course of in- 
 struction for the und(;rgra<luates entering u})on their two weeks' term of 
 service. To this end the junior pupil, during tlie first few days of his service, 
 is required to ol).serve the management of the confinements in tlie ol)stetrical 
 clinics of the Institution or in tlu^ outdoor service, and to visit puerperal 
 Avonien and their chiidi'cn i!i the tenement houses. lie is instructed in the 
 
Fig. 1. — Labor Bag. 
 {From a photograph.) 
 
PRACTICAL INSTRUCTION GIVEN BY THIS HOSPITAL. 
 
 53 
 
 care of mother and cliiul, both in the wards and outdoor service, as well as 
 in the contents of the labor and postpartum bags and their uses. 
 
 It may be stated here that students are termed Juniors in the lirst, and 
 Senioi's in the latter, half of their term of service. As soon as the student 
 has sio-ned his name to the rules of the Institution and been assio-ned to his 
 quarters, he is given the above preliminary instruction by one of the resi- 
 dent staff especially appointed for the purpose. 
 
 The bag used by the Hospital to carry the articles needed at a confine- 
 ment case in the tenements is opened and emptied before the students, and 
 its contents severally described, together with the importance of cleanli- 
 ness in their use. (See Fig. 1.) 
 
 Society of the Lying -In Hospital 
 
 OF THE CITY OF NEW YORK. 
 
 CONTENTS OF LABOR BAG. 
 
 Right Side of Bag. 
 
 ALCOHOL. 
 
 Bottom Pocket. 
 
 THREE BASINS. 
 
 ERGOT. 
 
 ACETIC ACID. 
 
 SILVER NITRATE SOLUTION. 
 
 RUBBER CATHETER. 
 
 TAPE FOR CORD. 
 
 Centre of Bag. 
 
 STERILIZED VULVA PADS. 
 
 STERILIZED COTTON WiPES. 
 
 PELVIMETER. 
 
 OBSTETRICAL PAD. 
 
 DOUCHE BAG. 
 
 Left Side of Bag. 
 
 EYE WIPES in Boracic Acid. 
 
 BOTTLE CONTAINING 
 TWO DOUCHE TUBES, 
 
 ONE GLASS CATHETER. 
 
 DRY WIPES(Umbilical Dressings). 
 
 SOAP. 
 
 VASELINE. 
 
 BICHLORIDE TABLETS. 
 
 Left Cover of Bag. 
 
 SCISSORS. 
 EYE DROPPER. 
 
 POWDERED STARCH. 
 C. C. PILLS. 
 
 Bight Cover of Bag. 
 
 SIX REPORT BLANKS. 
 
 Top Pocket. 
 
 SCALES. 
 
 NAIL BRUSH 
 
 TAPE MEASURE. 
 
 LABOR RECORD. 
 
 CHILD'S RECORD. 
 BIRTH CERTIFICATE. 
 APPLICATION CARD. 
 
 STUDENT'S PAD. 
 
 1.— Before leaving case, pupils must see that all of above 
 articles are returned to bag. 
 
 2.— Jars containing vulva pads, cotton wipes and catheters, are 
 not to be opened until required for use. 
 
 3.— All bottles, instruments, rubber apparatus, etc., must be 
 ■wiped dry and free from blood stains before being returned 
 to labor bag- Students will be held responsible for any 
 damage to labor and postpartum bags resulting through 
 uncleanliness or carelessness. 
 
54 
 
 REPORT OF THE SOCIETY" OF THE LYING-IX HOSPITAL. 
 
 The same iiistriictiou is then liiven in the cave and use of the bag used 
 bv the IIos]Htal in visitini];- niothet's and their children after confinement. 
 (See Fig. i'.) 
 
 Society of the Lying-in Hospital 
 
 OF THE CITY OF NEW YORK. 
 
 CONTENTS OF POSTPARTUM BAGS. 
 
 Itiuht Side of Bag. 
 
 EYE WIPES IN BORACIC ACID. 
 DRY WIPES (Umbilical Dressing). 
 
 Left Side of Bag. 
 
 SOAP. 
 BICHLORIDE TABLETS. 
 
 Upper Pochet. 
 
 NAIL BRUSH. 
 TAPE MEASURE. 
 
 Lower Pocket. 
 
 STARCH. 
 C. C. PILLS. 
 
 Centre of Bag. 
 
 STERILIZED VULVA PADS. 
 
 STERILIZED COTTON WIPES. 
 
 BASIN. 
 
 1. — Before leaving case, pupils must see that 
 above articles are returned to bag. 
 
 2. — Jars containing vulva pads, cotton wipes and 
 catheters, are not to be opened until re- 
 quired for use. 
 
 3. — All bottles, instruments, rubber apparatus, utc, 
 must be wiped dry and free from blood 
 stains before being returned to labor bag. 
 Students will be held responsible for any 
 damage to labor and postpartum bags re- 
 sulting through uncleanliness or carelessness. 
 
 At this lime, as a ])i<'lnniii;uy lo the later instruction, the general rules 
 of asepsis and antisepsis are gone over with especial reference to the exam- 
 ining ])and, an«l to those are added tlie general principles in the treatment 
 of normal labor and the ])uej-|)ei-al woman and hei- child. 
 
 The in.structor then introduces the ])ii|»il to the history-room of the 
 Hospital, jtroduces a series of history l>lanks, and e,\])lains In^w, when, 
 
Fig. 2. — Postpakttjm Bag. 
 (From a photograph.) 
 
PRACTICAL INSTRUCTION GIVEN BY THIS HOSPITAL. 
 
 55 
 
 and where the observations called for upon the latter are to be recorded. 
 (See Histor}'' Blanks.) 
 
 A blank-book called the " Student's Record " is then given to the pupil 
 (see below), in which he is instructed how to enter the (1) number of 
 cases confined, (2) the number of cases at which he was present, (3) tlie 
 number of antepartum examinations made, and (4) the number of post- 
 partum visits made. 
 
 This Record is verified from time to time by the instructor, and later 
 corrected by comparison with a general record-book of students' work 
 kept by the Hospital. 
 
 STUDENT'S RECORD. 
 
 \idime, 
 
 SerOice be^an_ 
 " • ended. 
 
 J86)_ 
 J8G). 
 
 DATE. 
 
 CONFINED 
 
 CASES 
 No. 
 
 PRESENT 
 
 AT CASES 
 
 No. 
 
 VISITED 
 
 CASES 
 No. 
 
 EXAMINED 
 
 CASES - A. P. 
 
 No. 
 
56 REPORT OF THE SOCIETY OF THE LYIXG-IN HOSPITAL. 
 
 Pi. TiiK ExA:\nNATio.\ (1f Pregnancy — ANrKfAuiiM Instkictiox. 
 
 At the ])ivsent time most of the antepartmu instruction of this Insti- 
 tution is carried on in the main Hospital building, and this work continues 
 tiirough the student's two weeks"' term of service. The instruction in the 
 examination of pregnancy has been systematized during the past year by 
 the Medical Board, so that each student examines and records the history 
 of pregnancy on an average of O.O-i cases under comjietent and critical 
 supervision. 
 
 The examiniuff-rooms, three in number, are, dui-inii,- live afternoons of 
 the week, under the charge of the Assistant Attending Physicians. \\\\o 
 serve in rotation. 
 
 Patients apply^ing for admission to the outdoor oi- ward service of the 
 TIos])ital are subjected to a thorough examination, and unless the case 
 be an emergency one, the services, of the Hospital are refused unless the 
 patient submit to such examination of pregnancy. 
 
 Under the supervision and criticism of the assistant attending })hysi- 
 cian on dut}', students are required to make a thorough examination and 
 diagnosis of pregnancy, including pelvimetry, and properly to fill out the 
 History of Pregnancy. 
 
 The Medical Board has seen fit to make this record, as well as the sub- 
 se(|uent history blanks of Labor and of the Child, fuller and more detailed 
 in their requirements than perhaps the ])urely medical records of the 
 Hosi)ital would demand. This is done in order to bring out the student's 
 faculties of observation, and a Avider consideration of the subject than is 
 generally considered necessary. 
 
 ^Moreover, this is the time we have selected to inculcate in the student 
 the ])rinci})les of obstetric cleanliness, mechanical and chemical. Soa]), 
 brushes, bowls of mercuric chloride, and an aliundant and convenient water 
 sujiply are to be found in the examining-rooms of the Institution. And 
 under critical supervision, each student is required to carry out the same 
 rigid cleaning and disinfecting of the hand and forearm in his examination 
 of ])regnancy as in the confinement cases. 
 
 It is the aim of the .Medical Board to have these examinations of the 
 dispensary women resemble as nearly as possible the "touch courses" of 
 the foreign maternities. Two students, after a thorougli cleaning of the 
 hands, examine a ca.se of pregnancy botli externally and internally. The 
 instructor in charge then examines the case, and questions the students 
 regarding the general condition of the ])atient, the pei'iod of gestation, 
 posture and presentation of the fcrtus, condition of tlie nianimary glands, 
 anterior abdominal walls, external genitals, and pelvic contents, together 
 with the size of the bony pelvis, and departures from tJK', normal in 1h(^ 
 hard and soft parts. 
 
 i'ai-ticuhir attention is at this time <:iven. lii'st, tr> llie siz(^ of the jx'his; 
 and, second, to the size of the fu'tal head. K.xaminations thus carried out 
 under the eye of the insti-nctoi-, with attention to iniiiiitc details, as well as 
 
PRACTICAL INSTRUCTION GIVEN BY THIS HOSPITAL. 57 
 
 o-eneral observations in the examination and care of even a few cases of 
 pregnancy, will prove of far greater advantage to the student than a much 
 greater number of cases of pregnancy examined by him without direct 
 instruction and supervision. 
 
 C. The Care of Labor Cases— Intrapartum Instruction. 
 
 The pupil's training in the care of w^omen during labor is obtained 
 during his junior week by acting as assistant to senior pupils when the 
 latter are sent to cases of labor in the tenements, and in his senior 
 week by himself taking charge and caring for the woman in labor, in turn 
 assisted by another junior pupil, but always under the su])ervision and 
 criticism of members of the resident Hospital staff. 
 
 Juniors, as well as seniors, during their term of service, are required to 
 attend the obstetric clinics of the Hospital. 
 
 The junior pupil, early in his term of service, accompanies one of the 
 senior pupils when the latter responds to a call from a labor case in the 
 tenement district. At these calls the junior acts in the capacity of an 
 assistant to the senior pupil, and the latter, in turn, as assistant to the one of 
 the resident staff of the Hospital who visits the case immediately after the 
 two pupils. It is under the supervision and criticism of this resident staff 
 officer that the treatment of the case is carried out. 
 
 Although the Institution permits of confinements being carried out by 
 the senior pupil, in normal uncomplicated cases, under supervision of the 
 staff officer, still, as the rules which he has already read, and to which he 
 has subscribed, state, the student is debarred from prescribing for any case, 
 from performing any obstetric operation, interfering in malpresentations 
 or positions, or even giving an intrauterine douche. All such questions as 
 these are referred to the supervising staff officer, or, in his absence, 
 directly to the Kesident Physician at the Hospital, by means of the printed 
 blank with which all labor bags are provided. In order that the Resident 
 Physician may keep in touch with the progress of all cases in the outdoor 
 service, both normal and abnormal, the accompanying printed blank has 
 been made more comprehensive than would seem necessary, and the senior 
 pupil is required to send in every two hours reports of the progress of his 
 case to the Resident Physician. (See Blank on page 59.) 
 
 The junior pupil thus has the opportunity of witnessing the practical 
 application of the rules governing his present and future conduct, in the 
 first few days or hours of his service. He now sees the paraphernalia of 
 the labor bag put into actual use. He arranges the bed in as cleanly a 
 manner as possible ; assists in securing the necessary hot water and in the 
 preparation of the mercuric chloride solution for the hands and external 
 genitals ; cleanses his hands and forearm in the manner already taught at 
 the Hospital; washes the patient's external genitals first with soap and 
 water, and then with a sublimate solution, using the sterilized cotton con- 
 tained in the labor bag ; after further cleansing of his hands, follows the 
 senior pupil in examining the patient internally, and is shown how to enter 
 
58 REPORT OF THE SOCIETY OF THE LYING-IN HOSPITAL. 
 
 his diagnosis upon thi' Labor ("luirt, as well as tlio nuiiil)ei' and time of bis 
 internal examinations, to wlucli he is required to sign liis name. 
 
 Here it will be well to describe the system by means of which the senior 
 and junior pupils are assigned to cases of continement, and the checks and 
 sujiervision brought to bear upon them by the resident staff, so as to ])re- 
 vent accident and bring the case to a successful termination. 
 
 1. The two pupils lirst on call are summoned by the office clerk upon 
 the receipt of the Hospital of a demand from one of its patients for med- 
 ical attendance. 
 
 2. Proceeding to the oiRce, they find awaiting them a labor bag (see 
 Fig. 1), and the Antepartum History Blank of the case in question, upon 
 which the patient's address is recorded. 
 
 3. V])on a blackboard provided for the purpose the i)upils' names and 
 destination are then written, and u})()n another l)oard the number of the 
 lal)or bag, so that record may be kept of the whereal)0uts of the pupil and 
 the nosi)ital property. 
 
 4. Arriving at the patient's home, the bag is })artly unpacked and 
 arrangements made for the examination of ])regnancy. The finger-nails 
 are cleaned, and the hands and forearms of the pupils are washed and 
 disinfected after the prescribed rules of the service. The junior pupil then 
 adjusts the Kelly pad, Avashes the lower abdomen, up])er thighs, and 
 genitals of the patient, first with soap and water, and then with sublimate 
 soluti(jn. Pupils are instructed at this time to expose tlie woman as 
 little as possible. Patients, although tenement-house and charity ones, 
 are treated with the same attention and consideration as those of private 
 practice. Tlie external examination of pregnancy is then made b}' both 
 pupils, and by abdominal ])alpation the attempt is made to determine the 
 presentation and |)osition. The situation and rate of the foetal heart are 
 then noted and recorxled. 
 
 ."). The hands and forearms of the pupil are then scrubbed for three 
 minutes with soft soap and nail-brush in hot water, and subsecpiently in a 
 solution of corrosive sublimate, and the vaginal examination of ])regnancy 
 is made. As a routine, the pupil is required to make the following obser- 
 vations is this examination: 
 
 (1) Is pregnancy present? 
 
 (2) Is the woman in labor ? 
 
 (8) AVhat is the stage of labor ? 
 
 (4) The condition of the os, size, dilatal>ility. 
 
 (5) The position and ])resentation. 
 (0) The internal conjugate diameter. 
 
 (7) Any apparent dis})ro])ortion between the ])resenting ])art and tlic 
 size of the ])elvis. 
 
 The pupil then ascertains the condition of the bowels, bladder, stomach 
 (food), and, if n(!C«;ssary, shall sec; to the emj)tving of tlie two former. 
 
 The senior })U])il is expected to instruct his junior in the minor details 
 of the management of the first and tliird stages of labor, as, for instance, 
 the care of thr- finKhis uteri during these two stages. 
 
PRACTICAL INSTRUCTION GIVEN BY THIS HOSPITAL. 59 
 
 6. The first report to the Resident Physician is at this time made out 
 and dispatched by the husband of the patient, or one of the household, to 
 the main Hospital building, or, if more convenient, to tlie sub-station in 
 Broome Street; from there it is telephoned to the Hospital. A copy of 
 this blank is herewith ap])ended: 
 
 SOCIETY OF THE LYING-IN HOSPITAL OF THE CITY OF 
 
 NEW YOPtK, 
 251 East IYth St., New York City. 
 
 When sending to the Hospital for assistance, students must in all cases 
 
 use and fill out this blank. 
 
 New York, o'clock, M. 
 
 Patient's Name, 
 
 Address, 
 
 House, Floor, Room, 
 
 Number of Pregnancy, 
 
 Month of Gestation, 
 
 Duration of 1st Stage, 
 
 " 2d " 
 
 3d " 
 
 Pulse, Temp., 
 
 Foetal Heart (frequency), position, 
 
 Dorsal plane, 
 
 Head, .' 
 
 Small parts, 
 
 Movements, 
 
 Presentation, Position, 
 
 Os uteri (size), condition, 
 
 Membranes, 
 
 Above brim, 
 
 Engaged, 
 
 At "outlet, 
 
 •- On Perineum, 
 
 Character and frequency of labor pains, 
 
 Foetus 
 
 by abdominal 
 
 palpation, 
 
 Presenting part, - 
 
 General conditions and remarks : 
 
 Attendant. 
 
60 REPORT OF THE SOCIETY OF THE LYING-IN HOSPITAL. 
 
 In ordinai-v uncomplicated cases these reports of the progress of the case 
 are sent in at two-hour intervals. In ])rinnparfe, a report is returnable 
 Avhen the os is fully dilated, and in all eases at the completion of the second 
 and third stages of labor. 
 
 In com])licated cases, or in tho ])resence of sudden emergencj'', reports 
 are disjiatched as often as the necessities of the case may demand. 
 
 7. Following- soon uptm the departure of the students from the llos- 
 j)ital, the member of the resident staff first on regular turn visits the case, 
 gives what instruction is necessary to the ])upil, and, in many cases of 
 primi})ara\ takes charge of the l)irtli of the head and shoidders. 
 
 At the completion of the second stage of labor, the fundus of the 
 uterus is given over to the care of the junior pn])il, while the senior gives 
 his entii'c attention to the care of the new-born child. 
 
 The throat and eyes of the child are wiped out witli tlie Ijoracic wipes 
 provided in the labor l)ag. (See Labor Bag.) It is the teaching of the II os- 
 ]>ital that the eye should be wiped away from the nose, and that a. separate 
 wij)e should be used for each eye. 
 
 Ilespiration in the child is now established, and unless there is some 
 positive contra-indication, it is the custom of the Hospital not to tie the 
 umbilical cord until the pulsations cease. The usual two ligatures are used 
 in our services, and after division of the cord, the foetal stump is carefull}'- 
 washed with mercuric chloride solution, and a drv occlusion dressiner 
 a])j)lied. 
 
 8. The third stage having been successfull}?^ completed, the senior pupil, 
 assisted In' the junior, aibninisters a vaginal sublimate douche. 
 
 0. It then becomes the junior pupil's duty to hold the fundus uteri for 
 one hour, carefully watching for dangerous relaxation. 
 
 10. In the meantime, the senior pupil Aveighs and measures the child, 
 stri]ts and dres.ses the cord. (See History of Child.) 
 
 11. The mother is then cleansed of blood, wet bedding removed, the 
 abdominal bandage and vulva pad adjusted, and her pulse and temperature 
 finally taken and recorded. (See Labor Chart.) 
 
 The labor bag is now repacked, each article being checked off fi-om the 
 printed list found on the cover, and the ])U})ils j-eturn with it to the Hos- 
 pital, and there the senior pupil makes his linal re])o]'t to the Resident Staff 
 Ollicei- <jf the condition of the ])atient when last seen. 
 
 The pupils' names are now erased from the Mackboard in the office, and 
 they boconie last on turn, awaiting an ap|)ointment to anotlier case, and 
 the recei[)t of the labor bag is recorded, with its nund)er. 
 
 Jj. Ti;i;aimknt ok Afo'iiiKif and Ciiii.I) Airi:i; Cuminkmknt — Pos'ii-AirniM 
 
 Insti.-i criox. 
 
 (^/j (hifiloar or Disjx tisarij Scrrtce. 
 
 In the treatment of puei'|)eral women and th«.'ir childi-en, as in the care 
 of confinement cases, the Hospital utilizes the material (^f both outdoor 
 and ward services for purposes of itist ruction. 
 
PKACTICAL INSTRUCTION GIVP:N BY THIS HOSPITAL. 61 
 
 In this Hospital tlie postpartum instruction given to graduate and 
 undergraduate pupils occurs early in their hospital course. In both 
 instances, the first postpartum calls are made in the company of a member 
 of the resident staff who is expected to give systematic instruction in the 
 work. 
 
 Arriving at the house of the patient, the pupil, under the critical 
 supervision of the instructor, cleanses his hands and forearms according 
 to the regulations of the Hospital. 
 
 Having brought with him the ])ostpartum bag already illustrated and 
 descril)ed, the pupil is instructed in the making of the necessary solution 
 of sublimate. 
 
 While Avaiting for the tablet of mercuric chloride to dissolve, the aspect 
 of the patient is noted, and record is made of the temperature, and the 
 condition of the bowels, breasts, and bladder. 
 
 The hands of the pupil are again cleansed. With the exercise of the 
 greatest care that his hands come in contact with absolutely nothing 
 between the mercuric chloride solution and the vulva of the woman, the 
 vulva pad is removed from the patient, the character of the lochial dis- 
 charge upon it carefully noted, and the hands are a third time dipped in 
 the mercuric chloride solution. 
 
 The genitals are then carefully washed with fresh mercuric chloride 
 solution with the sterilized cotton provided in the postpartum bag, and a 
 fresh vulva pad applied. (See Contents of Postpartum Bag.) 
 
 After this the height of the uterus above the symphysis, the sensitive- 
 ness and contractibility of the uterus, and the condition of the iliac fossae 
 are noted, and the abdominal binder reapplied. 
 
 The pulse of the patient is taken both at the beginning and at the end 
 of the postpartum call. 
 
 It is customary at present for the pupils of the Hospital to carry note- 
 books in which are entered, by means of a rubber stamp, a copy of the diur- 
 nal observations, to be made at the postpartum visit, for mother and child. 
 The pupils are required to copy these observations in ink, in their proper 
 places on the history charts of Mother and Child upon the day of the 
 observation. 
 
 The mother being attended to, the pupil directs his attention to the 
 child. His hands are again scrubbed in the solution of mercuric chloride, 
 and the umbilical cord of the child is dressed according to the prevailing 
 custom of the Hospital. 
 
 The condition of the child's eyes, skin, bowels, and bladder are noted 
 and entered on the history chart. Several postpartum calls, as they are 
 termed, may thus be made in the course of a few hours. In such post- 
 partum Avork the pu])il acquires a knoAvledge of the daily changes in the 
 lochia, au}^ alteration in the stump of the umbilical cord, in the breasts, 
 and other postpartum phenomena Avhich is of quite as much value as the 
 management of a case of normal labor. 
 
 Upon his return to the Hospital, the pupil is required to report the condi- 
 tion of his postpartum cases to the Kesident Physician or his representative. 
 
6-2 REPORT OF THE SOCIETY OF THE LVI^^G-IX HOSPITAL. 
 
 (h) Indoor o/- ]fit/'(/ Pi'tictice. 
 
 In April, 1895, systeinatic instruction in the care of the piierpei'al 
 woman and her child was begun in the wards of the Hospital. Each 
 week the junior j)upils coming on duty are divided into three equal grou})s. 
 Each group serves on ward duty for t\vo days, and during this time is 
 under the direct supervision of an assistant resident physician, who is 
 detaikni for ward duty. Each morning the grou]) on duty meets the 
 assistant on ward duty in the wards of the iros])ital, and is given 
 ]">ersonal instruction in tlie care of the puerperal woman and her child. 
 This instruction includes: 
 
 1. (Observations on the general condition of the motluM- — her tempera- 
 ture. ])ulse, resj)irations, bowels, bladder, condition of breasts, diet, char- 
 acter of lochia, ap})lication of binder and vulva pad, asepsis and antisepsis, 
 and any complication or abnormality that may be present. 
 
 '1. Observations on the general condition of the child — its temperatui-e, 
 ]nilse. and respirations; condition of stools, bladder, mouth, nose, eyes, 
 breasts; method of nursing, dressing of stump of cord, cleansing of mouth 
 and eyes, and api)licatiou of binder. 
 
 E. Obstetrical Clinics, Including Nokmal Labor and Obstetrical 
 
 Surgery. 
 
 The equipment of the o[)erating-room and amphitheatre of the Hospital 
 allows of each normal and abnormal delivery, operation, or examination 
 beinjj: made the occasion for an obstetric clinic. 
 
 The rules require tliat all stall' oiticers, undergraduate and gi'aduate 
 pupils, and nurses shall be summoned to such clinics. 
 
 Tlicse clinics are conducted by the Attending Physician on duty, or one 
 of the resident staff officers, and are made to take the nature of demon- 
 strations. The steps of the examination, delivery, or operation are 
 explained and enlarged upon by the lecturer, and in abnormal cases, post- 
 graduate ])upils are called down to the o])erating table to examine the case. 
 
 I-'or these obstetric clinics to be properly carried out, it is necessary 
 that tiie resident staff of the Hospital shall also be a teaching staff, and 
 that a preliminary history of the case in sucii instances shall be concisely 
 statcMJ, as well iis a careful ex])osition of each step of the lal)or or opera- 
 tive procedure. 
 
 It is the intention of the .Mcdicnl iJrcird that these clinics shall evcutu- 
 ally resemi)le the diagnosis chiss<'s held iibroad, as in Munich and Prague. 
 In the maternities of these cities, ])arturient W(»iii('n arc bi'ought into 
 tlie :imphitheatr(? of tiie IIos])ital fr(jiii tlu^ ward or <l('iivery-ioom, and 
 two students arc cidlcd (h>wn IVom thcii- scats and i-ecjuired to rcndei- tlieir 
 liands and forcwnns obstetrical ly clean in ihc pi-csence and under the; criti- 
 cism of tluj instructor, examine tlu^ case, and make the dingnosis of l)r(!g- 
 nancy or labor, j)resentation, condition of the os. nienibi-nnes, vagina, 
 vulva, i)ladd(?r, and, finally, undergo (jiicslioning from Ihc instructor 
 regarding their lindings in iIm; case. 
 
PRACTICAL INSTRUCTION GIVEN BY THIS HOSPITAL. 03 
 
 Should operation or interference be called for, it is performed by the 
 instructor; but should the case prove a normal one, the student will be 
 ])ermitted to complete the case, always under the criticism and supervision 
 of the instructor, who shall be expected to address, not only the students at 
 the case, but the entire audience. 
 
 Many points of ])ractical interest connected with the management of 
 the second and third stages of labor, the handling of the child, the care 
 of its eyes, the administration of the postpartum douche, the watching of 
 the fundus uteri, the application of the occlusion dressing and abdominal 
 binder, may be dwelt upon in a most thorough as well as interesting manner. 
 
 Some idea of the scope of the clinical teaching in these obstetric clinics 
 may be gathered from the following table, which indicates that from Feb- 
 ruary 18, 1895, to April 1, 1896, two hundred and fifty-six (256) clinical 
 lectures were delivered either by the attending, assistant attending, or 
 resident physicians of the Hospital. 
 
 Table of Clinical Lectures Delivered up to April 1, 1896. 
 
 Numher of Confinements from February 18, 1895, to 
 
 April 1, 1896 256 
 
 Number of normal delivery 130 
 
 premature births 45 
 
 abortions 17 
 
 forceps delivery 22 
 
 versions 8 
 
 accouchement force and version T 
 
 accouchement force 6 
 
 craniotomy 3 
 
 decapitation (Barnes's hook) 1 
 
 symphysiotomy 1 
 
 manual extraction of breech 16 
 
 Total 256 
 
 Special Graduate Instruction, 
 antepartum, intrapartum, postpartum, operative. 
 
 With the exception of certain privileges, the intrapartum instruction 
 to graduates differs little from that given to the undergraduate pupil by 
 the attending physicians and resident staff of the Hospital. 
 
 The same oversight, the same checks, the same supervision are brought 
 to bear upon the work of the former as well as upon that of the latter. 
 The general Hospital regulations apply to him. Cases are assigned to him 
 in regular rotation with the undergraduate pupils, but with this privilege — 
 that he may, at his own discretion, forfeit his turn. A case once assumed, 
 however, must be carried to its completion. He sends in to the Resident 
 
64 REPORT OF THE SOCIETV OF TUF LYING -IN HOSPITAL. 
 
 Physician the reguhii" ropoi'ts of the progress of the cases; he fills out, in 
 sending in word of complications to the Hospital, the blank ])rovided for 
 that ])urpose, and is not allowed to interfere without i)ermission of the 
 resident or attending j)hysicians. 
 
 The privileges tendered the graduate consist, Jirst, in the fact that he 
 may select his cases; and, secondly, he is pei-mitted to perform sucli opera- 
 tions as the Attending Physician may assign him. He remains one month 
 in the Hospital, and agrees to confine at least fifteen cases. 
 
 The Hospital ofl:ers two s])ecial courses of graduate instruction, as 
 follows: 
 
 A. The GRAorATE Operative Course. 
 
 Physicians entering upon this course of instruction are expected to 
 reside in the Hospital building, in separate apartments set apart for the 
 purpose, and they shall during their term of service be subject to the 
 Special Hules for Graduate Pupils, and also to the General Rules of 
 the Hospital. 
 
 This course includes the care and delivery of normal cases, and the 
 witnessing of all the operations performed in tlie service of the Hospital, 
 and the performance of such obstetric operations by the pupil as the Dii-ec- 
 tor may assign to him, and each pupil shall receive at least one obstetric 
 o})eration in each two weeks of his service. 
 
 Pupils in this course, in order to obtain the Certificate of the Institu- 
 tion, shall attend in confinement at least seven patients in each fortnight 
 of the course, and they shall have the privilege of indicating to the Resi- 
 dent Physician the time when they desire such cases shall be assigned to 
 them. But once having undertaken a case, they shall attend it until dis- 
 charged from the service, 
 
 Ij. Graduate Diagnosis, or Touch ('ourse. 
 
 Physicians taking this course do not reside in the Hos])ita] building, 
 but each afternoon receive instruction in the ante})artuin examining-room 
 from the attending or assistant attending physician on duty. 
 
 In addition, members of this course are permitted to witness all opera- 
 tions performed in the service, and are permitted to examine such abnor- 
 mal cases as require operation. 
 
 The fee f(jr the above course of two \veeks is §20. 
 
THEORETICAL LECTURES 
 
 Demonstrations. — Recitations. 
 
 Although the Medical Board requires that students shall have some 
 theoretical knowledge of obstetrics before taking a course at this Hospital, 
 a certain amount of theoretical instruction is combined with the practical 
 instruction given in the clinics and at the bedside in the tenements. Obvi- 
 ously, in the short time that a student is at the Hospital, but a small part 
 of the more important subjects can be taken up which it is possible to 
 teach in a theoretical lecture. Realizing this, the Medical Board has been 
 compelled to limit the subjects of theoretic instruction mainly to the man- 
 airement and mechanism of normal labor. These lectures are illustrated 
 and made more practical by the ordinary aids to didactic teaching. Dem- 
 onstrations on the blackboard, charts, and anatomical preparations, a metal 
 pelvis which is mounted on a tripod, and the phantom of Schultze, are the 
 aids which are constantly employed. Wax models showing the anatomy 
 of the generative organs, embryological models, and wet specimens, and a 
 series of deformed pelves serve to illustrate the special lectures which are 
 given bv the attending physicians whenever cases of special interest occur 
 in the service of the Hospital. 
 
 It is believed that more practical good can be accomplished by didactic 
 lectures which have a direct bearing on the work in hand, than by any 
 lecture following a routine, and which must be repeated from week to week 
 as each new set of students come on duty. In short, theoretic instruction 
 should precede and follow the instruction given during the student's Hos])i- 
 tal course, when he is gaining that practical experience and self-reliance 
 which onlv come from observation, and by the personal examination and 
 care of women during pregnancy, childbirth, and the puerperium. 
 
 Theoretic instruction by didactic lectures is given under the supervision 
 of the Medical Board by the attending physician on active duty, and by 
 the attending ph3^sician on septic duty. The Board of Assistant Attend- 
 ing Physicians has charge of the recitations, the assistant on regular duty 
 reviewing the subject matter of the regular lectures and the work in the 
 antepartum rooms. Instruction is also given by the house staff. This 
 part of the work, however, comprises instruction in the outdoor service, 
 and is described elsewhere. 
 
 The lecture given by the attending physician is called the regular 
 
66 REPORT OF THE SOCIETY OF THE LVING-IX HOSPITAL. 
 
 lecture, and is delivered early in tlio course. The ground covered l)y this 
 lecture is summarized as follows: 
 
 1. Intnnhtvtori/. — A short ex})laiuition of the i)rintcd rules. The neces- 
 sity of discipline in Hospital woi'k, and the conduct to be observed in the 
 presence of patients. The rules which govern the student in the Ilos[)ital 
 are read by each man before beginning his service,, and are appended here. 
 
 Rules for Undergraduate J*ui'ils. 
 
 I. Each pupil shall, before going on duty, pay to the Chief Cleric the 
 prescribed fee, and will, in return, receive a receipt which will entitk^ him 
 to reside at the Hospital and receive the regular instruction for the period 
 of two weeks. IStudents or graduates wishing to remain a longer or a 
 shorter pei'iod of time will be allowed to make special conti'acts, subject 
 to the a]>))roval of the ^fetlical lioard. 
 
 '2. Any ])upil wishing to leave the Hospital before his allotted term of 
 service has expired, must notify the Director at least forty-eight hours 
 before leaving. 
 
 3. Any pupil may be denied the use of the Hospital at the discretion 
 of the Director. 
 
 4. All ])upils shall be under the direct control of the House Physician. 
 
 5. No pupil shall be absent from the Hospital all night, except in the 
 discharge of his duty. Pupils shall board in the neighborhood at their own 
 exj:)ense. They shall report to the medical clerk upon going to meals and 
 upon returning. 
 
 (». Pupils shall be assigned cases in regular rotation. If the pupil on 
 turn be out in the duty of the Hospital when a case comes in, he shall lose 
 the case, but he shall not lose his turn. H", however, he be absent on his 
 own ])leasure, he shall lose both the case and his turn. A case thus trans- 
 ferred goes to the pupil next in the order of rotation. 
 
 7. No ))U])il shall be present at any labor not falling to him in turn, 
 except in tiie case of operations, and only in such cases as the Director 
 shall permit. 
 
 8. Each pu]»i] shall visit twice (hiily, or oftener if necessary, ])ost- 
 partum cases assigned to him, and also such other cases as the House Phy- 
 sician shall direct. He shall, at these visits, observe the strictest antisepsis, 
 and shall i-e))ort after each visit the jiatient's conditicm to the assistant 
 resident ])hysician on septic and history duty, or in his absence to the 
 ine<Jical clerk. 
 
 \). All ])U|)ils, on returning from a case, shall immediately make the 
 entry of their notes upon the ])ro])er blanks ])rovid(Ml by the Hospital. 
 
 10. No ])upil, whil(! in pisrformance of his duties, shall advise or ))i-e- 
 scribe for any ])atient who may apply to him. 
 
 II. \o pupil shall perform any obstetric o|)eration, nor interfere with 
 any mal-presentation, nor give an intrauterine douche. If he deem such 
 interference necessary, he shall send iiiiincdiately to the Hospital for assist- 
 ance. 
 
THEORETICAL LECTURES. 07 
 
 1 2. Pupils shall be furnished by the Hospital Avith clinical thermome- 
 ters, tape measures, locker keys, and stethoscopes on receipt of the pre- 
 scribed deposit. Pupils shall be responsible for tlie return of these articles 
 in ii'ood condition. 
 
 13. Pupils, when sending to the Hospital for help, shall invariably fill 
 out the blanks })rovided for that purpose, being particular to note the time 
 and reason for sending. 
 
 14. Pupils shall, at the discretion of the Director, be isolated from 
 attending normal cases of labor, to attend any septic case that may arise. 
 
 15. No pupil shall receive personal remuneration from a patient under 
 any circumstances. 
 
 16. Each pupil shall, before going on duty, deposit with the Chief 
 Clerk the sum of ten dollars as security for the cost of keys, thermometer, 
 tape measure and stethoscope, and as a guarantee that he will serve his 
 full fourteen days. This deposit will be forfeited in case the pupil leaves 
 or is dismissed before the end of his full term of service. Any pupil may 
 be dismissed by the Director, subject to the approval of the Medical Board. 
 
 IT. Pupils shall serve for a term of two weeks from 9 o'clock in the 
 morning on the date of appointment until 12 o'clock noon on the fifteenth 
 day thereafter, or until they shall have made, reported, and recorded their 
 postpartum calls for that day. 
 
 18. Each pupil at the termination of his service, provided he shall have 
 performed his duties faithfully, and for the full time of his appointment, 
 to the satisfaction of the Medical Board and of the Governors, may receive 
 from them a certificate thereof. 
 
 2. The Examination of Pregnant Women. — The methods of examina- 
 tion are taken up and described with the aid of the Pregnancy Sheet, 
 which is printed in connection with the description of the methods of 
 keeping statistics. Students are taught to make observations and to record 
 them systematically. The ordinary symptoms of pregnancy, the suppres- 
 sion of menses, date of quickening, and the methods of calculating the 
 probable date of confinement are discussed. 
 
 3. The Manageinent of Labor is described, using the charts as a guide. 
 The methods of diagnosis of presentation and position, particularlv by 
 abdominal palpation; the diagnosis of the existence of labor and the 
 mechanism of normal labor are referred to; it being, however, supposed 
 that the student has some previous knowledge of this part of the subject. 
 
 The division of labor into stages having been explained, the manage- 
 ment of each stage is in turn taken up and described. The greater part of 
 the time is used in the explanation of the principles of preserving the peri- 
 neum from rupture and illustrating these on the phantom. The proper 
 management of the placental stage is minutely described, and, finally, the 
 care of the mother and child subsequent to labor. The manual pressure 
 on the uterus as a guard against postpartum hsemorrhage, the application 
 of the binder, the cleansing of the child's eyes and mouth, and the ordi- 
 nary methods of establishing respiration, all form a part of the lecture. 
 
68 REPORT OF THE SOCIETY OF THE LYIXG-IX HOSPITAL. 
 
 4. The Oi'dinio'i/ CompUcatioihs of normal labor are referred to, and 
 the printed sheet used in sending for assistance is shown. 
 
 [it) Delayed labor, with its causes, in the various stages; 
 
 {h) Ketained i)lacenta or membranes; 
 
 {c) Lacerations of the genital tract; and 
 
 {(I) Haemorrhage, are each taken and described. 
 
 Excepting in the case of haemorrhage, treatment is not touched upon, 
 the tlirections being that the student send at once to the Hospital for 
 assistance. In the case of luiMnori-hage, and while waiting for assistance, 
 the use of the douche and the other methods of securing contraction of the 
 uterus are explaineil. 
 
 ."). Pofttjnirtum Visits and the DaUij Records of Mother and Child. — The 
 ro\itine treatment and observations to be made at these visits are taken up 
 in connection with the histor}" charts. 
 
 '■'. Denionstrations of Abnormalities or Ojferatimis of the Past WeeJi. — 
 This forms a very important and constantly varying part of the lecture, 
 and covers, from time to time, almost the whole subject of dystocia and 
 obstetric surgery. On the phantom, versions or forceps operations are 
 I'epeated, the indications for o]ierating ex])lained, and the technique illus- 
 trated. It may be added that at the conclusion of this, the regular lecture, 
 the students are encouraged to ask questions, thus bringing the lecturer 
 more closely in touch with the class. 
 
 The Septic Lectures, 
 
 On the following day, or as soon after the regular lecture as possible, a 
 lecture is given In' tlie sciatic attending physician. This lecture is also 
 didactic, and may be summarized as folloAvs: 
 
 1. Antisepsis in ]al)or. 
 
 a. Sterilization of the hands and forearms. 
 h. Sterilization of tlie patient. 
 
 e. Sterilization of the dressings and everything whicii may be 
 brought in contact with the patient. 
 
 2. Tlie nature and causes of ]iuer])eral fever. The ordinary sources 
 tlirougli whicli a ])atient may be intV'ct(Ml, and the prevention. 
 
 ?>. The classification of puerpcial fever. 
 
 4. Sym])tomatf)l()gy and dijignosis (jf the various forms. 
 
 ."). The treatiiK'Hl of ])U(')'[)eral bnei-. 
 
 a. Use of thf douche. 
 
 h. Use of the cni-cttc 
 
 c. Various oj)erations. 
 0, F'ever due to causes other thmi iiilccl ion. 
 
 a. Frrmi the digestive ti-act. Care of the bowels, and use of 
 cathartics. 
 
 h. Care of the breasts. 
 
 c. Other conqdications, causing rise in tcnqierature. 
 
THEORETICAL LECTURES. 69 
 
 7. The necessity of antisepsis during the puerperium. Vulva dressings. 
 
 8. The necessity of cleanliness and antisepsis in nursing. 
 a. Care of the nipples. 
 
 h. Care of the chikrs mouth. 
 
 9. Abnormalities of the breasts. 
 a. Flat or deformed nipples. 
 
 h. Ei'oded, fissured, and cracked nipples. 
 
 c. Painful distention, and so-called caked breasts. 
 
 d. Mammary abscess. 
 
 10. The necessity of antisepsis in dressing the umbilical cord. 
 
 a. Disinfection of the cord, and materials for antiseptic dressings. 
 h. Separation of the cord, and dressings for the stump. 
 
 c. Purulent umbilicus: its treatment, and sepsis in the child (fever). 
 
 d. Icterus in the child. 
 
 11. The necessity of antisepsis in the care of the child's eyes. 
 a. Crede's method of using nitrate of silver. 
 
 h. Frequent washings with boracic acid. 
 
 G. Ophthalmia neonatorum : its causes, symptoms, and treatment. 
 
 The regular and septic lectures comprise all the didactic teaching given 
 by the Medical Board. Although the lecture is theoretic, it is based each 
 week mainly upon clinical grounds, having for its prominent subject cases 
 which have actually been seen by the students. 
 
 Recitations. 
 
 Toward the end of the student's first week of service, a recitation is 
 held b}^ the assistant attending physician on duty. As has already been 
 stated, these recitations are based upon the subjects of the regular and 
 septic lectures. They include, also, questions upon the antepartum work 
 and outdoor work. Even at the risk of needless repetition, a synopsis of 
 the recitation is also made. 
 
 1. Antepartum work. 
 
 a. Signs of pregnancy. 
 
 h. Methods of phj^sical examination. 
 
 c. Diagnosis of presentation and position. 
 
 2. Labor. 
 
 a. Diagnosis. 
 
 h. Mechanism of vertex cases. 
 
 c. Management of the three stages. 
 
 3. Postpartum work. 
 
 a. Dressings and the care of mother. 
 h. Visits, temperature, pulse, etc. 
 c. Care of child. 
 
70 REPORT OF THE SOCIETY OF THE LYING IN HOSPITAL. 
 
 4. C'om[)licatioiis. 
 
 <i. In pregnancy. 
 
 h. In labor. 
 
 c. In the puerjieriuni. 
 
 5. Sepsis and antisepsis. 
 
 Fiiuillv, it will lie seen, that although the student is supposed to be 
 familiar with obstetrics to a certain extent, still a large part of the theory 
 is taught by this method; the lectures and recitations ser\'ing as a review, 
 so that, in the ])rac-tical ex]ierience that is acquired by a course in the Hos- 
 pital, the theoretical ]mrt of the subject is kept constantly in mind. 
 
THE INSTRUCTION OF NURSES. 
 
 It has seemed to the Medical Board of this Hospital that the system of 
 instruction as carried out in the Nurses' Training Schools, with which we 
 are sufficiently familiar to make it proper for us to judge, was susceptible 
 of improvement in certain particulars. Without assuming to criticize the 
 methods adopted by any school, we believe that the error has been com- 
 mitted of teaching- the nurse too much theoretical medicine. Lecturers 
 and classroom instructors in training schools seem to look upon the pupil 
 nurse much as they look upon the medical student. Their lectures and 
 their questions differ little from those adapted to the medical student in the 
 early years of his study. Why should the}^ insist that the nurse, whose 
 knowledge of physiology, anatoni}^, and materia medica is quite elemen- 
 tary, should learn pathology, symptomatology, and treatment of disease 
 with as much accuracy and in as much detail as the medical student ? 
 Would it not be wiser to teach nurses just enough of the theoretical parts 
 of the subjects upon which the}^ are working to make it possible for them 
 to do their work intelligently ? 
 
 Moreover, nurses are often forced to do so much arduous manual labor 
 in the course of their daily work, that they are in no condition of mind or 
 body to study during the time when their ward work does not occupy their 
 attention. If, therefore, it is deemed Avise to require nurses, in addition to 
 their trying bedside work, to do much of the work of an orderly, they 
 should not also be expected to commit to memor}^ medical facts which are 
 almost unintelligible to them. 
 
 It is to be remembered that this Hospital does not maintain a nurses' 
 training school. It simply furnishes obstetric training to the nurses of 
 other hospitals. In so far, however, as it is possible, in this limited field, 
 it has been the aim of the Board to embody its ideas on the subject of 
 nurses' training in the course herein described. It has attempted to limit 
 the theoretical teaching of its nurses, as indicated above, and to make it 
 possible for them to do whatever stud3^ing may be necessar}^, without over- 
 taxing both mind and body. At present the bedside work of the nurses is 
 limited to the indoor service of the Hospital. It is hoped at some future 
 time to utilize the outdoor service as well, but as yet no feasible plan has 
 been devised. The nurses of the Hospital are derived from two sources : 
 the Training Schools of St. Yincent's Hospital in this city and of St. Mary's 
 
72 REPORT OF THE SOCIETY OF THE LYING-IN HOSPITAL. 
 
 Hospital ill r>i-u(.)klyn. Those mirses come to the Jlospital in the latter 
 part of tlieir coui*se of training for a period of three months. 
 
 The niirsin*: department of the Hospital is in charge of the Chief 
 Nurse and her Assistant. The Chief Nurse is in absolute control of her 
 dei)artment, both as to the disposition of the work among her nurses, and 
 as to mattei*s of disci])line, and she is responsi])le and answerable to the 
 Meilical IJoard only. The course of instruction may be outlined as 
 follows: 
 
 1. Theoretical: 
 
 Lectures. 
 
 Classroom recitations. 
 1'. Practical: 
 
 ( )utdoor I)ej)artment — Laboratory. 
 
 ( )utdoor l)ej)artment — ( )l)stetrical examinations. 
 
 Indoor Department — AVard work. 
 
 Indoor Department — Operating-room. 
 1. Lictiii'is. — This part of the instruction has been deputed l)y the 
 Medical Board to the Assistant Attending Physicians. The lectures extend 
 over a ])eriod of two months, and are delivered weekly ])y the assistant 
 attending [)hysician on duty. 
 
 OiTLixE OF Lectures to Nueses. 
 
 1. Gross Anatomy and Physiology. 
 
 '1. Pregnancy, signs: labor, mechanism, ])resentation, phenomena. 
 
 3. Cleanliness, sepsis, bacteriology. 
 
 4. A})plication of cleanliness: methods. 
 ."». Pre])aration. 
 
 «;. Care of woman, antepartum and })ostpartum. 
 
 7. Care of child. 
 
 8. Emergencies; relation of nurse to doctor. 
 
 LECTURE I. 
 
 Gross Anatomy 
 
 of Female Pelvis. 
 
 Genitalia and pelvis. 
 
 False and true. 
 
 Brim and outlet. 
 
 Bones. 
 Soft Parts. 
 
 Urethra. l)l;i(ld<>r. ui-eters, Icidneys. 
 
 Rectum. 
 
 Vagina, uterus, tubes, ovaries. 
 
 Vulva, clitoris, meatus, ostium vagina;. 
 
 Anus. 
 
 Perineum. 
 
 Abdomen. 
 
THE INSTEUCTION OF NURSES. 73 
 
 Gross Physiology 
 
 of Female Genitalia. 
 
 Puberty and menopause, menstruation. 
 
 Ovulation. 
 
 Impregnation and development of foetus. 
 
 Parturition, abortion. 
 
 Puerperium. 
 
 Urinary system; excretory. 
 Gastro-intestinal ; alimentary and excretory. 
 
 LECTUEE II. 
 
 Pregnancy. 
 Signs. 
 
 a. Subjective. 
 h. Objective. 
 Mechanism. 
 
 Signs of beginning labor. 
 
 First stage: dilation of cervix. 
 
 Character of pains. 
 Second stage: expulsion of child. 
 
 Character of pains. 
 Third stage: expulsion of placenta. 
 Presentation. 
 Yertex. 
 Breech. 
 Shoulder. 
 
 Prolapse of umbilical cord. 
 " " Arm and hand. 
 " " Leg and foot. 
 
 LECTURE III. 
 
 Cleanliness. 
 Importance. 
 
 Asepsis and antisepsis. 
 
 Auto-infection (?) and ex-infection. 
 Origin. 
 
 Clothing, skin, catheter, rectum. 
 
 Patient's hands, physician's hands, nurse's hands. 
 
 Bedpans, daily dressings, neighboring erysipelas, pneumonia, sore 
 throat, child's eyes and navel. 
 Bacteriology. 
 
 Staphylococci. 
 
 Streptococci. 
 
 Gonococci. 
 
 Colon baciUi. 
 Immunity. 
 
74 REPORT OF THE SOCIETY OF THE LYING-IN HOSPITAL. 
 
 LECTURE IV. 
 
 Principles and Aj^plication 
 of cleiinliness to 
 
 (a) Instriinients and apparatus. 
 
 Dressiniis, vulva pads, bandages, etc. 
 Bed clothing. 
 
 Dress of nurse and physician. 
 {h) Kui'se and physician. 
 Disinfection: hands, nails. 
 Care of hands. 
 A^aginal examination. 
 Use of vaseline. 
 Method of introducino- hnffer. 
 External examination. 
 Methods of securing asepsis in private houses in 
 {a) City, with conveniences. 
 (h) Country, with no conveniences ; old linen, wash boiler. 
 
 LECTURE v. 
 
 Preparation for Labor. 
 Body. 
 
 Attention to bladder, rectum, nervousness, feeding, clothing, baths, 
 flannel drawers, hair braided. 
 Bed and Iloom. 
 
 Temperature of room, seventy-three degrees or more. 
 
 Boom cleansed and plain. 
 
 Hair nuittress ])referred. 
 
 Karrow bed. 
 
 Bubbei- sheeting, absorbent pad. 
 
 Old (juilt, sheets in ]ilenty, old blanket, sterilized. 
 
 Sheet fastened to foot of bed to grasp. 
 Prepai'ation of supplies. 
 Prepai-ation of nurse. 
 
 Toward liousehold, doctor, and patient. 
 
 Removal of placenta and blood. 
 
 LECTURE VL 
 
 Care of AVoman. 
 Antepartum. 
 
 liowels, liladder. 
 
 Comfort; varirosities, pendulous abdomen or l)reasts, l)reathing. 
 Feeding. 
 
 Allay nervousness. 
 
 Watch for mental changes; mania, melancholia, headache, blindness, 
 cedcma, vomiting, iiiiiu!. 
 
THE INSTRUCTIOiSr OF NUfiSES. 75 
 
 During Labor. 
 
 That patient is not exposed. 
 
 Catching cold. 
 
 Is clean. 
 Postpartum. 
 
 Catheterization. 
 
 Urine: relaxation, haemorrhage. 
 
 After pains. 
 
 Lactation, feeding. 
 
 Pulse, temperature, breathing. 
 
 Caked breasts, fissured nipples. 
 
 Constipation. 
 
 Fever, douches. 
 
 Involution and lying in bed. 
 
 LECTURE VII. 
 
 Care of Child. 
 Washing. 
 
 Yernix caseosa. 
 
 Oil, soap, sponge, temperature of bath, baby powder, frequency. 
 Clothing. 
 
 Cloths for navel. 
 
 Binder, flannel slips, napkins, etc. , stockings. 
 Feeding. 
 
 Size of child's stomach, frequency. 
 
 Weigh weekly. 
 Sleep. 
 
 Surrounding temperature. 
 
 Cry. 
 
 IS^ormal injuries during delivery. 
 
 Shape of head, cephalhsematoma. 
 
 Discolored face. 
 Observe : 
 
 Genitals, anus, and deformities, cleft palate, hare lip, tongue-tie, 
 talipes. 
 Eyes. 
 
 Ophthalmia. 
 Mouth. 
 
 Thrush. 
 Yomiting, colic, diarrhoea, constipation, descent of bowels, worms. 
 Petention of urine and fgeces, incontinence. 
 Bleeding from the navel, from bowel. 
 Icterus (no change in urine or faeces or eyes). 
 
 Naevi and eruptions, burns and scalds. 
 
 Atelectasis. 
 
 Swelling of breasts. 
 
 Convulsions. 
 
76 REPORT OF THE SOCIETY OF THE LYIXG-IN HOSPITAL. 
 
 Care of CliiUl. 
 
 Icterus (no cliange in urine or fjeces or eyes). 
 Bruises, s])rains, fractures, outs. 
 
 Stings of insects, foreign bodies in eyes, ears, nose, and throat. 
 Bleeding from nose, earache, fever. 
 Prenuiture chiklren. 
 
 LECTURE VIII. 
 
 Emergencies. 
 
 Delivery if doctor does not arrive. 
 
 Holding back liead and delaying labor until arrival of doctor. 
 Ante})artuui. 
 
 Kephritis, eclam])sia, mania, haemorrhage, placenta prgevia. 
 
 Abortion or miscarriage. 
 At Lal)or. 
 
 Operations, perineorraphy, etc. 
 
 Haemorrhage. 
 
 Prolapse of cord. 
 Postpartum. 
 
 Ila^mori'liage. 
 . After pains. 
 
 Mania. 
 
 Caked breasts and abscesses. 
 
 Fever. 
 
 Sickness of mother or child. 
 Tact in calling doctor. 
 Relation of nurse to doctor and to ])atient and to patient's household. 
 
 Clasifrooiii Worl-. — The classroom work is carried on by the chief nurse. 
 She holds recitations weekly upon subjects prescribed by the Medical 
 Board. These subjects have reference to the lectures of the assistant 
 attending physician and to the ward work of the nurses. In the instruc- 
 tion of the nurses, as well as of students, it is the purpose of the Board to 
 confine the attention of their ])U])ils to tlioii* ])vactical work as a source of 
 study i-atbcr than to text-books. 
 
 II. ( hiidi, (I r Department. — {<i) J.iih(ir<il<>/'i/ Worl-. — Th(» woi-k under this 
 heading (insists in the ])i"opai'ation and care of tlie material and ])ai'a- 
 ])liernalia in use in the outdoor depai-tnicnt of the Hospital, a-nd it is the 
 first work to wliicli the nurse is assigned. Two nurses are on duty at the 
 sjime tiiMf; in this i-ooni, and the term of service is two wecH-cs. Praxttically 
 all of the woi-k is done (hii-ing the day hours, so tliat these nurses are rarely 
 called at night. 
 
 The following is an outline of their work in tliis de])artment: 
 
 l*(j8tpai'tuin. and Labor BaijH. — Every case of labor in the outdoor 
 sen'ice necessitates the use of a labor bag, and every student in the Hospi- 
 tal uses two j)ostpartum bags (hiily in making his cmHs. In addition the 
 
THE INSTRUCTION" OF NURSES. 77 
 
 staff make use of a considerable number of bags in the course of their 
 work. It is the duty of the nurses to clean and fill these bags after their 
 return from service in the tenements. To facilitate the work, a list of 
 articles which should be found in each bag is pasted on the inside of the 
 cover. These lists can be found in the portion of this article treating of 
 the subject of practical instruction to students, and a perusal of their con- 
 tents will convey a better idea of the practical value of this work. 
 
 Ytdva Di'essings. — The nurses are also obliged to prepare, with the aid 
 of helpers, all the dressings in use in the out-patient dej^artment. The 
 heavy work of the laboratory, such as cutting the gauze and cotton for the 
 vulva pads, is done by an orderly. These dressings are then enclosed in 
 cop])er receptacles having perforated caps at both ends, and sterilized. 
 
 Instruments. — All instruments in use in this department are cleaned, 
 sterilized, and again prepared for service by the nurses. It will thus be 
 seen that everything having to do with the preparation and care of the 
 material and paraphernalia of the labor and postpartum rooms becomes 
 familiar to the nurse before her admission to the wards and operating- 
 room. 
 
 (b) Ohstetrical Examinations. — During their period of service in the 
 laboratory of the outdoor department, the nurses are required to spend as 
 much time as may be necessary daily, except Sunday, in the examining- 
 rooms. They are here under the supervision of the assistant to the chief 
 nurse and one of the assistant attending physicians. They learn the man- 
 ner of preparing a patient for an antepartum examination, and the 
 manner of conducting the examination easily and with as little annoyance 
 as possible to both patient and physician. 
 
 Indoor Department. — Ward Work. — Each nurse is on day duty for 
 four consecutive weeks, and on night duty for four weeks. The day nurses 
 relieve the night nurses at seven o'clock in the morning, and are relieved 
 by the night nurses at seven o'clock in the evening. 
 
 Briefly rehearsed, the ward work consists in noting pulse and tempera- 
 ture; in performing the necessary daily dressings of breasts and genitals, 
 including the application of the binders to both breasts and abdomen; in 
 administering food and medication; in the bathing and dressing of the 
 infant, and its application to the breast ; in noting, for purpose of report, 
 the character of the lochia, the stools and the breasts of the mother, and 
 the skin, mouth, umbilicus, eyes, and stools of the child. They are also 
 taught methods of stuj^ing breasts and abdomen, the administration of 
 the vaginal douche, and the use of the catheter in postpartum women. 
 Incidentally, they have considerable practice in keeping obstetric records 
 according to fixed forms. 
 
 The nurses are present at rounds in the morning, and hear the clinical 
 teaching of the medical officer in charge of the instruction of the students. 
 In the course of her ward service, a nurse may at any time be isolated for 
 the care of a septic case, or detailed for special service upon some operative 
 case of unusually serious character. 
 
 Operating-room Work. — The Hospital at present has no special corps 
 
78 REPORT OF THE SOCIETY OF THE LYING-IN HOSPITAL. 
 
 of o]ierating-room nui*ses, and, therefore, this work is included in the ward 
 service. 
 
 Tlie operating-room is in use daily for the ]nir]iosc of normal deliveries, 
 at whicii one or more nui'ses are in constant attendance. .Vpart from her 
 own work at this time, the nurse hears the instruction given to the stu- 
 dents, and she must necessarily ohtain valual)le information therefrom. 
 Each lalfor is the suigect of a continual clinical lecture, and quite often 
 these lectures are given by the attending and assistant attending physicians. 
 
 In the absence of both the attending j)liysician and his assistant, it is 
 the duty of the house physician, or the mendjer of the statf on ward duty, 
 to give this instruction. 
 
 Here she is trained in her duties as an assistant to the accoucheur dur- 
 ing normal labor and during oi)erative procedures, and sees constantly the 
 administration of chloroform and ether. 
 
 ^lethods of making vaginal examinations are taught during the first 
 and second stages of labor, so that the nurse is competent to give an intel- 
 ligent and reliable report of the condition of the cervix and the mem- 
 branes, and of the position of the presenting ]iart relative to the perineum. 
 She learns also how to " strip " and tie the umbilical cord, and care for the 
 new-born infant, as well as methods of resuscitation of an asphyxiated 
 child. The manner of holding the uterus through the abdominal wall 
 before and after the expulsion of the placenta is also explained. In short, 
 every procedure whicli is carried on in the delivery-room becomes thor- 
 oughly familiar. 
 
 It is also to be remembered that many of the most serious operative 
 cases of the outdoor service are l)rought to this room for operation, 
 making tlie operative service unusually large. The rule in such cases is 
 that all the nurses not on duty are summoned to the operating-room to 
 witness major operations. During the course of an operation, the nurses 
 on duty in the operating-room have certain specific duties assigned to them 
 under tlie charge of the assistant to the chief nurse. By rotating the 
 nurses from one set of duties to another in the operating-room, they 
 become familiar with every phase of the w^ork of preparation and assist- 
 ance. Each nurse, also, during her ward service, has sole charge of the 
 delivery-room during a certain number of normal deliveries. She thus 
 learns by constant practice the actual performance of the nurse's duties in 
 the lying-in room, both in normal and operative cases; and, finally, while 
 in charge of the operating-room she assumes the res])onsibilities of an 
 important position which slici iriust fill afterwards in private jn-actice, while 
 she is still under supervision, and where her (M-rors can be pointed out and 
 remedied. 
 
 It would sr-em that such a cours(! of 1r;iiniiig, conscientiously adminis- 
 tere<l, would give the nurse a thorough preparation for her obstetric work. 
 
STATISTICAL SYNOPSIS. 
 By H. McM. Painter, M.D. 
 
 The following statistical report covers a period of six years and three 
 months, from the foundation of the Midwifery Dispensary to April 1, 1896. 
 It will be noted that the cases of the outdoor department only are 
 included in this report. 
 
 The disparity which will be noticed under all headings between the 
 number of cases in the service, 10,233, and the number of observations 
 recorded, is explained by the fact that in a service of this character there 
 are many cases in which it is impossible to obtain the desired information ; 
 in some cases there is no record to be made; e.g., presentation, sex, pla- 
 centa, etc. , in cases of abortion ; etc. 
 
 Applications 12, 802 
 
 Confinements 10,233 
 
 Living children 9,457 
 
 Still births 359 
 
 Abortions 41T 
 
 10,233 
 
 Nativity, 
 
 United States 910 
 
 Germany 422 
 
 Russia 6,885 
 
 Poland 257 
 
 Ireland 342 
 
 England 123 
 
 Austria 751 
 
 Roumania 138 
 
 Hungary 174 
 
 10 
 
 4 
 
 9 
 
 22 
 
 1 
 
 1 
 
 Scotland . . . . 
 
 Holland 
 
 Switzerland . . 
 Italy 
 
 Egypt 
 
 Isle of Jersey 
 
 Palestine . . . 
 Bohemia . . . 
 
 Wales 
 
 Arabia 
 
 Canada 
 
 France 
 
 Nova Scotia 
 Finland .... 
 Turkey .... 
 Australia . . . 
 Sweden .... 
 Armenia . . . 
 Unknown . . 
 
 1 
 
 2 
 1 
 
 2 
 6 
 2 
 1 
 2 
 2 
 1 
 6 
 1 
 159 
 
 Total 10,233 
 
80 
 
 REPORT OF THE SOCIETY OF THE LYING-IN HOSPITAL. 
 
 Civil Condition. 
 
 Married 10,182 
 
 Single 8 
 
 Widowed 12 
 
 Unknown 31 
 
 Total 10,233 
 
 Age. 
 
 15-20 years 943 
 
 20-25 ' " 3,670 
 
 25-30 " 3,088 
 
 30-35 " 1,485 
 
 35-40 " ,.... 821 
 
 40-45 years 104 
 
 45-50 '' 13 
 
 50-55 " 1 
 
 Unknown 98 
 
 I. 
 II. 
 
 TIT. 
 IV. 
 
 V. 
 
 YT. 
 
 VII. 
 
 VIII. 
 
 IX. 
 
 X. 
 
 In 
 cases. 
 
 para 
 
 Para 
 
 Cases. 
 2,157 
 1,901 
 1,566 
 1,228 
 
 939 
 
 724 
 
 557 
 
 389 
 
 249 
 
 171 
 
 Total 10,233 
 
 Cases. 
 
 79 
 
 70 
 
 38 
 
 16 
 
 8 
 
 1 
 
 1 
 
 139 
 
 XII. 
 
 r 
 
 XIII. 
 
 
 XIV. 
 
 
 XV. 
 
 
 XVII. 
 
 
 XX. 
 
 
 Unknown 
 
 
 Total 
 
 Presentation. 
 the 10,233 cases it was possible to observe the presentation in 8,969 
 
 
 No. of 
 Cases. 
 
 Ratio. 
 
 CHILDREN. 
 
 Died during 
 
 Presentation. 
 
 Living. 
 
 Still-born. 
 
 211 
 
 8»; 
 24 
 
 3 
 
 
 
 1 
 
 325 
 
 34 
 
 359 
 
 the 
 Puerperium. 
 
 Vertox 
 
 8,495 
 
 341 
 
 91 
 
 36 
 
 4 
 
 2 
 
 1 in 1.05 
 1 in 26.30 
 1 in 98.56 
 1 in 249.13 
 1 in 2242.25 
 1 in 44.S4.50 
 
 8,284 
 
 255 
 
 67 
 
 33 
 
 4 
 
 1 
 
 149 
 
 Breodi 
 
 Slioulder 
 
 Face 
 
 35 
 2 
 3 
 
 Prow 
 
 
 
 Kar 
 
 
 
 
 
 
 8,969 
 847 
 417 
 
 8,644 
 
 189 
 
 Presentation not ) 
 
 obscrv(*d f 
 
 Abortions 
 
 
 813 
 
 25 
 
 
 
 
 
 
 
 Total 
 
 10,233 
 
 9,457 
 
 214 
 
 
 
 
statistical synopsis. 81 
 
 Displacement of Fcetal Parts. 
 
 With regard to the following table, it must be stated that only those 
 cases are included in which the displacement occurred spontaneously. If 
 the extremities or the funis became displaced during some manipulation or 
 operative procedure, such cases are not recorded in this table. 
 
 "Extension" of upper or lower extremity signifies a displacement 
 upward. The meaning of "prolapse" is obvious. This explanation is 
 given because the terms may be misleading, inasmuch as a prolapsed arm 
 may be an extended arm, etc. We adhere to these terms, however, in this 
 respect, as they are in common use. In the 10,233 cases reported, there 
 were 242 early abortions. The cases here tabulated may, therefore, be 
 said to have occurred in 9,991 cases of labor. 
 
 Upper extremity : Cases. 
 
 Prolapse 72 
 
 Extension 23 
 
 Lower extremity : 
 
 Prolapse 14 
 
 Extension 16 
 
 Funis — Prolapse 106 
 
 Placenta Prsevia 31 
 
 Presentation in Cases of Displacement of Foetal Parts. 
 
 In the cases of prolapse of the upper extremity, the presentation was 
 
 as follows : 
 
 Cases. 
 Yertex presentation 35 
 
 Breech " 1 
 
 Shoulder " 36 
 
 Total 72 
 
 Tw4ns, 8 cases. 
 
 In the cases of extension of the upper extremity, the presentation was 
 as follows: 
 
 Cases. 
 Yertex presentation 1 
 
 Breech " 21 
 
 Shoulder " 1 
 
 Total 23 
 
 Twins, 2 cases. 
 
 In the cases of prolapse of the lower extremity, the presentation was 
 
 as follows: 
 
 Cases. 
 Yertex presentation 1 
 
 Breech '' 10 
 
 Shoulder " 3 
 
 Total 14 
 
82 REPORT OF THE SOCIETY OF THE LYING-IN HOSPITAL. 
 
 In the cases of extension of the lower extremity, the presentation was 
 as follows: 
 
 Cases. 
 
 Breech presentation 11 
 
 Shoulder ' ' 5 
 
 Total 16 
 
 Twins, 1 case. 
 
 In the cases of prolapse of the funis, the presentation was as follows: 
 
 Cases. 
 
 Vertex presentation 61 
 
 Breech " 20 
 
 Shoulder " 24 
 
 Face '' 1 
 
 Total 106 
 
 Twins, 10 cases. 
 
 Sex of Child. 
 
 In the 10,233 cases, the sex was observed in 9,661 cases. 
 
 Cases. 
 
 Male 5,088 
 
 Female 4,573 
 
 Total 9,661 
 
 Delivery of Placenta. 
 
 9,034 observations. Cases. 
 
 Natural forces 1,517 
 
 Expression 7,335 
 
 Manual extraction 182 
 
 Total 9,034 
 
 Implantation of Cord. 
 
 9,305 observations. Cases. 
 
 Central 5,232 
 
 Lateral 3,622 
 
 Marginal 447 
 
 Velamentous 4 
 
 Total 9,305 
 
 Cases. 
 
 Normal 8,127 
 
 Calcareous 749 
 
 Succenturiata 24 
 
 Apoj»lectic 30 
 
 Condition of Placenta. 
 
 9,670 observations. 
 
 Cases. 
 
 Cystic 30 
 
 Fibrous 290 
 
 Fatty 420 
 
 Total 9,670 
 
STATISTICAL SYNOPSIS. 
 
 83 
 
 Tempeeatuee of Mother (one houe aftee laboe). 
 8,948 observations. 
 
 Cases. 
 
 95i°- 96i° 15 
 
 90^°- 9Yi° 109 
 
 97i°- 98i° 3,027 
 
 9Sr- 99r 4,905 
 
 99i°-100*° 
 
 783 
 
 100i°-101i° 
 101i°-102i° 
 102i"-103i° 
 103i°-lo4° 
 
 Cases. 
 90 
 14 
 
 Total 8,948 
 
 Pulse of Mother (one hour after labor). 
 9,107 observations. 
 Cases. 
 
 30-40 2 
 
 40-50 25 
 
 50-60 415 
 
 60-70 1,824 
 
 70-80 3,874 
 
 80-90 2,118 
 
 90-100 
 100-110 
 110-120 
 120-130 
 130-140 
 
 Cases. 
 599 
 141 
 
 84 
 
 18 
 
 7 
 
 Total 9,107 
 
 Vaginal Examinations. 
 First Stage. 
 
 Cases. 
 
 
 327 
 
 6 
 
 1,222 
 
 7 
 
 1,071 
 
 8 
 
 1,199 
 
 9 
 
 714 
 
 10 
 
 10 and over. 
 
 These examinations were made by : 
 
 Cases. 
 Pupils of the Hospital 5,109 
 
 House Staff. 
 
 Midwives 9 
 
 Second Stage. 
 
 Cases. 
 
 1 1,269 
 
 2 2,098 
 
 3 1,224 
 
 4 972 
 
 6 467 , 
 
 These examinations were made by 
 
 Cases. 
 Pupils of the Hospital 5,843 
 
 6 
 
 7 
 
 8 
 
 9 
 
 10 and over, 
 
 House Staff. 
 
 Cases. 
 654 
 359 
 261 
 122 
 396 
 
 Cases. 
 
 1,907 
 
 Cases. 
 438 
 179 
 162 
 80 
 137 
 
 Cases. 
 1,912 
 
 Midwives 19 
 
84 
 
 REPORT OF THE SOCIETY OF THE LYIXG-IN HOSPITAL. 
 
 Wekuit of Child at JBiktii 
 9,389 observations. 
 Cases 
 
 1-2 
 
 lbs 
 
 2-8 
 
 •« 
 
 3-4 
 
 (( 
 
 4-5 
 
 '' 
 
 5-0 
 
 '' 
 
 6-7 
 
 
 7-8 
 
 u 
 
 8-9 
 
 (( 
 
 9 
 
 22 
 
 81 
 
 153 
 
 452 
 
 1,355 
 
 3,440 
 
 2,314 
 
 Cases. 
 9-10 ll)s 1,052 
 
 10-11 
 11-12 
 12-13 
 13-14 
 14-15 
 
 340 
 128 
 
 27 
 7 
 3 
 
 Total 9,389 
 
 Tempeeatuke of Child at Birth. 
 0,90o observations. 
 Cases. 
 
 96*'- 97° 777 
 
 97°- 98° 1,590 
 
 98°- 99° 2,703 
 
 99°-100= 
 
 1,538 
 
 100°-101° 
 lOl°_102° 
 
 Cases. 
 
 312 
 
 34 
 
 Total 0,900 
 
 Temperature of Mother during the Puerperium. 
 
 A.M. 
 
 
 96^° 
 
 974° 
 
 98^ 
 
 99i° 
 
 100^° 
 
 1014° 
 
 102i° 
 
 103i° 
 
 1044° 
 
 ISTuinber 
 
 Day. 
 
 to 
 
 to 
 
 to 
 
 to 
 
 to 
 
 to 
 
 to 
 
 to 
 
 to 
 
 of Cases 
 
 
 97r 
 
 98^° 
 
 99i° 
 
 100i° 
 
 101i° 
 
 102i° 
 
 103^° 
 
 104i° 
 
 1054" 
 
 Observed. 
 
 Labor. 
 
 37 
 
 871 
 
 1,740 
 
 291 
 
 20 
 
 
 
 2 
 
 3 
 
 
 2,970 
 
 1st . . . 
 
 106 
 
 3,867 
 
 4,148 
 
 394 
 
 57 
 
 34 
 
 11 
 
 5 
 
 
 8,022 
 
 2d ... 
 
 106 
 
 3,709 
 
 4,244 
 
 387 
 
 04 
 
 33 
 
 10 
 
 (i 
 
 1 
 
 8,500) 
 
 3d ... 
 
 70 
 
 3,493 
 
 4,292 
 
 482 
 
 97 
 
 38 
 
 20 
 
 10 
 
 8 
 
 8,510 
 
 4th... 
 
 62 
 
 3,204 
 
 4,070 
 
 472 
 
 77 
 
 50 
 
 22 
 
 13 
 
 7() 
 
 8,112 
 
 5th... 
 
 69 
 
 3,338 
 
 3,908 
 
 431 
 
 88 
 
 35 
 
 22 
 
 4 
 
 
 7,955 
 
 6th... 
 
 57 
 
 3,045 
 
 3,018 
 
 302 
 
 90 
 
 43 
 
 24 
 
 5 
 
 
 7,250 
 
 7th... 
 
 50 
 
 2,605 
 
 2,958 
 
 337 
 
 53 
 
 38 
 
 24 
 
 () 
 
 
 0),()71 
 
 8th... 
 
 37 
 
 2,300 
 
 2,453 
 
 249 
 
 30 
 
 23 
 
 15 
 
 
 
 3 
 
 5,128 
 
 9th... 
 
 46 
 
 1,531 
 
 1,503 
 
 133 
 
 28 
 
 19 
 
 14 
 
 
 
 3 
 
 3,343 
 
 P.M. 
 
 I.,abor. 
 
 44 
 
 1,136 
 
 2,516 
 
 683 
 
 83 
 
 19 
 
 2 
 
 
 
 4,483 
 
 1st . . . 
 
 86 
 
 2,937 
 
 3,726 
 
 476 
 
 84 
 
 28 
 
 19 
 
 4 
 
 3 
 
 7,303 
 
 2d ... 
 
 54 
 
 2,186 
 
 3,088 
 
 486 
 
 101 
 
 42 
 
 10 
 
 4 
 
 1 
 
 5,978 
 
 3d ... 
 
 1 44 
 
 1,715 
 
 2,537 
 
 544 
 
 87 
 
 51 
 
 31 
 
 12 
 
 1 
 
 5,022 
 
 4th . . . 
 
 29 
 
 1,277 
 
 2,033 
 
 358 
 
 102 
 
 50 
 
 25 
 
 6 
 
 1 
 
 3,881 
 
 5th . . . 
 
 24 
 
 1,158 
 
 1,841 
 
 305 
 
 70 
 
 41 
 
 26 
 
 10 
 
 4 
 
 3,47!> 
 
 6th . . . 
 
 19 
 
 709 
 
 930 
 
 183 
 
 57 
 
 31 
 
 22 
 
 8 
 
 5 
 
 1,904 
 
 7th... 
 
 16 
 
 553 
 
 629 
 
 146 
 
 48 
 
 22 
 
 15 
 
 12 
 
 3 
 
 1,444 
 
 8th... 
 
 19 
 
 398 
 
 509 
 
 90 
 
 31 
 
 28 
 
 18 
 
 8 
 
 4 
 
 1,105 
 
 9th... 
 
 3 
 
 236 
 
 318 
 
 70 
 
 23 
 
 13 
 
 13 
 
 7 
 
 2 
 
 085 
 
STATISTICAL SYNOPSIS. 
 
 85 
 
 Pulse of Mother during the Pueeperium. 
 
 A.M. 
 
 
 50 
 
 60 
 
 70 
 
 80 
 
 90 
 
 100 
 
 110 
 
 120 
 
 130 
 
 JSTumber 
 
 Dav. 
 
 to 
 
 to 
 
 to 
 
 to 
 
 to 
 
 to 
 
 to 
 
 to 
 
 to 
 
 of Cases 
 
 
 60 
 
 TO 
 
 80 
 
 90 
 
 100 
 
 110 
 
 120 
 
 130 
 
 140 
 
 Observed. 
 
 Labor 
 
 . 150 
 
 604 
 
 1,322 
 
 642 
 
 523 
 
 134 
 
 46 
 
 8 
 
 1 
 
 3,430 
 
 1st . . 
 
 399 
 
 1,785 
 
 4,048 
 
 1,767 
 
 501 
 
 114 
 
 48 
 
 16 
 
 6 
 
 8,684 
 
 2d .. 
 
 256 
 
 1,419 
 
 4,100 
 
 2,029 
 
 559 
 
 157 
 
 49 
 
 14 
 
 6 
 
 8,589 
 
 3d .. 
 
 166 
 
 1,232 
 
 4,075 
 
 2,218 
 
 677 
 
 153 
 
 60 
 
 1 
 
 1 
 
 8,583 
 
 4th. . 
 
 185 
 
 1,230 
 
 3,965 
 
 1,932 
 
 609 
 
 121 
 
 68 
 
 9 
 
 3 
 
 8,122 
 
 6th. . 
 
 209 
 
 1,271 
 
 3,953 
 
 1,775 
 
 517 
 
 139 
 
 42 
 
 9 
 
 3 
 
 7,918 
 
 6th.. 
 
 240 
 
 1,243 
 
 3,692 
 
 1,536 
 
 418 
 
 91 
 
 32 
 
 11 
 
 2 
 
 7,265 
 
 7th.. 
 
 140 
 
 859 
 
 3,017 
 
 1,370 
 
 433 
 
 100 
 
 45 
 
 8 
 
 3 
 
 5,975 
 
 8th.. 
 
 132 
 
 803 
 
 2,617 
 
 1,116 
 
 314 
 
 95 
 
 28 
 
 9 
 
 2 
 
 5,116 
 
 9th.. 
 
 91 
 
 498 
 
 2,072 
 
 777 
 
 183 
 
 55 
 
 14 
 
 6 
 
 
 3.696 
 
 P.M. 
 
 Labor 
 
 . 257 
 
 924 
 
 1,856 
 
 970 
 
 284 
 
 75 
 
 34 
 
 7 
 
 4 
 
 4,411 
 
 1st. . 
 
 316 
 
 1,365 
 
 3,314 
 
 1,681 
 
 416 
 
 115 
 
 30 
 
 17 
 
 10 
 
 7,264 
 
 2d .. 
 
 164 
 
 909 
 
 2,658 
 
 1,563 
 
 473 
 
 139 
 
 66 
 
 19 
 
 3 
 
 5,994 
 
 3d .. 
 
 128 
 
 676 
 
 2,184 
 
 1,398 
 
 424 
 
 129 
 
 69 
 
 18 
 
 5 
 
 5,031 
 
 4th.. 
 
 91 
 
 592 
 
 1,683 
 
 1,044 
 
 317 
 
 98 
 
 53 
 
 16 
 
 14 
 
 3,908 
 
 5th. . 
 
 91 
 
 572 
 
 1,625 
 
 828 
 
 223 
 
 69 
 
 38 
 
 12 
 
 7 
 
 3,465 
 
 6th.. 
 
 69 
 
 340 
 
 878 
 
 437 
 
 150 
 
 47 
 
 35 
 
 14 
 
 32 
 
 2,002 
 
 7th.. 
 
 26 
 
 184 
 
 608 
 
 326 
 
 121 
 
 51 
 
 22 
 
 7 
 
 2 
 
 1,347 
 
 8th.. 
 
 22 
 
 118 
 
 474 
 
 275 
 
 110 
 
 62 
 
 15 
 
 5 
 
 2 
 
 1,083 
 
 9th.. 
 
 21 
 
 90 
 
 296 
 
 156 
 
 75 
 
 23 
 
 8 
 
 1 
 
 3 
 
 673 
 
 An Analysis of Cases of Vertex Presentation. 
 
 Total number of cases of vertex presentation 8,495 
 
 l!^umber of mothers who sm^vived 8,466 
 
 " died- 29 
 
 N^mnber of children born alive 8,284 
 
 still-born 211 
 
 " " dying during puerperium 149 
 
 * Among the 29 cases are four cases of women with twin children, one of which 
 was a breech presentation. These four women, therefore, appear again as mothers 
 who died, in the corresponding entry under Analysis of Breech Presentatioii. 
 
 Moreover, there are four cases of death of mothers which were confined by mid- 
 Avives, the presentations of which are unknown to the Hospital. 
 
86 REPORT OF THE SOCIETY OF THE LYING-IN HOSPITAL. 
 
 Day of Dkatii of ]\Iotiikrs. 
 
 5 mothers died on Labor day 
 
 7 *' " 1st day postpartum. 
 
 4 " - 2d ''" 
 
 L> - •• 4th " 
 
 3 " '* (Uh " 
 
 2 " " Tth " " 
 
 1 mother '' 10th " " 
 
 1 " '' 11th " '* 
 
 I .» - 02d " " 
 
 1 " " 25th " " 
 
 1 " " an unknown day in I)elle\'ue Hospital. 
 
 1 " '' an unknown day after the 2Tth day post- 
 
 partum in Bellevue Hospital. 
 
 29 
 
 Cause of Death of JVIoTnERs in Cases of Vertex Presentation. 
 
 (See list of Fatal Cases, C. X. 101; 420; 1,016; 1,198; 1,425; 1,547; 
 1,723; 2,381: 2,429; 3,267; 3,314; 3,351; 3,564; 4,655, twins; 4,683; 
 4,726; 5,190; 5,473; 5,633; 5,708; 5,799; 6,235; 6,925; 7,070; 7,263; 
 7,538; 8,034; 10,047; 10,218, twins.) 
 
 Cases. 
 
 Acute Nephritis; a?deraa of the lungs 1 
 
 Consultation case; antepartum haemorrhage; woman moribund upon 
 
 arrival of Hospital 1 
 
 Erysij)elas, facial 1 
 
 Inanition ; no cause could be assigned, except the low physical condition 
 
 of the woman l)efore labor 1 
 
 ]\forbus ]\Iaciilosus WcM'lliofii; ])ostpartum htemorrhage 1 
 
 Pneumonia, acute ]ol);ir 1 
 
 Placenta pi-evia 1 
 
 J'hthisis; luLTiiorrhage Jiiid (edeiiiii of lungs. 1 
 
 Postpai'tiiiii liji'iiiorrhage in induction of l;il)oi', Ttli moiilli 1 
 
 Kuj)ture oi ut<!rus (one case with septica-iiiia ;ilso) 3 
 
 iScj)tica'iiii;i (one e;is(! witli pliieejitii ])ra'viii ;in(l one ;i midwife case), ... 8 
 Surgical kidney in ndh-xue ilos|)ital al'tei- opeiation I'oi- vesico-vaginal 
 
 fistula ac(juii"ed undei- eai-c of outside ])hysicians 1 
 
 Uritniid and eclampsia 8 
 
 Total 29 
 
statistical synopsis. 87 
 
 Possible Causes of Still Birth in Cases of Yeetex Presentation, 
 
 Cases. 
 
 Anencephalus 1 
 
 Child of unusual size (15 lbs.), difficulty in delivery of head 1 
 
 Cord around child's neck once 7 
 
 " " " " three times , 1 
 
 '' " " " five times, once around shoulders 1 
 
 " " " shoulders 2 
 
 Deformed pelvis in mother 8 
 
 ' ' cord around neck once 1 
 
 ' ' prolapse of cord 5 
 
 " tonic contraction of uterus, prolonged labor — 93 hours. 1 
 
 " fracture of child's skull 2 
 
 ' ' prolapse of cord ; hydramnios 1 
 
 ' ' prolapse of cord and upper extremity 1 
 
 ' ' hydrocephalus 1 
 
 ' ' cord around neck ; pressure of forceps blade upon cord . 1 
 
 Extreme moulding of child's head 1 
 
 Eclampsia , 1 
 
 Eclampsia ; twins 2 
 
 Hydramnios 2 
 
 Hydrocephalus 1 
 
 ' ' prematurity 1 
 
 Macerated 34 
 
 ' ' prematurity 9 
 
 " hydrocephalus 1 
 
 " twins 2 
 
 ' ' deformed pelvis 1 
 
 Prematurity 11 
 
 " tAvins 1 
 
 ' ' cord around neck of child once 2 
 
 Prolapse of cord 11 
 
 " " twins 1 
 
 " " extension of upper extremity after version 2 
 
 " " and of upper extremity ; fracture of humerus 1 
 
 Prolonged labor 4 
 
 " " cord around neck of child once 1 
 
 Placenta praevia 2 
 
 " " prematurit}^ 1 
 
 " " prolapse of upper extremity 2 
 
 Eupture of uterus 4 
 
 " " prolapse of cord 1 
 
 Twins 9 
 
 Tonic contraction of uterus ; contraction ring ; patient in state of col- 
 lapse ; delivery attempted by outside physicians 1 
 
 ]S"o complications 68 
 
 Total 211 
 
88 REPORT OF THE SOCIETY OF THE LYING-IN HOSPITAL. 
 
 Day of Dkatii of Children in Vertex Presentation, Dying During 
 
 the puerperium. 
 
 Of the 8,284 children born aliYe in Yertex presentation, 149 died 
 during the puerperiunu 
 
 85 children died on the 1st day of life. 
 
 14 " '' " 2d " " 
 
 8 " " *' 3d " " 
 
 9 '' '' " 4th " " 
 
 6 " " " 5th " " 
 
 5 " " " Cth " 
 
 6 " " " 7th ^' " 
 
 3 " " " Sth " " 
 
 3 " " '' 0th " " 
 
 3 " " " loth" " 
 
 1 child " " 13th" 
 
 •2 children '' " loth" 
 
 1 child •' " 18th" 
 
 1 " " " 19th" " 
 
 1 " " " 21st " " 
 
 1 " " " 23d " " 
 
 149 
 
 The remaining 8,135 children were discharged from the care of the 
 Hospital in good condition. 
 
 Causes of Death of Children in Cases of Vertex Presentation, Dying 
 
 During the Puerperium. 
 
 Cases. 
 
 Anencejihalus 1 
 
 Atelectasis 9 
 
 As]>hYxia 1 
 
 Convulsions 3 
 
 ' ' forceps 2 
 
 " eclampsia in mother 1 
 
 " fontanelles bulging; pressure <tii fontaiiollcs ])roduced con- 
 
 vulsi(jiis 1 
 
 Cholera infantum 1 
 
 Deformed jiel vis ; forceps 1 
 
 T)<'])rr'ss('(l friictiii'c of sl<iill: (Icfoj-mcd |»('lvis; version 1 
 
 Ervsipf'las 2 
 
 Eclampsia in mother; accouchement force 1 
 
 Fo'tal deformities; un<h'velo]X'd 
 
 Found dead upon postpartum visit; ncv(,'i' ))resente(l any symptoms. ... 3 
 
 Haemorrhage from cord; jiarents attem])ted to detach cord forcibly. ... 1 
 
 IIa*mophilia 4 
 
STATISTICAL SYNOPSIS. 89 
 
 Inanition ; could not be fed 2 
 
 Opium; overdose given by parents 1 
 
 Pneumonia 8 
 
 Prematurity (before the eighth month) 36 
 
 ' ' fatty placenta 1 
 
 ' ' deformed pelvis 1 
 
 Spina bifida 1 
 
 Syphilis 3 
 
 Suppurative infection of umbilical cord 1 
 
 " " " " icterus 1 
 
 " " " " cerebro-spinal meningitis 1 
 
 Suspended animation 22 
 
 " " placenta prsevia ; version .... 2 
 
 " " forceps 1 
 
 " " hydramnios 1 
 
 Weak and poorly nourished at birth 10 
 
 No cause assigned 16 
 
 " " " cyanosis 3 
 
 149 
 With regard to the above table, and similar tables under other presenta- 
 tions, it should be said that it is often difficult for the Hospital to arrive 
 at any satisfactory opinion as to cause of death, both on account of the 
 difficulty of obtaining autopsies and because the children are so little 
 under observation in the outdoor service. We have, therefore, recorded 
 every symptom and circumstance which could throw light on the cause of 
 death. There are many cases of prematurity, and many cases in which 
 the children are of very low weight, poorly nourished, of low vitality, and 
 it is practically impossible to feed them under tenement-house conditions. 
 Such children are included under the headings, Prematurity, Inanition, 
 Suspended Animation, Weak. It has also happened that children who 
 were perfectly well at the last visit of the Hospital, have been found dead 
 upon a subsequent visit. 
 
 An Analysis of Cases of Breech Presentation. 
 
 Total number of cases of breech presentation 341 
 
 Number of mothers who survived 335 
 
 " died-^ 6 
 
 Number of children born alive 255 
 
 " " still-born 86 
 
 " " dying during puerperium 35 
 
 Day of Death of Mothers. 
 
 1 mother died on Labor day. 
 
 1 " " " 1st day postpartum. 
 
 Smothers " " 2d " " 
 
 1 mother " " 22d " " 
 
 * Of these six cases, there are four cases of twins, in which one child was a vertex 
 presentation. (See footnote under Analysis of Vertex Presentation.) 
 
90 report of the society of the lyixg-ix hospital. 
 
 Cause of Death of Mothers in Cases of Breech Presentation. 
 
 (See list of Fatal Cases, C. K SG4; 1,547; 2,881; 4,655; 5,955; 10,218.) 
 
 Cases. 
 
 Erysipelas 1 
 
 SepticaMuia 1 
 
 Suppression of urine ; Ca?sarean section 1 
 
 Uraemia and eclampsia 3 
 
 6 
 
 Possible Causes of Still ])Irth in Cases of Breech Presentation. 
 
 Cases. 
 
 Anencephalus 2 
 
 Cord around neck of child three times 1 
 
 Deformed pelvis 3 
 
 Early ru])ture of membranes (several days) : tonic contraction oi uterus 1 
 
 Ilydrocej)halus 3 
 
 Lower extremity extended; in labor three days before calling- Hospital. 1 
 
 Macerated 11 
 
 deformed pelvis ... 2 
 
 " prematurity 12 
 
 '* cord around neck of child six times 1 
 
 uj)per extremities extended 1 
 
 '*' both upper and lower extremities extended 1 
 
 Prematurity 5 
 
 hydramnios 1 
 
 '* cord around neck of child once 1 
 
 •• twins 2 
 
 Prolapse of cord 1 
 
 • ' ' ' upper extremities extended 1 
 
 " " " " " fracture of Immerus 1 
 
 " '• '^ " " '' jaw 1 
 
 " " pi'fjlapse of lower extremities; u])p(n' extremities ex- 
 tended 1 
 
 Upper extremities extended 1 
 
 '' ])r(>lapse of lower extremities; contraction 
 
 ring present 1 
 
 " " " tofTother with lower extremities 1 
 
 *' " " togetlier witli lower extremities; arms 
 
 locked Itcliiiid head 1 
 
 " *' " twins 1 
 
 Midwife in charge of case; delay of oim- lioiir in l)ii'tli of shoulders. ... I 
 
 Neglected breech; cliiM partly born upon anivai of Hospital 1 
 
 Placenta praivia; juiMiiaturity 1 
 
 Twins 3 
 
 No comi)licatioiis 22 
 
 80 
 
STATISTICAL SYNOPSIS. 91 
 
 Day of Death of Children in Cases of Breech Presentation, Dying 
 
 During the Puerperium. 
 
 Of the 255 cliildreii born alive in breech presentation, 35 died during 
 the puerperium. 
 
 23 children died on the 1st day of life. 
 
 4 " " '' 3d " " 
 
 1 child " '' 4th " 
 
 1 '' '' " Tth " " 
 
 1 " " " 9th " " 
 
 1 " " " nth " " 
 
 1 " '< " 12th " " 
 
 35 
 
 The remaining 220 children were discharged from the care of the Hos- 
 pital in good condition. 
 
 Causes of Death of Children in Cases of Breech Presentation, 
 Dying During the Puerperium. 
 
 Cases. 
 
 Atelectasis 2 
 
 ' ' prematurity 1 
 
 Anencephalus 1 
 
 ' ' Csesarean section 1 
 
 Cholera infantum 2 
 
 Convulsions ; icterus ; umbilical stump normal 1 
 
 Foetal deformities ; undeveloped 1 
 
 Delayed labor; head caught in cervix 1 
 
 Prematurit}^ 11 
 
 ' ' fatty placenta 1 
 
 Pneumonia 2 
 
 Suspended animation 4 
 
 Spina bifida 1 
 
 S3q3hilis 1 
 
 Small hgemorrhage into pleura and pericardium; no cause discovered 
 
 on autopsy 1 
 
 Weak 2 
 
 No cause 2 
 
 An Analysis of Cases of Shoulder Presentation. 
 
 Total nmnber of cases of shoulder presentation 91 
 
 Number of mothers who survived 84 
 
 " died 7 
 
 " children born alive 67 
 
 " " still-born 24 
 
 " " dyiiig during the puerperium 2 
 
 35 
 
92 report of the society of tpie lying-in hospital. 
 
 Day of Death of Mothers. 
 
 3 mothers died on Labor day. 
 
 1 mother died on 1st day postpartum. 
 
 1 '^ " 8d •■' " 
 
 1 " " 10th " " 
 
 1 '' " I'ith " " 
 
 Cause of Death of Mothers in Cases of Shoulder Presentation. 
 
 (See list of Fatal Cases, C. N. 330; 349; 426; 769; 3,562; 5,686; 
 5,824.) 
 
 Cases. 
 
 Carcinoma of the cervix ; j^ostpartum haemorrhage 1 
 
 Pneumonia, acute lol>ar 1 
 
 Placenta pra-via 2 
 
 Prolonged labor; imjmcted shoulder; midwife 1 
 
 Septicaemia; pneumonia 1 
 
 Uraemia and eclampsia 1 
 
 Possible Causes of Still Birth in Cases of Shoulder Presentation. 
 
 Cases. 
 
 Anencephalus : liydramnios 1 
 
 Deformexl pehis 
 
 " '' impaction of shoulder at outlet; decapitation 
 
 Forceps to after-coming head 
 
 Prematurity 
 
 Placenta ]>rievia 
 
 " " ])rematurity ; prolapse of cord 
 
 Prolapse of cord 
 
 " " ])rola])S(' of n]~)p('r oxtroniities 
 
 " '• " •• " tonic contraction of uterus 
 
 " '' and riglit luiiid : left arm extended 
 
 Prolapse of upj^er extremities 
 
 " '' " case in cliar^^c of midwife 
 
 " " coi-(l four times ai-oiiiid neck of cliild.... 
 
 UplMT cxtremitif's oxtfTidcd; coi-d oiicc ai-omid ii('(l< of child 
 
 Ura-mia in motlKT 
 
 Tonic contraction of uterus; contractifxi lini^- ])i('sent 
 
 Twins 1 
 
 Ko coiiij)licalions 3 
 
 24 
 
statistical synopsis. 93 
 
 Day of Death of Childken in Cases of Shoulder Presentation, 
 Dying During the Puerperium. 
 
 Of the 67 children born alive, 2 died during the puerperium. 
 
 1 child died on the 1st day of life. 
 
 1 " " " 5th '' " 
 
 Causes of Death of Children in Cases of Shoulder Presentation, 
 Dying During the Puerperium. 
 
 Cases. 
 
 Convulsions ; no cause 1 
 
 Suspended animation ; placenta prsevia 1 
 
 The remaining 65 children were discharged from the care of the Hos- 
 pital in good condition. 
 
 An Analysis of Cases of Face Presentation. 
 
 Total number of cases of face presentation 36 
 
 ISTumber of mothers who survived 36 
 
 " " " died 
 
 " children born alive 33 
 
 " " still-born 3 
 
 " " dying during the puerperium 3 
 
 The position in the 36 cases of face presentation was as follows: 
 
 Cases. 
 
 L. M. A 12 
 
 R M. A n 
 
 Cases. 
 
 L. M. P 7 
 
 E. M. P _6 
 
 13 
 
 Cases. 
 
 In the anterior positions, delivery occurred by normal mechanism 19 
 
 Whole child turned to obtain a vertex anterior position 1 
 
 Manual assistance to flexion as face was born 1 
 
 Podalic version for prolapse of cord 1 
 
 " " " uterine inertia 1 
 
 23 
 
 Cases. 
 In the posterior positions, delivery occurred by normal mechanism .... 3 
 
 Manual rectification to vertex anterior position 1 
 
 Podalic version 5 
 
 Forceps with rotation to mento-anterior 4 
 
 13 
 
94 refort of the society of the lying-in hospital. 
 
 Possible Causes of Still Biktii in Cases of Face Presentation. 
 
 Cases. 
 
 Anencephrtlus; hytlraimiios 1 
 
 Attemj)ted forceps; poilalic version; woman had been the subject of 
 
 Alexander's ojieration 1 
 
 Kectitication attempted; }K)dalic version 1 
 
 ~3 
 Day of Death ok Children in Cases of Face Presentation, Dying 
 During the Puerperiim. 
 Uf the o."^> chiUlrcn born alive in face presentation, 3 died during the 
 puerperium. 
 
 1 child died on the 1st day of life. 
 
 2 children died on the .2d day of life. 
 
 The remaining 3o children were discharged from the care of the IIos 
 pital in good condition. 
 
 &" 
 
 Causes of Death of Children in Cases of Face Presentation, Dying 
 
 During the Puerperium. 
 
 Cases. 
 
 Broncho-pneumonia 1 
 
 Suspended animation 1 
 
 '' " podalic version; fracture of humerus 1 
 
 3 
 
 There were four cases of Ijrow presentation. 
 
 All of the mothers survived, and all of the children were born alive. 
 
 In two cases the brow presentation was changed manually into an ante- 
 rior position of the vertex. In one of these two cases, labor was there- 
 after terminated normally. In the other case, forceps failed to accomplish 
 tlelivery, and podalic version was performed. This child subsequently 
 developed into a microcephalic idiot. 
 
 In one case the brow presentation changed spontaneously into an ante- 
 rior position of the face, and labor progressed to a normal termination. 
 
 In one case s\nnphysiotomy was ]:)erformed for deformed pelvis. The child 
 was then delivered by podalic version, and breech extraction after version. 
 
 There \vere also two cases in which the ear presented. In one case the 
 child was born alive by means of podalic version. In one case the lower 
 uterine segment was so thinned that podalic version was not considered 
 a sjife procedure. The child was dead, and craniotomy was performed. 
 
 It will Ijc noted that the children whose day of death and the causes of 
 wliose death have been recorded in the preceding tables under the analysis 
 of the several ])resentations, are children whose ])resentation was observed 
 at the time of hdx^r. Tliere were also l,li 04 eases in which the i)resen- 
 tation was nr>t observed. Among these l,2<i4 cases there were 813 
 eliildren bf)rn aliv(;. Of these Hi 3 children born alive, 2.") died during 
 the piuTperinm. In order, therefore, to make c()m])h!te the records of 
 death of chil<lr<-ii dying (hii-ing the puerjici iimi. the following lables must 
 1»<' add<'d : 
 
STATISTICAL SYNOPSIS. 
 
 95 
 
 Day of Death of Children in Cases in which Presentation could 
 NOT BE Observed, Dying during the Pueeperium, 
 15 children died on the 1st day of life. 
 
 4 
 
 a u 
 
 1 
 
 child 
 
 1 
 
 
 1 
 
 
 1 
 
 
 1 
 
 
 1 
 
 
 25 
 
 
 2d 
 3d 
 
 7th 
 
 9th 
 
 13th 
 
 15th 
 
 23d 
 
 The remaining 788 children born alive in cases in which presentation 
 could not be observed, were discharged from the care of the Hospital in 
 good condition. 
 
 Causes of Death of Children in Cases in which Presentation could 
 NOT BE Observed, Dying during the Puerperium. 
 
 Cases. 
 
 Atelectasis; prematurity 
 
 ' ' twins 
 
 Foetal deformities; undeveloped 
 Haemophilia , 
 
 1 
 
 1 
 
 1 
 
 1 
 
 Haemorrhage from nose; found dead upon postpartum visit 1 
 
 Pneumonia 1 
 
 Prematurity 8 
 
 Purulent conjunctivitis ; tympanites ; diarrhoea 1 
 
 Suspended animation 1 
 
 Stomatitis 1 
 
 Traumatism ; fell to floor in precipitate labor 1 
 
 Unattended; deep cyanosis and cold surface; moribund upon arrival of 
 
 Hospital 1 
 
 "Weak ; could not be fed , 1 
 
 No cause or symptoms found 5 
 
 25 
 Umbilical Cord. 
 
 7,787 observations. Cases. 
 
 The cord was detached on the 1st day in 3 
 
 2d 
 
 61 
 
 3d 
 
 655 
 
 4th 
 
 ' 1,799 
 
 5th ' 
 
 ' 2,203 
 
 6th 
 
 ' 1,648 
 
 7th 
 
 829 
 
 8th 
 
 413 
 
 9th ' 
 
 139 
 
 10th ' 
 
 37 
 
 7,787 
 
96 report of the society of the lyixg-in" hospital. 
 
 Uterus. — Heiuht ahovk Symphysis, in Inches, during Puerperium. 
 
 Day. 
 
 4 
 
 t— 1 
 
 09 
 
 CO 
 
 c 
 
 1— ( 
 
 h- 1 
 
 <v 
 c 
 
 1— 1 
 
 09 
 
 CO 
 
 <v 
 
 o 
 
 a 
 
 H-l 
 
 o 
 c 
 
 t— 1 
 
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 o 
 1—1 
 
 CO 
 
 a; 
 
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 (— 1 
 
 cr 
 
 o 
 c 
 
 CO 
 
 O 
 l-H 
 
 CO 
 
 imber 
 Cases 
 >served. 
 
 
 l-H 
 
 12 
 
 CM 
 
 CO 
 
 TtH 
 
 >o 
 
 O 
 
 755 
 
 GO 
 
 Oi 
 
 o 
 
 T— 1 
 
 T— 1 
 T— 1 
 
 CM 
 
 CO 
 
 1—1 
 
 ^^O 
 
 Labor 
 
 IS 
 
 109 
 
 580 
 
 1,729 
 
 1,957 
 
 165 
 
 29 
 
 6 
 
 1 
 
 
 1 
 
 5,362 
 
 1st 
 
 24 
 
 59 
 
 347 
 
 1,691 
 
 3,411 
 
 2,671 
 
 797 
 
 174 
 
 24 
 
 10 
 
 
 
 
 9,208 
 
 L>a 
 
 21 
 
 110 
 
 748 
 
 2,873 
 
 3,331 
 
 1,572 
 
 354 
 
 87 
 
 10 
 
 1 
 
 
 
 
 9,113 
 
 3a 
 
 31 
 
 274 
 
 1,626 
 
 3,564 
 
 2,565 
 
 777 
 
 137 
 
 17 
 
 2 
 
 1 
 
 
 
 
 8,994 
 
 4tli 
 
 75 
 
 522 2,559 
 
 3,291 
 
 1,620 
 
 375 
 
 62 
 
 10 
 
 
 
 
 
 
 8,520 
 
 :.th 
 
 144 
 
 1,033 2,830 
 
 2,801 
 
 1,085 
 
 208 
 
 26 
 
 4 
 
 
 
 
 
 
 8,131 
 
 «;th 
 
 L>4«; 
 
 1,379 2,700 
 
 2,081 
 
 012 
 
 120 
 
 15 
 
 
 
 
 
 
 
 7,159 
 
 Tth 
 
 :VSu 
 
 1,27»» 2,114 
 
 1,232 
 
 410 
 
 74 
 
 11 
 
 
 
 
 
 
 . , 
 
 5,441 
 
 ^;th 
 
 313 
 
 1,1211,547 
 
 724 
 
 108 
 
 49 
 
 5 
 
 2 
 
 1 
 
 
 
 
 1 
 
 3,931 
 
 y th 
 
 250 
 
 539 768 
 
 330 
 
 91 
 
 18 
 
 2 
 
 
 
 
 
 
 
 2,004 
 
 Plural Births. 
 
 In the period covered by this report of 10,233 cases there were 161 
 cases of twins, or one to every 63.55 cases. 
 There was one case of triplets. 
 
 Presentation. 
 
 In the 132 cases of twins in which it was possible to make observa- 
 tions, the presentation was as follows: 
 
 Cases. 
 
 Vertex and breech 58 
 
 Both vertex 55 
 
 Both breech 11 
 
 Vertex and face 1 
 
 Breech and shoulder 
 Vertex and shoulder 
 
 Cases. 
 4 
 
 3 
 
 Total 132 
 
 In the case of triplets, the presentation was, first, vertex; second, 
 breech; third, vertex. 
 
 Placenta. 
 
 In the arrangement of placenta and membranes it was found that the 
 placenta was: 
 
 Cases. 
 
 Single 71 
 
 Double 82 
 
 Unknown 8 
 
 Total 101 
 
STATISTICAL SYNOPSIS. 97 
 
 Amniotic Cavity. 
 
 The amniotic cavity was: 
 
 Cases. 
 
 Single 7 
 
 Double 95 
 
 Unknown , 59 
 
 Total 161 
 
 In the case of twins there was: 
 
 Cases. 
 
 A single placenta and double amniotic cavity 43 
 
 A single placenta and single amniotic cavity 4 
 
 A double placenta and single amniotic cavity 1 
 
 In the case of triplets there was a double placenta with a very small 
 placenta succenturiata. There was a double and a single amniotic cavity. 
 
 Sex. 
 
 In the case of twins the sex was as follows: 
 
 Cases. 
 
 Male and female QQ 
 
 Both female 35 
 
 Both male 53 
 
 Unknown 7 
 
 Total 161 
 
 In the case of triplets the sex was : 
 First child, female. 
 Second child, male. 
 Third child, male. 
 
 Mortality. 
 The result to mother and child in the twin cases was as follows: 
 
 Cases. 
 
 Mother living 156 
 
 " dead 5 
 
 Total 161 
 
 Living children 287 
 
 Still-born 35 
 
 Total 322 
 
 In the case of triplets, all three children were living. 
 
 Cause of Death of Mother. 
 
 Cases. 
 
 Erysipelas (antepartum) 1 
 
 Eclampsia " 4 
 
 Total 5 
 
 7 
 
98 REPORT OF THE SOCIETV OF THE LYING-IN HOSPITAL. 
 
 Possible Causes of Still Bikth in Twin Cases. 
 
 Cases. 
 
 Abortion 2 
 
 Child born before arrival of IIos])ital 4 
 
 " '' " membranes imi'ii])tiire(l 1 
 
 " " " " '* early separation of placenta 1 
 
 " " " " " midwife in attendance ; bod}'" born; 
 
 head retained within ]>elvis... 1 
 
 Eclain])sia in mother; accouchement force 2 
 
 Forceps low 1 
 
 Fci'tal lieart sounds not lieard; c<n'd not pulsating 1 
 
 Fibrous degeneration of ])lacenta 1 
 
 Macerated 7 
 
 ^Mummified fo-tus (pi four months of ftrtal life, with living fa^tus of 
 
 six months of foetal life) 1 
 
 Placenta praevia ; manual extraction ; prematurity 4 
 
 Prematurity ; manual extraction 3 
 
 l*r(jla])se of funis ; foetal heart sounds not heard 1 
 
 Separation of placenta before labor; antepartum haemorrhage; short 
 
 umljilical cord ; three coils of cord around child's neck 1 
 
 Shoulder presentation; prolapsed arm; extended arm locked behind 
 
 child's head 1 
 
 Xo cause assigned in history 8 
 
 35 
 Day of Death of Children of Twin Cases, Dying during Puerperium. 
 
 Cases. 
 
 Death on 6th day 2 
 
 Tth "' 1 
 
 " 8th " 
 
 9th " 2 
 
 " 10th " _o 
 
 Total 38 
 
 The remaining 249 children were discharged from the care of the Hos- 
 pital in good condition. 
 
 Causes of Dp:atu in Children of Twin Cases, Dying during Puerperium. 
 
 Cases. 
 
 Atelectasis; prematurity 2 
 
 Circulation poor; respiration superficial 2 
 
 Convulsions on 6th and Tth days; icterus; (li<<l on Tth day; born in Sth 
 month intrauterine life; uiid)ilical cord se})arated on 4tli day 
 
 without suppuration 1 
 
 Cholera infantum 1 
 
 Ilajmorrhagos, small in size, into ])lein"i and |)(')ica,i-(lium, shown by 
 
 autopsy; no definite cause discovered 1 
 
 Poorly nourished; would not nurse 5 
 
 Prematurity (born before eightli month) IS 
 
 Xo cau.se assigned (one child described as de('|)]y cyanosedj S 
 
 38 
 
 
 
 
 Cases. 
 
 Death 
 
 on Labor day .... 
 
 15 
 
 
 1st 
 
 '' 
 
 12 
 
 
 2d 
 3d 
 4th 
 5th 
 
 ii 
 
 3 
 
 
 a 
 
 2 
 
 
 a 
 
 1 
 
 
 a 
 
 () 
 
STATISTICAL SYNOPSIS, 
 
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100 REPORT OF THE SOCIETY OF THE LYING-IN HOSPITAL. 
 
 Tho o]>Pi*ation of forceps was performed 290 times in the service of 
 lO,:i;)o cases, or once in 3r).2l) cases. 
 
 Tlie observations are tabulateil as follows: 
 
 High forceps was [)erfornieil in 86 cases. 
 
 Cases. 
 
 Deatli of motlier 3 
 
 •• child 3 
 
 Still birth 8 
 
 To after-coming head 4 
 
 Death of mother 2 
 
 Still birth 4 
 
 Median forceps was performed in 87 cases. 
 
 Cases. 
 
 Death of mother 1 
 
 '' '' child 1 
 
 Still birth 10 
 
 Low forceps Avas performed in 111 cases. 
 
 Cases. 
 
 Death of mother .• 1 
 
 " " child 2 
 
 Still birth 9 
 
 iXot noted 4 
 
 Symphysiotomy. 
 
 The operation of sym]ihysiotomy has been performed six times in the 
 service of 10,233 cases. In all six cases the incision has been made over 
 the joint, and the joint has been opened from behind forward and from 
 above downward. Gauze drainage has been used for twenty-four hours at 
 least. The sutures have attempted to include the iibrous tissue over the 
 joint. 
 
 In all six cvuses the child has l)een delivered by versi<m. 
 
 In all six cases living children were born, and the mothers recovered 
 without loss of function and without inconvenience after resuming their 
 •iuties. 
 
 CyKSAKKA.V SKCniON. 
 
 Ca?sarean section has ijcen pcrloriiicd twice in the service of 10,233 
 cases, or once in .5, 116.. 5 cases. 
 
 In one caso (C. X. .')..")()♦; ; Dr. Markoe) the o])(;ration was performed 
 for d«f<iriiied pelvis. lUAh mother and child survived. 
 
STATISTICAL SYNOPSIS. 101 
 
 The following is an outline of the other case (C. N. 5,955; Dr. Edgar): 
 
 Labor obstructed by fibroid tumor of lower uterine segment; breech 
 presentation; hydramnios; Caesarean section; anencephalic child; suppres- 
 sion of urine in mother; fever in mother; death of mother forty-eight 
 hours postpartum. 
 
 The patient, a Russian, married, aged 35 years, para Y., tenth month 
 of gestation, was first seen by a Hospital officer, April 9, 1894. At this 
 time the patient had already been several hours in the first stage of labor. 
 
 No history of any miscarriages could be obtained, and of the four pre- 
 vious labors difficulty had been experienced in the last one only, which 
 occurred in 1892. 
 
 At 5 P.M. on April 9, 189-4, when first visited by this Hospital, in the 
 labor under discussion, weak uterine contractions were found to be present, 
 the membranes intact, the breech presenting, and the subjective symptoms 
 of obstructed labor well marked. 
 
 Further internal examination revealed a fibroid tumor, about the size of 
 a small foetal head, attached to the left wall of the lower uterine segment, 
 and one inch above the ring of the internal os. 
 
 The tumor was of a hard consistency and filled in the upper and posterior 
 space of the left half of the true pelvis. A space of only two inches was 
 left between the right wall of the uterus and the right pelvic wall. 
 
 An attempt to push the tumor above the brim of the true pelvis was 
 unsuccessful, even after the patient had been placed under ether. 
 
 Laparotomy was at once decided upon as offering the best chances for 
 mother and child, and was accordingly performed. The usual Sanger 
 Caesarean operation was done, the uterus being turned out of the abdominal 
 cavity before the incision in its wall was made. 
 
 An anencephalic foetus was delivered, which survived forty hours. The 
 mother developed total suppression of urine, with fever, and died forty- 
 eight hours postpartum. 
 
 A fuller account of the case, with the bibliography of the subject of 
 obstructed labor due to uterine fibromata, will appear in a subsequent 
 report. 
 
 Craniotomy. 
 
 The operation of craniotomy was performed three times in the service 
 of 10,233 cases, or once in 3,411 cases. 
 
 C. IST. 2,176. — III. para; ninth month of gestation; ear presentation; 
 woman gave previous history of puerperal sepsis which had been treated 
 b}^ abdominal section ; uterus firmly bound by adhesions so as to be curved 
 laterally, with convexity to left side ; no foetal heart heard ; internal ver- 
 sion impossible, on account of inability to reach feet, due to mal-position 
 of uterus; craniotomy and extraction; recover}^. 
 
 C. N. 2,769. — Y. para; ninth, month of gestation; vertex; L. O. A.; 
 deformed pelvis. Podalic version; manual traction and traction with ceph- 
 alotribe insufficient to accomplish delivery ; after-coming head perforated 
 through neck, and head extracted ; recovery. 
 
102 REPORT OF THK SOCIETY OF THE LVIXG-IX HOSPITAL. 
 
 C. X. 5,411'.. — IV. piira: ninth niontli of o-estation; vertex; E. O. P.; 
 deformed pelvis; version attempted; pulseless cord prolapsed; craniotomy 
 and extraction ; recovery. 
 
 Fatal Cases.* 
 
 It should he said, in regard to the following notes upon Fatal Cases, 
 that it is verv rarelv possihle to ohtain an autopsy in the service of this 
 Hospital, <»n acvount of the religious scruples of the Hebrews. 
 
 1. ('. N. l<il. — Age 28; III. para; eighth month of gestation; confined 
 by Hospital; vertex; R. O. A.; ])ostpartum liaMuorrhage; septicaemia; 
 pneumonia; death eleventh day. 
 
 2. C. K. 295. — Age 28; II. ])ara; ninth inoiitli of gestation; confined 
 by midwife ; first seen sixth day postpartum ; se])ticaMnia ; pneumonia ; 
 metastatic abscesses; ha?matemesis ; death forty-eighth day postpartum. 
 
 3. C. N. 330. — Age 33; VIII. para; confined by Hospital; shoulder 
 jiresentation ; podalic version; su])pression of urine; ura?mia; death first 
 day postpartum. 
 
 4. C. N. 349. — Age 34; thirty-fourth week of gestation; confined by 
 Hospital; shoulder presentation ; placenta ])raevia; podalic version; oedema 
 of lungs; death third day jiostpartum. 
 
 5. C. X. 399. — Age 28; I. para; confined by midwife; first seen third 
 day j)Ost)xirtum; se])ticfemia ; collapse; death fourth day post])artum. 
 
 G. C. X. 420. — Age 24; I. ])ara; confined by Hospital; hydrocephalus; 
 vertex presentation; podalic version; severe lacerations of cervix and 
 perineum; septicEemia; death sixtli day postpartum. 
 
 7. ('. X. 420. — Age not noted; I. para; ninth month of gestation; 
 confined by Hospital after re])eated failure by midwives to deliver ; 
 shoulder presentation; first seen in second stage; sliock; podalic version; 
 collaiiso; death on day of confinement. 
 
 s. C. X'. 709. — Age 27; V. para; ninth inontli of gestation; confined 
 by Hos])ita]; shoulder presentation; general condition bad; ])odalic ver- 
 sion; forceps to aftei--coming head; extensive carcinoma of the cervix; 
 antepartum and post])artum haemorrhage from cervix; colla])se; death 
 seven hours ])ostpai'tum. 
 
 9. C. X. 804. — Age 40; VI. para; confined l\y Hospital; breech j^res- 
 entation; labor easy; ]merperium normal until tenth day; septicaiuiia; 
 sent to Bellevue Hospital fifteenth day postpartum; death twenty-second 
 (lay |)ost])artum. 
 
 10. (.'. X. 99.".. — Age 25; V. i)ara; ninth month of gestation; confined 
 by midwife; seen Ijy Hospital on first (hiy postpartum, with fever; septi- 
 caemia ; curettage; acute exacerbation of |)uhiioiu(iy tul)ci'culosis. lle- 
 movcfl on sixth day to (iouverneui" IIosj)ital; died twenty-sixth day 
 |)ostpartum, cjf tulx-reuhisis and s<'])ticiemia. 
 
 ' R«g"arding Uie abovo notes on Fatal Cases, it should !)<■ said tliaf tlu' records 
 sliow that all tlif cases were visited rej^'-nlarly 'h' the attending'' physician or liis 
 a.SHiHtant, wliether he had In-en the ojxM'at/or or not. 
 
STATISTICAL SYNOPSIS. 103 
 
 11. C. N. l,Oir>. — Age 35; VII. para; ninth month of gestation; con- 
 fined by Hospital ; vertex presentation; labor normal; septicaemia; nephri- 
 tis; death sixth day postpartum. 
 
 12. C. ]Sr. 1,093. — Age 35; X. para; ninth month of gestation; confined 
 by midwife; labor easy; first seen third day postpartmn; septicaemia; 
 albuminuria; ])neumonia; death sixth day postpartum. 
 
 13. C. X. 1,198. — Age 36; VI. para; sixth month of gestation; con- 
 fined by Hospital ; vertex presentation ; placenta praevia ; dilatation by 
 Barnes's bags; rupture of uterus; podalic version; death second day, from 
 shock. 
 
 14. C. K. 1,425. — Age 34; V. para; ninth month of gestation; con- 
 fined by Hospital; vertex; E,. O. A.; pulmonary oedema in second stage 
 of labor, and s3'mptoms of acute nephritis; death from above cause on 
 fourth day. 
 
 15. C. N. 1,547. — Age(?); para(?); month of gestation (?); confined by 
 Hospital; twins; vertex and breech presentations; breech extraction; facial 
 erysipelas of eight days' duration; woman first seen in second stage of 
 labor, and at that time Avas in collapse; death from shock on second day 
 postpartum. 
 
 16. C. IST. 1,723. — Age 38; VI. para; seventh month of gestation; con- 
 fined by Hospital; vertex; L. O. A.; prolapse of hand ; temperature on 
 labor day, 101.1 degrees; pulse, 132; broncho-pneumonia and death on 
 seventh da}". 
 
 17. C. N. 2,381. — Age 24; I. para; ninth month of gestation; confined 
 by Hospital; twins; vertex and breech presentations; low forceps; breech 
 extraction; eclampsia; death on first day. 
 
 18. C. 'N. 2,429. — Age 35; XI. para; ninth month of gestation; con- 
 fined by Hospital; vertex; L. O. A. ; still birth; antepartum hemorrhage; 
 slight postpartum haemorrhage; temperature on labor day, 100.2 degrees; 
 death from inanition, on seventh day. 
 
 19. C. X. 3,267.— Age 34; VII. para; ninth month of gestation; con- 
 fined by Hospital; vertex presentation; previously evidently in charge of 
 midwife ; patient suffering from shock when first seen ; rupture of uterus, 
 of several hours' duration; manual extraction of child and placenta from 
 abdominal cavity through utero- vaginal rent; death in thirty-six hours, 
 from shock. 
 
 20. C. ]N^. 3,314. — Age 23; II. para; eighth month of gestation; con- 
 fined by Hospital ; vertex; R. O. P. ; pendulous abdomen ; rupture of 
 uterus; prolapse of funis; podalic version; manual extraction of placenta; 
 death fourth day, from shock. 
 
 21. C. N. 3,351. — Age 22; I. para; ninth month of gestation; confined 
 by Hospital; vertex; R. O. P.; advanced pulmonary tuberculosis; pul- 
 monary haemorrhage before and during delivery ; extensive oedema of 
 lower extremities ; pulmonary oedema ; death from exhaustion in two hours 
 postpartmn. 
 
 22. C. N. 3,562. — Age 30; VII. para; ninth month of gestation ; con- 
 fined by Hospital; shoulder presentation; placenta prasvia; haemorrhage; 
 
104 REFORT OF THE SOCIETV OF THE LYING-IN HOSPITAL. 
 
 shock; accouchement force; podalic version ; extraction; death from shock, 
 a few houi-s hiter. 
 
 -2'A. C. X. :>,r)»'.4. — A«:e lM : I. i)ara; ninth month of gestation; confined 
 hv Hospital; vertex; K. O. P.; eckimpsia; k)\v forceps; coma; death few 
 hours postpartum. 
 
 •J4. ('. X. 4, (').">,"). — Age 22; I. para; ninth month of gestation; con- 
 tined hy Hospital ; twins ; vertex and hieech presentations ; forceps ; 
 eclampsia; death on second day. 
 
 2."). C. X". 4,«is;>. — Age 24; II. ])ara ; thirty -fourth week of gestation; 
 confined liy Hospital; vertex; L. O. A.; eclampsia; manual dilatation; 
 high forceps; death six hours later. 
 
 26. C. X. 4,720. — Age 22; III. ])ara; ninth month of gestation; con- 
 fined by IIos])ital; vertex; L. O. A.; Morbus Maculosus Werlhofii; severe 
 haemorrhage from mouth and uterus before and during labor; general con- 
 dition bad; forceps; postpartum haemorrhage. Death on first day, from 
 luemorrhage and shock. 
 
 27. ('. X. 5,190. — Age 36; YI. para; ninth month of gestation; con- 
 fined by Hospital; vertex; L. O. A.; septiciemia on third day post]xirtum; 
 transferred to Bellevue Hospital on nineteenth day postj)artum ; subse- 
 quently died in Bellevue Hospital on an unknown day. 
 
 28. C, X. 5,473. — Age 38; XII. para; seventh month of gestation; 
 confined by Hospital; vertex; L. O. A.; induction of labor for death of 
 cliild in utero in last four pregnancies; manual dilatation; podalic version; 
 post])artum luemorrhage six hours after labor; death from haemorrhage on 
 first day. 
 
 29. C. X". 5,633. — Age 19; I. ])ara; niiitli month of gestation; con- 
 fined by Hospital; vertex; L. O. A.; albuminuria; forceps for contracted 
 pelvis; death on first day postpartum, of unemia. 
 
 30. C. X. 5,686. — Age 26 ; VIII. para ; ninth month of gestation ; 
 confined by Hospital; slioulder ])resentation and prolapsed hand; podalic 
 version; septicicmia; curettage; pneumonia; death on twelfth day. 
 
 31. C. X. 5,708. — Age 34 ; IX. para ; ninth month of gestation ; 
 confined by Hospital; vertex; L, O. A. ; high forceps for contracted ])elvis; 
 sent to Ik'Uevue Hos])ital on twenty-seventh day postpartmn with vesico- 
 vaginal fistula; subsecpiently died in Bellevue Hospital, of surgical kidney. 
 
 32. C. X'^. 5,799. — Age 24; III. })ara; ninth month of gestation; confined 
 by Hospital; vertex; L. O. A.; general condition bad; history of tuber- 
 culosis, rlMMunatism, ami cardiac disease; uterine inertia; manual dilata- 
 tion; j)odalic version; septicaMiiin ; dcjith on twenty-fifth day ])ostpartum. 
 
 33. C X. 5,824. — Age 35; III. |)ara; nintli month of gestation; con- 
 fined by Hospital; shoulder presentation; version; (Usath from acute lol)ar 
 pneumonia on tenth day. 
 
 :54. C,". X. 5,955. — Age 35; V. ])ara; ninth ntonth of gestation ; confined 
 by Hospital ; breech presentation ; Ca'sarcau section for uterine fibroid ; 
 com|)let<; suj)pression of urine; death on second day. 
 
 35. (y. X. 6,235. — Age 30; II. j)ara; ninth month of gestation; con- 
 fined In* Hospital ; twins ; both vertex presentation ; eclampsia ; manual 
 
STATISTICAL SYNOPSIS. 105 
 
 dilatation ; podalic version for both cliildren ; death seventh hour post- 
 partum. 
 
 3G. C. N. 6,925. — Age 21; II. para; eighth month of gestation; ver- 
 tex; L. O. A. Case seen in consultation with outside physician; patient 
 found in collapse ; moril)und; symptoms of haemorrhage; placenta delivered 
 by Hospital; death on first day postpartum. 
 
 37. C. IN". 7,070. — Age 26; II. para; ninth month of gestation; con- 
 fined by Hospital ; vertex; L. O. A. ; eclampsia ; accouchement force ; 
 Diirhssen's incision of cervix; podalic version; death thirty-six hours post- 
 partum, from uraemia. 
 
 38. C. ]Sr. 7,263. — Age 41; XV. para; tenth month of gestation; con- 
 fined by Hospital; vertex; R. O. A. ; tedious labor; prolapsed cord; rupture 
 of uterus; podalic version; septiceemia; death on sixth day. 
 
 39. C. ]^. 7,538. — Age 35; Y. para; ninth month of gestation; con- 
 fined by Hospital; vertex; R. O. A.; septicgemia; death tenth day post- 
 partum. 
 
 40. C. ]Sr. 8,034. — Age 39 ; XIII. para; tenth month of gestation; 
 confined by Hospital ; vertex presentation ; placenta previa ; manual dila- 
 tation ; podalic version ; postpartum haemorrhage ; death on second day, of 
 septicaemia. 
 
 41. C. IST. 10,047. — Age 30; XI. para; ninth month of gestation ; mid- 
 wife found in attendance; vertex; L. O. A.; deformed pelvis; septicaemia 
 on eighth day; sent to BeUevue Hospital, where she died on twenty-second 
 day postpartum. 
 
 42. C. 'N. 10,218. — Age 35; lY. para; tenth month of gestation; con- 
 fined by Hospital; twins; vertex and breech presentations; eclampsia; 
 death twenty-four hours after delivery, from uraemia. 
 
 In addition to the above deaths, one patient died before delivery, 
 
 A. N. 8,308. — Age 26; I. para; seventh month of gestation; advanced 
 
 heart disease; treated for nine days with marked improvement; subsequent 
 
 heart failure and death on the tenth day. 
 
STUDENTS OF THE HOSPITAL. 
 
 Total number of graduate students 210 
 
 " '' undergraduate students 1,335 
 
 " " cases at which students assisted in the 
 
 confinement 7,495 
 
 " " cases in which the confinement was 
 
 witnessed by students 8,2-12 
 
 " " pregnant women examined by students 5,145 
 
 The 210 graduate students registered from the foUowing Medical 
 
 Schools : 
 
 Medical Department of the Univei'sity 
 
 of the City of New York 60 
 
 Bellevue Hospital Medical College. . . 32 
 
 College of Physicians and Surgeons . 28 
 Medical and Surgical College of New 
 
 York 1 
 
 Memphis Hospital Medical College . . 1 
 
 University of Vermont 8 
 
 Jeffei-son Medical College 1 
 
 University of Minnesota 2 
 
 Dartmoutli Medical College 3 
 
 Queens College, Kingston, Ontario. . 1 
 
 Bowdoin College 1 
 
 University of Virginia 4 
 
 College of Phj'sicians and Surgeons, 
 
 Chicago, III 1 
 
 Yale Univei'sity 7 
 
 Buffalo University 3 
 
 Col umhia College, Washington, D. C. 5 
 New York Homoeopathic Medical Col- 
 lege 2 
 
 Chicago Homceopathic Medical Col- 
 lege 1 
 
 Torontf> Medical College 1 
 
 Long Island College; Hospital 2 
 
 St^.'rling Medical College, Colunihus, 
 
 Oliio 1 
 
 I^juJHville Medical College, Loui.s- 
 
 ville, Ky 2 
 
 Cooler Medical College, San Fran- 
 cisco 1 
 
 Maine Medical College 2 
 
 Marion Sims College, St. Louis, Mo. 1 
 
 St. Louis Medical College 1 
 
 Georgetown Medical College 2 
 
 Woman's Medical College, Chicago, 
 
 111 2 
 
 University of Montana 1 
 
 " " Michigan 1 
 
 Eclectic Medical College 2 
 
 1 
 1 
 5 
 1 
 1 
 3 
 
 Chicago, 111. 
 Cincinnati. . 
 
 Atlanta ' ' 
 
 Syracuse ' ' 
 
 Albany 
 
 Rush 
 
 Miami " 
 
 Woman's ' ' 
 
 University of Jena, Germany 1 
 
 1 
 
 1 
 
 . 1 
 
 " " Toronto, Canada 
 
 " " Niagara 
 
 " " South Tennessee 
 
 College of Physicians and Surgeons, 
 
 Baltiinoi'c 1 
 
 KcnturUy Scliool of Medicine 1 
 
 New York Woman's Infirmary 2 
 
 Graduated Nurse from the New York 
 
 Hospital 1 
 
 Graduated Nurs(!s from the German 
 
 Hospitiil 8 
 
 Gradiiat/'d Nurse from tlu! Womans' 
 Ilos|)ital 1 
 
 Total 210 
 
STUDENTS OF THE HOSPITAL. 
 
 107 
 
 The 1,335 undergraduate students of the Hospital registered from the 
 following Medical Schools : 
 
 Medical Department of the Univer- 
 sity of the City of New York 582 
 
 Bellevue Hospital Medical College . . 370 
 
 College of Physicians and Surgeons. 221 
 New York Homoeopathic Medical 
 
 College for Women 6 
 
 New York Homoeopathic Medical 
 
 College 49 
 
 Long Island College Hospital 17 
 
 University of Virginia 1 
 
 " " Kingston, Ontario ... 1 
 
 Yale University Medical School .... 14 
 
 University of Vermont 2 
 
 College of Physicians and Surgeons, 
 
 Chicago, 111 1 
 
 New York Eclectic Medical College . 5 
 
 Albany Medical College 22 
 
 Columbia Medical College, Wash- 
 
 mgton, D. C 5 
 
 Harvard University Medical College 1 
 
 Womans' Medical College, New York 2 
 
 Tufts College, Medford, Mass 2 
 
 Syi-acuse Medical College 2 
 
 Dartmouth Medical College 14 
 
 Jetferson Medical College 1 
 
 Buffalo University 7 
 
 Michigan University 2 
 
 South Carolina Medical College .... 1 
 
 Ann Arbor Medical College 1 
 
 Niagara University 1 
 
 McGill College, Montreal, Canada. . 1 
 
 Toledo Medical College 1 
 
 Howard Medical School, Raleigh, 
 
 N. C 1 
 
 Cleveland University Medical Col- 
 lege 2 
 
 Total 1,335 
 
STATISTICAL REPORT OF FORCEPS OPERATIONS. 
 By Austin Flint, Jr., M.D. 
 
 Of the various operations in obstetrics, by far the most frequently 
 performed is a forceps o])eration. The apjilication of forceps may be indi- 
 cated in so great variety of conditions, that it has seemed to the writer 
 that the sul)jeot was of suthcient importance to make a special report of the 
 cases occurring in the service of this Hospital. 
 
 All of the cases u])on wliicli observations were made occurred in the 
 outdoor service of the Hospital. As "delayed labor" was the most fre- 
 quent indication, it may be proper to describe something of the routine 
 treatment of cases in which forceps were ajiplied. Patients are under the 
 immediate care of students, who are not allowed, under any circumstances, 
 to interfere with the course of labor. Reports from students are sent to 
 the Hos])ital at frequent intervals. The cases are visited by members of 
 the stall" assigned to outdoor duty, who supervise the students' work, con- 
 firm the reports as regards diagnosis, and instruct the students in the 
 various details of the management. In cases of abnormalities of any sort, 
 the details are sent to the sub-station or to tlie Hos])ital directly, as may be 
 more convenient, and nothing is done by the staff member present unless 
 there is immediate necessity. Cases in which forceps are indicated are thus 
 referred first to the Hospital, and from there to the attending ])]iysician 
 on (Uity. Tliis routine makes the application of forceps less fre(|uent than 
 is usual in ]iosj)itals conducting a purely indoor service. 
 
 Forcej)S were a])|»li('d 2!>4- times, or in 2.S7 ])er cent, of all cases. This 
 percentage is 2. '.>'.», subtracting the 417 abortion cases from the total. 
 
 Tlie general results were : 
 
 Of tlie mothers 288 recovered. 
 
 6 died. 
 
 Total 294 
 
 Of the chihh-eii 252 recovered. 
 
 " " 33 were still-born. 
 
 " " died (hiring the puerperium. 
 
 Total 294 
 
STATISTICAL REPORT OF FORCEPS OPERATIONS. 109 
 
 This is a maternal mortality of 2.04: per cent., and an infant mortality 
 of 14.35 per cent. 
 
 Of the six fatal cases, five occurred after a high operation, and one 
 after a low operation. In but two instances could the fatal result be 
 ascribed in any way to the operation. 
 
 The cause of death and operations are divided as follows: 
 
 Cases. 
 
 Eclampsia, high operation 2 
 
 Sepsis, " " 2 
 
 Haemorrhage and shock, high operation 1 
 
 Eclampsia, low operation 1 
 
 Total 6 
 
 In one-half of the cases, therefore, eclampsia Avas the direct cause of 
 death, and the operation was merely incidental. The case of hsemorrhage 
 and shock was antepartum, and is recorded as the indication for the for- 
 ceps delivery. It is probable that there was a low implantation of the 
 placenta. The reraainiag two deaths were due to sepsis, which might have 
 occurred under the surrounding conditions, even if the forceps had not 
 been applied. The causes of the foetal deaths do not admit of exact deter- 
 mination. Undoubtedly many of the still-born children were dead at the 
 time of operation. ISTo foetal heart sound could be heard in a larger 
 number of cases than the total number of still-births registered. The 
 necessity of making some exact distinction between the high, median, 
 and low operations, was appreciated early in the history of the Hospital, but 
 it was not until a large number of operations had been recorded that such 
 a distinction was made. The figures in the whole series, therefore, make 
 no mention of median forceps, but the "high operation" is defined as an 
 operation within the uterus, whether the forceps blades were applied above 
 the pelvic brim or within the excavation. The term "low operation" is 
 defined as an operation in which the blades are applied to the presenting 
 part when it had reached the pelvic floor and had passed through the 
 cervix. 
 
 I have included under high operations a large number of cases which 
 were really median operations, in order to be consistent in the earlier and 
 later observations. 
 
 The classification now employed is as follows: 
 
 1. High Forcejps. — The greatest diameter of the head is above the brim 
 of the pelvis. 
 
 2. Median Forceps. — The greatest diameter of the head has passed the 
 brim of the pelvis, subdivided into : 
 
 («) Within the cervical canal. 
 (J) Outside the cervical canal. 
 
 3. Low Forceps. — The head is on the pelvic floor. 
 
 As nearly as it is possible to determine, the median operation was per- 
 formed eighty-seven times. 
 
110 REPORT OF THE SOCIETY OF THE LYING-IN HOSPITAL. 
 
 Incliulino; most of the iiiodian operations among the high, forceps were 
 applied as follows: 
 
 Iliirh 141 times. 
 
 Low 153 ' * 
 
 The high oi)eration, therefore, was done in a very large ])roportion of 
 the total number. The explanation of this fact is the routine b}^ which 
 women are allowed to remain in labor until it is almost imperative that 
 some active interference be em])loved. A large number of patients who 
 linally deliver themselves, would be subjected to a low forceps operation in 
 ordinary private practice. Such a routine is perhaps not so good obstetrics, 
 but is far safer under the conditions than a more indiscriminate use of 
 the forceps would be. Even after it has been determined that force]is 
 would be advisable in a given case, the delay in reporting to the IIos])ital 
 ami securing the attending physician to operate, not infrequently results 
 in a s])ontaneous delivery while the preparations for a forceps delivery are 
 l)eing made. 
 
 The total number of 294 observations includes not only actual deliveries, 
 but all cases in which forcei)s were used at any time during labor. I have 
 se|)arated the latter cases and tabulated them, as follows: 
 
 Cases. 
 
 1. Vertex presentations, in which forceps were attempted, and de- 
 
 livery was finally accomplished, after a podalic version 10 
 
 2. Vertex presentation, in which forceps were attempted, antl delivery 
 
 was left to nature 1 
 
 3. ]>reech presentation, in Avhich the forceps were applied directly 
 
 to the breech 1 
 
 4. Forceps to the after-coming head ;> 
 
 Total 15 
 
 In twf) of the three cases of forceps to the after-coming head, delivery 
 was accom})lisiied; and in the other, after traction had been made, the 
 forceps were removed, and delivery accomplished by manual efforts. 
 
 In the total numl)er of 294 cases, the presentation was as follows: 
 
 Vertex 270 
 
 Face 5 
 
 Shoulder .") 
 
 Ijreech 1 
 
 Brow 1 
 
 Not noted S 
 
 Total 294 
 
 Forceps were apj)li(Ml directly to the ])res('iitiiig part in all but tlie three 
 cases of shoulder presentations, which terminated as follows: 
 
 In one, ce))ha]ic version Avas ])erforme(l, force))s a|)|)li('(l to tlie head, 
 which failed to engage;, and delivej-y ^vas effected al'lei" podalic version. Jn 
 this case, both mot her and diiM siii'vivc<l. In the second case, podalic 
 version was |t<Trornic<l. dnrin;^- which the cord [o-ohipscd ; IVji-ccjps were 
 
STATISTICAL REPORT OF FORCEPS OPERATIONS. 
 
 Ill 
 
 applied to the after-coming head, ^^ liich was finall}^ extracted manually, 
 resulting in tlie recovery of the mother and death of the child. 
 
 In the third case, podalic version was performed, and the after-coming 
 head delivered by forceps through a rigid cervix. The child was still- 
 born and the mother recovered. 
 
 The position was as follows: 
 
 L. O. A 
 E. O. A 
 L. O. P 
 K. O. P 
 K. M. P, 
 L. M. P 
 
 161 
 49 
 25 
 41 
 
 E. Scap. A 1 
 
 E. " P 1 
 
 L. " P 1 
 
 Not noted 10 
 
 Total 294 
 
 In the total number of 276 vertex cases, the occiput occupied an anterior 
 position in 210 cases, and a posterior position in 66 cases. Thus, in a large 
 number of cases, the posterior position of the occiput was the cause of the 
 delay, and an indication for forceps. 
 
 The number of the confinement is divided as follows : 
 
 I. para 155 
 
 IL " 38 
 
 III. " 19 
 
 lY. " 21 
 
 y. " 14 
 
 YI. " 10 
 
 YII. " 8 
 
 YIII. " 4 
 
 IX. para 7 
 
 X. " 4 
 
 XL " 3 
 
 XII. " 1 
 
 XIII. " 1 
 
 :N"ot noted 9 
 
 Total 294 
 
 A little more than 50 per cent, were primipara. 
 
 Age. 
 
 Below 20 19 
 
 20-25 156 
 
 25-30 59 
 
 30-35 29 
 
 35-40 15 
 
 40-50 4 
 
 JS^ot noted 12 
 
 Total 294 
 
 The indications for forceps include a large number of accidental com- 
 plications. Nearly all the indications might be included in the term, 
 ' ' delayed tedious labor, ' ' but an attempt has been made to ascertain the 
 cause of the delay, whenever possible. As the term is used in the table, 
 the delay has been either in the case of a disproportion between the size of 
 the head and the canal, without pelvic deformity, or an inherent weakness 
 of the uterine contractions. 
 
112 KEPORT OF THE SOCIETY OF THE LYIXG-JX HOSPITAL. 
 
 The indications and complications luive been tabulated together, the 
 complication frequently being the sole indication. 
 
 Indications and Complications. 
 
 1. Delayed tedious labor (no cause for delay assigned) . 108 
 
 2. Uterine inertia, exhaustion 65 
 
 3. Strong uterine contractions, no progress 26 
 
 4. Deformed pelvis 4-i 
 
 5. Eclampsia 8 
 
 G. Albuminuria (threatened eclam])sia) 5 
 
 7. Rigiility and oedema of cervix 7 
 
 8. Occiput posterior, failure to rotate 7 
 
 9. Large head 5 
 
 10. lliemorrhage 6 
 
 11. Prolapse of the cord 7 
 
 12. Face presentation 2 
 
 13. Brow, failure to extend 1 
 
 14. Prolapsed arm 1 
 
 15. Tonic uterine contractions 1 
 
 16. " Dry labor " 1 
 
 Total 21>4 
 
 I have thought it best, in making this table, to adhere closely to the 
 histories. A])parent inaccuracies exist, but a close studv shows that they 
 are only apparent. For example, there were five face presentations in all, 
 but only two appear as the indication, and the other three are included — 
 two among " strong pains, no advance," and one among " uterine inertia." 
 To change the indications and include the two apparently uncomplicated 
 face ])resentations among the others, would necessitate a change in the 
 history charts, and lead to endless complications and confusion. The 
 indication " deformed pelvis " also needs some explanation. There were 
 forty -four such cases recorded, as follows: 
 
 " Contracted or deformed " 27 
 
 Justo-minor 8 
 
 " Flat " and '' promontory ])i'<>inincnt " 9 
 
 Total 44 
 
 In but thirty of tiicse was the def(jrmity marked, as has been shown in 
 an article elsewhere in this Report. In the remaining fourteen cases, a 
 diagnosis of dofonnity was questionable, and not sustained by ]wlvic meas- 
 urements. The histories of these questionaljle cases contain simply a state- 
 ment, in the account of the operation, that the " ])elvis was rather small," 
 or "arch narrow," or " promontory jutted forward." They were usually 
 consultation cases, with no actual mc^asui-cments, and have not been 
 
STATISTICAL REPORT OF FORCEPS OPERATIONS. 113 
 
 included as deformed in the article on Pelvic Deformity. They are re- 
 corded, however, as an indication for forceps, and the histories have not 
 been changed, for the reasons stated before. 
 
 The condition of the foetal heart at time of operation is recorded as 
 follows: 
 
 Cases. 
 
 From 12(1 to 130 29 
 
 '' 130 to 140 102 
 
 " 140 to 150 61 
 
 " 150 to 160 14 
 
 " 160 to 170 2 
 
 " 170 to 180 1 
 
 Foetal heart not heard 85 
 
 Total 294 
 
 The results as regards the mortality for children have already been 
 stated. 
 
 It may be repeated in conclusion, that, while the foregoing statistical 
 synopsis develops nothing new as regards the technique of forceps opera- 
 tions, the results are worthy of notice. 
 
 The forceps which are commonly employed are of the Elliot pattern, 
 and have given general satisfaction. As a rule, they are used in the low 
 operation, and have frequently been applied within the cervical canal. 
 The axis-traction forceps of Prof. Alexander Simpson are also employed in 
 the high operation. Forceps of various other patterns have been used by 
 the Hospital from time to time, including the new^er model of Tarnier in 
 difficult deliveries, and the forceps of Milne-Murray. 
 
 The statistics show, perhaps, as the most prominent feature, that a con- 
 servative use of forceps is productive of good results. They were employed 
 but once in about thirty-three deliveries. A very large proportion of the 
 total, nearly one-half, w^ere high operations. Notwithstanding this large 
 proportion of high operations, and the frequency of complications, the 
 mortality from all causes was but a fraction more than two per cent. 
 
 In another place in this Report the surroundings and disadvantages under 
 which these operations were performed have been explained in detail. 
 
 Asepsis of the operator, instruments, and the lield of operation, 
 described in the article on Morhidity and Moi^tality, is the explanation 
 of results which compare favorably with reports of operations performed 
 under more cleanly surroundings. 
 
 Squalor and filth, while of unquestioned disadvantage, need not deter 
 an operator from interfering in the course of labor when forceps are 
 clearly indicated, promled facilities can be had for what may be called 
 local antisepsis. 
 
THE PEEMATUEE INTEKRUPTION OF PKEGNANCY. 
 
 By James Clifton Edgar, M.D. 
 
 Introduction. 
 
 ^^E intend in tliis article to make a study of the prematurel}'' inter- 
 rupted pregnancies which occurred in the first 10,000 cases of confinement 
 in the practice of this Hospital during the period from January 27, 1800, 
 to February 28, 1896. 
 
 The histories of these 10,000 cases show that there was among them a 
 total of G35 premature interruptions of pregnancy. In the three Medical 
 ltej)orts of the Hospital previously ])ublished, no mention has been made of 
 these 635 cases of the untimely interruption of pregnancy, other than in a 
 general way, so that we now purpose to make a critical study of the entire 
 number. 
 
 Character of tue Cases Studied in this Article. 
 
 The practice of this Hospital, during the period covered by this article, 
 lias been almost exclusively among tlie ])<)()rest of the Polish Jews, Ger- 
 mans, and Russians of the tenement-house district of tlie lower East Side 
 of this city. 
 
 These ])eo))le constitute an exceedingly primitive class, who are not only 
 quite ignorant of the first ]n'inci))les of cleanliness, but who consider it 
 the proper thing to neglect an untimely interruption of pregnancy, so 
 that when the Hospital has l)een applied to for aid, it has usually been late 
 in the course of the case, and for some serious comj)lication as, for example, 
 persistent haemorrhage, or local or general septic coiulitions. 
 
 This is evident from the fficts, as a critical study of our (535 cases shows 
 that, in most instances, the sym])toms had alnjady existed for some time 
 when tJie case was lirst Ijrought to the notice of the Hospital, and that the 
 largf! j)roportion of cases, when they were seen, were of the incomplete or 
 neglecte<l variety of the prem.'iture interru]ition of pregnancy. 
 
 Thus, as regards the <hir;itioii of the syiii|)toins, ;it the time when the 
 Hospital ])hysician w;is lirst suiiiinoiied to the ease, we liiKJ, from oui- analy- 
 sis, the following: 
 
THE PREMATURE INTERRUPTION OF PREGNANCY. 115 
 
 Duration of Symptoms "when First seen by the Hospital. 
 
 Average duration 
 Longest ' ' 
 
 Shortest " 
 
 EARLY abortions, 
 
 129 Observations. 
 
 3 days 22 hours. 
 3 weeks. 
 10 minutes. 
 
 LATE abortions, 
 
 57 Observations. 
 
 6 days 19 hours. 
 T weeks. 
 1 hour. 
 
 Again, for example, the table setting forth the character of the early 
 abortions (see Definitions), when first seen, indicates the following : 
 
 Complete early abortions 14 
 
 Incomplete " 
 Inevitable ' ' 
 Threatened " 
 JSTot noted " 
 
 162 
 
 48 
 
 6 
 
 12 
 
 Total 242 
 
 As the foregoing table shows, a large proportion, nainely, 162, of the 
 early abortions were of the incomplete variety when the Hospital physician 
 was first summoned; 48 were inevitable, and in only 6 instances were the 
 services of the Hospital physician demanded before the partial or com- 
 plete expulsion of the ovum. 
 
 Several interesting facts will be noted from a study of the first of the 
 above tables. 
 
 In the first place, in both the early and late abortions, the average 
 time from the onset of the symptoms to the application to the Hospital 
 for aid, was over three days ; and, in the second place, in the late abortions 
 (see Classification and Definitions), this same interval was nearly twice as 
 long as in the early abortions, as one would naturally suppose would be 
 the case, in \dew of the larger amount and greater frequency of the haem- 
 orrhage in interrupted pregnancies occurring in the first third of gestation. 
 
 Since, as we have shown in the preceding paragraph, most of our cases 
 of abortion have been seen late in the progress of the process, some of the 
 statistics of this article cannot, in fairness, be compared with those of the 
 large maternities of France and Germany, in which many of the cases 
 Avere under observation from the very onset of the symptoms. 
 
 The following tables of attendance in early and late abortions and in 
 spontaneous premature labor cases also emphasize the above statements: 
 
 Attendance in Early Abortion Cases. 
 
 ISTumber of cases confined by the Hospital 88 
 
 " " " unattended 143 
 
 " " " not noted on histories 11 
 
 Total 242 
 
IIG REPORT OF THE SOCIETY OF THE LYING-IN HOSPITAL. 
 
 Attendance in Late Abortion Cases. 
 
 Number of cases coiifiiUHl by the Hospital 60 
 
 " '• '• unattiMukHl 99 
 
 ' not nottnl on histories 16 
 
 Total 175 
 
 ArrENDANCE IN Spontaneous Premature Labor Cases. 
 
 Number of cases confined by the Hospital 170 
 
 " " " unattended 28 
 
 " " '' not noted on records 20 
 
 Total 218 
 
 It is not alone in maternity hospitals, but in private practice as well, 
 that histories and reported cases of interrupted pregnancies would prove 
 of the utmost value; because, as Winckel has observed, more interrupted 
 jH-egnancies occur in private practice than ever come to hospitals for 
 treatment, and such cases are more favorable for active interference, because 
 seen earlier, and, moreover, the effect of an early curettage upon subse- 
 quent uterine disease and conception can be critically observed. 
 
 These 635 cases of the premature interruption of pregnancy treated by 
 this Hosjiital are from among the abject poor, Avho, by reason of their 
 poverty, are unable to procure the services of skilled medical assistance, 
 and who, unless treated in some such service as this Hospital carries on, 
 would receive little treatment, would be neglected, or would have no atten- 
 tion whatever in their confinements. 
 
 These individuals are, in the main, foreigners, or but recently natural- 
 ized, and are, of necessity, of the tenement-house population, as is sliown 
 by the accompanying figures. 
 
 Thus, of the first 8,0()8 cases of confinement treated by this Hospital, 
 we find that there were: 
 
 5,39.") Russians, 
 724 Native Born, 
 583 Austrians, 
 
 346 Germans, 
 
 211 Poles, 
 
 13S Hunirarians, 
 
 and tlie remaind<'i- ItaliMiis, lioutnclians, Swedes, etc. 
 
 it will be seen, thciHifore, that it is nniong llx; foreign-l>oiii population, 
 and cspfcialiy among the Russians, Austrians, Germans, and ]*olish- 
 IIcl)rews, tliat these cases have be(.'!n treated. 
 
 Moreover, the above-cited 1(»,000 cases of confinement were treated in 
 th<;ir own homes, situaUid in i\u) tcncinciit-house district of th(; lo\v<;r East 
 Si'h' of tlio city. 
 
THE PREMATURE INTERRUPTION OF PREGNANCY. 
 
 117 
 
 I'he tenement-house census for 1893 shows that the most densely popu- 
 hited areji in New York City is situated in this district covered by the Hos- 
 pital Service in the Eleventh AVard, and is bounded by Second Street, 
 Columbia, Rivington, and Clinton Streets, and is known as Sanitary Dis- 
 trict A of the ward. 
 
 This area contains 32 acres, has a population of 25,015, or about 800 
 persons to the acre, equal to a population of 513,901 to the square mile. 
 
 It is interesting to note that the density of population in the above- 
 cited area has actually increased during the past few years. 
 
 Thus, in the Annual Report of the Kew York City Board of Health 
 for 1894, p. 101, we find: 
 
 YEAR. 
 
 WARD. 
 
 SANITARY DISTRICT. 
 
 DENSITY PER ACRE. 
 
 1890 
 
 11th. 
 11th. 
 11th. 
 
 A. 
 A. 
 A. 
 
 763.59 
 
 1893 
 
 800.47 
 
 1894 (estimated) 
 
 986.4 
 
 Previous to 1890, Germans and Bohemians predominated in this dis- 
 trict; after 1890, Germans and Hungarians. (Vital Statistics, p. 101.) 
 
 Again, during the past thirty years the greatest density of population 
 per acre was to be found in the Sixth, Tenth, and Eleventh Wards, all of 
 which are included in the tenement-house district of the lower East Side, 
 above referred to. 
 
 Thus, the following table, taken from the Report of the Tenement- 
 House Committee to the New York State Senate (1894),* indicates at a 
 glance the progressive increase of population in these wards during the 
 thirty-four years : 
 
 YEAR. 
 
 WARD. 
 
 DENSITY PER ACRE. 
 
 1860 
 
 6th. 
 11th. 
 10th. 
 10th. 
 10th. 
 
 310.4 
 
 1870 
 
 327.7 
 
 1880 
 
 432.3 
 
 1890 
 
 525.6 
 
 1894 (estimated) 
 
 701.9 
 
 
 
 The New York State Census for 1 892 shows that the seven most densely 
 populated blocks in this city have each a population exceeding 3,000 per- 
 sons to the block, and an aggregate population of 22,970. 
 
 * Eeport of the Tenement-House Committee to New York State Senate, 1894, by 
 F. E. Pierce. 
 
118 REPORT OF THE SOCIETY OF THE LYING -IX HOSPITAL. 
 
 Tlie fii*st of these is in the district covered by the service of this Hos- 
 pital, and they have the foHowino- boundaries: 
 
 Popuhxtion. 
 
 2d and 'MX Streets, Avenues B and C 8,532 
 
 48th and 40th Streets. 10th and 11th Avenues 3,517 
 
 48th •• 4i>th '* Oth " lOth ^' 3,365 
 
 40th " 50th " 10th " 11th " 3,339 
 
 44th '* 45th " 10th " 11th " 3,151 
 
 52d " 53d " 9th '' loth " 3,040 
 
 39th •' 4(tth " 9th '' lotli " 3,026 
 
 Aggregate population 22,970 
 
 Further, the same census sliows that seven blocks in the immediate 
 vicinity of the original administi'ation building of this Lying-in Service 
 (314 Broome Street), in Avhich district the uuijority of the cases included in 
 this article were treated, have each a population of 2,500 individuals or 
 over, and an aggregate population of 18,603. 
 
 These blocks and their po})ulation are as follows: 
 
 Population. 
 
 Ridge, Pitt, East Houston, and Stanton Streets 2,985 
 
 Market, Pike, Madison, and Henry Streets 2,503 
 
 Market, Pike, Madison, and Monroe Streets 2,586 
 
 Pike, Rutgers, Madison, and Monroe Streets 2,662 
 
 Madison, Monroe, Scammel, and Jackson Streets .... 2,500 
 
 Rivington, Stanton, Willett, and Pitt 2,548 
 
 2d and 3d Streets, Avenues A and J} 2,819 
 
 Aggregate population 18,603 
 
 The most densely populated district is bounded by Second Street, Riv- 
 ington, Columbia, and Clinton Streets; it covers 32 acres, has a population 
 of 25,615, or 800 per acre, according to the Tenement-House Census of 
 1893. This makes a ])opulation of 513,901 persons to the square mile. 
 
 Some interesting figures concerning the inhabitants of a portion of 
 the district covered l)y this Hosjiital are to be found in the latest special 
 r(;jK)i-t of the Commissioner of Labor at AVashington. 
 
 Tlie tenement-hous(; districts investigated are those of New York, 
 Chicago, l)altimore, and Pliilad('l])hia, and these by sam])le, as it were. 
 Thus, in New York, for instance, tlu^ disti'icts chosen were west of the 
 Bowery, \vholly within the Sixth ;md Fourteenth Wards, and made up of 
 an almost cxcbisivc Italian p<)j)ulati<)n, though it included fliinatown. 
 
 Directly adjoining this district, to the east, across the Bowery, is one 
 in which most of the cases treated in this Ilcport reside, a people exclu- 
 sively iiussian Hebrew; and just U> the south, on Cherry Hill, a character- 
 i.stic Irish population. 
 
 Neither of these two latter districts found a place in the above Report, 
 which in some im|)ortant particulars thisy would have modified, but all 
 these are included in the service of this Ilosjutal. 
 
THE PREMATURE INTERRUPTION OF PREGNANCY. 119 
 
 The investigations of the Commissioner sought the plain facts of slum 
 life, and such as might be arranged for statistical study. 
 
 Foreigners Predominate. — In New York the foreign-born number 42.28 
 per cent, of the total population of the city, but in this tenement-house 
 district studied, it reaches 62.58, an excess of 20.35 per cent. Persons of 
 foreign parentage are largely in excess, namely, 95.23 per cent, for this 
 district, to 80.46 per cent, of the whole city; in other words, only 4.77 
 per cent, were of native parentage. 54.61 per cent, are males, and 45.39 
 ])er cent, are females. Tliis preponderance of the men perhaps accounts 
 for the greater wickedness of this district, as the police records of arrests 
 show a proportion of 1 in 6 for this district, and 1 in 18 for the entire city. 
 
 They are a Conjugal People. — They marry early and have larger families 
 than those who are better off as to residence. Single blessedness is unpop- 
 ular, widowers are scarce; some widows were reported, but fewer than 
 the proportion shown by a census of the whole city; divorce is all but 
 unknoAvn, only .01 per cent, of males and females were reported as 
 divorced. 
 
 Illiteracy. — For New York, as a whole, the percentage of illiterates is 
 1.16 of the whole native-born population, and 14.06 of the foreign-born, 
 the percentage for both being 7.69, while for the district under discussion, 
 the percentage of native-born who are illiterate is 7.20, and of the for- 
 eign-born, 57.69, being, for both, 46.65. Fortunately, the illiteracy is 
 almost entirely confined to adults. 
 
 There are more women who cannot read than men, and in point of 
 succession, the most ignorant are the Italians, then come the Russians, then 
 the Poles. 
 
 Croioded Tenements. — Comparing similar tenement-house districts of 
 Baltimore, Philadelphia, New York, and Chicago, New York has, by far, 
 the greatest crowds under one roof, but the percentage of crowding in the 
 rooms is smaller than in the other cities named; thus, the percentage of 
 families living in one room is 13.16 in Baltimore, 12.10 in Philadelphia, 
 5.87 in Chicago, and 5.62 in New York. 
 
 It should be added that the houses are larger in Chicago and New York 
 than in the other cities named. 
 
 Sanitary Cleanliness. — Only 2.33 per cent, of the families have access 
 to a bathroom, the percentage for the similar districts being, in Baltimore, 
 7.35; in Philadelphia, 16.90; in Chicago, 2.83; 96.67 per cent, of the houses 
 of the district in New York have no bathrooms, and the average number 
 of persons compelled to use the same water-closet or privy is 10.52 persons 
 (in Philadelphia the number is 6.86). 
 
 Classification and Definitions. 
 
 It will be well at the outset, before entering upon a closer examination 
 of the cases of interrupted pregnancy included in this article, to set forth 
 clearly our classification of these cases, and come to a definite understand- 
 ing of the definitions of the terms here used. 
 
 We find that most of the German textbooks of obstetrics, with the 
 
120 KEl'OHT OF THE SOCIETY OF THE LVING-IN HOSPITAL. 
 
 exception of tliose of A. ^lartin aiul AViiickel, look upon the separation 
 of abortion and immature labor as unjnstiiiable, and consider the period of 
 viability, at the end of the seventh month, as the only admissible point 
 of division. 
 
 It will be found, moreover, upon reference to most of the French text- 
 books, that thev understand the term acoriemeni to extend to the end of 
 the seventh month of intrauterine gestation. 
 
 Afcordinu- ti> A>it (^[idler's Handbook), all cases occurring- within the 
 first t\venty-eig-ht weeks of ]ireg-nancy should be grou[)ed under the term 
 ahortion, because, uj) to this tinu\ })ractically no i-egai'd need be paid to the 
 life of the fVetns, which may be looked upon as practically lost. 
 
 In former times, the ditferences in the course of the prenuitni'c inter- 
 ru])tions of pregnancy led to a division into abortion, immature labor, and 
 ])i-emature lal)or; but Ave no longer make the first two distinctions, because 
 in the coui-se of abortion occurring even in the first three months of gesta- 
 tion differences may be observed which are so great that, even here, one 
 would be jnstified in making additional divisions and classi 11 cations. For 
 exam])le, some of the French writers speak of "ovular aboi-tions," occur- 
 ring in the first six weeks of gestation; " embryonal abortions," occurring 
 from the eighth to the twelfth week of gestation ; and of " fa?tal abortions," 
 occurrino; from the twelfth to the twentv-fourth Aveck of gestation. 
 
 In general, Ave may place the time-limit of the term ah(>iilo)i at the 
 twenty-eighth Aveek from the beginning of the last menstrual period; but 
 Ave nuist not lose sight of the fact, on the one hand, that foetuses may not 
 be vialjle after this time (in the first place, because the calculation of ju'eg- 
 nancy Avas faulty; and, secondly, because the resisting jxnver of the 
 foetus is at a Ioav point at about the tAvonty-eighth Aveek); on the other 
 hand, that, exceptionally, a child born previous to the calculated tAvent}'- 
 eighth AA^eek of gestation may live. Ahlfeld^ is among those who believe 
 that tlie assum]ition that children born before the end of the seventh 
 lunar month are non- viable, is entirely too arbitrary. He quotes many 
 cases in ]iroof of the fact that children may survive, even if born before 
 the com])letion of the twenty-eighth Aveek, and he warns us not to allow 
 tliis arlntrary division to deter us from making every possible effort at our 
 command to resuscitate a premature infant, no matter Avhat the supposed 
 period of gestation or develo])ment of the fcetus, so long as there are any 
 signs of life. Lusk subsecpiently expressed himself to the same effect. 
 
 The marvellous results obtained in the Paris nuiternities, notably under 
 Hudin and Tarnier, by the use of the couA'euse and gavage, show that a 
 cei'tiun pro])oi'tion of children born at the twenty-seventh, twenty-sixth, 
 twcnty-lifth, and even twenty-fourth Aveek of gestation has been preserA'ed, 
 l>udin claims to have saved ;;(i jx-r cent, at the tAventy-fouiMi week. 
 
 Although the ]»eri(jd of viai)ilitv has been, and may in the future be 
 still further, reduced, undei- favorabh! ciirumstances, still, since the pro- 
 portion of iidanls saved befoic the tAventy -eighth Aveek is as yet small, and 
 the good r(;sults are eonlined to maternity hospitals; and, monjover, since 
 our 417 cases of interrupted pregnancies falling in the lirst twenty-eight 
 
THE PREMATURE INTERRUPTION OF PREGNANCY. 121 
 
 weeks of gestation liave all been treated in their own homes in tenement 
 houses, where, heretofore, the use of the couveuse and gavage has not been 
 practicable,* therefore we have seen fit still to retain the end of the 
 twenty-eighth week as the period of viability and tlie point of division 
 between abortion and ]n'ematnre labor. 
 
 For the foregoing reasons, and also as a matter of convenience, the 
 Medical Board of this Hospital recently decided to classify all cases of the 
 pi-emature interruption of pregnancy under two main heads, as follows: 
 
 Classification of the Pkemature Intekruption of Pregnancy. 
 
 1. Abortions. 
 
 2. Premature labors. 
 
 1. Ahortions are those premature interruptions of pregnancy occurring 
 l)efore the completion of the seventh month of intrauterine gestation; 
 namely, the first six and three-quarter months, or the first twenty-seven 
 weeks. 
 
 2. Premature labors are those premature interruptions of pregnancy 
 taking ]3lace at and after the completion of the seventh lunar month, 
 (twenty-eighth week) ; namely, from the twenty-eighth to the tliirt3^-eighth. 
 week. 
 
 In this article, however, for clinical and anal3^tic purposes, it has been 
 deemed advisable to make a further subdivision of the 417 cases of inter- 
 rupted pregnancy occurring before the completion of the twenty-eighth 
 week, in order that a closer and more profitable study may result. So 
 that, for purposes of convenience solely, we have divided these 417 cases 
 falling under the definition of ahortion into — 
 
 (1) Early abortions. 
 
 (2) Late abortions. 
 
 We include under the term early ahortion those instances of the prema- 
 ture interruption of pregnancy occurring in the first three months, or 
 twelve weeks, of uterine gestation. 
 
 Cases of late ahortion are those falling within the period from the 
 beffinnine: of the fourth to the end of the seventh month. The term 
 premature lahor covers the remaining cases of the premature interruption 
 of pregnancy. Our 635 cases of the premature interruption of pregnancy 
 therefore include: 
 
 Cases. 
 
 Early abortions 242 
 
 Late abortions 175 
 
 417 
 Premature labor 218 
 
 Total 635 
 
 * Since the opening of the main Hospital buikling in November, 1894, premature 
 infants, when possible, are transferred to the Hospital for couveuse treatment. 
 
l'^-? KEPORT OF IHK SOCTETV OF THE LYING-IN HOSIM'J'AL. 
 
 Our arbitrary division ol" the cases of abortion into those of early and 
 late abortion has been made use of because, clinically, in most instances, 
 the i)rogress of an early abortion can be sharply differentiated from that 
 of a late abortion. Before the beginning of the fourth month, the clinical 
 ])ictare presented by the em])tying of a i)regnant uterus is usually alto- 
 gether dilferent from an expulsion of the uterine contents subsequently. 
 
 During the tirst three months the ovum is expelled as a Avhole, or 
 broken up, with more or less ])rofuse haemorrhage, hence it is that usually 
 but a siuii'le staii'e of labor can be recognized; while after the third month 
 the course of labor corresponds more nearly with parturition at term, and 
 in most instances tliree stages of labor can be distinctly differentiated. 
 
 A study of our histories bears out this fact, for in the 242 early abor- 
 tions we find no record of the stage of labor present \vlien the case Avas 
 first seen by the Hospital ])hysician; while in the 175 late abortions we 
 find lifty observations upon the stage of labor present at the time the 
 physician from the Hospital first visited the patient. 
 
 Stage of Labor in amirji Late Aboktions wekk Fikst A^isited jsy the 
 
 , Hospital. 
 
 Cases. 
 
 Visited l^y the Hospital in the first stage 25 
 
 second stage 12 
 
 '' '* '• '• third stage 13 
 
 Not noted on the histories 125 
 
 Total 1 75 
 
 Further, it is (juite true that during the empt3'jng of the pregnant 
 uterus in the fourth, fifth, and sixth months of pregnane}', haemorrhage 
 may and does occur, and the ovum may be expelled intact, yet this is the 
 excejition rather than the rule, and therefore does not militate against our 
 arbitrary classification. Moreover, owing to the luiMnoi'i-liage which is so 
 constantly present in the first three months, the trt^atment is often differ- 
 ent, to a certain extent, from that employed after that time. 
 
 In c<jmparing the course of labor in late al)oilioiis and ]))'ei)iatiii'e labor, 
 we find that, clinically, tlie most iin])ortant distinguishing feature between 
 the two is the course <4" tlx; third stage of labor. After tlu^ end of the 
 twenty-eightli week, the tliii'(l stage of laboi' dilVers in no way tVoni the 
 tliird stage at fid! term ; while l)efo)'e the seventh month, the thii'd stage 
 may continue days and weeks unless its course is artiiicially terminated. 
 (See Treatment.) 
 
 Finally, as a matter of convenience and foi- clinical study, the sulxlivi- 
 sion of the term ahnrfion is jiistifialile and desii'able, because in the iirst 
 three months the oviiin with tlu; placenta are often ex])e lied together, <))■ 
 the cscajx; of the fcjctus is unobserved Ijecause of its nnnute size. Henc(^, 
 tliere is jiractically no point at wliich we can date the; onset of the third 
 stage of labor. After the tliird month, and the formation of the ])lacenta, 
 
THE PREMATURE INTERRUPTION" OF PREGNANCY. 123 
 
 Oil the other hand, our records indicate that the third stage is a distinct 
 period in the course of the premature enipt34ng' of the uterus. 
 
 This chissification into early abortions, late abortions, and premature 
 labors, although purely artificial, we ado])t in this article because of the 
 differences in the pathology, s3miptomatology, and treatment of the three 
 groups thus designated. 
 
 For the foregoing reasons, therefore, we deem it most advisable to 
 adopt this purely artilicial division of the premature interruption of preg- 
 nancy, designating the accident occurring in the first three months, or 
 twelve weeks, of uterine gestation an early abortion; that occurring in the 
 fourth, fiftli, and sixth and three-quarter months, or twenty-seven weeks, 
 a late abortion; and, finally, that falling in the period from the twent}^- 
 eightli week, the generally accepted period of viability, to the thirty- 
 eighth week, or to the time Avhen the measurements of the foetus are prac- 
 tically indicative of maturity, premature labor. 
 
 Statistical and Classification Tables. 
 
 For convenience' sake, and to further our subsequent study of these 
 635 cases of the premature interruption of pregnancy, we have divided 
 them in three statistical tables, according to our definitions (see Classifica- 
 tion and Definitions), and placed these three tables, of early abortions, 
 late abortions, and spontaneous premature labor, respectively, at this por- 
 tion of our report. 
 
 Early Ahortions. — By reference to the table of our 212 cases of early 
 abortion, it will be seen that for convenience of reference Ave have 
 arranged in parallel columns the information obtained from a laborious and 
 critical examination of each separate history chart, upon the following 
 points : 
 
 1. Confinement number. 
 
 2. Birthplace. 
 
 3. Age. 
 ■i. Para. 
 
 5. Month of gestation. 
 
 G. Previous interruptions of pregnancy. 
 
 7. By whom delivered. 
 
 8. Character of the abortion when first seen. 
 
 9. Duration of the symptoms when first seen. 
 
 10. Previously attended by whom. 
 
 11. Condition of ovum. 
 
 12. Condition of embryo. 
 
 13. Haemorrhage. 
 
 li. Interval between first visit by Hospital physician and operation. 
 
 15. Temperature at various periods. 
 
 16. Treatment. 
 
 17. Complications. 
 
 IS. Discharge; day of puerperium and condition. 
 
1'2A REPORT OF THE SOCIETY OF THE LYING-IN HOSPITAL. 
 
 Zah Ahortt'oii.-i.— The table of the 17."> cases of late abortion is arranged 
 very much in the same manner as the })receding', only that here additional 
 space is given for the presentation and condition of the foetus, and for the 
 duration and termination of the third stage of labor. 
 
 Sponfaneoffd Premalure Labor. — The plan of this table is practically a 
 repetition of the one for late abortions, and includes 218 cases. 
 
 T/u'i<iti)n(1 Ahoiilons. — It has been thought best to leave out of this 
 Report cases of threatened abortion, because among our earlier cases the 
 diagnosis of the condition has in several instances been uncertain, and sat- 
 isfactory histories are lacking. 
 
 Among our recent cases, however, more exact and careful observations 
 are recorded, and this material will jn-ove of value for a future study. 
 
 l*erioi1 of (.Tcsiatoi/i. — In our al)ortion cases, both early and late, the 
 period of gestation at whicli the accident occurred has been determined from 
 the time that elapsed from the last menstrual period, from the size of the 
 uterus, and from a microscopical examination of the ovum, embryo, or foetus. 
 
 As wiU be observed in our tables, measurements of the ovum, embryo, 
 and fcptus are Avanting in most of our cases of earl}'' and late abortions. 
 Unfortunately the embryos and foetuses of our abortion cases were 
 destroyed before the writer could obtain access to them, and the early 
 histories lack records of weights and measurements. 
 
 In our present histories, records of the measurements and weights are 
 entered at the time of the abortion. On the other hand, the diagnosis of 
 the period of pregnancy in our premature labor cases has been determined 
 partly from the duration of gestation at the time the pregnancy was inter- 
 ru]>ted, but especially from the size of the ftetus at the time of its expulsion. 
 To this end we have taken into consideration (1) the length, (2) the weight, 
 and (yj the measurements of the foetal head, in the order named. 
 
 Regarding the head measurement, only the (1) great (occipito-mental) 
 and ( 2) small (suboccipito-bregmatic) circumferences have been used as a 
 suliicient index of the size. 
 
 V>\ reference to our table of premature labors, it will be observed that 
 in l)ut a few instances are the above measurements lacking. 
 
 EDfOATIONAT. FkATURES. 
 
 During the period covered by this Iteport, namely, a little over five 
 years, there have resided at the Hospital buildings 9 resident ])hysicia,ns, 
 67 assistant resident ])hysicians, 2(»8 graduate students, and 1,315 under- 
 graduate ]m])ils. It can be safely stated that each of these 1,599 individ- 
 uals jilaycd a greater or lesser ])art in the treatment and management of 
 the 0:^*5 untimely interrupted ])regnancies here studied. 
 
 Further, as will be seen I'loin tlic section on '^{"'rcatment, .'{.''l of (tiii' (i;>5 
 cases were sui)jectcd to cui-cttagc; and as this o])('i'ation is ijcrfoi'mcd only 
 by an attending, assistant attending, i-csidcnt, assistant resident, or gi-ad- 
 uate physician, we can truthfully state tli;it our .■i;'>I cases of curettage 
 were iM-rfoi-ineil by at l(3<ist 15<i difrciciit dpi r;it,(;rs. 
 
[ogle rise on 4tb ilay. 
 
 
1 
 s 
 
 
 
 
 Birthplace 
 
 i, 
 
 
 
 
 8 
 
 Germany. 
 
 28 
 
 CO 
 
 Russia ... 
 
 a 
 
 If 
 
 U. S 
 
 
 
 Huiism-j- . 3( 
 
 ■ iMiami::.': 
 
 -? 
 
 i 
 
 Il.lits Russia — 
 
 _'i 
 
 19 
 
 m 
 
 XI 
 30 
 
 l.li; Irdand ... 
 I.aiiclei-manv.. 
 
 37 
 
 UiljUMisia .!.'! 
 
 3 
 
 ^ i''i<.5ia"..:! 
 
 M 
 i\ 
 23 
 30 
 34 
 ? 
 
 31 
 
 '.; 
 
 20 
 1! 
 
 man 
 
 |3,9.i4 
 3,971 
 » 3,985 
 
 'u«ia .... 
 
 2h 
 
 39 
 12 
 ii 
 il 
 3.1 
 
 5 
 5 
 
 31 
 2 
 20 
 3a 
 3 
 If 
 
 1. 
 II. 
 
 
 
 II. 
 
 
 V. 
 
 
 V. 
 
 ■M 
 
 
 3( 
 
 Ill 
 
 
 I. 
 
 11 
 
 
 
 III. 
 
 
 \v: 
 
 V 
 
 VI. 
 
 
 V. 
 
 
 
 
 X. 
 
 
 VII. 
 
 <l 
 
 IX. 
 
 
 
 
 
 
 XII 
 
 31 
 
 III. 
 
 
 IV. 
 
 .-. 
 
 V. 
 
 31 
 
 VII 
 
 31 
 
 IV. 
 
 
 IV 
 
 
 
 + 
 
 111. 
 I. 
 
 4 
 
 3 tlays . . 
 weeks 
 
 7 days . . . 
 13 houi-s. 
 
 Duration 
 Symp- 
 
 2 days . . 
 1 day . . . 
 
 weeks 
 
 4 days . . . 
 
 days . . . 
 IShoure. 
 
 1 montb. 
 
 SYNOPSIS OF 175 CASES OF LATE ABORTIONS. 
 
 TliMPERATUHE. 
 
 2 weeks. 
 1 day . . . 
 
 Few hn 
 1 day . . 
 
 1 
 
 ■3 
 > 
 
 ] 
 1 
 
 1 
 
 1 
 
 1 
 1 
 
 1 
 1 
 1 
 1 
 
 1 
 
 1 
 1 
 
 1 
 1 
 
 1 
 1 
 
 1 
 1 
 
 1 
 1 
 
 1 
 
 1 
 
 1 
 1 
 
 1 
 = 
 
 C 
 
 % 
 
 1 
 
 1 
 
 .1 
 1 
 
 1 
 
 1 
 
 1 
 1 
 
 1 
 
 1 
 1 
 
 1 
 1 
 1 
 
 1 
 1 
 1 
 1 
 1 
 1 
 1 
 
 1 
 1 
 1 
 1 
 
 1 
 1 
 1 
 
 1 
 
 1 
 1 
 1 
 
 1 
 1 
 1 
 
 1 
 1 
 
 1 
 
 1 
 
 1 
 1 
 
 1 
 1 
 1 
 1 
 
 1 
 
 1 
 1 
 
 1 
 1 
 1 
 1 
 1 
 1 
 1 
 1 
 1 
 1 
 
 1 
 
 E 
 
 1 
 I 
 1 
 
 1 
 
 1 
 
 1 
 
 1 
 
 1 
 
 1 
 1 
 
 1 
 
 1 
 1 
 1 
 
 1 
 1 
 
 1 
 
 1 
 
 1 
 E 
 S 
 I 
 
 1 
 
 1 
 
 I 
 1 
 
 1 
 
 1 
 
 1 
 
 1 
 
 1 
 
 1 
 1 
 1 
 1 
 1 
 
 1 
 1 
 1 
 1 
 
 1 
 
 1 
 1 
 1 
 1 
 1 
 
 1 
 
 1 
 1 
 
 1 
 1 
 1 
 1 
 1 
 
 1 
 
 1 
 1 
 
 1 
 
 1 
 
 1 
 1 
 
 1 
 
 1 
 1 
 1 
 1 
 1 
 1 
 
 1 
 1 
 1 
 1 
 1 
 1 
 1 
 1 
 
 D'lll 
 
 1 
 
 1 
 1 
 
 Si- 
 
 1 
 
 Weak-. 
 Good. 
 
 Weak. 
 Good .' 
 
 j Retroflexed ( „,.„„„ 
 1 Reti-overted r "*^^'^"« ■ 
 
 Caked' breasts. " ^ 
 Foul lochia; fever. 
 
 Fever; sepsis 
 
 Case left to midwife. 
 Postpartum ha^morrhag--. 
 Sepsis; b£emorrh.9thd,;/6U6?- 
 
 Fever ; bronchitis 
 
 Fever; sepsis. 
 
 Postpartum eiise. 
 
 Fever; unknowa cause 
 
 r ; cause unknown 
 Fever; sepsis 
 
 Fever ; sepsis 
 
 Fever ; sepsis. 
 
 jDca(/^ from shock , 
 
 Fever ; constipiition 
 
 Fever; coustipatiou.... 
 
 Caked breasts 
 
 Fever ; sepsis. 
 Fever ; sepsis . 
 Fever; sepsis... 
 
 Fever; sepsis; albuminuria. 
 
 Temperature after ( 
 
 [fuse &foul f or (i days. 
 th d. & on; bend extraction; lochia pro- 
 
 Case turned over t 
 Placenta with fiugi 
 
 prii 
 
 ? Dr. immediately after oper. 
 
 of placenta. 
 
 ion; piae. pnevia; aceouchement f orc6. 
 
 Out of bed 12th day. 
 
 Placenta pifevia; death of mother; nipt.utei-^is; pod. version. 
 Postpartum case; ovum delivered iutact. 
 
 Duly temperature rise, 3d day; no fever after. 
 
 Cbild died soon after birtb. 
 
 Private doctor called In. 
 Child died 1st day. 
 
 iverneiu- Hospital ; no fc^^er. 
 
 Hycfatiform mole; no complications. 
 
 Gouverneur Hospital; treated 
 cellulitis. 
 
 Caked breasts; child lived a few houi-s. 
 No subsequent fever. 
 
 Child lived a few 
 
 . SlWithfem. after oper.; refused furtherti-eatmentSd day; 
 syphilis; ulceration in pharynx; cardiac emphys. 
 
 Everything 
 
 N. R. = No record ; L. d. = Labor day. 
 

 123 
 
 
 
 
 
 
 
 
 
 LATE ABORTIONS 
 
 .—(Continued.) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Stage j 
 
 
 
 
 
 
 
 
 g 
 
 
 
 
 :; 
 
 
 i ! 
 1 1 ■ 
 
 3 fk i 
 para. ^ 
 
 III 
 
 11.4 
 
 ik I 
 
 
 Pi 
 
 fcetus. ce^ 
 
 A- c 
 
 Duration ^ 
 of ^ 
 
 
 Temperature. 
 
 Tkeament. 
 
 
 i 
 
 
 
 . 
 
 f 
 
 1 
 1 
 
 4,053 
 
 Birthplace, t 
 
 SEEN^ I>"ration| 
 
 i 
 
 
 Time 
 Between 
 - Pii-st 
 S Visit and 
 3 Opern- 
 a tion. 
 ; 
 
 J 
 5 
 
 
 
 Gauze 
 
 He- 
 mained 
 How 
 Lon^. 
 
 s 
 
 Complications. 
 
 Remarks. 
 
 1 
 
 toms c 
 
 When = 
 
 First .jJ 
 
 .^ Seen. ^ 
 
 s 1 
 
 1 
 
 If 
 
 % ^ - ■ 
 1 lis 
 
 3 1 ^ 
 
 lei 1 li 
 
 ill I II 
 
 o. Third 
 
 « Stage of i' 
 
 5 Labor. S 
 
 If ^ 
 
 11 1 
 
 1 
 1 
 
 1 
 
 
 < 
 
 1 
 
 
 s 
 < 
 
 S 
 
 isl 
 
 ■gi- 
 a 
 
 
 1 
 
 1 
 s 
 
 > 
 
 i 
 1 
 
 2 
 
 p 
 
 ! 
 
 j 
 
 a 
 
 i 
 
 i 
 
 1 
 
 I 
 
 1 
 
 1 
 
 m 
 
 tussia .... 3.. 
 
 1 1 day ... . 
 
 
 
 
 1 I 
 
 1 
 
 At once. 
 
 
 
 
 
 
 
 
 Good.. 
 
 
 
 91 
 
 1,103 
 
 ....3C 
 
 VI. 6 1 
 VIII. 3J 
 IV. 6 
 
 1 1 hour. . . 
 
 1 13 hours. 
 
 1 7 weeks . 
 
 1 
 
 
 1 
 
 1 1 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 8 
 
 
 
 Placenta remarkably fatty. 
 
 92 
 93 
 
 4,107 
 4.198 
 
 " ....3t 
 ....3" 
 
 
 
 
 1 1 
 
 1 
 
 2 hrs — 
 
 
 
 
 101.8 
 
 1st d. 
 
 1 day ... . 
 
 
 1 
 
 
 
 
 
 
 9 
 
 
 Fever ; sepsis 
 
 Hydrocephalus; no curetting; plac. almost entirely fattv 
 Single rise in temp. 'M and 4tli day; out of bed 6th day. 
 
 94 
 
 4,343 
 
 ....3 
 
 U.S 1 
 
 Kussia .... i 
 
 !-5 
 
 1 
 
 
 
 
 
 1 
 
 r .1 
 
 98.5 
 
 
 
 101.4 
 
 4th '■ 
 
 Few hrs. 
 
 
 
 
 
 
 
 
 7 
 
 
 Fever ; sepsis 
 
 95 
 96 
 
 4.284 
 4,309 
 
 I. o 
 VUI. 4 I 
 
 1 
 
 3 days . . . 
 
 
 
 
 
 1 I 
 
 12 "'.'.'.'. 
 
 
 
 101.2 
 
 101.2 
 
 0th" 
 
 
 
 
 
 1 
 
 
 
 
 9 
 
 " ;; 
 
 Fever ; constipation 
 
 Singrle rise in temp, after operation, on Gth day; bleedini; 
 
 '97 
 
 4,320 
 
 
 II. 3( 1 
 
 
 
 
 
 
 1 1 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 during entire pregnancy. 
 Extraction of breech. 
 
 9S 
 
 4.597 
 
 '".'.2 
 
 IV. 6( 2 1 
 
 1 
 
 1 
 
 4 inch. 
 
 3 lbs. 1 
 
 
 1 33niin. ... 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 7 
 
 
 
 99 
 100 
 101 
 102 
 103 
 104 
 105 
 106 
 
 4.608 
 4.672 
 4,774 
 ,834 
 4,903 
 4,910 
 4,919 
 3,043 
 
 Sngland . . % 
 
 Russia .... 'Z 
 
 " ....-£. 
 
 [taly 
 
 Poland.... 3f 
 Russia .... 2 
 
 Austria ... 3^ 
 
 VIII. 4 3 
 IV. 5 1 
 II. 4 1 
 VUI. 4 6 
 
 X.3i 1 
 IV. 3J 1 
 II. 3J 1 
 IV. 5 1 
 
 1 3 " ... 
 
 3 " ... 
 1 
 
 18boui-s. 
 1 Iday.... 
 1 2 weeks . 
 1 3 " . 
 
 1 
 1 
 
 1 
 
 
 1 
 1 
 
 1 1 
 1 1 
 
 Fewmin. 
 
 1 
 1 1 
 
 1 
 1 1 
 1 1 
 
 1 
 
 At once. 
 
 100.5 
 
 100.5 
 
 101.3 
 
 102 
 
 2d " 
 
 3 days . . . 
 
 
 
 
 1 
 
 D'll 1 
 
 
 
 r 
 
 11 
 
 6 
 6 
 
 f 
 
 7 
 
 Fair.:: 
 
 Good . . 
 Impr. . 
 
 Fever ; sepsis. 
 
 Hjemorrliage ; ancBmia 
 
 Woman s(rtrui7!ff ; fcetiis membranes removed intact will 
 dressing forceps. 
 
 Constip.; hysteria; lochia serous, mod,; slight odor. 
 No subsequent fever ; out of bed 3d day. 
 
 lOT 
 
 5,044 
 
 Russia .... 
 
 4 
 
 1 6 hours.. 
 
 
 
 
 
 1 1 
 
 
 103 
 
 103 
 
 100.4 
 
 103 
 
 L. " 
 
 Few hrs. 
 
 
 
 
 1 
 
 D'll 1 
 
 
 
 i 
 
 Good.. 
 
 Fever; sepsis 
 
 108 
 
 5,051 
 
 " ■■■ ? 
 
 IV. 5 
 
 1 3days... 
 
 
 
 
 
 1 1 
 
 
 
 
 
 102.6 
 
 1st " 
 
 
 
 
 
 
 " 1 
 
 
 
 5 
 
 
 Fever; unknown cause 
 
 No fever after 1st day. 
 
 109 
 
 5.153 
 
 
 III. 5 
 
 1 3 ■' ... 
 
 
 
 
 
 1 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 4 
 
 
 
 
 110 
 
 5,219 
 5.343 
 
 '* .'.'.'. 2 
 
 1.4 1 
 
 
 
 
 
 
 1 1 
 
 
 100.6 
 
 100.6 
 
 100.6 
 
 100.6 
 
 1st " 
 
 
 
 1 
 
 
 
 
 
 
 7 
 
 
 Fever ; sepsis 
 
 Patient discharged in apparently good condition: 2 week- 
 later again seen, treated, finally sent to hospital ; piim- 
 
 111 
 
 
 ni.41 
 
 1 1 day ... . 
 
 
 M em. 
 
 
 
 1 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 4 
 
 
 
 113 
 
 3,380 
 
 !!!". 2 
 
 m. 6 1 
 
 1 
 
 
 
 
 1 1 
 
 1 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 S 
 
 
 
 
 113 
 
 5.29S 
 
 iouraaaia. 2i 
 
 VII. 6 1 
 
 
 
 
 
 1 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 b 
 
 
 
 
 1U5.318 
 
 Russia .... 
 
 III. 6J 1 
 
 4 weeks . 
 
 
 
 
 1 1 
 
 1 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 Lacerated cervi.x. 
 
 11515.339 
 
 '• ....3( 
 
 II. 5 1 
 
 1 1 
 
 
 8 
 
 
 1 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 f 
 
 
 
 
 11615,338 
 
 " ....3 
 
 VIII. 4 1 1 
 
 
 1 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 117 3,389 
 
 ....3 
 
 VII. 3 1 
 
 1 
 
 1 
 
 
 
 
 1 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 3 
 
 
 
 
 U8 5.483 
 
 ....2 
 
 1.5 
 
 1 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 6 
 
 
 
 
 119 5.478 
 
 
 I.3t 
 
 1 1 4 days . . . 
 
 1 
 
 
 
 
 1 1 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 I 
 
 
 
 1 
 
 
 
 
 130 5.575 
 
 
 4 1 
 
 11 4 " ... 
 
 
 
 
 1 
 
 1 1 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 [one foetus muuiinifiecl. 
 
 131 5,6.33 
 
 '.'.'.'. 2> 
 
 5 V. 5 1 
 
 1 
 
 
 
 
 1 30 rain... 
 
 1 1 1 
 
 
 
 
 
 101 
 
 3d " 
 
 
 
 1 
 
 
 1 
 
 1 
 
 
 1 2 days. 
 
 ( 
 
 
 Caked breasts; fever 
 
 No fever, excepting 3d day ; sinfrle rise in temp.; twins ; 
 
 132 .5,647 
 
 
 i in. 6 
 
 13 " ... 
 
 1 1 
 
 
 
 
 1 1 
 
 
 101.4 
 
 
 
 
 L. " 
 
 
 
 
 
 
 D's. 1 
 
 
 
 6 
 
 
 Fever; sepsts 
 
 No subsequent fever. 
 
 13313.636 
 134 .5.637 
 
 '.'.■.■. 2 
 
 J ni. 4 3 
 
 5 II. 4 1 
 
 1 1 Iday.... 
 
 
 
 
 1 
 
 1 1 
 1 1 
 
 5 days . . . 
 
 N. R. 
 
 103.4 
 
 
 103.4 
 
 L. " 
 
 
 
 
 
 
 " 1 
 
 
 3 " 
 
 6 
 5 
 
 
 Fever ; sepsis 
 
 
 115 
 
 3.660 
 
 U. S 3 
 
 1 1. 3 
 
 1 1 3 days... 
 
 
 
 
 1 1 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 li " 
 
 
 
 126 
 
 5.683 
 
 
 II. 4 1 
 
 1 3 ■• ... 
 
 
 
 
 1 
 
 1 1 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 5 " 
 
 1] 
 
 
 
 Fretus by volseUum forceps. 
 
 137 
 128 
 
 3.737 
 3,769 
 
 Russia 2 
 
 5 1. 4 1 
 
 
 1 3 " ... 
 1 1 
 
 
 
 
 1 
 
 1 1 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 5 " 
 
 J 
 
 
 
 Foetus by dressing forceps. 
 
 129 
 
 3.793 
 
 Germany.. 2 
 
 4 4 1 
 
 1 12 houi-a. 
 
 1 
 
 
 
 1 
 
 1 1 
 
 
 101.2 
 
 101.3 
 
 100.8 
 
 100.8 
 
 1st " 
 
 1 day .... 
 
 
 ^ 
 
 
 
 1 
 
 
 5 " 
 
 ( 
 
 
 Fever ; sepsis 
 
 lst&2d stage together; susp.crim.abortion; nosubseq.fever. 
 
 130 
 
 5,880 
 
 Russia — ; 
 
 VI. 4 
 
 3 days . . . 
 
 1 
 
 
 
 
 1 1 
 
 At once. 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 3 " 
 
 10 
 
 
 
 Umbihcalliernia in patient. 
 
 131 
 
 5.927 
 
 ....3 
 
 6 IV. 5 
 
 3 '■ ... 
 
 
 
 1 
 
 1 
 
 1 1 
 
 7 hrs. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 10 
 
 
 
 
 132 
 
 0.098 
 
 Austria ... 2 
 
 9 IV. 6j 1 
 
 1 
 
 
 124 in. 
 
 5 " 1 
 
 1 1 
 
 15 " 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 10 
 
 " ;* 
 
 
 
 133 
 
 6.112 
 
 U.S 3 
 
 3 VI. 6 4 1 
 
 I 
 
 
 
 1 
 
 1 1 
 
 At onee . . . 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 4 " 
 
 16 
 
 
 
 Adherent membranes. 
 
 134 
 
 6,371 
 
 Germany.. ; 
 
 6 IX. 5 3 
 
 
 
 
 
 1 
 
 1 1 
 
 At once. 
 
 
 
 
 
 
 
 
 
 
 ] 
 
 1 
 
 
 
 
 
 
 
 133 
 
 6,383 
 
 Russia — ;: 
 
 5 IV. 1 
 
 1 3 weeks . 
 
 
 
 1 
 
 1 
 
 1 33niin 1 
 
 1 day . . - 
 
 101.5 
 
 101.5 
 
 101.5 
 
 
 
 1 " 
 
 
 
 
 
 D'll 1 
 
 
 4 " 
 
 ( 
 
 " [\ 
 
 Sepsis; prolapsed cord; fever 
 
 No subsequent fever. fno fever after 1st day. 
 
 136 
 
 6.362 
 
 
 1. 5i 1 
 
 1 
 
 
 91 ■' 
 
 U " 
 
 5min.... 1 
 
 3 hrs. 10 m. 
 
 
 101 
 
 
 
 103 
 
 L. " 
 
 1 " '.'.'.. 
 
 
 
 
 
 
 
 
 8 
 
 
 Unknown cause ; fever 
 
 Cause of fever not known; child lived about 5 minutes; 
 
 137 
 
 6.674 
 
 
 2 n. 3 1 
 
 1 
 
 
 
 
 1 
 
 1 1 Ihr.aOm.. 1 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 11 
 
 
 
 Lochia scant ; serosang. 
 
 138 
 139 
 
 6.702 
 6.743 
 
 .'.'.'.I 
 
 4 III. 6i 1 
 IX. 6 1 1 
 
 1 
 
 1 
 
 
 3 ■' 
 
 3t " 1 
 1 
 
 1 1 
 
 1 ] 
 
 35min 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Refused treatment on 4th day. 
 
 140 
 
 6.863 
 
 ....3 
 
 V. 6 1 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 141 
 
 6,909 
 
 Germany.. 
 
 9 11.4 
 
 
 
 
 
 1 
 
 . , 
 
 
 
 
 
 
 
 
 
 
 
 
 . 
 
 , 
 
 3 " 
 
 i 
 
 
 
 Cultures refused. 
 
 ^ 
 
 6.915 
 7,034 
 7,073 
 7,098 
 7,107 
 7,199 
 7,360 
 
 r,408 
 7,405 
 7.571 
 
 Russia ... 
 
 IV. 4 1 
 
 13 hours. 
 
 
 
 
 
 1 1 
 
 Ohi-s 
 
 101 
 
 99.6 
 
 
 
 
 Few hrs. 
 
 
 
 
 ] 
 
 I 
 
 1 
 
 5 " 
 
 10 
 
 
 Fever; sepsis 
 
 Woman aniemic ; complaining of pains in back, etc. 
 
 1+ 
 
 
 4 III. 4 3 ] 
 J VIII. 1 
 
 1 week . . 
 
 1 
 
 
 
 1 
 
 1 
 
 1 
 
 6 " 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 4 " 
 
 11 
 10 
 
 
 
 Scrapings for examinations. 
 Record of child missing. 
 
 
 
 
 1 
 
 1 
 
 
 
 1 
 
 1 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 5 
 
 
 
 Placenta prfevia suspected in pregnancy; not verified. 
 
 141: 
 14- 
 
 148 
 
 
 VI. 4 
 . VIII. 5 
 10 VI. 61 1 
 
 7 IV. .51 
 
 1 3 weeks . 1 
 
 1 1 
 
 
 
 
 1 1 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 1 
 
 1 
 
 4 " 
 
 16 
 
 
 Uterus retroflexed 
 
 Temp. 100 on Ist, 2d. 10th, and 12th days. 
 
 
 1 
 
 1 
 
 1 1 
 
 
 13 " 
 " 
 
 a ■• 1 
 
 Ooz. 
 
 1 1 
 Fewmin. I 
 
 1 1 
 
 20 " 
 
 1 
 
 1 hr 
 
 
 
 
 103.4 
 
 nth" 
 
 8 days . . 
 
 
 
 
 
 1 
 
 1 
 
 
 8 
 11 
 
 6 
 
 Bad . : : 
 
 Good.. 
 
 Fever ; caked breasts 
 
 Fcetus found in unruptured. . 
 Child took only one breath; lochia never offensive; private 
 
 physician called in : late sepsis. 
 Ether ; degen. of membr. & plac; removal of pieces of 
 
 membrane with curette ; out of bed 5th day. 
 
 149 
 15 
 15 
 
 Postpartum hieraorrhage 
 
 
 3i 4 
 « VIII. 4 
 
 1 
 
 1 
 
 1 
 
 
 
 
 1 1 
 
 3hrs ... 
 19 •'.... 
 
 
 
 
 
 
 
 
 
 1 
 
 
 1 
 
 1 
 
 4 " 
 
 
 
 
 15 
 
 7M- 
 
 
 3 IV. 41 1 4 
 
 1 
 
 1 
 
 
 
 , 
 
 1 1 
 
 
 
 
 
 
 
 
 
 1 
 
 
 1 
 
 
 
 J 
 
 
 
 
 15 
 1.5) 
 13 
 
 T,679 
 7,68i 
 7,683 
 
 U.S. ...'.'.'. 
 Russia 
 
 » V.3J 
 •7 in. .31 
 .8 III. 4 
 
 4 days... 
 
 
 
 
 1 
 
 1 1 
 
 6 •'.... 
 
 101.3 
 
 101.2 
 
 101.3 
 
 102.8 
 
 2d " 
 
 14 " .. 
 
 
 
 1 
 1 
 
 
 1 
 
 
 
 H^ 
 
 Bad .:: 
 
 Good . . 
 
 Fewer; sepsis; pericarditis.. 
 
 Sent to St. Francis' Hospital. 
 
 1.5f 
 
 7,75 
 
 Poland '.'.'.. 
 
 1 3 
 
 
 
 
 
 
 1 1 
 
 1 day .... 
 
 
 
 
 
 
 
 
 
 1 
 
 
 1 
 
 1 
 
 
 
 
 
 
 15 
 
 7,90 
 
 Russia 
 
 ^ III. 01 
 
 1 
 
 
 13 " 
 
 3 lbs. 1 
 
 
 '25 " .... ' 
 
 
 
 
 
 
 
 
 
 
 
 ^ 
 
 ^ 
 
 
 IS 
 
 Fair . '. '. 
 
 Endocarditis 
 
 Incubator child; child disch. living; died later, hydroccpb.; 
 
 15 
 
 a.or 
 
 
 37 XI 5 11 
 
 ^ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 double mitral; ascites; hepatic congestion. 
 
 15 
 M 
 
 le 
 
 8,03 
 8,16 
 8.34 
 -8,40 
 
 Rouraania. 
 Russia 
 
 U.S. ..;;; 
 
 36 IX. 4i 2 
 M VI. 5 
 33 IV. 4 8 
 23 Vin. 5 3 
 
 1 Sev. wks. 
 1 4 hours. . 
 1 
 1 
 
 
 101" 
 
 It " 1 
 
 1 
 
 1 1 
 
 1 
 
 1 Notobs.... 1 
 1 
 1 1 
 1 30min. .. 
 
 Immed.. 
 
 
 
 
 101.2 
 
 8th" 
 
 Few hrs. 
 
 
 
 1 
 1 
 
 
 1 
 
 1 
 1 
 
 1 
 1 
 1 
 
 2 days. 
 1 day . . 
 
 10 
 
 10 
 
 i 
 
 IC 
 
 Good : : 
 
 Fair . ! : 
 
 Fever ; constipation 
 
 Head caught in os; convul- 
 
 Mo furtlier record. 
 
 Manual extraction of clots from uterus. 
 
 16 
 
 8.-33 
 
 " 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 sions 7th and 10th day. 
 
 
 n 
 
 
 
 27 IV 5 
 
 
 
 
 
 1 Ret. 
 
 lined 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Curettage refused : discharged. 
 
 
 5 8^74 
 
 [reland!!! 
 
 28 II" 5 
 
 
 
 
 
 1 
 
 1 3 hrs. 5 m.. 1 
 
 
 
 
 
 
 
 
 
 
 1 
 
 1 
 
 
 
 
 9 
 
 Good . . 
 
 
 Manual removal of placenta and membrane. 
 
 1( 
 
 
 Russia . 
 
 29 V 4 
 
 
 
 
 
 1 1 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 1 
 
 
 
 
 8 
 
 
 
 Manual e-vtraction of foetus, placenta, and membrane. 
 
 1( 
 
 16 
 If 
 
 1 
 1 
 
 -8;61 
 
 8 8,87 
 
 9 8,93 
 9.11 
 19.38 
 2 9.43 
 
 3 U. S 
 
 3 " 
 
 Russia 
 
 [ ;; .... 
 
 34 IX: 4 4 
 10 1.5 
 
 i \.l * 
 
 31 ? 6 4 
 40 VI. 5 
 
 1 
 1 
 1 1 
 1 1 
 
 1 
 1 
 
 Twins . 
 
 1 
 
 
 37 grms. 
 
 1233 " 1 
 1310 " f 
 
 1 
 
 1 1 1 
 1 1 
 1 1 
 I 1 
 
 1 1 
 
 1 
 
 5 days . . . 
 
 
 
 
 101 
 
 4th " 
 
 3 days . . . 
 
 
 1 
 
 1 
 
 1 
 
 1 
 
 
 1 
 1 
 
 1 
 1 
 
 1 " .. 
 3 days. 
 
 9 
 10 
 S 
 4 
 
 g 
 
 
 Fever; sepsis. 
 
 Macerated child 
 
 Uterine douche prevented by contracted os. 
 
 Breech piesentation ; monsti'osity. 
 Slight digital dilatation. 
 
 
 Head caught In os 
 
 1 
 
 f»f 
 
 3 Ireland".!'. 
 
 29 IV. 4 
 
 30 III. .ii 
 
 1 
 
 1 
 
 1 
 
 10 " 
 
 1 lb. 13 oz. 
 
 1 
 
 1 1 
 
 SOmln 
 
 1 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 1 
 
 1 
 
 2 " 
 
 5 
 
 6 
 
 Good.. 
 
 
 Alcoholic; discharged. 
 
 1 
 
 59,T. 
 
 -.Russia .... 
 
 28 II. 4 
 
 1 12 houra. 
 
 
 1 
 
 30 •• 
 
 
 
 
 
 101 
 
 5th " 
 
 Few hrs. 
 
 
 
 
 
 
 
 
 5 
 
 
 Fever; constipation. 
 
 
 
 1 1 
 
 
 
 
 
 1 1 
 
 1 
 
 
 
 
 
 
 
 
 _ 
 
 
 
 
 
 
 
 1 
 
 
 
 Hidwife called in; discharged. 
 
 : No record ; L. d. = Labor day. 
 
■O3tp.'luciaor; Jev 
 
 ... iL -on. rtccoMHio on.no 
 
 
 
SPONTANEOnS PREMATOTtE 1 
 
 Up; loclilQsllKht; serous. 
 
 
 
 
THE PREMATURE INTERRUPTTON OF PREGNANCY. 
 
 131 
 
 Pelativk Frequency. 
 
 For many reasons exact figures as to the relative frequency of prema- 
 turel}^ interrupted pregnancies are difficult to obtain. During the first 
 eight weeks undoubtedly many interruptions of pregnancy pass unnoticed, 
 and later in pregnancies very few enter maternities, and many even do not 
 come under the notice of private ^^hysicians or polyclinic hospital services. 
 In favor of a greater accuracy of our statistics is the fact that all of tlie 
 635 cases of untimely interruptions of pregnancy were outdoor or polyclinic 
 cases, and patients under such circumstances — in their own homes — are 
 more likelj^ to seek aid under their OAvn roof than apply for admission to a 
 general or maternity hospital. Therefore, while it is impossible, with the 
 material at our command, or, in fact, with any material, to indicate in a 
 precise way the frequency of interrupted pregnancy, and at what period 
 this accident is most prone to occur, still, for reasons already given, we 
 believe in a general way our statistics and findings are valuable and in- 
 teresting. 
 
 Among the 10,000 cases of labor studied in this Report, we find 635 
 premature interruptions of pregnancy; namely, 417 abortions and 218 
 premature labors. This gives us a relative frequency of: 
 
 One abortion to every 24 labors. 
 
 One premature labor to every 45.8 labors. 
 
 One premature interruption of pregnancy to every 15.7 labors. 
 The 635 cases of the premature interruption of pregnane}^ studied in this 
 article may be divided and classified according to the nativity of the 
 patients, as in the following table: 
 
 Table or I^ativity. 
 
 Nativity. 
 
 Early 
 Abor- 
 tions. 
 
 Late 
 Abor- 
 tions. 
 
 Pre- 
 mature 
 Labors. 
 
 Total 
 Inter- 
 rupted 
 Preg- 
 nancies. 
 
 Full 
 
 Term 
 
 Labors. 
 
 Total 
 Inter- 
 rupted 
 and 
 Full 
 Term. 
 
 Per- 
 centage 
 of Inter- 
 rupted 
 Preg- 
 nancies. 
 
 United States . . 
 
 Germany 
 
 Russia 
 
 Poland 
 
 Ireland 
 
 England 
 
 Austria 
 
 Roumania 
 
 Hungary 
 
 Scotland 
 
 23 
 
 14 
 
 160 
 
 5 
 11 
 
 4 
 10 
 
 3 
 
 19 
 
 5 
 
 117 
 
 3 
 
 4 
 
 2 
 5 
 6 
 1 
 
 27 
 15 
 128 
 4 
 7 
 3 
 7 
 8 
 2 
 
 69 
 34 
 
 405 
 12 
 
 22 
 
 9 
 
 22 
 
 16 
 
 6 
 
 819 
 
 378 
 6,282 
 244 
 311 
 112 
 707 
 
 lis 
 
 168 
 
 10 
 
 3 
 
 6 
 
 888 
 
 412 
 
 6,687 
 
 256 
 
 333 
 
 121 
 
 729 
 
 134 
 
 174 
 
 10 
 
 4 
 
 9 
 
 7.77^ 
 8.25^ 
 6.08^ 
 4.70^ 
 6.63^ 
 7.43^ 
 3 . OU 
 11.94^ 
 3.44^ 
 
 Holland 
 
 
 
 1 
 3 
 
 1 
 3 
 
 25 . 00^ 
 33.00^ 
 
 Switzerland . . . 
 
 
 
 
 
 
13-2 REl'ORT OF THE SOCIETY OF TlIK LVlNeMX HOSPITAL. 
 
 Table of Xativiiy. — (Continued.) 
 
 Nativity. 
 
 Earlv 
 Abor- 
 tions. 
 
 Late 
 Abor- 
 tions. 
 
 Pre- 
 mature 
 Labors. 
 
 Total 
 Inter- 
 rupted 
 Preg- 
 nancies. 
 
 Full 
 Term 
 Labors. 
 
 Total 
 Inter- 
 rupted 
 and 
 Full 
 Term. 
 
 Per- 
 centage 
 of Inter- 
 rupted 
 Preg- 
 nancies. 
 
 Sweden . ... 
 
 
 
 
 5 
 4 
 3 
 1 
 2 
 20 
 1 
 1 
 1 
 1 
 166 
 
 5 
 4 
 3 
 
 1 
 
 2 
 
 23 
 1 
 1 
 1 
 1 
 199 
 
 
 Canada . . . i 
 
 
 
 r ranee 
 
 
 
 AVales . . 
 
 
 
 Turkev .... 
 
 t 
 
 
 
 Italy." 
 
 Iv'V])t 
 
 1 
 
 1 
 
 1 
 
 3 
 
 13.04^ 
 
 Vrabia . 
 
 
 
 Permuda . 
 
 
 
 
 Australia 
 
 
 
 
 Unknown 
 
 •» 
 
 12 
 
 12 
 
 33 
 
 16.58$^ 
 
 Total 
 
 242 
 
 175 
 
 218 
 
 635 
 
 9,365 
 
 10,000 
 
 
 Again, the 635 cases of the untimely interruption of pregnancy analyzed 
 in this article may be divided and classified according to the age of the 
 women, as in the accompanying table. For purposes of comparison here, 
 as in the Table of Nativity, we have added the numbers of the full-term 
 labors occurring in the service of the Hospital during the same period. 
 
 Table of Age of Patients, 
 
 
 Early 
 Abor- 
 tions. 
 
 Late 
 Abor- 
 tions. 
 
 Pre- 
 mature 
 Labors. 
 
 Total 
 Inter- 
 rupted 
 Preg- 
 nancies. 
 
 Full 
 Term. 
 
 Total 
 Inter- 
 rupted 
 and 
 Full 
 Term. 
 
 Per- 
 centage 
 of Inter- 
 rupted 
 Preg- 
 nancies. 
 
 19 and under. .. 
 
 20-24 
 
 25-29 
 
 30-34 
 
 35-39 
 
 4(»-44 
 
 45-49 
 
 8 
 54 
 72 
 47 
 34 
 11 
 
 7 
 42 
 52 
 32 
 25 
 
 4 
 
 17 
 86 
 57 
 26 
 23 
 3 
 
 32 
 182 
 181 
 105 
 
 82 
 18 
 
 905 
 
 3,455 
 
 2,821 
 
 1,328 
 
 670 
 
 77 
 
 11 
 
 1 
 
 97 
 
 937 
 
 3,627 
 
 3,002 
 
 1,433 
 
 782 
 
 95 
 
 11 
 
 1 
 
 112 
 
 3.42,^ 
 5.01^ 
 6.02^ 
 7.33^ 
 10. 4S^^ 
 18.94,^^ 
 
 50-54 
 
 
 
 
 
 
 Unknown 
 
 16 
 
 13 
 
 6 
 
 35 
 
 31 . 25^ 
 
 Tot;.l 
 
 242 
 
 175 
 
 218 
 
 635 
 
 9,365 
 
 10,000 
 
 
THE PREMATURE INTERRUPTION OF PREGNANCY. 
 
 133 
 
 In the foregoing table we have, in addition, worked out tlie percentages 
 of the frequency of interrupted pregnancy in the different five-year groups 
 of ages. 
 
 Our table shows a progressive increase in the percentages of the fre- 
 quenc}^ of the untimely interruption of pregnane}^ from the group aged 
 nineteen years and under, until the maximum is reached between the fortieth 
 and fortv-fourtli years. It will be noticed that there is little variation in 
 the percentages of interruption from the twentieth to the thirtieth year, 
 that there is a marked increase for the period between the thirty-fifth and 
 thirty-ninth year, and a still more marked increase for the period between 
 the fortieth and forty-fourth year, which latter period gives us the maxi- 
 mum of interruption for our cases. 
 
 From our studies we may safely draw the conclusion that the least 
 probability of an untimely interruption of pregnancy is before the twenty- 
 fifth year, and that the greatest probability is after the fortieth year. 
 
 In the following table we have arranged the relative frequency of in- 
 terrupted pregnancy according to the number of preceding labors ( — para), 
 and in this table, too, for purposes of comparison, we have added the num- 
 ber of mature labors. 
 
 Table of Para. 
 
 Para. 
 
 Early 
 Abor- 
 tions. 
 
 Late 
 Abor- 
 tions. 
 
 Pre- 
 mature 
 Labors. 
 
 Total 
 Inter- 
 rupted 
 Preg- 
 nancies. 
 
 Full 
 Term. 
 
 Total 
 Inter- 
 rupted 
 and 
 Full 
 Term. 
 
 I 
 
 29 
 31 
 32 
 
 29 
 28 
 16 
 18 
 15 
 8 
 10 
 
 2 
 
 22 
 
 24 
 
 26 
 
 29 
 
 15 
 
 12 
 
 9 
 
 15 
 
 6 
 
 3 
 
 3 
 
 i' 
 
 71 
 31 
 
 29 
 
 19 
 
 18 
 
 11 
 
 11 
 
 8 
 
 4 
 
 5 
 
 1 
 
 1 
 
 4 
 
 122 
 
 86 
 
 87 
 
 77 
 
 61 
 
 39 
 
 38 
 
 38 
 
 18 
 
 18 
 
 8 
 
 3 
 
 5 
 
 3 
 
 1 
 
 2 
 
 2,009 
 
 1,784 
 
 1,438 
 
 1,120 
 
 860 
 
 661 
 
 485 
 
 343 
 
 227 
 
 148 
 
 66 
 
 65 
 
 33 
 
 13 
 
 7 
 
 2,131 
 
 II 
 
 Ill 
 
 1,870 
 1,525 
 
 TV 
 
 1,197 
 
 Y 
 
 921 
 
 YI 
 
 700 
 
 YII 
 
 523 
 
 YIII 
 
 381 
 
 IX , 
 
 X 
 
 245 
 166 
 
 XI 
 
 74 
 
 XII 
 
 XIII 
 
 68 
 38 
 
 XIY 
 
 3 
 1 
 1 
 
 16 
 
 XY 
 
 
 
 8 
 
 XYI 
 
 
 1 
 
 
 XYII . ... 
 
 1 
 
 1 
 
 XYIII 
 
 
 
 
 
 
 XIX 
 
 
 
 
 
 
 
 XX 
 
 1 
 Itt 
 
 
 
 1 
 
 28 
 
 105 
 
 1 
 
 Unknown 
 
 10 
 
 4 
 
 135 
 
 
 
 Total 
 
 242 
 
 175 
 
 218 
 
 635 
 
 9,365 
 
 10,000 
 
 
 
134 
 
 HEPOHT OF THE SOCIETY OF THE LYIN(i-IN HOSPITAL, 
 
 If, for purposes of convenience, we condense the })receding table of para, 
 and recognize three groujis only, according to the number of preceding 
 laboi*s. namely, ]n*imi]xira\ ])luriparn?* and multipara^ {i.e., more than Y. 
 paiw), and construct a tal)le on this basis, we will have the following: 
 
 Table of Para. — (Condensed.) 
 
 Para. 
 
 Primii)ara3 . 
 
 Pluripara^ '- 
 Multipara^ , 
 Unknown . . 
 
 Total. 
 
 Early 
 
 Late 
 
 Abor- 
 
 Abor- 
 
 tions. 
 
 tions. 
 
 29 
 
 22 
 
 120 
 
 94 
 
 TO 
 
 49 
 
 14 
 
 10 
 
 242 
 
 175 
 
 Pre- 
 mature 
 Labors. 
 
 71 
 
 97 
 
 4(3 
 
 4 
 
 Total 
 Inter- 
 ruj^ted 
 Preg- 
 nancies. 
 
 122 
 311 
 174 
 
 28 
 
 218 
 
 635 
 
 Total 
 
 Full 
 
 Term. 
 
 2,009 
 
 5,202 
 
 2,047 
 
 107 
 
 9,365 
 
 Total 
 Inter- 
 rupted 
 and 
 Full 
 Tenn. 
 
 2,131 
 
 5,513 
 
 2,221 
 
 135 
 
 10,000 
 
 (Jur foregoing table shows tliat in primigravidse gestation is least en- 
 dangered in the first months of pregnancy; for among 122 untimelj^ in- 
 terruptions in ]irimigravidae we find 29 early abortions, 22 late abortions, 
 and 71 premature labors. Thus we see again from the above that the fre- 
 quency of interruption increased with the further advance of pregnancy. 
 
 A glance at our table Avill show that in ])lui'i]mra^ and multipara^ tlie 
 relation is reversed; the majority of interruptions among these occurring 
 in tlie first montlis of pregnane}', and that the frequency of interruption 
 now decreases with the furtlier advance of gestation. 
 
 The greater frequency of uterine disease in multipara^, and the large 
 number of preceding labors, some of them, at least, undoubtedly anomalous, 
 is a sufficient explanation of the greater fre(|uency of abortion than of 
 ])remature la1>or in multipara'. 
 
 Tlie study of our material also allows us to coniirm the ol)servations of 
 Winckel,'-^ Stunq)f.' and others, that with every additional interruption of 
 j)regnancy tlie tiiiu^ of gestation recedes, so tliat aftei' the occurrence of a 
 j)remature lahoi- tliei-e ensue, first, late abortions, and iinally early aboi'tions. 
 The uterus, tJKjrefore, in the jireseiice of iiteiiiie disease, becomes ever less 
 tolerant of siibseciuent ])i-egnaiicies, and expels its eoiiteiits earlier, in pro])0)'- 
 tion to the number of preceding inten'upti<jns of picgnancy. As Winckel 
 and Stum])f put it: " The longer existence of iiteiine disease leads to ever 
 earlier intfjrniption of pregnancy.'" 
 
 In the following table we indicate tlx- ric(|tiency of the iititimely intei-- 
 ruption of pregnancy in the different montlis of gestation: 
 
 ' ]'liiri|.nr:.--^II., III., IV.. V. panu. 
 
THE PREMATURE INTERRUPTION OF PREGNANCY, 
 
 135 
 
 Month of Gestation. 
 
 
 
 Xumber 
 
 Percentage 
 
 
 Week. 
 
 Month. 
 
 of 
 
 of Inter- 
 
 
 
 
 Cases. 
 
 ruption. 
 
 
 4 
 
 I. 
 
 
 
 
 6 
 
 H 
 
 
 
 10 Not N'oted. 
 
 8 
 
 II. 
 
 61 
 
 9.61^ ) 
 6.29^ V 
 
 
 10 
 
 n 
 
 40 
 
 232 Early Abortions. 
 
 12 
 
 III. 
 
 131 
 
 20.63^ ) 
 
 
 14 
 
 31 
 
 21 
 
 3.31^1 
 
 
 16 
 
 IV. 
 
 62 
 
 9.76^ 
 
 
 18 
 
 4i 
 
 9 
 
 1.42^ 
 
 
 20 
 
 V. 
 
 35 
 
 5.51^ ^ 
 
 175 Late Abortions. 
 
 22 
 
 5i 
 
 9 
 
 1.42^ 
 
 
 24 
 
 VI. 
 
 28 
 
 4.42^ 
 
 
 26 
 
 6i 
 
 11 
 
 1.73^^ 
 
 
 28 
 
 VII. 
 
 47 
 
 7.40^1 
 
 
 30 
 
 n 
 
 14 
 
 2.20^ 
 
 
 32 
 34 
 
 VIII. 
 
 8i 
 
 65 
 15 
 
 10.26^ 
 
 2.37^ ' 
 
 218 Premature Labors. 
 
 36 
 
 IX. 
 
 50 
 
 7.99^ 
 
 
 38 
 
 H 
 
 27 
 
 4.26^^ 
 Total... 
 
 635 interrupted Pregnancies. 
 
 In the foregoing table the month of gestation is not noted in ten cases 
 only (early abortions). 
 
 Our material and the above table accentuate the well-known liability 
 to the occurrence of interruptions at the third month (23,91 per cent.). 
 
 Further, it is of interest to note the slight liability at the sixth month 
 (6.15 per cent.); and also, but with a slight increase, at the seventh month 
 (9.6 per cent.); while it will be noted that in the eighth and ninth months 
 the frequency again rises (12.63 per cent, and 12.25 per cent, respectively). 
 
 Pathology. 
 
 The patholog}'" of interrupted pregnancy, like the bacteriology, differs 
 little or not at all from the disease processes taking place at full term. 
 The same degenerations (syphilitic, hj^datidiform, fatty, sarcoid) and the 
 same infections (septicaemic, pyaemic, saprsemic, and tuberculous) are found. 
 It is difficult to assign any relative value to these morbid conditions in this 
 connection, but in view of the greater frequency of sepsis in childbed we 
 shall consider that portion of the subject first. 
 
136 REPORT OF THE SOCIETY OF THE LVlNtMN HOSriTAL. 
 
 The identity of soptio infections in all parts of the body, though pre- 
 senting the most varied clinical ynctures, has been lirndy established by the 
 demonstration of the ))art played in them etit)loiiieally by ])athogenic 
 miero-organisms. The changing degree in these processes, nowhere moi'e 
 marked tl»an in tlie puerperium, patent to all observers, is explained by the 
 theory of a variation in virulence of the microbes. It is not necessary to 
 review the classifications adopted b}' various authors before the advent of 
 bacteriological science; we merely refer to the pa})ers of Chailly/ Maun- 
 sell,^ and Churchill*' as exam})les of the work done in this line during the 
 earlier part of the present century. The best work of the bacteriologists 
 is of very recent date. Haushalter,^ in 1890, declared that the strepto- 
 coccus pyogenes is the active factor in all forms of ])uerperal sepsis; accord- 
 ing to his investigations, it is present in acute septicaemia without suppura- 
 tion, in pseudo-membranous septicaemia, in pyoliiBinic septicjemia, and in 
 erysijielas. De Marbaix,^ three years later, proved the above-mentioned 
 changes in virulent power of this same microbe. He believes that viru- 
 lence is lessened by age and by the failure of growth of new generations; 
 that it is increased by inoculation into rabbits; and, in support of his theory, 
 ]n'oduced eiysipelas in mice from harmless streptococci of the buccal cavity 
 and showed the change to innocuousness of the germ taken from an endo- 
 carditis. WidaP classifies se])tic infections as (lij)htlieritic, purulent, and 
 septica'mic — all due to invasion l)y the streptococcus. Bumm's '^' classifica- 
 tion is, however, the one most generally accepted, and arranged in increas- 
 ing order of virulence is as follows : Localized septic metritis, thrombotic form 
 of ]nierperal fever, ordinary lymphatic form, and internal erysipelatous form. 
 Gartner's " work is considered unsatisfactory by bacteriologists iov the rea- 
 son that he claims that culture methods are unreliable, and pins his faith to 
 stained sections alone for differentiation. He attempts no classification. 
 
 Septic infection may have its starting-point in any solution of continuity 
 of the mucous surfaces of the birth canal. Consequently, many infections 
 of a lighter character begin in injuries of the cervix and perineum. 
 Fritsch,^ among others, has particularly emphasized the formei* avenue as 
 the route of invasion, and the thickenings in the cervical region in multi- 
 parae are too familiar to gynaecologists to need even a mention. Pelvic 
 abscess, thickening of the round and sacral ligaments, and inHammatory 
 changes in tliem are secjuehe of cervical infection. 
 
 Bumm '" and Giirtner" have made clear the mode of invasion of the 
 organisms at the phicental site; the classification of Jhinim is the result of 
 study of his microscopic preparations. According to him, se[)tic endo- 
 metritis shows a superficial layer of necrotic tissue pervaded by ])yogenic 
 and })utr<'factivo germs, A zone <^^)f i'('a(^tic)n, of pj-otection, consisting of 
 leucocytes, li(;s just below tliis, including th<! remains of tlu; incnilji'anes 
 and part of the nmscular coat, but containing no bacto-ia. The llironibotic 
 form is (>n]y a greater d(^V(;lo])nient, tog(!t]iei' with a gcnieral systemic in- 
 fection through th(.' venous radicles. Buti'id <'n(lom(!tritis and the reaction 
 zone are present, but there is, in addition, a |»ui-ul('nt ])hlebitis and throm- 
 bosis at the j)hu;ental site. 'I'lx- tliroinlii iiiulcrgo piinilciitdegeneration, 
 
THE PREMATURE INTERRUPTION OF PREGXAXCY. 137 
 
 and portions of thorn arc carriod in the I)loo(l sti-eam over tlie body. In 
 the lymphatic variety, infection takes place throngh these channels and 
 resnlts in a general systemic invasion. The decidua3 are necrotic and pre- 
 sent the appearance called croupous. The organisms pass from the endo- 
 metrium into the open lymphatics, AVhich undergo degeneration and form 
 pus cavities. The last two forms may, of course, occur together. The in- 
 ternal erysipelatous variet}" shows microscopically necrotic decidua in the 
 nterus and an exudate or false membrane in the vagina. Microscopically, 
 there is an ill-defined reaction zone, the cocci have invaded the uterine 
 muscle and the smaller Ivmphatics. There is usually a septic peritonitis 
 from extension. TTe do not understand how this is to be separated in any 
 way from the lymphatic form, nor do we see the necessity for the division. 
 Gartner," by his researches, has confirmed Bumm's statements as to his 
 thrombotic and lymphatic forms of septic invasion. He finds no histo- 
 logical difference between pyaemia and septicaemia, a result not unexpected 
 nor unsupported, and thinks the chemist must make the diagnosis between 
 the two. 
 
 AVe have examined microscopically the scrapings of the uterus in seven 
 of our cases, and present the results for what they are worth. (Compare 
 Synopsis Tables.) 
 
 Case 6,897. — "Well-formed placenta showing amnion, chorion with dis- 
 tinct villi covered with epithelium, decidua with characteristic large cells. 
 Normal. 
 
 Case 6,900. — About three months. Yilli extremel}^ long and slender, 
 cells distinct, vessels distended with blood. Normal. 
 
 Cases 7,211, 7,133, and 7,083. — Xormal, well-formed placenta, showing 
 amnion, chorion, and decidua with its spongy and compact layers well 
 defined. Normal. 
 
 Case 7,011. — Chorionic villi, long and slightly vascular; decidua cells 
 distinct. Less than three months. Normal. 
 
 Case6,8M. — Two s|)ecimens. a. Amnion and chorion normal. Spongy 
 layer of decidua shows necrotic areas around which is marked infiltration 
 of "round cells." Several small vessels contain thrombi, h. Scrapings 
 from uterus show decidua only. Uterine glands present of about usual 
 size. Large cells of decidua normal, and many are multinucleated. Two 
 areas of necrosis larger than in specimen a. Thrombosis also found in 
 small vessels. Clearly, a case falling in the thrombotic class in Bmnm's 
 classification. 
 
 Attention is drawn to a point in treatment suggested by these patho- 
 logical findings, which will be considered at greater length farther on ; viz. , 
 the necessity for non-interference, surgically speaking, with a septic uterus. 
 It is never possible to decide macroscopically to what extent microbic inva- 
 sion of the muscular wall has taken place; and curettage, in its softened 
 condition, is more than likely, instead of removing the offending material, 
 to cause a general infection by loss of the protective zone of reaction, and 
 the opening of venous and lymphatic channels to the cocci present. This 
 point is emphasized by Williams ^^ and others. 
 
138 REPORT OF THE SOCIETY OF THE LYIN(MN HOSPITAL. 
 
 Genital tuberculosis may 1)0 either a priiiiarv or a secondarv infection. 
 In the fii*st case, it takes place often through the vagina, usually by coitus ; 
 in the second, it derives its origin from a focus of disease in the bodv. In 
 either case the tubes are most often first attacked, especially during the 
 period of menstruation (^Si])pell "). It is the uterus, however, with ^vl]ich 
 Ave are chiefly concerned here. Williams''' and CuUen,"^ of the Johns 
 IIo])kins Hospital, have investigated the sul)ject thoroughly. Their papers 
 contain a practically complete bibliograpliy, with reports of their own cases, 
 and their conclusions may be accei)ted as representing the fullest state of 
 our present knoNvledge. Chronic diifuse tuberculosis begins usuaUy at the 
 top of the fundus. In the earlier stages it cannot be made out macroscopic- 
 ally, and may be beyond the reach of the curette, hidden in the cornua. 
 Later the nodules appear beneath the surface and finally ulcerate. The 
 endometrium is transformed into caseous material, and if the cervix is 
 occluded, the cavity may fill with detritus, simulating pyometra. After a 
 time the tuberculosis includes the jnuscular wall. Histologically, in the 
 beginning, the epithelium is intact or proliferated into papillary ])rojections, 
 the tubercles lying in the stroma; later, the glands are affected, tubercles 
 a]:)]iear in their avails, thev are obliterated, and their place is taken by 
 tuberculous material. The line of juncture between sound and diseased 
 tissue is sharply defined l)y a layer of round-cell infiltration. Extension 
 usually takes place from the tuljes to the uterus, and the process in them is 
 more advanced tlian in the latter organ. It may, however, be infected 
 ])rimarily and directly from without. Although no case of premature de- 
 livery has, to our knowledge, l)een reported as due to uterine tuberculosis, 
 it is not dirticult, in view of the picture just given of the degeneration in 
 endometrium and muscle, to conceive how such a condition may become 
 possil)le. 
 
 Lehmann ^ repoi'tctl t(j tlie iJerlin Medical Society two cases of placental 
 tuberculosis, one of the maternal portion in a phthisical woman, the other 
 of the foetal ])art. The changes were very slight in the jilacenta, but they 
 point out an avenue of entrance for bacilli into the infant body, Ilirsch- 
 feld '^ and Schmorl ^ found tubercle l)acilli in the foetal liver, the mother 
 being |)hthisical. 
 
 P(;i'ha})S the mo.st important ])oint connected with the pathology of 
 al)ortion is the l)elief which has been in the ]>ast few yeai's slowly gaining 
 ground, that even in instances of so-called com])]!'!!' abortion, with un- 
 ruptured ovum, some slireds of decidua always ivmain Ijehind, a theory 
 whicli is str(;Mjrthcne<l bv the; fact tliat these cases, treated exiiectanth', 
 always liave a nujrc; or less olb-nsivc lochia, and that invohition is always 
 retarded (DiilirssfMi '"j. 
 
 As we have; alrcadx' pointed ont. the Icnii (//>(>/■/ in/i, in its naiTowest 
 sense, is confined to tin- spontaneous ••iiij)tying of the ntcrns in tluHirst 
 twelve weeks ol" gestation ; namely, to tlu^ ])eriod when th<' decidua I'etlexa 
 and vera have not been united, and when active treatment has for its object 
 not only the removal of the ovum with the decidua reflexa and ])lacental 
 attiichment, but also of the decidua vera. Vn{\\ recently, the accepted idea 
 
THE PREMATURE INTERRUPTION OF PREGNANCY. 139 
 
 has been thut the ovum separates from l)ekj\v upward (Schroeder,'^ Spiegel- 
 berg "^), but the studies of Diihrssen^" and others (Dohrn — personal letter to 
 Diihrssen) ai)pear to prove that this mechanism is not tlie usual one, at 
 least. On the commencement of uterine contractions, separation begins at 
 the placental site, followed by the remainder of the decidua vera from 
 above, downward. Careful investigation of cases bears out this statement. 
 
 Cases of inevitable abortion, with an unruptured ovum, which permit of 
 the passage of the finger through the os, reveal one of the two following 
 conditions : 1. Passing between the ovum and uterine wall, the finger 
 finds a more or less firm attachment at the fundus. If this is broken up, 
 the ovum, consisting of decidua reflexa and the rudimentary placenta, is re- 
 moved, leaving the decidua vera, entire or in part, behind. Its smooth 
 surface, lining the uterus except at the fundus, where many fine shreds are 
 found, is easily felt by the finger. Kemoval by curettage proves this reten- 
 tion beyond doubt. If separation took place from below, upward, the 
 finger would pass between uterine wall and decidua to the placental site, 
 and the ovum be removed intact. This does occur in excej^tional cases, but 
 as a rule the finger feels two smooth apposite surfaces, that of the reflexa 
 over tlie ovum and that of the vera on the uterus. This is due to the fact 
 that until the end of the third month the firm attachment of the vera guides 
 the finger within its cavity, between it and the refiexa. 2. The ovum in 
 this case is found in the dilated cervix, attached to the uterine wall b}^ a 
 pedicle composed of the vera. The vera was detached from above, down- 
 ward, and is still fastened to the lower segment of the organ. Attempts 
 at expression or detachment result in tearing this pedicle, and part of the 
 decidua vera remains behind. If separation occurred, as formerly thought, 
 from below, up, the pedicle would extend to the placental site, at which 
 point alone the ovum would be held. This finally giving way, the uterine 
 contents would be expelled entire, we should have a complete abortion, and 
 the curette would not be needed. It is because the first is the more frequent 
 occurrence that retention of the decidua happens after spontaneous abortion 
 or abortion after the use of tampons, and hsemorrhage and sepsis are pro- 
 duced. (As Diihrssen ^'^ and others have pointed out, it is quite possible 
 that varieties of placental attachment may influence the mode of separation 
 and expulsion.) 
 
 Moreover, the decidua vera may be expelled even before the ovum, when 
 it becomes detached from the uterine walls by blood extravasation. Again, 
 in old cases of neglected incomplete abortion, the curette secures nothing 
 but a portion of rudimentary placenta, because the vera has been washed 
 away after breaking down, as in labor at term. 
 
 Macroscopical examination cannot always determine that the ovum is 
 intact. Exploration of the uterus alone gives a positive diagnosis. Diihrs- 
 sen^^ curetted after twelve cases of apparently complete abortion, and 
 the microscope demonstrated that more or less decidua was retained. 
 
 Winckel ^^ believes that the entire ovum, intact with the vera, may pass 
 out in the first months. AVhen separation does take place, it is, in his 
 opinion, at the decidua serotina, leaving the ovum behind. Again, the 
 
140 KEPURT OF THE SOCIETV OF THE LVINIMN HOSPITAL. 
 
 ivHexa may be lorii in the ovuui's tlosc-eiit, loavinii- it witli the vera and 
 sei'otina to })ass away durinii- the puerpei-ium, ov to be reuioveil by curet- 
 tage. It is possible for the chorion to be ruptured as well, the cord being- 
 torn from the placenta; and the embryo, enclosed in amnion, alone expelled. 
 The mechanism last mentioned is the rarest, but may occur even at the 
 sixteenth or twentieth week. A mollification of it is shown when decidua 
 vera, reflexa, and chorion are torn away, leaving the placenta, fitted like 
 a cap, on the amnion. 
 
 The question of the propriety of interfei-ence must rest npon clinical 
 results, iiowever, and not upon theoretical deductions. Clinical experience 
 shows us that the mechanism of placental and decidual separation varies 
 according to the ])eriod of gestation. Klein-' has recentW studied the 
 process of involution of the decidua after abortion and labor at term. lie 
 reached the conclusion that, after abortion, the vera remains wholly or in 
 part in the uterus. The decidual cells and superficial epithelium ])erish 
 in loco by necrosis. The necrotic mass is absorbed or expelled, and the 
 epithelium regenerated from l)elow. The ])rocess is terminated in four to 
 six weeks. At term, a fatty degeneration, a coagulation necrosis, occurs 
 in the cells of the decidua, which fomis a line of demarcation between the 
 deep layer of the vera remaining in the uterus and the upper destructible 
 layer forming a physiological separation zone, so tluxt at labor there passes 
 out with the ovum the greater part of the uterine surface which has be- 
 come decidua. The membranes and placenta are completely expelled, except 
 when they are more intimately attached to the wall, as by inflannnatory 
 change in chronic endometritis. This physiological change of fatty necro- 
 sis, the anatomical condition resulting from it, and the method of separa- 
 tion at term, vary widely from that found in abortion explained above, and 
 constitute the great argument in favor of an active treatment in abortion 
 dui'ing the ])eriod before the sixteenth week. 
 
 The sequelae of incomplete abortion furnish further proof of the necessity 
 of oi>erative interfei-ence. Ekstein-' l^elieves endometritis post al)ortum to 
 be of common occurrence; and in two cases in which curettage alone 
 brought the haMuorrJjage to a standstill, the microscope revealed in the 
 shreds glandular hy))ertro])hic endometritis. Kiii'stner^' has brought 
 positive proof to show that an enilometritis nui}' depend on inconq)lete 
 aijortion, iOv in a ])oly]nis removed from a uterus he found placental 
 cotyledons. Fritsch ■■^' is convinced that endometritis is es])ecially liabh> to 
 follow abortions. The decidua, being already hypertrophic and unable to 
 involute, undergoes furtlier thickening and remains subject to hiLMUorrhage. 
 Aside from this, interstitial iuManunation and other inflammatory con- 
 •ditions arise, resulting in involvement of tin; glands and jn-esenile atrophy, 
 Schroeder'^ s])eaks of the inllammatoi-y interstitial areas, and states that 
 they must be difFcrentiated IVoin so-calli'd eiidoinetritis post, altdi'tiim in 
 which the haemorrhage results by re;is(»n of retained seeundines niei'eiy. 
 On the other hand, Wi nek el, 2''' followiiiL:' oiit his claim that abortion may 
 be complete, h(;lds that the chronic enduniet rit is is dui' to puerpei'al causes, 
 an upward extension <•!' ;i eci\ ic;d 'iitnn-h. I'oriik,"' IVoni ;i study of ;]20 
 
THE PREMATURE INTEllRL'PTIOX OF PREGNANCY. 141 
 
 cases of abortion aiul iiiiinature lal)or, although recognizing tliickoning and 
 adhesion of the decidua to be the most frequent cause of the accident, denies 
 that the condition demands curettage, reserving the latter for hiemorrhage 
 and endometritis, holding at the same time that the membranes are spon- 
 taneously eliminated. 
 
 We have now reached the last division in the subject of patholog}^, 
 namely, the degenerations of placenta and decidua concerned in the pro- 
 duction of abortion or occurring as a sequela of the accident. Of these, 
 the syphilitic is, of course, much the most important, not onl}'" in view of 
 its frequency, but as regards the infant mortality, even in cases when the 
 labor is at term. According to Councilman, s" little advance has been 
 made in this line since the publication of Frankel's classical work. Briefly 
 summed up, the conclusions are these: {a) There is a syphilitic disease of 
 the placenta, found only with congenital disease of the foetus, characterized 
 by hyperplasia of the epithelial and stroma cells of the villi, producing 
 compression, sometimes complete obliteration of the vessels. The pro- 
 liferated cells finally undergo fatty degeneration. The vessels themselves 
 show few changes, and these chiefly of an atheromatous nature (Oedmans- 
 son). There are slighter, focal changes in the placenta in syphilis, which 
 are probabl v of much less importance to the foetus. Macroscopically, the 
 lesions consist of a hypertrophy of the entire organ or some of its cotyle- 
 dons. (Jj) AVhen the disease is conveyed by the father, the mother being- 
 healthy, the foetus and placenta are affected. When the mother is attacked 
 with the embrvo in conception, the placenta is generally diseased in both 
 foetal and maternal portions. If the woman becomes syphilitic later, the 
 placenta may be sound or diseased ; in the latter case, its affection is gum- 
 matous syphilis. In infection after the seventh month there is usually no 
 specific change in foetus or ])lacenta. It is often difficult to decide whether 
 intrauterine death and abortion are due to this disease of the placenta 
 alone, since the lesions in the child are often far more advanced, although 
 its injurious effect on foetal vitalit}^ must remain unquestioned. 
 
 Among the important causes of intrauterine death are faulty conditions 
 of the foetal envelopes and appendages. These conditions, on the maternal 
 side, according to Priestly,^- are imperfect or excessive development of the 
 decidua or extravasation of blood between reflexa and chorion, causing 
 the so-called apoplexy of the ovum. Inflammation of the decidua, decidual 
 endometritis of whatever form, is a prime factor (Virchow) in the causation 
 of chorionic disease, the villi being unable to take root in its indurated and 
 thickened substance. The death of the foetus is the natural sequence of 
 chorionic changes Avhich are chiefly cystic, resulting in the condition known 
 as hydatidiform mole. Virchow's view, that the true nature of this de- 
 generation is myxomatous, is, as will be seen, at least probably correct. 
 Hehrer ^' has tabulated fifty cases of this affection, showing clearly its rela- 
 tion to our subject. Abortion occurred at the fourth month in fifteen 
 cases, at the fifth in thirteen; two only were delivered at term, and two 
 aborted in the second month. In more than half the patients, flooding 
 
142 KEl'OHT OF THK SOCIKTV OK THK LYINC-IX HOSPITAL. 
 
 occiirred. In tlnrty-four cases expectant treatment vesnlted satisfactorily, 
 l)Ut aniono; the rest were cases of debility, fever, etc., a clear indication 
 for jM'ophylactic curettage, altliongh no deaths resulted. Sterility was by 
 no means the rule in these cases after molar ])regnancy. 
 
 Hvdatidiform degeneration of the placenta has ac(]uirod in late j'^ears a 
 new interest, aside from its role in the etiology of abortion. This is found 
 in its frequent occurrence, not to put the case too strongly, })receding the 
 condition appropriately termed " deciduoma malignum.'" Of twenty-six 
 undoubted cases collected by 'Williams,^ eleven have followed hydatidiform 
 moles. ''When we consider the marked infrequency of hydatidiform 
 moles in general, and the very large proportion of the cases of deciduomata 
 which have been preceded by them, it is not difficult to believe that they 
 stand in some sort of causal relation." Williams thinks thiit too much 
 stress should not be laid on this, since there is no structural difference be- 
 tween deciduomata following moles and ordinary pregnancies. Preg- 
 nancy itself seems to be a condition sine qua non for the tumor develop- 
 ment, foi' of the remaining fifteen cases, five followed full-term pregnancies, 
 five followed abortions, one a tubal pregnancy ; in three the form was not 
 stated. Decidnoma maltgiium is a clinical term, including several varieties 
 of tumors, sarcomata, carcinomata, and mixed growths, all being derived 
 from one or both of the component parts of normal decidua, connective 
 tissue, or epithelium. Metastases form in various parts of the body (the 
 vulva, in "Williams's case), and present all the characters of the original 
 tumor. In case the growth is derived from the stroma, it is a sarcoma; 
 when from one or both layers of decidual epithelium, a carcinoma. Menge ^ 
 has described a case in which both varieties occurred too-ether. llistoloo-- 
 ically, the greater part of the tumor, as well as the metastasis, is made up 
 of blood lying free in the tissues or enclosed in spaces formed l)y the tumor 
 cells. In the carcinomata, the cellular portion consists of ei)ithelioid cells 
 derived from the Langhans layer of the decidual epithelium or of masses of 
 syncytium, a protoplasmic network without definite division into cells, with 
 dee])ly staining nuclei, vacuolated, the vacuoles being empty or containing 
 a trans]>arent suljstance. This syncytium, cut in various directions, gives 
 the giant-cell appearance so often described, protoplasmic masses filled with 
 nuclei, in the ]ilacenta; in short, it is merely a reproduction of the outer, 
 probal^ly maternal, layer of chorionic e])itholiuni. ^"o traces of ])lood- vessels 
 are to be found nnd no I'dicnhiin. Tlic cpitliclioid colls and syncytial 
 masses arc ari-an^cd without an atti'inpt at foi'ination, without connection 
 witii suri'ounding tissues. The sarcomata liave \\\o, same blood si)aces, sui"- 
 rounded, however, by connective-tissue (•••lis witli a well-marked sti-oina, no 
 syncytium being ])resent; tlx' carcino-sai'coniala ])i'esent the; coml)ined 
 features of these two tumors. "When l)y cell proliferation the blood s|)a.ces 
 are obliterated, the tumoi- undergoes central necrosis. 
 
 Clinically, tJK; growth is of fi-ightful malignity, (h^ath usually occui-i-ing 
 within six months aft(ir tin; first a|)pearancc of sym])toms. It soon in- 
 filtrates the uterine well, destroying it, entering th(.' blood stream, and re- 
 ])rodMcing itself in other ])arts. In view of the iniilignity of decidnoma, 
 
THE PREiMATURE I^'TERRUPTION OF PREGNANCY. 143 
 
 earlv diagnosis is imperative, and in cases of haemorrhage late in the puer- 
 ])erium or jnst following it, especially in a hydatidiform ])regnancy, curet- 
 taa'e of the uterine cavitv should be done at once. If traces of deciduoma 
 malignum are found, the uterus should be at once extirpated, if it is not 
 already too late. (A complete bibliography, with illustrative histological 
 plates, will be found in Williams's ^^ article.) 
 
 Conditions of the Ovum, Embkyo, and Fcetus, and Pkesentation of 
 THE Fcetus, in oue 635 Cases of Untimely Intekkuption of Preg- 
 nancy. 
 
 Early Abortions. — Our statistical tables shovr that the ovum in our 242 
 cases of early abortion was expelled unruptured in only forty-two instances, 
 or one-sixth of all cases; that in sixty-nine instances rupture of one or 
 more envelopes of the ovum occurred before expulsion, resulting in an ex- 
 pulsion in a more or less broken-up condition, in one or other of the 
 mechanisms already pointed out in foregoing sections. 
 
 Expulsion or the Ovum in Eakly Abortions. 
 
 Cases. 
 
 Ovum expelled unruptured 42 
 
 Ovum expelled broken up 69 
 
 ]^ot noted on histories 131 
 
 Total 242 
 
 Our tables further show that of our 242 cases of earlv abortion, 162 
 were of the incomplete variety ; namely, the embryo had escaped, lea^n^ng 
 behind the whole or a part of the secundines, when the Hospital official 
 made his first visit. Further, of the 176 cases in which, when first seen, 
 the embryo had escaped, only 14 were considered, from an examination of 
 the decidua, to be " complete ' ' abortions. 
 
 Regarding the nature of the remaining <6'6 cases, when first visited 48 
 were inevitable, of 12 we have no record, and 6 were threatened, but sub- 
 sequently, in spite of treatment, aborted. 
 
 Character of the Early Abortions when First Visited. 
 
 Cases. 
 
 Incomplete abortion 162 
 
 Inevitable abortion 48 
 
 Complete abortion 14 
 
 ISTot noted on histories 12 
 
 Threatened abortion 6 
 
 Total 242 
 
 Late Ahortions. — The statement found among most classical authors, 
 that, as a rule, in abortion the foetus has ceased to live before its expulsion, 
 
14-1: REPORT OF THE SOCIEfV OF THE LYING-IX HOSPITAL. 
 
 would a})peav to be strengthened by our observations, although some mod- 
 ern writers, notably of the French school, contradict this statement. 
 
 Condition of the Fcetls at Time of .1)1kth in Late Abortions. 
 
 Cases. 
 
 Still-born 106 
 
 Still-born and macerated 19 
 
 Lived a lew minutes 
 
 Lived a few hours 3 
 
 No record on histories -11 
 
 Total 1 
 
 iO 
 
 Spontaneous Premature Labor. — As regards the condition of the foetus 
 and the subsequent results for living children, we are at once impressed 
 with the very small proportion of children alive at birth that survived even 
 the short ]ieriod of attendance, which in spontaneous premature delivery 
 averaged 9 days and T hours. 
 
 After the establishment of a main Hospital Ijuilding in November, 1894, 
 when possible, cases of [)remature children were transfei'red to the Hospital 
 wards and placed in the couveuse. By referring to the latter portion of 
 our statistical table of premature labor, it will be seen that a number of 
 such children were so treated. While the number of children so treated 
 was small, still the results seen in even this small number were better than 
 those of the ordinary treatment of the tenement houses. 
 
 Condition of the Child at Time of Bikth in Peematuke Labor. 
 
 Cases. 
 
 Still-born 47 
 
 Still-born and macerated 43 
 
 Lived a few minutes 4 
 
 Lived some hours 25 
 
 Lived some days 53 
 
 Living wlien discliarged 32 
 
 No recoi'd on histories 34 
 
 Total 238 
 
 Twins, 20 cases. 
 
 In late abortions, as well as in spontaneous premature labors, the great- 
 est interest, to the writer at least, centres about the I'clative frequency of 
 the various pi'esentations of the foetus. We cannot but believe, as the re- 
 sult of an extended study of the literature of the subject, that this portion 
 of the pathology of llic premature interru]»1 ion of pregnancy has been sadly 
 neglected. 
 
 We find the repeated classical statemcnl tli;U at lull term vertex pre- 
 sentations obt;i in in '.».") i)(;i- cent, of cases, ;inil tlial the ])ercentage is much 
 
THE PREMATURE INTERRUPTION OF PREGNANCY. 145 
 
 less prior to tlie delivery of a mature foetus, but in what })roportioii few 
 have attempted to enlighten us. 
 
 We believe the statements of Matthews Duncan and the later ones of 
 Pinard are not dis])uted; namely, that during the first six months of gesta- 
 tion the superior segment or fundus of the uterus is more develo])ed than the 
 inferior, and, likewise, that during this period the head of the foetus is rela- 
 tively much larger than its bod^v. 
 
 Further, during the first two-thirds of pregnancy, by reason of the liquor 
 amnii, the foetus enjoys certain liberties and readily moves about and 
 changes its presentation and position ; but as the last third of gestation 
 progresses, the general movements become less and less, and the foetus 
 graduall}^ assumes what are recognized as its normal attitude, presentation, 
 and position. Up to the last third of gestation the total area of the uterine 
 cavity far exceeds that of the foetus, so that before this time and in the 
 early part of the last third the tendency to accommodation is not absolute 
 as it subsequently becomes. 
 
 Presentations of the Fcetus in Late Abortions. 
 
 Cases. 
 
 Cephalic presentation 11 
 
 Podalic presentation 11 
 
 Shoulder presentation 
 
 IS'ot noted on histories 153 
 
 Total 175 
 
 We observe in the foregoing table that of the 22 cases of late abortion 
 in which the presentation Avas noted, this number is equally divided between 
 cephalic and podalic presentations. This substantiates what we have 
 already said regarding the accommodation or adaptation between the 
 superior and inferior uterine segments and the relative size of the foetal 
 body and head. 
 
 Unfortunately, we have no records of the relative f requeue}^ of shoulder 
 presentation to compare with the above. 
 
 Our table shows, however, that in the fourth, fifth, and sixth months of 
 gestation, the foetus being quite movable in the liquor amnii, the superior 
 uterine segment being relatively larger than the inferior, and the foetal 
 head relatively larger than the body, the breech presents with equal fre- 
 quency as the vertex (11 to 11). 
 
 Turning now to spontaneous premature labor and comparing the pres- 
 entations here with those of late abortions, we observe a gradual increase 
 in the proportion of vertex presentations and a lessening of the proportion 
 of breech presentations. In the seventh, eighth, and ninth months of 
 pregnancy the adaptation or accommodation of the cephalic and podalic 
 extremities of the foetus to the corresponding smaller and larger uterine 
 segments respectively becomes more constant, and the foetus gradually takes 
 up the physiological posture of normal vertex presentation. 
 
 It will be observed, moreover, that while the number of shoulder pres- 
 
 10 
 
146 KEPORT OF THE SOCIETY OF THE LYIXG-IN HOSPITAL. 
 
 entations is ooi n ] )a rati vol y small (7 in 288 presentations), still the propor- 
 tion is much greater than that of t'nll-term delivery; namely, 1 in 34 
 presentations, as against 1 in 250 presentations. 
 
 Presentations of the Fcetus in Spontaneous Premature Labor. 
 
 Cases. 
 
 CVi)halic (vertex) presentation 129 
 
 Poilalic (breech) jiresentation 55 
 
 Shoulder presentation 7 
 
 Xot noted on histories 47 
 
 Total ~2SS 
 
 The above table includes twenty cases of twin delivery, and we append 
 the presentations in these cases separately, in the following table: 
 
 Presentations of the F(etus in Twenty Cases of Spontaneous Twin 
 
 Premature Labor. 
 
 Cases. 
 
 Both twins cephalic presentation 6 
 
 Both twins podalic presentation 4 
 
 One cephalic and one podalic presentation 7 
 
 One cephalic and one not noted 1 
 
 One podalic and one not noted 1 
 
 Xot noted on histor}^ 1 
 
 Total 20 
 
 Although, as we believe, little, if any, interest attaches to the subject, 
 still we append the sex of child in our 238 children born in spontaneous 
 premature delivery. 
 
 Sex of Child in Spontaneous Premature Labor. 
 
 Cases. 
 
 Male 107 
 
 Female 113 
 
 Xot noted on history 18 
 
 Total 238 
 
 We have endeavored, further, to establisli Irom our cases of spontane- 
 ous premature delivery th(; connection and relationship existing between 
 the vai'ious jjrosontations, according as tlic fo'tus be dead or alive. Tii the 
 total numljcr of 2;5s premature cliikh-en, including living, still-lK)i-n, twins, 
 and still-born and nuicerated, there were: 
 
 Cases. 
 
 Cephalic (vertex) presentation 121) or 54.20^ 
 
 Pochilic (breech) presentation 55 " 23.12ji^ 
 
 Shoulder prcsfntalion 7 " 2.95^ 
 
 jS'ot noted (.ii history 47 " 19.23^ 
 
 Total 238 
 
THE PRKMATrUE INTERRUPTION OF PREGNANCY. 147 
 
 111 the total number of 238 premature children, including the twenty 
 
 twin cases: 
 
 Cases. 
 
 Foetus was born living 114 or 4Y.89^ 
 
 Foetus was still-born 47 " 19.75^ 
 
 Foetus was still-born and macerated 43 " 18.07^ 
 
 Condition not noted on histories 34 " 14.29^ 
 
 Total 238 
 
 In the 114, or 47.89 per cent., cases of the preceding table in which the 
 foetus was born alive, we jfind the following presentations: 
 
 Cases. 
 
 Cephalic (vertex) presentation 75 or 31.50^ 
 
 Podalic (breech) presentation 22 " 9.24^ 
 
 Shoulder presentation 2 " 0.84^ 
 
 'Not noted on histories 15 " 6.30^ 
 
 Total 114 
 
 In the 47, or 19.75 per cent., cases of our table in which the foetus was 
 still-born, we find: 
 
 Cases. 
 
 Cephalic (vertex) presentation 22 or 9.24^ 
 
 Podalic (breech) presentation 14 " 5.88^ 
 
 Shoulder presentation 3 " 1.26^ 
 
 I^ot noted on histories 8 " 2.52^ 
 
 Total 47 
 
 In the 43, or 18.07 per cent., cases of our table in which the foetus was 
 both, still-born and macerated, we find: 
 
 Cases. 
 
 Cephalic (vertex) presentation 21 or 8. 
 
 Podalic (breech) presentation 15 " 6. 
 
 Shoulder presentation 
 
 ]^ot noted on histories 7 " 2.94^ 
 
 Total 43 
 
 From the preceding three tables we can construct the foUowdng: 
 
 Yertex. Breech, 
 
 Living children 31.50^ 9.24^ 
 
 StiU-born 9.24^ 5.88^ 
 
 Still-born and macerated 8.82^ 6.30^ 
 
 This table shows markedly the predominance of vertex presentations in 
 foetuses born alive (31.50 percent, vertex, and 9.24 per cent, breech, in 
 living foetuses) ; moreover, the sharp decline in the excess of vertex presen- 
 tations over breech when a still-born or still-born and macerated foetus 
 obtains (9,24 per cent, vertex and 5.88 per cent, breech in the former, and 
 8.82 per cent, vertex and 6.30 per cent, breech in the latter). 
 
148 REPORT OF THE SOCIETY OF THE LVIXlMN HOSPITAL. 
 
 It would 1)0 of interest at this point to stiulv the iulluence of tlic cause 
 of tlie premature deliverv ui)on the vitality and condition of the product 
 of conception at the tinu^ of bivth. Foi- exaini)le, what proportion of tlie 
 chiklren were born living, still-born, and still-born and macerated in 
 instances in which the cause of the interru])ted ])reg-nancy was known to 
 be faulty im])]antation of the placcMita (piun'ia), syphilis, and albuminuria 
 (toxa^m i a ) res | >ec t i vely 
 
 l)rit)n **^-' found that in vicious insertion of the ])lacenta the fo3tus was 
 born most fre(|U('ntly alive; in syphilis, almost always still-born and 
 macerated; and in albuminuria (toxaemia), the living and still-born children 
 were of about equal ])roportion. 
 
 Study and investigation in this direction ^vould doubtless aid us in the 
 ])reventive treatment of subsecpient interi'U})tions of pregnancy in those 
 instances in which only a suspicion of the real cause of the accident can be 
 obtained from the clinical history of a patient. Although our histories do 
 not i^ermit us in any l)ut a small ])roportion of our cases to state the cause 
 of the accident (see Etiology), still the above reference to the relationship 
 between the etiology and the condition of the child at birth is introduced 
 here in order that in future re]K)rts upon untimely interrupted pregnancies 
 the matter may be given due attention. 
 
 Bacteriology. 
 
 This division of the subject is introduced in the hope of forging an 
 additional link in the chain of argument in favor of the active procedure 
 adopted in most of our cases, as well as to place on record the results of 
 certain Imcteriological investigations which, to our knowledge, have not 
 ])reviously Ijeen made in pi'cmaturely interrupted deliveries both before and 
 after operation and at tlie end of the puerperium. Puerperal infection 
 is the same here, of course, as in full-term labors, sapra^mia or septictrmia 
 and pya-mia resulting from the invasion of sapro])li3^tic or j)athogenic organ- 
 isms in an identical fashion. Puerperal sapr^emia, a term iirst used by 
 ^[atthews Duncan,^ signifies a poisoning of the organism fi-om ])tomaines 
 resulting f)-oin ])Utrefaction processes in the l)irth caiud. Its a<lvocates 
 describe a com})lete symptom-complex f<j7' it. The saprophytes effect an 
 entrance usnally dui-inga prolonged and dilhcult labor, and A hi fold •'"makes 
 the statement that in well-conducted maternities the cases of fever from 
 auto-infection and sapraemia outnumber those in which there is a direct 
 contagion. Lately, this extreme view has been attacked. Pumm,-'" in 1SJ)1, 
 discovered streptococci in eight of eleven cases with a clinical history of 
 putrid endonu^tritis, and von Franque,^ in a typical case of sapraemia, 
 found f)n]y a ])ure cidturc of strc])tococci. lie iind Williams"'" regard the 
 condition :is i"ire in tlu; puerp(?rium. 
 
 No such uncertainty attaches to infectifni \>y pyogenic organisms. From 
 the time of the app(!arance in 18<ll of Semmehveiss's''" paper, opening the 
 (juestion, the doctrine; of infection in puerperal septicaemia has gained 
 ground; and. thanks to the labors of numerous inv(;stigators( May rhofer'"' in 
 1865, then Kin.Kleisch,''^ Recklinghausen,--' Waldeyer,** Klebs,« Orth,5« 
 
THE PREMATURE INTERRUPTION OF PREGNANCY. 149 
 
 Rpillman/" and otliers), the streptococcus was early recognized here, as in 
 otlier wounds, as the chief offender. Pasteur/^ in 1880, first cultivated it 
 from the uterus of a woman dead of childbed fever. He was followed 
 by many men (Friinckel,'"'^ AVinckel,^" Bumm,'"' Doderlein,^*' Winter,*'^ etc.) 
 whose names are a guarantee of their Avork. Brieger,^^ Czerniewsky,"^ 
 Fehling,^^ Hagler,^'' and Doderlein'^ have reported cases in which the 
 staphylococci were brought forward as the cause of mikler cases of puer- 
 peral septicaemia, following out their role in other wound infections, their 
 virulence being less than that of streptococci. Doderlein^^ has recorded 
 an epidemic in Leipzig in which the two were found together. These, how- 
 ever, are not the only pyogenic microbes concerned in the causation of 
 puerperal fever. Konig *^ has made a pure culture of gonococci from the 
 uterus in nine cases ; von Franque ^ found the bacillus coli communis in 
 pure culture in the uterus once; the bacillus proteus has been cultivated 
 from ovarian abscess and fatal peritonitis (Flexner^) caused by it, and 
 it seems probable that it will be found in cases of septicaemia, as Kuliscioff ^^ 
 surmised. Hej^se"*^ has recorded a case of puerperal tetanus in which the 
 bacilli were found in the woman's cervix and the dust of her room. 
 
 Having established the fact that these organisms may be concerned in 
 the origin of puerperal septicgemia, and granted the possibility of infection 
 by putrefactive germs, the question arises. Are they always introduced by 
 the attendant? Can a woman be infected by organisms which find their 
 habitat in her genital tract before delivery; i.e., suffer from auto-infection ? 
 Semmelweiss/*^ in the paper which laid the foundations of antiseptic mid- 
 Avifery, claimed that she might ; and he has had able supporters (Ahlfeld,^^ 
 Kehrer,"' Kaltenbach,^^ etc.). Working along this line, investigators have 
 reached various results; Gonner,*^** Thomen,™ and others failing to find 
 pathogenic organisms in women not previously examined, and Winter,^^ 
 DOderlein,^" Widal,'^ and Witte'^ discovering them in a large proportion of 
 cases. Yahle '^ finds that the vaginse of infants remain sterile for only 
 tAvelve hours after birth. At the end of three daj^s he discovered strepto- 
 cocci in 14.6 per cent., staphylococci in 4 per cent, of cases. Doderlein,^^ 
 however, in his consideration of 195 cases, succeeded in explaining the dis- 
 crepancy in these results. He discovered that there are tAvo A'^aginal secre- 
 tions, normal and pathological, the one containing yeast occasionally, epi- 
 thelium, and a non-pathogenic bacillus vaginae Avhich secretes lactic acid ; 
 the other, numbers of micro-organisms (streptococci in 10 per cent, of 
 cases). Williams ^^ has confirmed these results in 15 cases, 4 of Avhichwere 
 normal (55.3 per cent. Doderlein). In 8 cases, pyogenic microbes were dis- 
 covered. Witte,^^ of Berlin, reports 53 examinations on the same lines. It 
 must be granted that it lies within the reahus of possibility for these 
 pathological cases all to have childbed fever resulting from auto-infection. 
 HoAV can the enormous proportion (44.6 per cent. Doderlein) of these cases 
 be reconciled with the results obtained by Mermann,^^ who shows a mor- 
 tality of 6 per cent, in 900 labors, recording every fever over 100 degrees; 
 by Leopold,^^ Avho in 919 finds just 2 cases, or 0.21 per cent., in AA^hich there 
 was any possibility of auto-infection ; and by Hofmeier,'^ with a mortality of 
 
150 REPORT OF THE SOCIETV OF 111 K LVIXG-IX HOSPITAL. 
 
 o.«i per cent, in 2,000 cases ? ^lennaim used only sul)jecti\'e antisepsis; Leo- 
 })ol(l did not examine his women at all. It is ap])arent that something besides 
 the mere jiresence of pathogenic microbes is needed to ])roduce se])tica'mia, 
 Init what that something is we do not know. It is known, however, that 
 streptococci and st<iphylococci have been introduced into fresh wounds "with- 
 out result (Bossowskv,~' AVelch '^). Moreover, it is possible that the genital 
 secretion, e.(/., the lactic acid foi-mod by I)oderlein''s bacillus, as proved l)v 
 AVitte/- inhibits their activity, for pure cultures of streptococci have been 
 found by Czerniewsky ® and von Franque** in healthy uteri. Kronig'^ 
 has added by his researches further confirmation to this theory of inhibi- 
 tion. His cases number forty-eight. In them he found that not only is 
 the vagintU secretion in normal pregnancy free from germs, but that it pos- 
 sesses actual germicidal power. This is true of both varieties of secretion, 
 normal aiul ])athological. Various organisms were introduced into the 
 vagina. Streptococci were destroyed first, staphylococci and pyocyanei 
 linng twice as long. The resisting power of the tissues is the same to 
 si)ores and cocci, the genital tract being free in two days, at the longest, 
 after introduction. His conclusion is, that ]:>rophy lactic syringing should 
 be given up even in cases of gonorrhoea, since this germicidal power is lost 
 thereby. liumm'*^ has recently stated that, aside from cases of acute 
 septic, gonorrhoeal, or tuberculous endometritis, chronic endometritis of 
 the body and neck of the uterus is not of microbic origin. In some in- 
 stances, microbes were found in the secretions, but never in the tissues, and 
 they must be regarded as chance visitors of no importance. He does not 
 believe that chronic endometritis is invariably due to acute or subacute 
 septic or gonorrhoeal infection, but grants that by microbic invasion the 
 secretion may become purulent. 
 
 Menge," discussing Bumm's statement, declared that in 71 examina- 
 tions of uteri removed in Zweifel's clinic, he has never found, either in the 
 secretions or tissues of the uterine or cervical cavities, any micro-organisms 
 capable of existence on ordinary culture media. The same holds true as 
 regards normal organs and in the prcisence of chronic endometritis. In 
 view of these careful investigations, it seems probable, at least, that the 
 uterus may, and often does, remain germ-free, even when the vaginal secre- 
 tion is ])athological, by virtue of its antise])tic power ; and the mystery of a 
 <».♦; j)er cent, mortality in 2,000 la])ors remains so no longer. Walthard ^" 
 expresses the idea in another way — that the cervical canal is the border 
 between those ])ortions of the genital ti'act which are free from l)acteria 
 and those which contain them, and Ixdieves with Bumm that the sapro- 
 phytic germs are non-viruhjnt on healthy tissue, but become ])aTasitic when 
 the resistance of tho.se tissues is diminislMid. The mechanism (»r labor 
 througliout is, moreover, such as to offej- tli(! least oi)])ortunity loi- tli(! en- 
 trance of organisms from the vagina and cervix into the uterus. AVith 
 regard to auto- inf(!ction as to saprajmin. wliilr its existence must be ad- 
 mitted, the number of actual cases is small enough to be ])assed ov(m\ 
 
 Twelve of our cases were examined bactcriologically, tube cultures 
 being ma<if in tin- usmil \v;iy, wifh ;i swiib. t liroii«;ii a stcrili/cd ^jlass lulx;. 
 
THE PREMATURE INTERRUPTION OF PREGNANCY. 
 
 151 
 
 from vagina and uterus, botli before and after o])eration and at the end of 
 the puerperium; four cultures in most instances, and in some, six, as cul- 
 tures at the end of the puerperium were not always obtained. The vagina 
 was found to be sterile in two cases of the 12; i.e., no growth of bacteria 
 appeared on the media. Of the pathogenic organisms occurring in six cases, 
 or 50 per cent. , the streptococcus appeared once Avith tlie diplococcus sub- 
 flavus of Bumm; the sta])hylococcus albus twice, with the bacillus coli 
 communis once, alone once; the staphylococcus aureus, once with the ba- 
 cillus coli communis ; the bacillus coli communis with the bacillus fluores- 
 cens liquefaciens once, besides the instances mentioned. Red yeast was 
 cultivated from one vagina, and Bumm's diplococcus albicans from another. 
 A plate exposed half an hour in the room of the patient in the first of the 
 latter two cases showed colonies of sarcina, red yeast, penicillium glaucnm, 
 staph^dococcus albus, and bacillus subtilis and liquefaciens. In one of the 
 cases in which staphylococcus albus and bacillus coli communis occurred 
 together, an air plate from the room showed besides various fungi only the 
 staphylococcus. (Two of the twelve tubes were broken in transit.) In 
 these examinations, then, the white staphylococcus figured three times, the 
 bacillus coli communis four times, the golden staphylococcus and strepto- 
 coccus once each. 
 
 Below is a table showing these results: 
 
 
 ORGANISMS FOUND. 
 
 Case 
 ISTumber. 
 
 VAGINA. 
 
 UTEKUS. 
 
 
 Before 
 Operation. 
 
 After 
 Operation. 
 
 Before 
 Operation. 
 
 After 
 Operation. 
 
 7,211 
 7,465 1 
 
 7,683 
 
 7,177 
 
 7,167 -j 
 7,"l07 
 7,034 1 
 
 7,029 1 
 7,022 
 
 Red yeast. 
 Staph, aureus. \ 
 Bac. coli com. j" 
 Sterile. 
 (Broken.) 
 Staph, albus. 
 Bac. coli com. 
 Diplococcus albic. 
 Staph, albus. j 
 Bac. coli com. f 
 Streptococcus. 
 Diplococcus subf. 
 Sterile. 
 (Broken.) 
 Staph, albus. 
 Bac. coli com. 
 Bac. fluorescens. 
 
 (Air plate.) 
 Sterile. 
 
 a 
 
 Staphylococcus \ 
 albus. f 
 Sterile. 
 
 Bacillus coli com. 
 
 \ 
 
 Sterile. 
 Sterile. 
 
 a 
 a 
 
 a 
 
 ii 
 
 a 
 
 a 
 u 
 u 
 
 a 
 
 Sterile. 
 Sterile. 
 
 a 
 
 a 
 
 a 
 a 
 
 f 
 
 a 
 
 6,924 
 6,909 
 
 6,891 1 
 
 Sterile. 
 
 a 
 
 
152 REPORT OF TIIK SOCIETY OF THE LYIXCMN HOSPITAL. 
 
 After operation, in seven enltures, live, or 71.4 per cent., were sterile, 
 the other two showing bacillus coli communis and staphylococcus once each. 
 Thirteen examinations of uteri were made before operation without tlie dis- 
 covers' of an organism of any kind, and the same result was obtained in 
 eleven instances immediately after o])eration. One culture made from the 
 vao"inal fornix, at the end of the ]merperium, showed the white staphylo- 
 coccus. 
 
 Case 6,880 gave sterile culture from the uterus before operation; case 
 6,915, staphylococcus albus in the vagina at the end of the puerperium ; 
 case 6,855 showed the same in the vagina, the uterus being sterile at the 
 end of the puerperium. 
 
 These investigations bear out in a striking way Doderlein's^ assertion 
 that the uterus of tlie normal lying-in wonum is germ-free. No division 
 was made in them into normal and pathological, but it seems fair to infer 
 that, even in the ])resence of a pathological vaginal secretion, the uterus 
 mav jiersist in its freedom from invasion. No mention is made l)y the 
 l)acteriologist of the vaginal bacillus of Doderlein. The occurrence of the 
 bacillus coli communis is in greater proportion than previously reported (25 
 ]jer cent.); this is not a surprising condition, however, considering the 
 ]iroximity of the rectum, its ordinary habitat. Buimn'^^ declares that 
 inoculation upon animals is necessary to prove the virulence of these organ- 
 isms, and he seems to be correct, in view of the minute proportion of auto- 
 infection in Mermann's and Leopold's reports. It has not been done in 
 anv of our cases, but it is interesting to compare the clinical histories Avith 
 the bacteriological findings. 
 
 Case 6,855. — Abortion (?). Foetus passed forty-eight hours before 
 examination. Placenta and membranes found in uterus and removed manu- 
 ally, rterus curetted. Douche of sublimate solution (^oVir) and packing 
 of iodoform gau/.e. Ten days later, a culture from vagina showed staphylo- 
 coccus albus, uterus sterile. No fever. (Absence of fever in presence of 
 sta])hylococcus albus.) 
 
 Case 6,SK0. — r)'imii)ara; seventh month gestation; seen in second stage 
 of laijor, which lasted nine hours. Tem])erature, 101.2 degrees; pulse, 107 
 when seen; placenta manually extracted, adherent, markedly fatty, and 
 tf^rn in extraction. Duration of third stage, thirty minutes. Pieces of 
 placenta left in uterus removed as far as possible. Twenty- four hours 
 later, temperature, 103; ])ulse, 120. Chloroformed, external genitals and 
 vagina cleansed with lysol (five per cent.) and sublimate solution {i^^^). 
 Uterus curette<l with dull curette. Pieces of placenta and nu;ndn'anes 
 brought away. Irrigated uterus with sublimate solution (s^oo) and ])acked 
 it with gauze, ('hill immediately followed. Temperature, 104 degrees; 
 pulse, 120. Temperature, 101 to lo;5 degrees for four days. Gauze 
 removf;<l on second day. Examination sIiowcmI ut(!rus bound down, and 
 ));ir;ini<;tritis. After treatment, intrauterine and vaginal douches. No 
 fouliHJSsof lochia. Discharge on tenth day. No ])yrexia,. Pulse normal. 
 Culture from uterus showed absence of any organisms hefore operation. 
 (F'ever, with no oi-ganisms ])resent in iitciiis.) 
 
THE PltEMATURE INTERRUPTION OF PREGNANCY. 153 
 
 Case 6,891. — II. pcara, age 31, tliii'd iiionth. Al)ortion brought about 
 by strain forty-eight hours before being seen. Bleeding and pain. Uterus 
 sensitive, large, antefiexed ; shreds of membranes hanging from os. Cul- 
 ture from vaginal fornix showed colonies of bacillus coli communis and 
 bacillus tluorescens non-liquefaciens. Cervix dilated with sterilized Good- 
 ell dihitor, and culture taken from fundus, which was foand to be ster- 
 ile. Uterus irrigated Avith sublimate solution (soVu) ^^^^^^ curetted with 
 dull and sliarp curette. ISTo foetus found. Pieces of membrane removed. 
 After operation, culture from fornix, which remained sterile. Yagina 
 previously wiped with absorbent cotton. Uterus ])acked with iodoform 
 gauze. Removed after seventy-two hours. Discharged on fifth day. No 
 pyrexia. (Bacillus coli communis present, without fever.) 
 
 Case 6,915. — lY. para, fourth month. First seen August 20, 1894, at 
 11.30 A.M. Temperature, 101 degrees; pulse, 72. Headache and dizziness 
 for two weeks past. Hasmorrhage and pain during last twenty-four hours. 
 External os open. Seen again after seven hours. Yagina filled with clots. 
 Os admits two fingers, and membranes protrude. Ovum removed intact. 
 Temperature, 99.2 degrees; pulse, 80. After five and a half hours, ether 
 given and uterus curetted. A few pieces of membrane and clots removed. 
 Uterus irrigated with sublimate solution (t 0^017) ^^^ packed with iodoform 
 gauze. Gauze removed after five days. No fever after curettage. No 
 fetor in lochia. Discharged on tenth day. Culture made from posterior 
 fornix at end of puerperium showed staphylococcus albus. (jSTo fever 
 after curettage with staphylococcus present.) 
 
 Case 6,924. — YII. para, age 30. One previous abortion. Third month. 
 Firstseen August 21, 1891:. Temperature, 100 degrees; pulse, 108. Yagina 
 full of clots. Placenta protruding from os. Culture from posterior fornix 
 broken in transit. External genitals and vagina cleansed with soap and 
 water, lysol solution (five per cent.), and sublimate (tijott)- Culture from 
 fundus of uterus sterile. Placenta removed, uterus curetted, and irrigated 
 with sublimate solution (-g^oVo^)- Second culture from fundus uteri and fornix 
 both sterile. Curetting removed several pieces of membrane. Uterus 
 packed with gauze, which was removed after seventy-two hours. Tempera- 
 ture, 100.6 degrees; pulse, 114 on third day; temperature, 101.8 degrees; 
 pulse, 107 on sixth day. Constipation throughout puerperium. No odor 
 from lochia. Discharged on eleventh day. (Fever, with sterile cultures.) 
 
 Case 7,022. — II. para, age 24, third month. First seen September 3, 
 1894, at 1.30 a.m. Found patient suffering from heemorrhage, w^th foetus 
 lying in bed. Pain and hgemorrhage for five hours. Packed with iodoform 
 gauze, which was removed after ten hours, and placenta found in os. Cul- 
 tures from fornix and fundus both sterile. Uterus irrigated, curetted, 
 irrigated again, and second culture taken from it also sterile. Placenta 
 and membranes rotten ; foetus evidently dead some time previously. Gauze 
 removed from uterus at end of forty-eight hours. No record of pulse and 
 temperature before operation; afterwards, pulse, 106; temperature, 101.1 
 degrees. Fever undoubtedly present when first seen. (Fever case, with 
 rotten decidua, but no bacteria or other organisms discoverable. ) 
 
15-4 REPORT OF THE SOCIETY OK THE LYIXG-IX HOSPITAL. 
 
 Case 6,900. — II. para, a^o 10. When first seen, fivtus found in bed, 
 vao-ina filletl with clots, ami idacenta in cervix. Vau-ina packetl with 
 sterilized gauze. After ten hours, operation under ether. Genitals and 
 vagina cleansed in usual way. Uterine douche of bichloride (Wuir)- 
 Scraped with dull curette and decidua removed. Again douched with sub- 
 limate solution. No fever. Discharged on seventh day. Culture from 
 vagina before operation showed staphylococcus albus. Other three cul- 
 tures sterile. (No fever in presence of staphylococcus albus.) 
 
 Case T,o20. — A^II. para, age 32, two and one-half months. Seen first 
 September 3, ISO-t. Gave history of pain and luemorrhage for a few days 
 past. Had passed pieces of decidua. Curettage shortly after. Decidua, 
 but no foetus, removed. Uterus packed Avith gauze, whicli was removed 
 four days after. No fever. Discharged on seventh day. The stre])- 
 tococcus and diplococcus subflavus were found in the vagina before o])- 
 eration; the uterus sterile throughout. (Xo fever. Stre])t()coccus in 
 vagina.) 
 
 Case 7,034. — III. para, age o-t, fourth month. Seen September 3, 
 181I4. Ibemorrhage for week past. Sharp lijemorrhage at time of visit; 
 teni])ei'ature, 100 degrees; ]mlse, Oo. Foetus at vulva attached to placenta. 
 Uterus curetted, removing decidua. Uterus and vagina packed with gauze, 
 which was removed in four days. No pyrexia, no lochial odor. Dis- 
 charged on eleventh day. Culture from vagina before operation showed 
 Ijacillus coli communis with staph^dococciis albus ; after operation, bacillus 
 alone, while uterus remained sterile. (Virulent pathogenic organisms, 
 with no fever.) 
 
 Case 7,107. — A"IL para, age 3o. Seen September 13, 1801:. Bleeding 
 for one week. Treated by midwife and private physician. Pale, exsan- 
 guinated, chills; temperature, 00 degrees; pulse, llo. Uterus one and one- 
 half inch above pubis, and sensitive. Cervix hard and closed. Vagina 
 hot and dry. Curetted. Decidua and small ]iiece of ])lacenta removed. 
 Packed. No fever, no tenderness of uterus. Diplococcus albicans of 
 Bumni found in vagina before operation. No organisms discovered there 
 afterwards. (No fever and no pathogenic organisms.) 
 
 Case 7, Km. — X. para, age 4-2, eighth niontli. Placenta adherent to 
 uterine wall and manually removed. Douched with sublimate solution 
 (rslooj- T('m[)('i-atui'(' a few hours aftei- labor, lol.l- degrees; pulse, '02. 
 Temperature, lol to Jo:^, degrees for foui- davs. Tliii-d day, tympanitic 
 and tende*r abdomen. I.ai-ge, soft uterus. Cui-cttc^d, I'emoving small 
 pieces of deci<lua; douched and packed uterus. Ciauze removed on fourth 
 day. Tem]>erature, lOl degrees on liHii day. Discharged on eleventh 
 day in fair condition. The staphylococcus albus t'ouiul in vagina before 
 an<l after operati(jn ; bacillus coli couiuniiiis in (•()iMl)inati<m before. 
 Uterus sterile. (Fever. se|)ti<;eiiHa. willi b.icjiiiis cdM .ind sta])hylococcus 
 ]jresent in vagina. ) 
 
 Ca.se 7,177. — II. ])ara, age li'.'. iliinl uioulli. Midwil'c in aLtondance 
 two days when seen. Fterine lia-inorriiage ])ersistent. Uterus curetted, 
 douched, and |)acked. (liiu/.e rcinoNcd in t'oui' d;iys. Xo fever. No 
 
THE PREMATURE INTERRUPTIOX OF PREGNANCY. 155 
 
 lochial odor. Discharged on tenth day. Tul^e from vagina before opera- 
 tion broken; other three cultures sterile. (Xo fever, no organisms.) 
 
 Case 7,683. — III. para, age 28, fourth month. Foetal head found pro- 
 truding from vagina. Foetus removed manually, placenta and memljranes 
 adherent. A few hours later curetted, washed, and packed uterus with 
 gauze, which patient removed, substituting a sponge. ISTo fever. Dis- 
 charged in good condition. Sterile cultures throughout. (Xo fever. Xo 
 organisms.) 
 
 Case 7,165. — Four previous abortions. Three and one-half months. 
 Pain and haemorrhage. Yagina full of clots. Uterine cavity three inches 
 lono-. Foetus and placenta found in clots discharged. Curetted, douched, 
 and packed. Gauze removed on third d?ij. Lochia sweet. Xo fever. 
 Discharged eighth day. Culture from vagina before operation showed ba- 
 cillus coli and staphylococcus aureus ; the other three sterile. (Xo fever, 
 with bacillus coli and staphylococcus aureus present.) 
 
 Case 7,211. — TV. para, age 26; third month. Had bled profusely. 
 Vagina packed with gauze. Four hours later uterus scraped, douched, and 
 packed. Mass of decidua removed. Xo fever or other complications. 
 Patient removed gauze on third day, and refused further treatment. Eed 
 yeast only was found in the four cultures, although a plate exposed to air 
 of room showed colonies o| staphylococci. (Xo fever and no pathogenic 
 organisms.) 
 
 These fifteen histories furnish some curious data and not a little^ food 
 for reflection. Among them we find an absence of temperature above 
 100.5 degrees and of other svmptoms of infection in childbed no less than 
 seven times {4:6.6 per cent, of cases, or nearly one-half), when organisms of 
 whose virulence under ordinary conditions there can be no doubt Avere 
 found in the vagina before and often after operation, possibly continuously 
 present. If any inferences can be drawn from so small a number, there 
 must be some virtue in genital antisepsis, or else vaginal secretions dimin- 
 ish to a marked degree the pathogenic power of these microbes. Hardly 
 less striking are the three cases (20 per cent.) in which fever and, in case 
 7,022, a marked degree of septiceemia with putrid decidua occurred with- 
 out a growth of any kind appearing on the media. Four times the nat- 
 ural order of coincident absence of fever and micro-organisms appeared 
 (26.6 per cent.), and once, that of presence of the two (6.6 per cent.). In 
 other words, of the fifteen cases, four had symptoms of septic infection 
 and one only showed pyogenic microbes in her secretions. There Avas no 
 interference by midwives in this instance, and the continuous presence of 
 the staphylococcus albus in the vagina, with the addition of the bacillus 
 coli, before operation at least, appears to offer some ground for the theory 
 of auto-infection. 
 
 A chapter on the bacteriology of the lying-in period cannot be consid- 
 ered complete without some mention of the gonococcus. It was not found 
 in our observations, the people from whom they were drawn enjoying a 
 remarkable immunity from venereal disease. The present state of our 
 knowledge of gonorrhoea of the uterus has been satisfactorily summed up 
 
156 KEPORT OF THE SOCIETV OF THE LYING-IX HOSPITAL. 
 
 bv AVortlioiin ^' at the recent meeting of the German Gyna?colog-ical Society. 
 His dethictions are these: next to the urethi-a, the uterus is the most fre- 
 ijuent seat of disease. Infection is usually direct, and is often confined to 
 the uterus alone. Gonorrhcval vaginitis is comparatively a rare aflfectiou. 
 An acute and chronic stage of uterine gonorrhcva is clinically distinguish- 
 able, although a sharp line caniu^t be di'awn l)et\veen them. Infection 
 gives rise to ])urulent endometritis, the secretion containing numberless 
 cocci; but as the discharge lessens, they become fewer, and are replaced by 
 other bacteria. AVertheim found cocci in eight of eighteen uteri removed, 
 faOing to discover them in six cases with clear history. There is almost 
 always an acute interstitial endometritis ])resent, resulting finally in iutil- 
 tration of the muscle, with hyperplasia of the vessel walls, and a replace- 
 ment of the muscle fibres by connective tissue. Enlargement and pain in 
 the organ are evidences of this condition. In a certain number of chronic 
 cases there is, besides an increase of the glandular structure, glandular 
 endometritis. Inflammatory change becomes less marked as the external 
 OS is a)))iroached. Gonococci are found most readily in the mucosa, with 
 difficulty in the deeper tissues. Mixed or secondary infection is as rare as 
 in gonorrhceal salpingitis. The internal os offers no barrier to the ascent 
 of the process, shown by the presence of cocci in the endometrium when 
 the adnexa were apparently healthy (five cases examined). Exacerbations 
 are due t(j menstruation, coitus, and intrauterine treatment, dependent on 
 alterations in the nutritive medium, although there is always a possibility 
 of reinfection. The puerperium is a peculiarly unfavorable state, since an 
 invasion of previously unaffected parts takes place frequently. 
 
 Etiology. 
 
 A study of our (535 cases of the imtimel}' interruption of pregnancy 
 shows that the causes of the accident have but rarely been positively ascer- 
 tained. It must be remembered in this connection that all of the G35 cases 
 treated were cared for in an outdoor dispensar}' practice, in the patients' 
 own homes; that the majority (see Table of Nativity) was made up of the 
 ignorant foreign ])0]uilation of rlic lower East Side of the city, many of 
 whom liad been but a short tinu; in this country, and, through ignorance, 
 were unal)le to give anything approaching a definite history regarding the 
 character of tlieir ])rec(!ding interrupted pregnancies, lal)ors at term, })uei-- 
 peria, or ])re(!xisting uterine disease. 
 
 Kecords of the evidence of preexisting oi- ])r('sent disease of the uterus 
 are lacking in most of oui- liistories, and tliis fact is ])artly explained ])y the 
 nature of our service and the com jia rati vely short time that ])ati(;nts Avould 
 8ul)mit to treatment. For example, the avei'age duiution of after-treat- 
 iiHMit wiis as ioljows: 
 
THE PREMATURE INTERRUPTION OF PREGNANCY. 
 
 157 
 
 Average Duration of Treatment.* 
 
 Early abortions 7 days 8 hours. 
 
 Late abortions 7 days 21 hours. 
 
 Premature labors 9 days 7 hours. 
 
 The first visit and first examination of the patient in our early and late 
 abortions were usually made by one of the resident staff officers, after the 
 lapse of a considerable period from the onset of the first symptoms. This 
 is shown in the subjoined table: 
 
 Duration of Symptoms when First Seen. 
 
 EARLY ABORTIONS. 
 
 129 Observations. 
 
 LATE ABORTIONS. 
 
 57 Observations. 
 
 Average duration 
 Longest " 
 Shortest " 
 
 3 days 22 hours. 
 3 weeks. 
 10 minutes. 
 
 6 days 19 hours. 
 
 7 weeks. 
 1 hour. 
 
 The staff physician at this first examination endeavored to ascertain 
 only those conditions which call for immediate treatment; for instance, in 
 abortion the amount of hgemorrhage and the character of the abortion. In 
 this way the more minute changes in the condition of the uterus and its 
 appendages, which are associated with preexisting or present uterine 
 disease, escaped observation. This fact is true of our earlier cases, but 
 only partly true of our later ones. For since the appointment of a bac- 
 teriologist to the Hospital in 1894, bacteriological examinations of blood, 
 of uterine and vaginal secretions, both before and after operative interfer- 
 ence, have been made. Moreover, decidual scrapings have been preserved 
 and subjected to examination for evidences of disease (see Bacteriology and 
 Pathology), 
 
 * Duration of Treatment. — Abortion Cases. 
 
 
 early abortions. 
 206 Observations. 
 
 late abortions. 
 157 Observations. 
 
 Average duration 
 
 7 days 8 hours. 
 28 days. 
 Iday. 
 
 7 days 21 hours. 
 18 days. 
 Iday. 
 
 Longest " 
 
 Shortest " 
 
 Duration of Treatment in Spontaneous Premature Labor Cases. 
 In 143 Observations. 
 
 Average duration, 9 days 7 hours. 
 Longest " 40 days. 
 
 Shortest " 1 day. 
 
15S REPORT OF THE SOCIETY OF THE LYING-IN HOSPITAL. 
 
 Umluubtodly [)artit-ular stress sliuukl be laid upDii certain anomalies 
 c»i'curring in previous untimely interruptions of pregnancy, labors at term, 
 and puerperia, as these usually are the first expression of beginning uterine 
 disease or the direct ])recursor of such, but unfortunately our histories for- 
 bid anv accurate statements in this dii-ection. As has been frequently 
 pointed out by different observers,* a striking feature in the study of etioL 
 ogv is the number of preceding premature interru]itions of pregnancy. 
 
 To render this point more gra[)hic in regard to our cases, "we have con- 
 structed the following tiibles. 
 
 Pkkvious Untimely Intekkuptions of Pregnancy in Abortion Cases. 
 
 23 alK)rtion cases experienced 1 previous abortion. 
 
 (*) •• " " 2 '' abortions. 
 
 1 .. a u 2 u u 
 
 1 '' case " 4 " " 
 
 2 " cases " 5 " " 
 
 9 u u i( Q i( i( 
 
 38 
 
 54 abortion cases experienced . . 1 previous premature labor. 
 17 " " " . . 2 " " labors. 
 
 -IK i' a i( 3 " <' '' 
 
 -19 a u (I A u a ii 
 
 I u a a K a a a 
 
 1 " case " .. 6 " " " 
 
 103 
 
 Total number of al)ortion cases that experienced previous abortions, 3.8, 
 or IM ])er cent. 
 
 Total number of abortion cases that experienced previous premature 
 labors, lo;^>, or 24.7 per cent. 
 
 Total number of abortion cases that experienced previous untimely 
 interrupted pregnancies, 141, or ?A ])er cent. 
 
 Previous Untlmklv 1n'ikkki;i'ti<jns of Pregnancy in Premature Labor 
 
 Cases. 
 
 13 premature labor cases experienced ... I ]>revious abortion. 
 1 " " case " ... 2 " abortions. 
 
 15 
 
 * Winckel and Stumpf found among' 15.5 of flipjr multipara^ who aborted, 59, or .'{8 
 |)fr f<Mit., wln) liad previously suffered from iiiU-rruplcd prcj^uaiicics ; amouj,'' 1)1:^ willi 
 immature lab«a', 2i'>, or 28.5 percent. ; wmon^ JOI witli ])remature labor, 18, or 17.8 per 
 cent. ; and in 8 of tliase 103 ca.ses with precedinj? untimely labors, every pregnancy 
 had been a |»rfmatur<' f»Me ; .'5 were .'iliortions. I iinin.ifun' l.ibors, and only 1 prema- 
 ture lalxir. 
 
THE PREMATURE INTERRUPTION OF PREGNANCY. 159 
 
 17 premature labor cases experienced 1 previous premature labor. 
 
 (3 
 
 
 
 a 
 
 
 2 
 
 
 lab( 
 
 8 
 
 
 
 iC 
 
 
 3 " 
 
 
 (( 
 
 1 
 
 
 
 case 
 
 
 4 " 
 
 
 a 
 
 1 
 
 
 
 u 
 
 
 5 " 
 
 
 (( 
 
 1 
 
 
 
 ii 
 
 
 6 " 
 
 
 ie 
 
 Total number of premature labor cases that experienced previous abor- 
 tions, 15, or 6.9 per cent. 
 
 Total number of premature labor cases that experienced previous prema- 
 ture labors, 41, or 20.2 per cent. 
 
 Total number of premature labor cases that experienced previous un- 
 timely interruptions of pregnane}^, 59, or 26 per cent. 
 
 The most strikiuo- fact shown in the foreo-oino^ tables is the large num- 
 ber of previous untimely interruptions of pregnancy in our cases ; for, as 
 the tables show, among 417 women who aborted (using the term in its 
 broad sense), 141, or 34 per cent., suffered from previous premature inter- 
 ruptions of pregnancy; and among our 218 cases of premature labor, 59, 
 or 26 per cent. , experienced previous untnuely interruptions of pregnancy. 
 
 Again, the fact that those patients who aborted, and not the premature 
 labor cases, were those who previously had suffered most from former pre- 
 mature interruptions of pregnancy (34 per cent, as against 26 per cent.), 
 substantiates the well-known axiom, referred to in another place in this 
 article, that the longer existence of uterine disease leads to an ever earlier 
 interru])tion of pregnancy. 
 
 Traumata and fright were frequently averred by our patients as excit- 
 ing causes of interrupted pregnancy; but such statements, coming from the 
 patients themselves, have generally been disregarded. 
 
 Criminal Abortion.— The suspicion of criminal abortion was attached 
 to a number of the cases here studied, but in what proportion criminal 
 interference entered as an etiological factor is unknown. 
 
 Although in only 21 of our 417 cases of abortion do the histories indi- 
 cate that mid wives were in attendance, still we have reason to believe that 
 the midwife was responsible for a number of these premature interrup- 
 tions of pregnancy. It is a significant fact that the professional card of 
 a midwife was frequently found in the patient's apartment upon the arrival 
 of the physician from the Hospital. 
 
 We have ascertained that the most common method of criminal inter- 
 ference among the patients studied in this article is for the midwife, or the 
 patient herself, instructed previously by the midwife, to rupture the mem- 
 branes by means of a knitting-needle passed through the os. One drug- 
 gist on the lower East Side is said to do a large business in tupelo tents 
 sold to midwives; for what purpose can easily be conjectured. 
 
 Statements of the more intelligent midwives are to the effect that the 
 Italians of the district covered by this report make use of the oil or the 
 fluid extract of sabina (Juniperus sabina) to terminate an inconvenient 
 
ICU REl'OKT OF THK SOCIETY OF THE LYING-IX HOSPITAL. 
 
 pregnancy, ami, fiirthor, that the ilrug accoini)lishes the desired result 
 within twenty-foui* hours of the first dose. 
 
 In none of our eases was legal incjuirv set on foot, since direct i)roof of 
 criminal interference could never be obtained. 
 
 Porak,^ from his study of his 320 cases of early and late abortions, 
 could ascertain the cause of the accident in but few instances, but found 
 the most frecjuent anatomical cause to be alterations in the decidua, result- 
 ing in thickening and strong adhesion of the decidua to the uterine wall, 
 after expulsion of the ovum. 
 
 The microsco])ic examination of the decidual scrai)ings in our cases was 
 only set on foot towai'd the end of our series of 4-17 cases, and we have 
 reports of only seven cases to offer, the findings in Avliicli are practically 
 negative. (See Pathology.) 
 
 Porak^ found the accident, in his remaining cases, due to traumatism, 
 32; sN'pliilis, 32; mental emotions and fatigue, 22; retroversion of the 
 uterus, 13; cardiopathy, 13; typlioid fever, 13; pulmonary tuberculosis, 
 13; albuminuria and eclampsia, 12; twin ])regnancy, 10; defective inser- 
 tion of the ovum, 10; and scrofula, 8, 
 
 Prion's ^ critical study of 530 cases of abortion is most instructive, as 
 well as interesting. In only 163 of his 530 cases, or about one in four, 
 was he able to ascertain the cause of the accident. 
 The causes in the 1G3 cases were as follows: 
 
 Cases. 
 
 Faulty insertion of the placenta 64 
 
 Syphilis 52 
 
 Albuminuria 2Y 
 
 Hydramnios 13 
 
 Malformations and nuilposirious of tlic uterus 7 
 
 Total 163 
 
 Prion narroAvs down the causative factors to the above mentioned, and 
 draws attention to the fact that in 143 of his 163 cases of abortion the 
 causative factors Avere (1) faulty insertion of the placenta, 64 cases; (2) 
 syphilis, 52 cases; (3) albuminuria, 27 cases. lie refers to the statement 
 of liaudeloque, namely, that " the insertion of the placenta near the cervix 
 provokes abf)rtion," and to the recent teachings of Pinard, who insists upon 
 the influence of a faulty insertion of the phicenta at tlie internal os as a 
 fre(juent causative factor in tli(! ])roduction of an al)()i'tion. 
 
 Prion's^ conclusions r(;garding the 64 cases of faulty insertion of tlie 
 placenta are founded u[)on carcfid inspc^ction and measunjuunits of tlie 
 membranes in each case. Tlic into'cst in liis study centres around the two 
 conditions — faulty or ](>\v iniphintation of the; phicenta,, and albuminuria 
 (t<jxa'miaj, as tln" two main (-lusative factors in tlu; (etiology of his cases. 
 His conclusions in this direction were the result of m(!thodical and ])ains- 
 taking examinations of the decidua. ])lacenta, membranes, and mine in 
 every woman under his charire- 
 
 Acc*^>rding to Pinard and i't liling, r<;nal alterations (insufficiency, 
 
THE PREMATURE INTERRUPTION OF PREGNANCY. 161 
 
 nephritis) cause decidaal liremorrhages, and the character of the abortion 
 will de[)end upon the quantity or the greater or less repetition of these 
 haemorrhages, 
 
 Brion^- does not pretend to limit the etiology of abortion to these 
 three causes (faulty insertion of the placenta, syphilis, and renal disease), 
 Init merely aims to show what in his opinion are the most frequent causes. 
 He predicts that the more carefully we study the etiological factors of our 
 cases the fewer will we find falling outside of these three causes. He 
 pleads, moreover, for a future consideration of these three causes in formu- 
 lating the etiology, prognosis, diagnosis, and treatment of abortion. His 
 studies induce him, when in the presence of an abortion, the cause of 
 which is not evident, not to ascribe the condition to criminal interference. 
 
 It ma}" here be asked what were the etiological factors in our 417 cases 
 of abortion. "We reply we do not know. "We do not know, because few, 
 if any, of our cases were under observation at the onset of the attack ; 
 because it was not granted to us to make urinary analyses before the occur- 
 rence of haemorrhage; and because, in our earlier cases, postpartum exami- 
 nations of the urine were not made; and because the results in the few 
 recent cases in which the urine was examined, were practically negative. 
 
 In only six instances of the 242 early abortions was the Hospital phy- 
 sician summoned at the time the abortion was threatened; in only 48 
 was the condition inevitable; so that in the remaining 188 cases the 
 conditions were those of complete (14) or incomplete (162) abortions. 
 
 In late abortions our histories indicate only the following conditions as 
 the probable causes of the accident : 
 
 Causes of Late Abortions. 
 
 Cases. 
 
 Death of foetus (cause unknown) 106 
 
 Death and maceration of foetus (cause unknown) 19 
 
 Multiple (twin) pregnancy 2 
 
 Fault}" implantation of placenta (previa) 2 
 
 ]^ephritis and cardiac disease 1 
 
 Acute syphilis and cardiac disease 1 
 
 Albuminuria (toxaemia) 1 
 
 Ketroflexion 1 
 
 Hydatidiform mole 1 
 
 Alcoholism 1 
 
 UnknoAvn cause 40 
 
 Total 1T5 
 
 Spontaneous Premature Labor. 
 
 In spontaneous premature labor, on the other hand, the cause of the 
 
 accident was quite frequently determined, for the reason that, as a rule, 
 
 these of our cases were first seen by a Hospital official either in the first or 
 
 second stage of labor. Thus, the following table indicates the period in 
 
 11 
 
102 REPORT OF THE SOCIETY OF THE LYING-IN HOSPITAL. 
 
 the progress of labor at wliicli (.mv 218 cases of spoutaueous preniatiire 
 
 labor were first visitet I: r^ 
 
 Cases. 
 
 In the first stage of labor 125 
 
 In the second stage of labor 58 
 
 In the third stage of labor 20 
 
 Not noted on histories 15 
 
 Total 218 
 
 It will thus be seen that the majority (188) were under observation either 
 in the first or in the second stage of labor, and this fact enables us to for- 
 mulate the etiolog}' in a certain number of cases. The facts ascertained 
 appear in the following table: 
 
 Causp:s of Peematuke Labor. Cases 
 
 Death of fo?tus 47 
 
 Death and maceration of foetus 43 
 
 Multiple (twin) pregnane}^ 19 
 
 Faulty implantation of placenta (praevia) T 
 
 Faulty implantation of placenta, and twins 1 
 
 Albuminuria (toxaemia) 5 
 
 Syphilis 1 
 
 Syphilis and hytlramnios 1 
 
 Antepartum pneumonia 1 
 
 Pulmonary tuberculosis 2 
 
 Cause unlvnown 91 
 
 Total 218 
 
 Our etiological tables of late abortions and spontaneous premature 
 labors leave, as will be seen, the cause of the accident in a large number 
 of instances practically unknown, for the reason that the cause of foetal 
 death and maceration in the cases here studied is undetermined. 
 
 Tlie part played by paternal and maternal syphilis, b}?" toxaemia (albu- 
 minuria), and other causes of intrauterine death of the foetus which escaped 
 observation, we can only conjecture. That all causes which kill the foetus 
 may produce ])remature interruption of pregnancy, no one questions. 
 
 The large number (2ft) of multiple pregnancies found among the spon- 
 taneous ]iremature labors is iiitei-esting. Th(^ same may l)e said of faulty 
 ini))laiitatioii of the ])lacenta (8 cas(!s). 
 
 Pinai-d lias sho\v?i, as ah'cady I'eferred lo in (|no1ing ib'ion's statistics 
 of the causation of early aljortions, that s))oiitaiU'ous ])i'einature labor isdu(\ 
 in a large proporti(jM of cases, to tlie insei-tion of Ihc ])]aceiita in the; inferioi- 
 segment of the uterus. I'inaril has furl iM'rnioi'c sliown lliatthi^ ])r(Mna- 
 turc ru]»tui"e of the ni('iMb)-an(;s, wliicii, as a I'ule, ac(;o)ii panics a low im- 
 plantation of the placenta, is the (hitermining cause of the prenuiture 
 interruption of jtregnancy. 
 
 In regard to our 91 cases of spontaneous jirematun^ labor in which the 
 cause wa.s unknown, it jnust not be forgotten that certain women always 
 have short pregnancies, and children that, though undersized, do well. 
 
the premature interruption of prkgnancy. 1g3 
 
 Prognosis. — Complications. 
 
 1. IRvmorrh(uje. 
 
 Ilaenioi'i'liage is a complication of Importance. Misracbi '^ found in 1)2 
 cases the curette indicated for it 13 times, as against four cases of sepsis. 
 (Ilis controversy Avith Porak on this subject will be found reviewed under 
 Treatment. ) The statistics of our cases offer us no valuable data as to the 
 f requeue}^ of haemorrhage and the necessity of interference for it, since an 
 early intervention has been the custom of the Hospital physicians, this 
 having for its object not merely the prevention of sepsis, but subsequent 
 haemorrhage as well, in a class of patients prone to neglect abortions. Per- 
 sistent haemorrhage, though slight, induces a condition of weakness emi- 
 nently predisposing to infection later. Stumpf shows after-haemorrhages 
 in 4.1 per cent, of his cases under expectant treatment, and in 13.3 per 
 cent, of those manually treated. 
 
 A study of our statistical tables shows that haemorrhage as a prominent 
 symptom was noted in 207, or 85. 5T per cent, of our 242 cases of early 
 abortion before treatment. This agrees with what has already been stated 
 (see Classification) regarding the frequency of haemorrhage in early abor- 
 tions. After treatment in early abortions, we find the record of but one 
 case of haemorrhage. 
 
 It will be seen under the head of Treatment that 214 of these 242 
 cases of early abortion were subjected to active treatment; namely, curet- 
 tage, and that in 129 instances the operation was performed immediately 
 after arrival of the Hospital physician. We look upon these results as an 
 additional argument in favor of an active treatment. 
 
 In our 175 cases of late abortion, Av^e find haemorrhage as a prominent 
 symptom before or during delivery in 116 instances, or 66.29 per cent, of 
 cases. After delivery and treatment, we find but five instances of hgemor- 
 rhage. Referring once more to Treatment, it will be seen that 111 of these 
 175 cases were subjected to curettage, and that the operation was performed 
 at once in 55 cases. Regarding the third stage of labor, its average dura- 
 tion was 44 minutes. The placenta was spontaneously delivered in 35, 
 expressed in 19, manually removed in 26, instrumentally removed in 87, 
 and of 8 cases we have no record. 
 
 In our 218 cases of spontaneous premature labor, hsemorrhage before or 
 during delivery is noted in 14 instances, or 6.42 per cent., and haemorrhage 
 after delivery in 4 cases. Among our premature cases are eight of pla- 
 centa prsevia. In this connection it is interesting to note that the average 
 duration of the third stage of labor in our premature cases was 23 minutes. 
 
 HEMORRHAGE AS A COMPLICATION. 
 
 635 Cases. 
 
 Before Treatment. After Treatment. 
 
 Early abortions (242) 207 cases, 85.57^ 1 case. 
 
 Late abortions (175) 116 cases, 66.29^ 5 cases. 
 
 Before Delivery. After Delivery. 
 Spontaneous premature labor (218) 14 cases, 6.42^ 4 cases. 
 
IG-A REFORT OF THE SOCIETY OF THE LYING-IN HOSPITAL. 
 
 2. Rtitiiiion (if //n IVdci-nta, ((ml Proloixjed T/iird Sf <((/<'. 
 
 No statements regarding- the frequency of the retention of the ])h\eenta 
 and a prolonged third stage can be given, common complications though 
 they are, for two reasons. The ])atient's statements are untrustworthy, 
 and are rejected when she is seen at that ])ei'iod lirst. Secondly, the thirtl 
 stage with us is not permitted to continue, but is cut short by active meas- 
 ures, such as ex]>ression, manual or instrumental removal of the ])lacenta, 
 unless spontaneously brought to a close within half an hour. 
 
 Perhaps we cannot render our results more graphic in this connection 
 than by constructing from our statistical syno]isis two tables, placing in 
 juxtaposition the methods of placental delivery and the duration of the 
 third stage of labor in both late abortions and spontaneous premature 
 labors. As we have already stated, we have been able to recognize a third 
 stage of labor in but very few of onr early abortions. 
 
 Methods of Placental Delivery in Late Abortions and Spontaneous 
 
 Premature Labors. 
 
 Late Abortions. Premature Labors. 
 
 Spontaneous delivery 35 4s 
 
 Expressed 19 I-IT 
 
 Manually removed 26 20 
 
 Curettage after removal 87 6 
 
 Ko record 8 9 
 
 Total m 230 
 
 Duration of tue Third Stage of Labor in Late Abortions and Spon- 
 taneous Premature Labors. 
 
 Late Abortions. Premature Labors. 
 
 Average duration 44 minutes. 23 minutes. 
 
 Longest duration 3 hrs. 45 inin. 1 hr. 30 min. 
 
 Shortest duration 5 minutes. 2 minutes. 
 
 Compare Ilajmorrhage as a Complication, and Results of Treatment. 
 
 3. Septic Infection. Fever. 
 
 Fever as a Complwdtion in the TJntirnely Intel' ruption, of Pregnancy. — 
 We should state here that as regards the limit of the normal temperature 
 ante, intra, or post partum we liave acce})ted the deluiition of Leopold *' and 
 others, who jjhicc this limit at 38 degrees (Centigrade or lOO degrees Falu'- 
 enheit, so that in the dilTercnt classes of intra and ])ost partum fever liei-e 
 studietl, any temjx'rature of 100.5 degrees l-'ahrciiheit or over is look<'<l 
 upon as fever and a pathological condition. 
 
 Fever an a ('onijtliration in Karl;/ Aluirl'ionf*. — r)ur tablcss and critical 
 study of the 242 cas<*s of early abortion show that fever entei-ed into the 
 
THE PREMATURE INTERRUPTION OF PREGNANCY. 165 
 
 cases as a complication either before or after the date when the cases were 
 first seen by one of our physicians, in 28 instances, or 11. 5Y per cent., and 
 tliat in these 28 cases the origin of the fever was as follows: 
 
 Cases. 
 
 Fever due to sepsis 17 
 
 " "■ pulmonary tuberculosis 2 
 
 " " constipation 2 
 
 " " pneumonia 2 
 
 " " unknown cause 5 
 
 Total 28 or 11. 5Y^ 
 
 Further, that of these 28 cases of fever, 9 cases, or 32.18 per cent., 
 w^ere suffering from fever when first seen; 13 cases, or 46.57 per cent., 
 developed fever in the service of the Hospital; 6 cases, or 21.29 per cent., 
 have no record of the temperature w^hen first seen. 
 
 Of the 9 cases, or 32.18 per cent., suffering from fever when first seen, 
 the fever was due to : 
 
 Cases. 
 
 Sepsis 8 
 
 Tuberculosis 1 
 
 Total 9 or 32. 
 
 Of the 13 cases, or 46.57 per cent., that developed fever in the service 
 of the Hospital: 
 
 Cases. 
 
 Fever due to sepsis 7 
 
 " " tuberculosis 1 
 
 " " constipation 1 
 
 " " cause unknown 4 
 
 Total 13 or 46.57^ 
 
 Of the 6 cases, or 21.29 per cent., having no record of the temperature 
 when first seen, subsequently developed fever due to : 
 
 Cases. 
 
 Sepsis 2 
 
 Constipation 1 
 
 Pneumonia 2 
 
 Unknown cause 1 
 
 Total 6 or 21.29^ 
 
 Fever as a ComjMcation in Late Abolitions. — Again our tables show that 
 of the 175 cases of late abortion, fever appears as a complication in 38 
 
J6G REPORT OF THE SOCIETY OF THE LYING-IN HOSPITAL. 
 
 iiistauces, or 21.71 per cent., ami that in these 3S cases the origin of the 
 fever was as follows : 
 
 Cases. 
 
 Fever due to sepsis 27 
 
 "■' " constipation 5 
 
 " '' bronchitis 1 
 
 " '' mastitis 1 
 
 " " sepsis and mastitis 1 
 
 " " unknown cause '^ 
 
 Total 38 or 21.71^ 
 
 Further, of these 38 cases of fever, 20 cases, or .52.63 per cent., were 
 suffering from fever when first seen; 15, or 89.45 per cent., developed fever 
 in the service of the Hospital; and 3, or 7.89 per cent., have no record of 
 the temperature when first seen. 
 
 Of the 20, or 52.63 per cent., suffering from fever when first seen, the 
 fever was due to: 
 
 Cases. 
 
 Sepsis 16 
 
 Constipation 2 
 
 Unknown cause 2 
 
 Total 20 
 
 Of the 15, or 39.45 per cent., that developed fever in the service of 
 
 the Hospital, the fever was due to: 
 
 Cases. 
 
 Sepsis 8 
 
 Constipation ' 3 
 
 Bronchitis 1 
 
 Mastitis 1 
 
 Se])sis and mastitis 1 
 
 Unknown cause 1 
 
 Total 15 
 
 Of the 3, or 7.89 per cent., that have no record of the temperature when 
 first seen, the fever was due to: 
 
 Cases. 
 
 Sepsis 2 
 
 Unknown cause I 
 
 Total 3 
 
 Fever oh a Complication in Spontaneous Premature Lohor. — Of the 218 
 ca.sos of premature labor, our tables show that Uwv.v entcjred as a com])lica- 
 tion into 42 cases, or lit. 27 j)or cent., and that in tiiese 42 cases the cause 
 of the fever was as follows: 
 
THE PREMATURE INTERRUPTION OF PREGNANCY. 167 
 
 Cases. 
 
 Fever due to sepsis 20 
 
 " " mastitis 4 
 
 " " pneumonia 3 
 
 " " mastitis and sepsis 2 
 
 *' " constipation 3 
 
 " " abscess of breast 1 
 
 '' " pulmonary tuberculosis 1 
 
 " " eclampsia 1 
 
 " " unknown cause 7 
 
 Total 42 or 19.27^ 
 
 Further, of the 42 cases of fever, 9 cases, or 21.42 per cent., were suffer- 
 ing from fever when first seen; 31, or 73.80 per cent., developed fever in 
 the service of the Hospital; and 2, or 4.76 per cent., have no record of the 
 temperature when, first seen. 
 
 Of the 9, or 21.42 per cent., suffering from fever when first seen, the 
 
 fever was due to : 
 
 Cases. 
 
 Sepsis 4 
 
 Pneumonia 2 
 
 Unknown cause 2 
 
 Constipation 1 
 
 Total 9 
 
 Of the 31, or 73.80 per cent., that developed fever in the service of the 
 Hospital, the fever was due to : 
 
 Cases. 
 
 Sepsis 15 
 
 Mastitis 4 
 
 Sepsis and mastitis 2 
 
 Constipation 2 
 
 Phthisis 1 
 
 Cases. 
 
 Abscess of breast 1 
 
 Eclampsia 1 
 
 Unknown cause 5 
 
 Total 31 
 
 Of the 2, or 4.76 per cent., that have no record of the temperature 
 when first seen, the fever was due to : 
 
 Sepsis 2 cases. 
 
 Resume of Fever as a Oomjplication in our 635 Cases of Untimely 
 Interrupted Pregnancy. 
 
 Total number of fever cases in 635 cases of interrupted pregnancy, 108, 
 or 17.01 per cent. 
 
 Total number with fever when first seen, 38, or 5.98 per cent. 
 
 Total number that developed fever in the service of the Hospital, 59, 
 or 9.29 per cent. 
 
168 
 
 REPORT OF THE SOCIETV OF THE LYING-IN HOSPITAL. 
 
 Total number septic when iirst seen, 2S, or 4.11 })er cent. 
 
 Total number that develoi)eil sejKsis in the service of the Hospital, 31, 
 or -t. 88 per cent. 
 
 Sepsis is, of course, the chief complication of interrupted preg-uancy. 
 Stum})f's^ cases show a percentage of 10.7 of sepsis in those expectantly 
 treated, 20 ]ier cent, in tliose manually curetted. He uses the latter figure 
 as a Avarning against the danger of interference, and remarks that " un- 
 fortunately, the hand of the practitioner in outdoor service is not above 
 reproach."" In spontaneous expulsion his percentage is 9.1 per cent.; in 
 retention, 1*2.0 per cent. — figures wliicli wring from him the remark that 
 the unfortunate sequels, comparatively rare even with retention, are not 
 nearly so frequent as the advocates of interference would make us believe. 
 In our 242 cases of early al)ortion, IT showed fever due to sepsis (7 per 
 cent.), eight of which had fever when admitted. In 175 late abortions, 27, 
 or 15 per cent., had symptoms of sepsis, and IG of them were infected when 
 first seen. Making the corrections, our percentages of sepsis in abortion 
 cases are 3.7 per cent, and 6.8 per cent. ; on all cases, 5.3 per cent. 
 
 The gravity of abortion as a menace to life is due largely to septic 
 accidents. In Brion's^- 530 cases, 18 deaths are recorded (3.39 per cent.). 
 In the same period, in the same hospital, the mortality in normal delivery 
 was but 0.8 per cent. These figures are not so eloquent as those of New 
 York City records from 1884 to 1894, during w^hich period the deaths 
 directly due to "miscarriage" were equal to one-tenth of all deatlis from 
 puer))eral diseases (see ap])ended table). 
 
 Porak,^ in 25 cases delivered artificially, had a mortality of 4 per cent. ; 
 in 301 allowed to take their course, one died, a mortality of 0.3 per cent. 
 
 Tai5Le Showing Population, Deaths fkom all Causes in Childhed, 
 Deaths from Sepsis, and Deaths fkom Abortion and Premature 
 Labor, New York City (1884-1894). 
 
 
 
 Deaths from 
 
 
 Deaths from 
 
 Year. 
 
 Estimated 
 
 Puerperal 
 
 Deaths from 
 
 Abortion and 
 
 Population. 
 
 Diseases. 
 
 Sepsis. 
 
 Premature 
 
 
 
 (All Causes.) 
 
 
 Labor. 
 
 1884.... 
 
 l,356,r,22 
 
 438 
 
 240 
 
 34 
 
 1885.... 
 
 1,31h;.079 
 
 :',94 
 
 213 
 
 40 
 
 1886.... 
 
 1,436,789 
 
 371 
 
 ist; 
 
 37 
 
 1887.... 
 
 1,478,686 
 
 355 
 
 198 
 
 43 
 
 1888.... 
 
 1,521,805 
 
 442 
 
 246 
 
 41 
 
 1889.... 
 
 1,566,181 
 
 3!<3 
 
 226 
 
 47 
 
 1890.... 
 
 l,<;il,K.".l 
 
 383 
 
 208 
 
 45 
 
 1891.... 
 
 1,658,85)5 
 
 420 
 
 249 
 
 48 
 
 1892.... 
 
 1,707,226 
 
 417 
 
 277 
 
 30 
 
 1893.... 
 
 1,757,00!» 
 
 384 
 
 237 
 
 39 
 
 1894.... 
 
 1,808,244 
 
 358 
 
 193 
 
 47 
 
THE PREMATURE INTERRUPTION OF PREGNANCY. 1G9 
 
 "Sepsis" includes metritis, metroperitonitis, pyiTemia, septicaemia, and 
 puerperal fever. Abortion and premature labor ("miscarriage" in city 
 records) include all labors before full term. 
 
 Aside from the question of sepsis, fever due to other causes complicates 
 interrupted ])regnancies, as is to be expected. It is a matter of common 
 observation that a slight chill often follows curetting, particularly in septic 
 cases. In our cases of early abortion, of 211 curetted, 8 developed a fever 
 post operationein^ whose average duration was three days; in 111 late 
 abortions, 7 developed fever after scraping, Avhich lasted on an average one 
 and a half days. In 242 cases of early abortion we find : 
 
 Cases. 
 
 Fever due to pulmonary tuberculosis 2 
 
 " " constipation 2 
 
 " " pneumonia 2 
 
 " " unknown cause 5 
 
 In 175 late abortions there was: ^ 
 
 Cases. 
 
 Fever due to constipation 5 
 
 " " bronchitis 1 
 
 " " mastitis 1 
 
 " " sepsis and mastitis 1 
 
 *' " unknown cause 3 
 
 Rochet's ^^ findings are different. He says that the temperature faUs 
 at once after curettage, even in cases in which sublimate injections and 
 iodoform tamponade produced no effect. 
 
 tt. Parametritis. 
 
 Rochet^'' regards parametritis as one of the most serious complications. 
 Four of his 39 cases were so affected when oj)erated on, and recovered 
 slowly ; one went on to suppuration. The curette removed putrid tissue in 
 all four. Our tables shov*^ several such cases. 
 
 5. Endometritis. 
 
 There has been a warm controversy as to the occurrence of endometritis 
 as a sequela. Hyperplastic endometritis has been under special discussion. 
 Schroeder and Yeit ^'^^ sa}^ that it is impossible to tell whether the result of 
 a retention will be a complete restitutio ad integrum or a thickened en- 
 dometrium. Goldschmidt ^^ first called attention to the latter possibility. 
 Ruge^^ in eleven cases of hyperplastic endometritis, found a preceding- 
 abortion in four. Olshausen,^*^ with more abundant material, came to the 
 conclusion that an etiological connection between the two must be alto- 
 gether denied. Bischoff,^^ Brennecke,^^ Diihrssen,'^ Fritsch,^^ Henricius,^^ 
 Martin, ^^ and Kiistner,^'^ in opposition, lay stress on such a connection. 
 The cases of Henricius and Iviistner have this in common, that there was 
 little or no interference during abortion. This fact gives their opinion 
 weight, since one of the chief sources of error in examining cases of en- 
 dometritis is the reliance which must be placed on the patient's statement 
 as to previous occurrences. A decidua, also, firmly adherent to the uterine 
 wall, may give to the examining finger the sensation of an empty uterus 
 
170 REPORT OF THE SOCIETY OF THE LVIX(t-IX HOSPITAL, 
 
 when its ]>reseiico may cause an endometritis. Puppe^^ examined 100 cases 
 with the idea of throwing light on this sul)jeet. His examinations were all 
 macroscopical, and, consequently, are of little value, in spite of his pains- 
 taking care. 
 
 (>. Titini xs. 
 
 Tetanus has been reported as a sequel to abortion. Bennington col- 
 lected 41 cases of ]nierperal tetanus, and of these two followed abortion. 
 This serious complication is most often an accident in tlie course of a 
 general septicaemia. We have no instance of tetanus to report among our 
 635 cases of interrupted pregnancies, 
 
 7, l\rforaiio)i of ihe Uterine Walh. 
 
 Perforation of the uterine walls is a possible danger during curettage, 
 especially if the sharp instrument be used, and hence some authors advise 
 onlv the use of the dull or blunt instrument.*-' 
 
 In our 211 operations of instrumental curettage in early abortions, and 
 106 in late abortions, or 317 altogether, we have no perforation of the 
 uterine wall to record, and in most of these cases the sharp as well as the 
 dull curette was used. 
 
 As stated in another place, these operations were performed b}^ a large 
 number of different operators — one hundred for these operations would be 
 a low estimate. It must be remembered, moreover, that in our service the 
 sharp as well as the dull curette is used in almost every instance of curet- 
 tage in the first two-thirds of gestation. 
 
 Our experience has taught us tliat the use of the blunt curette alone is 
 insufficient, in cases of abortion, for the removal of the decidua, and Avas 
 thus made use of in only a few of our earlier cases. In the majority both 
 dull and sharp instruments were used. 
 
 The danger of perforation is reduced to a minimum if the curette, 
 when introduced into the uterus, is made to pass cautiously to the fundus, 
 and then a firm downward stroke is used to clear the uterine walls, espe- 
 cially at the horns. 
 
 8. Mortality in the 635 Cases of the Untimely Inter rxiption. of Pregnancy. 
 Mortality in Early Abortion. — We have to report among our 24-2 early 
 
 abortions no deaths from any cause. 
 
 During the time tlie Hospital physicians were in attendance u])on these 
 cases, none of thorn were transferred to other institutions, and, as far as 
 we liavo been able to ascertain, none of these 242 cases entered liospitals 
 for treatment subsequent to our attendance. 
 
 As we show in anotlier ]>lace, the average duration of treatment of 
 the.se early abortions was seven days and eight hours. l)y reference to the 
 statistical synopsis of tii(,'se cases, it will Ix' seen \\v,\\ a, few cases citlin- 
 refused tn-atment or called in ])i-iva,tc ])liysiciaiis or midwives in the llrst 
 few days of the puer]»ci-iuiii. and, cons('(|Ucntly, were discharged at that 
 time from the service of the Ilos])ital. 
 
 \^ i' have endeavoi-ed, dui-ing a ])erio(l of from one to four years after 
 the abortions in our 242 cases, to lind \\w. ))atients and asc(!i'taiii IVoni tlu'in 
 the subsecjuent histories regarding tiu; lat(; s(,'(ju(;he of abortion, and the 
 
THE PREMATURE INTERRUPTION OF PREGNANCY. 171 
 
 influence of various modes of treatment upon subsequent menstruation and 
 child-bearing (sterility). 
 
 As our tables indicate, we Avere able to find actually 76 of the total 242 
 cases and examine them regarding the above points of interest. (See Prog- 
 nosis and Sequela?.) 
 
 Mortality in Late Ahortions. — In the treatment of the 175 late abortions, 
 the average duration of attendance was seven days and twenty-one hours. 
 
 As in the case of early abortions, as will be seen by reference to the 
 statistical analysis, a very small proportion were discharged in the early 
 days of tlie puerperium because of the patients refusing treatment, or call- 
 ing in private ])hvsicians or midwives. 
 
 We have one death to report among the 175 late abortions. The fol- 
 lowing is an abstract of the case: 
 
 C. ]Sr. 1,198. — Russian; age 36; YI. para; sixth month of gestation; 
 no record of previous interrupted pregnancies ; s3aiiptoms of hasmorrhage 
 had continued twelve hours when first seen by the Hospital physician; 
 before being seen by the latter, two private physicians in attendance ; pla- 
 centa prcevia; severe antepartum hgemorrliage ; dilatation with Barnes's 
 bags; rupture of the uterus; jDodalic version; still-born child; placenta 
 manually extracted by the Hospital physician; duration of the third stage, 
 five minutes; death, thirty-six hours postpartum, of shock. 
 
 Five of the 175 cases of late abortion were for various reasons trans- 
 ferred to some other hospital at different periods of the puerperium. Two 
 of these were homeless and friendless; one was suffering from chronic 
 pulmonary tuberculosis; one from chronic pulmonary tuberculosis and 
 endocarditis; one from endocarditis, and one from parametritis. We 
 append abstracts of these cases. 
 
 1. C. ]Sr. 1,1:68. — Russian; age 36 ; Y. para; fifth month of gestation; 
 child born before arrival of Hospital official ; symptoms had continued two 
 days when the patient was first seen ; child still-born ; placenta broken u-p 
 in delivery; antepartum haemorrhage; instrumental curettage and intra- 
 uterine douche; no fever; patient transferred to Gouverneur Hospital 
 March 3, 1892. ISTo record of the patient can be found on the hospital 
 books ; she entered the institution under an assumed name. 
 
 2. C. jST. 1,785. — Roumanian; age 21; III. para; fourth month of ges- 
 tation; unattended by Hospital official; symptoms had continued one day 
 when seen ; child still-born ; placenta broken up ; antepartum haemorrhage 
 moderate; temperature 103 degrees Fahrenheit when seen; 103 degrees 
 Fahrenheit after o]3eration ; digital and instrumental curettage; transferred 
 to Gouverneur Hospital on the second day of the puerperium with symp- 
 toms of parametritis; records at Gouverneur Hospital state that the patient 
 was treated there three days for ' ' pelvic cellulitis ' ' and discharged 
 "cured." 
 
 3. C. ]^. 3,985.- — Russian; age 19; I. ^^ara; fifth month of gestation; 
 unattended by Hospital official; symptoms of haemorrhage had continued 
 twelve hours when first seen; child still-born ; placenta spontaneously deliv- 
 ered; membranes intact; vaginal douche the only treatment; no fever; 
 
IT'2 REPORT OF THE SOCIETY OF THE LYIN(?-IX HOSPITAL. 
 
 homeless ami I'rieiuUess ; went to some hospital on the third day of the 
 piierperiiim ; unable to trace the patient. 
 
 4. C. X. 5,215>. — Russian; age 21; I. para; fourth month of gestation ; 
 attended by the lIos|)ital official; child still-born; placenta broken up; 
 moderate antepartum haemorrhage; temperature 100. G degrees when first 
 seen; highest temperature, 100. C degrees; first day, day of highest tem- 
 perature; total duration of fever, a few hours; operation at once; instru- 
 mental cui-ettage. uterine douche; fever due to sepsis; discharged seventh 
 day in poor condition; seen two weeks later with parametritis; sent to 
 Gouverneur Hospital December IT. 1S03; discharged from that hospital 
 December 31, lS!t3, sutfering from inild endometritis. 
 
 5. C. X. 7,070. — American; age 30; V. para; third and a half month 
 of gestation; symptoms present four days when seen; ])lacenta broken uj); 
 moderate antepartum luemorrhage; six hours between first visit and o])er- 
 ation; temperature lol.2 degrees Fahrenheit when first seen, 101.2 degrees 
 after o})eration, 102.8 degrees on second day; fever lasted fourteen days; 
 instrumental curettage and uterine douche; discharged fifteenth day in bad 
 condition, to be transferred to St. Francis Hospital; sepsis and pericarditis. 
 The patient entered the hos]iital under another name and was lost sight of. 
 
 Jforttdiii/ in Spontaneous P/'eniaturc Labors. 
 
 Among the 175 spontaneous premature labors there were four deaths. 
 Tliree of these occurred in the service of our Hos]iital, and the causes of 
 death were (1) shock and liEemorrhage from a placenta praevia, (2) broncho- 
 pneumonia, and (3) eclampsia. Another patient died on the second day of 
 the puerperium, twenty-four hours after the case had been turned over 
 to a private ]:)hysician. 
 
 AVe have thus three deaths among the 175 cases in owy owii service, 
 and four if we include the case which subsequently terminated fatally. 
 
 As far as we have been aljle to trace our cases after their confinements, 
 the above include all the fatal cases. 
 
 Six other cases were transferred, for various reasons, to other institu- 
 tions, and as far as we have been able to follow these six cases there were 
 no fatal terminations. 
 
 The following is a synopsis of the four cases in which death followed 
 a s})ontaneous premature delivery: 
 
 1. (.'. X. 340. — Dutcli; age 31; 11. para; ninth and a lialf month of 
 gestation; conlincd \\\ the Hospital official; iirst seen in the first stage of 
 labor; child lived thr(!e days; phicenta ])ran'ia; podalic version; manual 
 extraction of tlic; ])lacenta; third stage lasted thirty-Jive minutes; death on 
 third day of ha-morrhage and slKx-k. 
 
 2. CJ. X. I.72;5. — American; age3S; VI. ])ara; uinth and a half montli 
 of ge.station; conlin(!(l by the Hospital olHcial; iirst se(;n in the Iirst stage 
 of labor; child lived two days; placenta ex])ressed; tliiid stage lasted 
 thirty minut(!s; prola))S(! of hand; no record of Uwo.r wli(;n seen; later teni- 
 pemture 1O0.2 degrees; death on seventh (hiy, of broncho-i)neumonia. 
 
 3. C. N. 6,925, — American; age 31 ; VIII. ])ara; ninth month of gesta- 
 tion ; two previous premature laboi-s: unatlcndcd by Hospital official ; still- 
 
thp: prematl:re ixtkrruptiox of pregnancy. 173 
 
 born child; placenta expressed; third stage lasted thirty minutes; albumi- 
 nuria; [)rivate physician took charge of case on first day of the puerperium ; 
 it was learned that the patient died twenty-four hours later, of nephritis. 
 
 4. C. K. 7,070. — Russian; age 26; II. para; ninth and a half month 
 of gestation; confined by the Hospital official; first seen in first stage of 
 labor; child lived only a few minutes; placenta expressed; third stage 
 lasted five minutes ; eclampsia ; manual dilatation and incision of the cervix ; 
 podalic version and extraction; death from eclampsia, on second day. 
 
 Six of our cases of spontaneous premature delivery were, for various 
 reasons, transferred to some other hospital. One was delivered of a ma- 
 cerated foetus while undergoing the usual antepartum examination in the 
 present sub-station building of the Hospital; she was homeless and friend- 
 less. The remaining five were transferred to other institutions because it 
 was judged that their condition demanded routine hospital treatment which 
 could not be properly carried out in the tenement houses. We append below 
 an abstract of these six cases: 
 
 1. C. IS". 150. — German; age 30; I. para; ninth month of gestation; 
 child lived one day; profuse postpartum hemorrhage; temperature 101.2 
 degrees when first seen; highest temperature 101.2 degrees, on second day; 
 fever lasted thirty days; instrumental curettage; sepsis; sent to Bellevue 
 Hospital on twenty-eighth day of puerperium; there she remained three 
 weeks, and was discharged entirely cured. 
 
 2. C. K. 189. — American; age 22; II. para; seventh month of gesta- 
 tion; one previous abortion; confined by Hospital official; first seen in 
 first stage of labor ; child lived five hours ; placenta spontaneously deliv- 
 ered ; antepartum hgemorrhage ; albuminuria ; discharged on eleventh day 
 in bad condition and transferred to Bellevue Hospital. 
 
 3. C. ]^. 657. — Russian; age 23; Y. para; eighth month of gestation; 
 confined by Hospital official; first seen in first stage of labor; child lived 
 three days; placenta expressed; third stage lasted five minutes; highest 
 temperature 101.3 degrees, on third day; duration of fever a few hours; 
 albuminuria; mastitis; extreme oedema and ascites at labor; discharged 
 on tenth day in bad condition; transferred to Belleviie Hospital, where the 
 patient remained only a few days. 
 
 4. C. jST. 3,690. — American; age 27; II. para; eighth month of gesta- 
 tion ; confined by Hospital official ; first seen in second stage ; macerated 
 child; placenta expressed; third stage lasted twenty minutes; no fever; 
 confined on examining table of the Hospital; transferred immediately to 
 Gouverneur Hospital, which she entered March 24, 1893, and was discharged 
 March 28, 1893, in good condition. 
 
 5. C. ]Sr. 5,945. — Russian; age 25; III. para; seventh month of gesta- 
 tion; one previous premature labor; confined by Hospital official; first 
 seen in second stage ; child lived one day ; placenta spontaneously deliv- 
 ered; duration of third stage ten minutes; temperature 103 degrees on 
 third day. Fever; pulmonary tuberculosis; discharged on ninth day in 
 bad condition; sent to Gouverneur Hospital April 17, 1894. Patient can- 
 not be traced, as she entered under an assumed name. 
 
IT-i REPORT OF THE SOCIETY OF THE LYlXtMN HOSPITAL. 
 
 G. C. N. 0,128, — Russian; age 20; I. ))ara; ninth niontli of gestation; 
 confined bv lIos})ital official; tirst seen in first stage; child lived one day; 
 placenta expresseil; third stage lasted fifteen minutes; temperature 104 
 degrees when first seen ; treated for two Aveeks jirior to hibor by ])rivate 
 ])h\sician for fever, heatlaclie, and diarrha?a (typhoid); transferred to ])elle- 
 vue Hospital on the third day of the puerperium. Admitted to Bellevue 
 Mav 0, 1804 ; treated there for tv])hoid fever ; discharged cured, IMay 30, 1894. 
 
 Bti<i(iii(' of t/ie Moi'taliti/ hi o(ir (335 Cases of Untimely Interrupted 
 J^regnanci/. 
 
 ^fortality in 242 cases of early abortion, per cent, 
 
 M(.)rtality in 17.") cases of late abortion, one case, or 0.57 per cent. Cause 
 of death was placenta ])riT3via and ru})ture of the uterus. 
 
 Mortalitv in 218 cases of spontaneous ])remature labor, three cases, or 
 1.37 per cent. Causes of death were (1) placenta pnevia, haemorrhage, 
 and shock; (2) broncho-pneumonia; (3) eclampsia. 
 
 Total Mortality in the 635 Cases of Interrupted Pregnancy, ().^?>2>er cent. 
 
 Summing up, Ave find as sequels or complications of interrupted preg- 
 nancy, first, and most important, sepsis in all its forms — metritis, parame- 
 tritis, endometritis, septicaemia, pyaemia, fever; intercurrent disease giving 
 rise to fever, e.g., tuberculosis, retention of placenta and decidua Avith con- 
 sequent hyperplastic endometritis, subinvolution, etc. ; haemorrhage leading 
 often to sepsis; tetanus; death as a result of one or more of these compli- 
 cations. 
 
 Prognosis, according to Lepage,'*'" varies according to: 
 
 (1) The period of gestation, the danger of being less toward the third 
 or fourth month. 
 
 (2) Retention of placenta and membranes. 
 
 (3) Treatment. 
 
 All these may be condensed into one Avord, treatment / and Ave have 
 altogether failed in this laborious undertaking if Ave have not made clear 
 and unmistakable our interpretation of the meaning of that Avord. 
 
 Skquel;e. 
 
 1. Sterility. 
 
 Oldhausen's school, Stumpf^ s^ivs, in particular, deserves what credit 
 there is in having " reduced to their ])roper level the fears of the evil 
 results to be anticipated from the retenti(m of membranes" in premature 
 \:\\)()v. Winter"" says the puerperium is not disturbed by retention, and 
 the inucous membrane regains its functional activity in a short time. 
 His point of vi(;w is purely clinical. In ;{s ])er cent, of his cases Avitli 
 partial or com})lete retention, pregnancy ensued early, while after re- 
 moval of the v(!ra, conception occurred in ('>.2!> per cent. only. Ru])])(;,"*' 
 Avho publislied thes(; results, conclud(!s from tlies(; ligui-es that a uterine 
 irnu'ous memy>rane completely renewed after abortion is less capable of 
 jdaying the j)art of a (hscidua of ])regnam-y than own Aviiich lias <l(jne so 
 before in whole or in |)art. One hun(h-ed cases Avere carefully kept un<l(M- 
 observation by him before, during, and for some time after abortion. The 
 
THE I'HEMATURE INTERRUPTION OF PREGNANCY. 
 
 175 
 
 menses returned usually in four weeks in. all cases. Puppe carefully se])a- 
 rated the healthy women from those previously diseased, but it does not 
 a))pear that he had seen the fruit of conception when it occurred. In 
 other words, he does not state tluit the child was carried to term. More- 
 over, he divides his cases into two groujjs: (1) cases running their course 
 with retention, and (2) those in which the entire vera was removed, and 
 draws his conclusions when he confesses himself unable to state that the 
 removal is ever complete. Durlius, on the other hand, mentions sixty 
 cases of conception following curettage. 
 
 Certainly, our figures lead one to a far different conclusion from Pup- 
 pets. Of 119 cases treated instrumentally, 38, or 31.9 per cent., had expe- 
 rienced one or more previous interrupted pregnancies; 5, or 4,2 per cent., 
 suffered subsequently in the same way; 48, or 40.3 per cent., gave birth to 
 living children at term; and 21, or 17.6 per cent., were found to be preg- 
 nant from the fourth to the eighth month when visited. These observa- 
 tions were made at the patients'' koines and the children seen. Of 28 cases 
 of abortion expectantly treated, 10, or 35.7 per cent., had had similar pre- 
 vious experiences. Wone suffered from subsequent interrupted pregnan- 
 cies; 7 gave birth to living children at term afterward (25 per cent.); 5, or 
 17.8 per cent., were found to be pregnant from the fourth to the eighth 
 month when visited. It is interesting to tabulate these results for com- 
 parison, in spite of the disparity in the number of cases. (It should be 
 borne in mind that these women were found with great difficulty, thus 
 accounting for the comparatively small number of returns.) 
 
 Treatment. 
 
 Subsequent 
 Interrupted 
 Pregnancy. 
 
 Full-term 
 Pregnancy. 
 
 Pregnant 
 
 4th to 8th 
 
 Month. 
 
 Expectant cases 
 
 0.0^ 
 
 4.2^ 
 
 25.0^ 
 40.3^ 
 
 17.8^ 
 
 Instrumental cases 
 
 17.6^ 
 
 (See Tables of Results in Early and Late Abortions.) 
 
 The points in which the instrumental treatment suffers by comparison 
 is in the percentage of subsequent interrupted pregnancies, and also in the 
 fact that 31.9 per cent, of the instrumental as against 35.7 per cent, of 
 expectant cases had previously aborted. One case digitally curetted gave 
 birth to two children afterward. 
 
 Diihrssen ^^ believes that the retention of a part of the decidua is the 
 rule, and that this retention is ominous, on account of hsemorrhage or 
 sepsis, Stumpf ^ denied this assertion, says it cannot be proved clinically or 
 anatomically, and claims that it is disproved by the observations of Winter ^°^ 
 and Puppe, ^^ and also by Klein, ^•'^ who concludes from his studies on involu- 
 tion that the vera is transformed in loco to mucous membrane in from 
 four to six weeks. We refer the reader to the section on Pathology for a 
 demonstration of the fact that Diihrssen is correct in the stand he takes. 
 
170 REPORT OF THK SOCIETY OF THE LYIXG-IN HOSPITAL. 
 
 2. En<1om€ti'iU'^ un<l Ojh I'at ire Intei'feri'iwe. 
 
 As regards endometritis, diametrically op])osite opinions are again 
 maintained. Stnm]it', Winter, and Pnppe say that it is not the result of 
 aboi-tion and retention of membranes, and point to Yeifs '"' curetted cases, 
 in which the endometritis had to be treated after the puerperium was 
 ended. They neglect to suggest the possibility of a ])rior abortion exjDec- 
 tantly treated being at the bottom of the trouble. Reference to the table 
 given above (^]xige 175) shows a 15.3 greater percentage of subsequent preg- 
 nancies when the secundines were instrumentally removed, which is toler- 
 ably fair evidence, at least, that these cases were free from endometritis. 
 
 We also attempted to learn and compare the character and duration of 
 the lochial discharge, the character, time, and duration of the first men- 
 struation following the al)ortion, in cases allowed to run their course with 
 retention of the vera (expectant treatment), and in those in Avhich the 
 entire vera was removed at the time of the abortion (curettage). 
 
 Our ()l)servations in the 1-1-8 cases of abortions (70 early and 72 late) 
 were mainly dependent upon the statements of the ]:)atients, and for this 
 reason we have considered them too doubtful and unreliable to use, and 
 have consequently abandoned them as useless. On the other hand, as 
 alreadv stated, our observations \\\>o\\ the subsequent labors at term and 
 subsequent pregnancies are exact, because, in each of the 148 cases reported 
 upon, the women and tlieir cliildren were seen. 
 
 AVe ajjjjend in the foot-note Fuppe's observations.* 
 
 *G. PuppE : Inaugural Dissertation, Berlin, 1890. 
 
 Turning now to the real object of the examiiiatioii, namely, the consideration of 
 the sequela? after abortion, we shall find that the material before us can be readily 
 divided into two groups corresponding to the starting point of the investigations : (1) 
 cases running their course ivith retention of the vera ; (2) those in which the entire 
 vera zras rentoi'ed dnring the abortion. Regarding the course of the abortion, the 
 latter group is again divisible into those cases in wiiich tlie entii'e ovum was sponta- 
 neou.sly e.xpelled, and those in wliich the removal of the entire vera required inter- 
 ference, though it be only a manual one. 
 
 Of the 100 cases here under consideration, ten belong to the first group, those 
 whicli have run their course without any medical interference ; but of these we must 
 exclude the lai-ger half (seven), l^ecause they complained before the abortion of symp- 
 toms wliich rend(!red disease of the uterus almost certain (cliiefly endometritis). The 
 exclusion is the more obvious, as our main object is to study the sequekc of abortion 
 in healthy women. For the same reason it is absolutely necessai'y to make a like 
 separation in the other groups made in this treatise. A separate section will b(^ 
 devoUid to tin; .seriuehe after abortion in uimirii pi-eviously di.seased. 
 
 In jr'''"'ral tln^ ova d(!rivc'd from tliis entire grouj), six of which Avere of the thii'd 
 montli and four of tin; sfrcond, W(;ri! nearly tln-onghout fine specimens, as I must not 
 fail to empluusize here. Tlie ovisacs were intact, frequently with recently dead, rarely 
 with partly al>s<jrlx;d, f(jetu.sex ; the chorion was. as a rule, surrounded with tlie un- 
 injured rertexa ; the dtn^idua, as is self-evid<;nt from the age of the ova, not adherent 
 togetber. the transition folds cle;irly jironounccul. As stated aliove, treatnuMit in all 
 tbes<; viisf^ IkkI l)e«'n made unnecessary by tli(^ spontaneous course ; by tlie time the 
 |K)lyr-]inifal ;ittendant rejioln-d tin; bedside tlie ova weri' in part delivered into tlie 
 vagina, wben tlie internal os Wiis always found closed; in jiart they were handed to 
 the attendant on his arrival, iis alnmdy fully delivered. 
 
THE PREMATURE INTERRUPTION OF PREGNANCY. 177 
 
 The several points to which the later examination had to be directed are the state 
 of the lochial discharge, tlie condition of the first and the subsequent menses. First, 
 as regards the lochial discharge, it lasted in two of the cases eight days, in the third 
 the length of time is given as six weeks, up to the time of the first menses. The 
 former two statements appear normal, but the latter surprised us, all the more because 
 the further symptoms in this patient (even conception occurring after five recurrences 
 of a normal menstruation) pointed to a healthy condition of the uterus. An explana- 
 tion of the fact niight perhaps be found in the normal mode of detachment of the 
 decidua vera from the uterine wall as descril^ed by Diihrsseu. According to this 
 observer the region of separation of the vera is not in its sui^erficial, but in the deeper 
 ampullary glandular layer. If we assume in our case a separation at first only in the 
 superficial region, then it was the object of the lochial discharge to complete it ; that 
 is to say, to eliminate the decidual elements as far as the deeper layer — a task which 
 could not be completed within the normal duration of the lochia. Whether this 
 explanation is true cannot be ascertained, since no microscopical examination was 
 made of the expelled vera ; at any rate it is probable. 
 
 As stated before, in this case the first menses occurred after the termination of 
 the lochia, i.e., in six weeks ; in the other two cases, after five and four weeks 
 respectively ; in all cases it was rather profuse without being painful, lasting three to 
 five daj^s. The i^rofuseness of the first catamenia is counterbalanced by the relative 
 scantiness of the next, a fact positively asserted by all the three patients. The suc- 
 cession of the several menstruations was in two cases regular, at four weeks' interval 
 (in one, see above, conception soon occurred) ; in the third case, which was compli- 
 cated with chlorosis, it was irregular, the interval being once five weeks, several times 
 three weeks. 
 
 Next to this group of cases with spontaneous course comes another which was 
 terminated manually only, in which the entire vera was removed from the uterus. 
 The number of cases belonging under this head is 14 ; again we must exclude 8 cases 
 as diseased previous to the abortion. Of the remaining 6 cases, 2 were of the second, 
 3 of the third, and 1 of the fourth month. In these cases the lochial discharge was 
 absolutely noi-mal ; as a rule it lasted eight days, only once the duration is given, as 
 in the former group, until the first catamenia. The first menses occurred four times 
 after four, once after five, and once after six weeks ; in the great majority it was 
 profuse and normal in duration. The further course of the menses was also normal ; 
 four Aveeks are uniformly stated as the interval. No conception is to be noted in this 
 group. 
 
 In endeavoring to draw a conclusion from all these abortions unquestionably 
 terminated by the expulsion of the entire vera, we are struck in the first place by the 
 large number of sick patients (15) in comparison with those not sick (9) ; all the more 
 because in every case the vera was detached spontaneously or by a purely manual 
 interference (hence without any great difficulty) . In the majority of cases the deciduae 
 are marked in my list as " thickened." If they form, as the history shows beyond a 
 doubt, the main constituent of an inflamed endometrium, the fact here observed 
 deserved mention in view of the circumstance also noted by Veit, among others, 
 ' ' that when it undergoes inflammatory thickening it becomes more firmly adherent 
 to the uterus." The large proportion of the sick to the well (5 to 3), in all of whom 
 the vera was detached spontaneously or with slight exertion, is, at all events, very 
 remarkable. 
 
 The period of involution was apparently normal in all cases ; the duration of 
 the lochia, its quality, the absence of haemorrhages, and the later well-being of the 
 patients indicate it. The first-named period is almost uniformly given as eight days ; 
 the two statements, which differ, can probably be sufficiently explained : the quality 
 of the lochia corresponds to the symptoms known from the puerperium, but the bloody 
 lochia here seem to be of much slighter importance. The statements made to me are, 
 as, a rule, that the lochial discharge had been at first bloody, had gradually become 
 12 
 
ITS REPORT OF THE SOCIETY OF THE LYING-IN HOSPITAL. 
 
 lighter, and tinally \vhiti;sh. Putrescence was denied in all cases ; only a stale odor 
 was admittetl. The quantity, too, was almost regularly slight ; the question whether 
 haMuorrhages had taken i)lace, or coagula passed, was always denied. 
 
 The condition of the liist menstruation is remarkable in so far as all the women 
 called it profuse. That tliis statement is correct can hardly be doubted, although 
 occasionally the statements of a single person are not always as reliable as might be 
 desii-ed. despite the most careful questioning ; yet when the reports are almost unani- 
 mous, doubt would scarcely be in place. Still the fact per se is remarkable enough. 
 When imder other conditions the genitals are subject to periodical engoi'gements of 
 blood which hiul expression in menstruation, it seems strange that, after tlie genitals 
 have just discharged a considerable quantity of blood, a profuse menstrual luomorrhage 
 again occui"s in four to at most six weeks. This phenomenon, however, finds its ana- 
 logue in the profuseness of the first eatamenia usually observed after delivery. 
 
 The time of the return of the first menses was in the majority of oases (5) four 
 weeks ; in 2. five weeks : and in 2, six Aveeks. The duration of the courses ranged 
 between three and eight days ; they were never painful. 
 
 Regarding the .srco»(Z and the later )neiises, the fitateinents obtained are normal ; 
 a type of four weeks exists throughout, with relative scantiness — a fact which deserved 
 to be specially emphasized in view of the profuseness of the preceding one. The 
 above-described single instance of conception occurring appears unsuitable for making 
 remarks about the regaining of the power of conception in this connection. A better 
 opportunity will ])resent hereafter. 
 
 Next in order after the abortions terminated by the positive removal of the entire 
 vera, it will be best to consider the group treated with the curette. In these cases, 
 likewise, we might a.ssert that the entire vera was removed by the curette, since this 
 was the object of the interference ; but I prefer to treat of the curetted cases in a group 
 by themselves. My motive in making this separation was this : I have above ex- 
 pres.sed my intention to separate the availal^le cases into those of total removal of the 
 vera, and total or partial retention of the vera, since what was handed to me as actu- 
 ally expelled was a voucher for the correctness of the relations named. In the cases 
 treated by curettage, however, it is a different matter. While it is most probable that 
 the thorough use of the curette has removed all of the v^era, we cannot be quite sure 
 that a smaller or larger piece of vera was not left adherent somewhere. 
 
 For the rea-son stated, we cannot assign tlie same reliability to the conclusions 
 drawn from the sequehe after abortion in tliis group as in the remaining cases ; but I 
 may re.strict my.self to the enumeration of tiie most important points for this group. 
 First, a.s regards the indication for the curettage in these cases, it may be said that it 
 wa.s found mainly in the presence of very firmly adherent shreds of vera which 
 resisted manual treatment. 
 
 Tlie inunber of curetted cases was 14, from wliich we must exclude 7 as pi'eviously 
 di.seased. Tiie remaining 7 differed from the former by a rather long duration of the 
 lochial di.scharge in tlie majority of ca.ses. In 2 the lochia continued until the iir.st 
 men.struation after the abortion, and in 2 others they lasted two weeks. This fact 
 might lend color to the above-mentioned po.ssibility that the curette had left ample 
 cause for tlie activity of tlie lochia. Two mor<! pati(Mits state the duration of the lochia 
 a.s ten and eight days res{)ectively ; tin; seventh claims not to have noticed tliem at 
 all. The quahty of the liK-hia was normal throughout ; the passage of coagula, por- 
 tions of the decidua, or perhaps a lucmorrhage, luul never been observed. 
 
 All wom^n menstruated first four weeks after abortion, and they too unanimously 
 reported that the men.ses were profu.se ; the duration ra!ig(^d between two and eight 
 days. According t*) the patients they wen; uiiifornily i)ainle.ss. The subseqiuMit eata- 
 menia api>eare<l in all women afUsr four weeks' int»!i'val, a Ivv^ays scantier than the first, 
 but normal. ( 'onception had not occurred in any of the jiatients at the; time of the 
 l-'LHt <'xamination. 
 
THE PREMATURE INTERRUPTION OF FREGXANCY. 
 
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THE PREMATURE INTERRUPTION OF PREGNANCY. 183 
 
 Treatment. 
 
 Turning to the treatment of sucli cases as form the subject of this paper, 
 it is well to review other Avork in the same line and to show how weight 
 of opinion, notably German, turns the balance in favor of the active treat- 
 ment we advocate. Curettage is not new. Eecamier used it in Austria 
 in 1846; Boetus^"^ advocated it in 187T. Opinions differ widely, as might 
 be ex^^ected, not only as regards indications for and the method of using it, 
 but as to its expediency in any case. Czobos ^°' advised expectant treat- 
 ment alone, setting aside the curette on the ground that active interference 
 is apt to produce septic absorption. His preference is for the tampon 
 and ergotin. E. Schwarz^*^^ uses manual dilatation and curetting if the 
 ovum is intact, instrumental procedure in case it is not. From these opin- 
 ions it is possible to pass by easy stages to the radical and uncompromising 
 stand of Weekbecker-Sternfeld ^*'' and Duhrssen,^°^ who condemn temporiz- 
 ing in any form. The latter is our position also. 
 
 All methods for the management of abortion may be systematically 
 classified as follows: 
 
 1. Purely conservative or expectant treatment. Interference is alto- 
 gether interdicted, and the sole reliance placed upon the tampon, vaginal 
 irrigation, and ergot. 
 
 2. Early artificial removal of the decidua or placenta— active treatment, 
 so called — in which curettage is the routine plan. 
 
 3. An intermediate or eclectic method, in which intervention is resorted 
 to only in order to control hemorrhage or sepsis. 
 
 Each of these methods, as remarked, finds its able advocates. Winckel,^^' 
 Stumpf,^^" and Zweifel "^ are notably among the endorsers of the first plan. 
 Among those who favor an active intervention in all cases of abortion, at 
 least those falling within the first four months of gestation, are Diihrs- 
 sen,^°® Auvard,"^ Borel,^"^ von Brehm,^^^ A. Martin, Prochownik,^^* Week- 
 becker-Sternfeld,^*^' Spondly,^'*^ and Voltz."^ In the last group, among 
 those who take an intermediate stand, we find Charles,"^ Porak,"^ and 
 Audebert."^ The work will be reviewed in accordance with this classifica- 
 tion and in chronological order, selection being made from the enormous 
 mass of literature bearing on the subject. 
 
 Czobos (1884) has already been referred to as an advocate of expectant 
 treatment. Winckel,^^'' at the first meeting of the Association of Upper 
 Bavarian Physicians, ])ronounced himself in favor of the most conservative 
 treatment of abortion and immature labor, as opposed to the spreading 
 tendency in favor of active interference. Stumpf supported Winckel at 
 this time, and later published an elaborate tabulated statement of 446 cases 
 from the obstetrical polyclinic at Munich. ^^^ One hundred and sixt3^-nine 
 cases of abortion were treated on the purely expectant plan, by tampon 
 and ergot, and 84 per cent, ran a favorable course. The number of cases 
 without complication in w^hich retention of membranes was noted, w^as 
 slightly less than of those in which the ovum was described as having been 
 
184 REPORT OP^ THE SOCIETY OF THE l.VlXli-TX HOSFITAL. 
 
 expelled intact. The percentage of hteiiiorvhage was three times greater 
 in the former than in the latter. One hundred and lifteen cases of imma- 
 ture lal)or (late abortions) showed worse results, 91 pursuing a favorable 
 course, 24 developing sepsis. Four cases of sepsis were fatal. Three of 
 them were treated by manual removal, and death was laid directly to this, 
 the author apparently forgetting his own statement, that interference was 
 not resorted to " unless it was absolutely necessary; " in other words, unless 
 the ])atient was in extremis from lurmorrhage or sepsis. ITis argument, 
 based on a 2o per cent, mortality for operative cases against 2 per cent. 
 for expectiint, fails for the same reason. Fifteen cases are, moreover, too 
 small a number to base sweeping deductions upon. 
 
 "Winter '- claims that the puerperium is not disturbed b}^ retention of 
 decidua, 38 per cent, of his cases becoming pregnant early, while after 
 complete removal, conception was seen in only 0.20 per cent. Puppe^*^ has 
 ])ublished the results in Winter's clinic. Winter makes this concession to 
 the advocates of active treatment, that partly detached and floating rem- 
 nants of retained decidua might become dangerous, and hence should be 
 removed. Olshausen, Schrtt^der, and Kiistner^^' advocate the expectant 
 ])lan also. 
 
 Varnier's '^ conclusions from a series of 501 cases are that retention of 
 the ])lacenta is exceptional, and retention prolonged for more than twenty- 
 foui- houi's is very unusual. lie allows nature to act until the ])lacenta is 
 in the vagina, and then removes it manually. Immediate delivery is indi- 
 cated in hiemorrhage, Init he does not clear away the dehris. He found 
 " complete " expulsion to occur onl}^ 48 times in liis series. 
 
 Boetus,'^ who iirst published satisfactory results in ten curettage cases, 
 advises against a ])i'e]iminary dilatation of the cervix, es])ecially in ])res- 
 ence of sejjsis and inflammation of the adnexa, but uses tlio curette freely 
 in all cases with good results. lie found complicating pelvic disease 
 improved after curetting, made worse by dilatation. Great care must be 
 used to remove every part of the retained placenta (1877). 
 
 After an experience Avith 90 cases, Fehling^^s (i878) believes insti'u- 
 mental removal of ovum or secundines is absolutely without djinger under 
 antise])tic precautions, and favors active pro]>]iylactic interference, since it 
 cau.ses ra[)id involution and saves the woman subsequent suffering from 
 j)elvic disease. He was able to demonstrate the retention of decidua in all 
 cases which he subjected to curettage. Eleven of his cases Avere septic when 
 first seen, antl two were fatah but in these the source of infection was 
 clearly trac<!d. 
 
 Jirion*' reports 24 (rases of retained ])la('enta after abortion, with 11 
 deaths; he divid(!S tliein into two cln-oiiological pei-iods, lss;',-lS8S, 1888- 
 1802. During the Iirst. irrigalioii only \v;is cniplcy*'*! : (hiring the second, 
 manual cun-lting was added. Four of (Ught casi^s (50 per cent.) died in 
 the first jKM-iod; five of twenty ('2;") ])er cent. ) in tlu^ second. Tliice and 
 four respectively were fa 1' ;id\'a need in sepsis wlieii admitted to the Hospital. 
 r)initting tliesr*, the ))ei'e(;ntages are 20 and O.r., difleniuce enough to 
 inaki- tlie autlioi- pronounee in favor of active trealni(;nt and most careful 
 
THE PREMATniE INTERRUPTION OF PREGNANCY. 185 
 
 antisepsis. His preference for the finger is founded on its sensitiveness. 
 He gives these indications for interference : 
 
 1. In case of death and maceration of the foetus. 
 
 2. In every case after incom])lete abortion in which the temperature 
 rises to 38 degrees Centigrade. The patient must be at once isolated and 
 cleUvered. The accidents in abortion are sepsis and hgeraorrhage, but as to 
 their rehitive frequency it is difficult to say. Sepsis, however, occurred 24 
 times to -I of haemorrhage in the author's 28 cases of placental retention. 
 
 In his paper read before the Buffalo Obstetrical Societ}^, M. Ilartwig ^'^^ 
 lays down the rule that it is best to remove what may become septic if not 
 already so. He finds dilatation seldom necessary, scraping the mucous 
 membrane with a dull curette until nothing but blood comes away. Ergot, 
 he finds, will not stimulate abortion, but will often prevent it. 
 
 Felsenreich ^^^ reports 20 cases of puerperal curetting, and finds it well 
 borne in presence of parametritis and perimetritis, even of inflammation 
 of the adnexa. He has seen women who aborted habitually, go to term 
 after curetting. 
 
 Weekbecker-Sternfeld ^''' prefer instrumental to digital curettage because 
 (1) the danger of infection is less, (2) less room is required, (3) removal of 
 decidual remnants is more positive, and (4) there is less disturbance and 
 injury to the patient. They give as indications for the use of the instru- 
 ment: («) in the first three months (1) retention of ovum intact, adherent 
 or (2) free ; (3) retention of secundines ; (h) in later months, for removal of 
 placental cotyledons, (c) as an irritant in an atonic uterus, {d) for removal 
 of placental polypoid growths. 
 
 Moses ^^ has reported 61 cases of threatened and incomplete premature 
 deliver}^ Ten were frankly septic, 51 non-septic. Expectant treatment 
 was pursued in 19 cases, while 42 were curetted — 7 for se|)sis, 9 for haemor- 
 rhage, 26 as a prophylactic measure. The result was apparently good in 
 all cases, with a single exception, a septic patient i7i artimdo mortis when 
 brought in. 
 
 Braun ^^^ says every j^hysician should know how to use a curette and 
 use it ; Pick ^°^ has employed it as a prophylactic procedure ; Schwarz ^^^ 
 recommends it whenever the ovum is not intact, and always in sepsis, even 
 when the patient is in collapse. 
 
 Dahlmann ^^^ states that in 130 cases the tampon was indicated only four 
 times, for the reason that, although it is the ideal method when practical, 
 the physician is usually called too late to apply it. His method is digital 
 curetting, followed by instrumental. The finger cannot remove the bits of 
 tissue which, left behind, are fruitful sources of trouble. One hundred 
 cases treated in this manner recovered without complication. Dahlmann 
 has observed the usual chill and temperature rise in curetted septic cases, 
 and though he believes in thoroughly cleansing the uterus, there was no 
 decomposition seen in three of his incomplete cases of several months' 
 duration. 
 
 Diihrssen,^^^ perhaps more than any other man, has brought the advan- 
 tages of curettage home to every obstetrician. He empties the uterus as 
 
186 REPORT OF THE SOCfETV OF THE LYTX(i-lX HOSPITAL. 
 
 soon as the abortion bei-onios inevitaMc. Two only of l^>-2 cases treated 
 by him died, in s))ite of the fact that many were advanced in sepsis wlien 
 first seen, or had sutfered from severe luemori'hages. Contrasting- the 
 expectant and active phins of treatment, he asks, *' Why, if interference is 
 tt>-day considered less (hmgerons than abortion, not make sure that every- 
 thing has been removed, when it can be so readily done ? " Involution 
 and time are necessary for convalescence after abortion ; the one is hastened 
 tiie other cut short after curetting. This is, of course, a boon to the work- 
 ing classes. The expectant plan requires two weeks for itself alone; after 
 instrumentation the j)atient leaves her bed on the fifth day. Pain and 
 physical discomfort, as well as mental perturbation, are greater than in the 
 exi)ectant methotl. Moreover, a large ])ro]K)rtion of so-called complete 
 abortion cases are followed by luemoi-riiages, subinvolution, acute and 
 chronic sepsis. Haemorrhage is always greater with expectant treatment. 
 Not more than half an ounce is lost by instrumentation before the fourth 
 month. 
 
 Diihrssen, unlike Munde, Boetus, and Ihiclmor, does not use the curette 
 to remove placenta after the twelfth ^veek. It is not ])ossil)le or safe to do 
 so, and as a greater number of abortions occur at the third month, the 
 method must be a combined one. The separation of the placenta is readily 
 accomjilished by the finger; the curette removes the decidua vera. In the 
 first two months, clearage can be accomplished with curettage alone, the 
 canal admitting the linger with difficulty and pain if anaesthesia is not used. 
 Uterine atony, as in our cases, is controlled l)y irrigation, and tamjwnade 
 with iodoform gauze. Ergot is rarely called for; the placental forceps 
 occasionally. 
 
 Doderlein,'-'^ also an advocate of active treatment, uses only digital 
 curetting for recent cases, reserving the instrument for instances of acute 
 and chronic endometritis. He emplo^^s anassthesia always. If the os will 
 not admit a finger, he uses a laminaria tent, and evacuates the next day. 
 lie reports 500 cases so managed in ZweifePs clinic, and has operated, as 
 Avell, in loo cases of profuse ha?morrhage following aboi-tion. Of the 500 
 cases, three, septic when admitted, died under expectant treatment. The 
 100 cases showed ]iolypi and endometritis, and took weeks to cure. 
 
 Iloc-het**^ pui-sues much the same plan, dilating with tents, and scraping 
 first with a blunt, tlien with a sharp, curette without anaesthesia. AVitli a 
 large curette, he claims, there is little danger of ])erfora,ting the uterus. 
 
 Eckstein '•''■ has rej)orte(l (!<» cases whicli wei-e curetted, and, in sj)it(^ of 
 complications, all made good recoveries, in s('])tic cases, Ik; pai'ticuhirly 
 declar(?s no time should b(^ lost in ch'ui'ingand disinfecting the utciMUt! cavity. 
 
 Authors might be (juot(*d in this connection in practically endless ai-ray, 
 for new ones are constantly being achhul to thi- ;iliv;i(ly long list. AVe may 
 be excused for naming in addition, as increasing the weight of ex])e)'i- 
 encc on the side of interference;, Palmer, nonifield.''"' Locke,'''' (irigoriawitz 
 (00 cases with one death), Ku])penheim '* of Ilciilclberg (100 cases, treated 
 by manual and instrumental removal in llir- lirsl three months, latei- by 
 han«l only;, Chaliex.'* liibot,"" von dcr (ioll/..'" 
 
TPIE PREMATURE INTERRUPTION OF PREGNANCY. 187 
 
 Between these two extremes of treatment stands the third class, com- 
 posed of men who, not caring tcj interfere in every case, or even in a 
 majority of cases, are still unwilling to allow nature to take its course Avhen 
 the uterus is a focus of septic infection. They claim that curettage does 
 not always give good results even when done by skilled operators. 
 Another objection offered is the elaborate preparation for operation. 
 Charles ^" cites cases to prove the former objection, and considers curettage 
 after abortion necessary only when there is an old endometritis, or when 
 the finger fails to remove the placenta. Yon JBraun-Fernwald ^""^ holds 
 that the passive attitude is best. Lauros ^^® waits until urgent symptoms 
 demand interference. Stratz ^'' believes that active treatment is only 
 required for haemorrhage and fever, and, even Avhen driven to it, prefers the 
 finger to an instrument. In five only of 486 cases did he deem it necessary 
 to use the curette. All of these were septic, and in all there was a tetanic 
 condition of the uterus, due to previous administration of ergot. Deme- 
 lin "^ advises removal of the placenta with two fingers at three months; at 
 four months it can be left to nature. Yelitz "^ concludes from a study of 
 4,333 cases in Tauffer's clinic that only when there are decided indications 
 need one resort to interference. Doleris^^'^ is especially identified with 
 ecouvillonage of the uterus, a procedure similar to the cleaning of lamp 
 chimneys, the organ being swept out. Misrachi^^^ advocates it also. 
 Porak ^^^ judged intervention necessary in only 25 cases out of 326, and in 
 these the operation was extremely simple. His percentage of fever in cases 
 of intervention was 36, and his mortalit}^ 4 per cent. ; in spontaneous 
 delivery, 10 per cent, and 0.3 per cent, respectively. He omits, however, 
 all mention of details regarding sepsis, its appearance in expectant cases, 
 etc., and the late results of his treatment. Misrachi^^^ undertook to 
 answer Dr. Porak, and stated that since he began interference in cases 
 of retention, he had had 92 cases of abortion. In 60, or 65.2 per cent., 
 intervention was necessary, the large proportion being caused by the char- 
 acter of his clientele. In 47 cases he was called at the first symptom, and 
 of these, 32 terminated spontaneously, in 15 he intervened (13 of haemor- 
 rhage, 2 of sepsis). The proportion of bleeding controverts Porak' s state- 
 ment as to the negligibility of this as an indication for interference. 
 
 Treatment of the Peematube Inteeeuption of Peegnanct as Caeeied 
 
 Out by This Hospital. 
 
 Treatment of Abortion. 
 
 By reference to the tables it will be seen that of the total 417 cases of 
 abortion, 324 were subjected to some form of curettage; the average period 
 between the time the cases first came under the observation of the Hospital 
 official and the curettage being 8 hours 45 minutes in early abortions, 10 
 hours 48 minutes in late abortions. The diagnosis of inevitable abortion 
 or of the fact that the accident had already occurred (incomplete ?) being 
 made, and leaving out of consideration the amount of hgemorrhage as an 
 indication for interference, the patient is plainly told that an operation is 
 necessary ; and if, upon explaining the danger of the situation to her, con- 
 
188 
 
 REPORT OF THE fiOCTETY OV THE LYIN(MX HOSPITAL. 
 
 sent for curettjige cannot be secured, she is treated according to Procedure 
 I. or II. (see infra) or referred to another institution or her private ph3^si- 
 cian. The patient's consent having been obtained, curettage is performed 
 within as short a time as possible. 
 
 Pr(>C('(I>(/Y I. — As a rule, during the ]ieriod covered bv this article, the 
 treatment of interru])ted })regnancy in the tirst three months of gestation 
 has been an active one, as the following table indicates : 
 
 Treatment in 417 Cases of Abortion. 
 
 Late 
 Abortions. 
 
 Instrumental curettage only 
 
 Combined instrumental and digital curettage 
 
 Digital curettage only 
 
 Intrauterine douche only 
 
 Expectant treatment 
 
 79 
 
 27 
 5 
 
 7 
 
 175 
 
 Time tuat Elapsed Between First Visit by the Hospital Official and 
 
 Operation. 
 
 Average |)eriod . . 
 Longest period , . . 
 Shortest period . . 
 Op(3ration at once 
 
 early abortions. 
 160 Observations. 
 
 8 hours 45 minutes. 
 3 weeks. 
 Few minutes. 
 In 129 cases. 
 
 LATE ABORTIONS. 
 
 96 Observations. 
 
 10 hours 48 minutes. 
 2 weeks. 
 Few minutes. 
 In 55 cases. 
 
 In addition to the labor bag (see Ite])ort) which has already been sent 
 to tlie ]);itient's liome, another one, known as the '' curettage bag," is sent, 
 which coMtains the followin"; articles: 
 
 Chloroform. 
 
 Mask ami tbopijcr. 
 
 Ether and cone. 
 
 N'aginal brush. 
 
 Kelly pad. 
 
 Douche bag. 
 
 Kubljer instruiMcnt trays, 8. 
 
 Crutch. 
 
 Xail l)ruslies, '•>. 
 
 Solution pans, 2. 
 
 Contents of Clrettage Bag. 
 
 Gauze — one tube iodoform, one tube 
 
 ])lain sterilized. 
 Sterilized towels, 4. 
 Bichloiide tablets. 
 Ccii'l)olic acid. 
 Ergot. 
 Whiskey 
 
 Agar-agar tubes and culture swabs, 4. 
 Catheter, glass. 
 Sims's speculum. 
 
Fig 1. — Curettage Bag, 
 
THE PREMATURE INTERRUPTION OF PREGNANCY. 
 
 189 
 
 Edebobls's speculum. 
 Yolsella, 2. 
 Dressing forceps, 2. 
 Curettes, 3 sharp and 3 blunt. 
 Uterine sound. 
 Cervical dilator. 
 Bandage scissors. 
 Fritscb return catheter. 
 
 Douche tube, glass. 
 
 Sterilized cotton, two tins. 
 
 Soap. 
 
 Lysol. 
 
 Alcohol. 
 
 Digitalis. 
 
 Strychnine. 
 
 Agar-agar exposure-plate, 1. 
 
 Two of the resident staff of the Hospital, accompanied by one or more 
 students, the latter for the purpose of instruction, then proceed to the case ; 
 all preparations are made, the patient is anaesthetized (with ether in most 
 cases), placed upon the kitchen table so as to secure light from window or 
 lamp, the Kelly pad adjusted, and the legs are secured in the lithotomy 
 position by canvas crutch. (See Fig. 1.) 
 
 The vulva now is usually shaved, and always scrubbed with lysol solu- 
 tion, five per cent. , or with green soap, using a stiff brush. The vagina is 
 then cleansed with the same solutions, and at different periods in the ser- 
 vice of the Hospital a stiff brush, a soft five-inch jeweler's brush, and 
 swabs of sterilized absorbent cotton or gauze upon long dressing forceps 
 have been used for this purpose. 
 
 The field of operation, including the vagina, is now cleared of soap 
 with boiled water, and a final thorough irrigation with sublimate solution 
 isooo) follows. 
 
 By means of towels, sterilized and brought from the Hospital, the imme- 
 diate septic surroundings are covered so as to exclude contact infection. 
 
 The perineum is now depressed with a speculum, the cervix grasped 
 and brought down with a volsella forceps, and, if required, the os is freely 
 and rapidly dilated with a steel dilator of the Goodell type. 
 
 The uterine cavity is now freely irrigated w4th a sublimate solution 
 (¥oVo)? ^ digital examination is made, followed by another irrigation, and 
 the uterus is thoroughly curetted, usually both sharp and dull instruments 
 being used, and during the operation the cavity is repeatedly washed out. 
 
 At certain periods in the history of the Hospital, the use of the sharp 
 curette has been confined to cases in which evidences of chronic inflamma- 
 tion of the uterus were present. 
 
 Iodoform gauze was not made use of for drainage among the earlier 
 cases ; later the uterus and vagina were rather tightly packed ; and in the 
 more recent cases a single strip only of gauze was introduced to the fundus, 
 and the vagina rather tightly packed with the same material. 
 
 Bacteriology. — For purposes of bacteriological study, four cultures are 
 taken at the time of the operation, the first and second from the vagina 
 and uterus before cleansing these parts, and the third and fourth from the 
 same points after cleansing and curetting. (See Bacteriology.) 
 
 In instances in which the diagnosis of abortion is questionable, no 
 embryo, foetus, or placenta having been found, but the symptoms point to 
 an incomplete abortion, scrapings obtained with the curette are placed in 
 
190 REPORT OF thp: society of the lvincmn hospital. 
 
 alcohol, marked with the Hospital luimlier o\: the case, and sent to the 
 ]iathologist for microsco])ical examination. i^lSee Tathology.) 
 
 ]*i'oce(1ure J I. — Dui'ilii:' certain periods a few cases of inevitable or 
 incomplete abortion, in w hicli the patient refuses to take an anaesthetic, and 
 in which all s\ini)tonis of se])sis are absent, have been accepted by the 
 llos|)ital and treated on a partially expectant plan. 
 
 The j)atient is placed in the lithotomy position and tlic vulva and vagina 
 are cleansed as in I'rocedure I. Then, if the dilatation of the os permits 
 it, curettage is performed as above, otherwise nothing further is done. In 
 a few of these cases of the incomplete variety, the uterus was irrigated Avitli 
 a sul>limate solution, and, if possible, a strip of gauze introduced for a drain, 
 
 I'roct'dnre III. — A few nou-septic cases have been accepted in which all 
 interference other than a digital examination has been refused by the patient. 
 
 Here a ])urely expectant treatment was followed, the external genitals 
 only being waslied with a sublimate solution {-^-^^ before and after the dig- 
 ital examination. These cases could not be kept under observation very 
 long, as the patients usually left their beds on the third or fourtli day to 
 attend to their housework. 
 
 Aftt'i'-Treatment. — Patients are kept upon fluid diet for two days after 
 curettage, and the vulva is washed once or twice daily during the puer])e- 
 rium with a sublimate solution (^o-y). If the tenijierature and ]Hilse remain 
 normal the vaginal and uterine gauze is left in sliu, until the fourth or fifth 
 day, then removed, and a vaginal sublimate douche (-joinr) given. Should 
 evidences of se])sis show themselves, the vaginal gauze is first removed and 
 the vagina irrigated; should they then persist, the uterus is em])tied of 
 gauze and iri'igated, and the washing is repeated if necessary. 
 
 Treatment and Results in Our 2-1:2 Cases or Early Abortion. 
 
 Treatment of Early Abortions. 
 
 In the study of any particular line of treatment for abortion and the 
 results obtained therefrom, the importance of making a distinction between 
 cases of septic and non-septic when first seen cannot be too strongly em- 
 ])hasiz('d. 
 
 The following tallies will show at a glance the treatment and results in 
 the several classes of cases: 
 
 Treatment in Early Abortions. r^ 
 
 (;ases. 
 
 Instrumental curettage 1C6 
 
 ('oMd)ined instrumental and digital curettage 45 
 
 I )igital cur(;ttage 3 
 
 Intrauterine douche only 6 
 
 P^xpectant treatment 22 
 
 Total 242 
 
 Cases. 
 No. of cases of early abortion with fever wlicii lirst seen ... 9 
 
 " " without fever when lirst seen. 283 
 Total 242 
 
THE PREMATURE INTERRUPTION OF PREGNANCY. 
 
 191 
 
 Treatment of 9 Cases of Eakly Abortion with Fever when First Seen. 
 
 Cases. 
 
 Curettage (1 digital, 6 instrumental) 7 
 
 Expectant treatment 2 
 
 Total 9 
 
 Treatment of 233 Cases of Early Abortion without Fever when 
 
 First Seen. 
 
 Cases. 
 
 Instrumental curettage only 160 
 
 Combined instrumental and digital curettage tto 
 
 Digital curettage 2 
 
 Intrauterine douche 6 
 
 Symptomatic or expectant 20 
 
 Total 233 
 
 Cause of the Fever, Treatment, and Termination of the 9 Cases of 
 Early Abortion with Febrile Symptoms when First Seen. 
 
 C. X, 
 
 213 
 
 727 
 
 781 
 
 l,01i 
 
 1,153 
 
 2,270 
 
 5,4:61 
 
 5,781 
 7,521 
 
 Cause of Fever. 
 
 Sepsis 
 
 Tuberculosis and sepsis (?) , 
 
 Treatment. 
 
 Digital curettage 
 
 Expectant 
 
 Instrumental curettage 
 
 Expectant 
 
 Instrumental curettag-e 
 
 Duration of 
 Symptoms. 
 
 1 da}^. 
 
 3 days. 
 1 day. 
 3 days. 
 Few hours. 
 I*^o record. 
 5 days. 
 3 days. 
 
 Eesults of the 233 Cases of Early Abortion that were without 
 Febrile Symptoms when First Seen. 
 
 Cases. 
 
 Undisturbed puerperium 214 
 
 Developed fever 19 
 
 Of the 214 cases that resulted in an undisturbed puerperium, the treat- 
 ment was as foUows: 
 
 Cases. 
 
 Curettage 188 
 
 Expectant 26 
 
192 
 
 REPORT OF THE SOCIETY OF THE LYING-IN HOSPITAL. 
 
 Cause of thk Fkvkr, Treatment, and Termination in the 19 Cases of 
 Early Abortion that Developed Febrile Symptoms in the Service 
 OF THE Hospital. 
 
 C. N. 
 
 Cause of Fever. 
 
 117 
 1,013 
 1,243 
 1,612 
 2,275 
 2,327 
 2,8<M 
 3, SO") 
 3,703 
 4,101 
 4,252 
 4,909 
 5,017 
 5,732 
 0,223 
 6,719 
 7,022 
 T,738 
 
 Sepsis 
 
 'Bronchitis (?) 
 
 Se]>sis 
 
 lUnknown 
 
 Pleiiris>' and sepsis 
 
 Sepsis 
 
 Unknown 
 
 Sei)sis 
 
 Tuberculosis 
 
 : Unknown 
 
 Sepsis 
 
 ;Consti])ation 
 
 Sepsis 
 
 lUnknown 
 
 j Pneumonia 
 
 jConstipation 
 
 Treatment. 
 
 Instrumental curetta«re 
 
 Duration of 
 Symptoms. 
 
 1 day. 
 3 days. 
 
 2 days. 
 
 3 days. 
 5 days. 
 
 1 daj^. 
 Few hours. 
 
 4 days. 
 No record. 
 Few hours. 
 days. 
 Few hours. 
 
 Li a 
 
 2 days. 
 Few hours. 
 
 2 days. 
 Few hours. 
 No record. 
 
 3 days. 
 
 Treatment and Eesults in Our 175 Cases of Late Abortion. 
 
 Tredtment of Ldie Ahortions. 
 
 As will be seen by reference to our table of the premature interruption 
 of ])regnancy, from the beginning of the fourth until the completion of the 
 sixth and three-fourths month of gestation, the treatment is usually of 
 the active variety in the early portion of this period, because clinically 
 we are unable to draw the line so sharply between early and late abortions 
 as some authorities would have us do, and in the fourth, fifth, and sixth 
 months the treatment becomes less and less aggressive, until it gradually 
 merges into that of premature labor and labor at term. 
 
 Tkkatmknt in Late Abortions. 
 
 Cases. 
 
 Instrumental curettage 79 
 
 (Joml)ined instrumental and digital curc;ttag(j 27 
 
 Digital curettage 5 
 
 Intrautc^rine douche only 7 
 
 Expectant treatment 57 
 
 Total 175 
 
THE PREMATURE INTERRUPTION OF PREGNANCY. 
 
 193 
 
 The following table shows at a glance the ratio of actual interference 
 progressively diminishing in the successive months : 
 
 Delivery of the Placenta in Late Abortions, Showing Ratio of 
 Intrauterine Interference Diminishing in the Successive Months. 
 
 Month of Gestation. 
 
 At 4th month, including 3|- 
 months 
 
 At 5th month 
 
 At 6th month, including 6|- 
 months 
 
 66 
 15 
 
 an 
 
 C/2 
 
 7 
 12 
 
 18 
 
 
 7 
 3 
 
 10 
 
 XI 
 
 1 
 
 2 
 
 15 
 
 o 
 o 
 
 Ratio of 
 Intrauterine 
 Interference. 
 
 73-88 = 1 in 1 
 18-37 = 1 in 2 
 
 13-50 = 1 in 4 
 
 Recognizing as we do the fact that the real criterion of late abortions 
 is the marked prolongation of the third stage of labor, naturally the inter- 
 est centres at this point. 
 
 It is obvious that the tendency in our treatment has not been to await 
 the natural course, the spontaneous detachment and expulsion of the pla- 
 centa, even in cases not complicated by dangerous haemorrhage or sepsis of 
 the secundines, but to clear tlie uterus as quickly as possible after the 
 diagnosis of an inevitable or incomplete abortion is made. 
 
 Cases falling in the first portion of this period are subjected to the 
 same active treatment, already described, as is applied to instances of 
 inevitable or incomplete abortion. Not only do w^e believe that the char- 
 acter of the outdoor service and environment of the patients demand and 
 justify this course, but the results obtained strengthen our ])osition. 
 
 Here again we cannot too strongly emphasize the importance of mak- 
 ing a distinction, when giving the results of any particular line of treat- 
 ment for the premature interruption of pregnancy, between cases non- 
 septic when first seen or operated upon and those that are septic. 
 
 The following tables indicate the line of treatment in 175 cases of late 
 abortion, of which 20 were febrile when first seen, and 155 were non- 
 febrile. 
 
 Treatment in Late Abortions. 
 
 Cases. 
 
 Instrumental curettage 79 
 
 Combined instrumental and digital curettage 27 
 
 Digital curettage 5 
 
 Intrauterine doucl^ only ^ 
 
 Expectant treatment 57 
 
 Total 175 
 
 13 
 
194 
 
 REPORT OF THE SOCIETY OF THE LYING-IN HOSPITAL. 
 
 Dklivekv of the Placenta in Late Aboktions. Q^^g^g 
 
 Spontaneously delivered 35 
 
 Placenta ex]iressed 19 
 
 Placenta removed manually l)y Hospital official 20 
 
 Curettage after manual removal 87 
 
 Kot noted on liistury 8 
 
 Total 175 
 
 No. cases of late abortion with fever when first seen. . . . 2(> 
 »' »' " '' without fever when first seen . 155 
 
 Total 175 
 
 Treatment of the 2o Cases of Late Abortion that had Fever when 
 
 First Seen. ^^^^^^ 
 
 Placenta delivered spontaneously 2 
 
 Placenta expressed 2 
 
 Placenta manually removed by Hospital official 4 
 
 Curettage after manual removal 4 
 
 Instrumental curettage 12 
 
 Results of the Treatment of the 20 Cases of Late Abortion that 
 WERE Febrile when First Seen. 
 The following table gives the cause of the fever, the treatment, and the 
 duration of the sym]^toms in the 20 cases of late abortion with fever when 
 fii"st seen by the Hos})ital official. 
 
 C. X. 
 
 Cause of 
 Fever. 
 
 Placenta. 
 
 Curettage. 
 
 Duration of 
 Symptoms. 
 
 215 
 
 283 
 
 Sepsis 
 
 Manual extraction . . 
 
 Instrumental .... 
 
 a 
 a 
 a 
 i( 
 u 
 
 Dio'ital 
 
 Few hours. 
 1 day. 
 
 871 
 
 
 
 Unknown. 
 
 1,177 
 1 002 
 
 
 
 3 (lavs. 
 
 
 
 Few hours. 
 
 1,785 
 2,11>2 
 2,755 
 3,808 
 
 
 
 2 days. 
 
 
 Spontaneous 
 
 ^lanual extraction . . 
 
 Instrumental .... 
 
 i( 
 
 a 
 u 
 u 
 u 
 
 4 davs. 
 1 day. 
 
 4,774 
 5,044 
 
 
 
 Spontaneous 
 
 2 days. 
 Few hours. 
 
 5 219 
 
 
 
 (I a 
 
 5,<;47 
 
 
 
 a a 
 
 5,702 
 
 
 
 1 d:iv. 
 
 0,885 
 
 .. 
 
 ^[anual extraction . . 
 
 " 
 
 0,5«;2 
 
 Unknown 
 
 Sej)sis 
 
 Expressed 
 
 >' 
 
 0,015 
 
 
 Instrumental .... 
 
 9 ii 
 Expectant 
 
 VvAV hours. 
 
 7,070 
 
 
 14 days. 
 
 8,087 
 9,643 
 
 Consti|)ati<;n. . . 
 
 i 
 1 
 
 Manual exti'actioii . . 
 Expressed 
 
 Few hours. 
 
 
 
 
THE PEEMATURE INTERRUPTION OF PREGNANCY. 
 
 195 
 
 Treatment of the 155 Cases of Late Abortion that were Non-Febrile 
 
 WHEN First Seen. 
 
 Cases. 
 
 Placenta spontaneously delivered 33 
 
 Placenta expressed 17 
 
 Placenta removed manually by Hospital official 25 
 
 Curettage after manual removal Y2 
 
 JN'ot noted 8 
 
 Total 155 
 
 Results of the Treatment of the 155 Cases of Late Abortion that 
 were Kon-Febrile when First Seen. 
 
 Cases. 
 
 Undisturbed puerperium 137 
 
 Developed febrile symptoms 18 
 
 Cause of the Fever, Treatment, and Duration of the Symptoms in 
 THE 18 Cases of Late Abortion that Developed Febrile Symptoms 
 IN THE Service of the Hospital. 
 
 C. K 
 
 64 
 
 407 
 
 567 
 
 580 
 
 911 
 
 939 
 
 1,055 
 
 1,267 
 
 1,326 
 
 1,922 
 
 4,198 
 
 4,242 
 
 4,309 
 
 5,051 
 
 5,635 
 
 5,656 
 
 7,260 
 
 8,872 
 
 Cause of 
 Fever. 
 
 Sepsis 
 
 Bronchitis . , 
 
 Sepsis 
 
 Unknown . . 
 Sepsis 
 
 Constipation 
 
 Sepsis 
 
 a 
 
 Constipation 
 Unknown . . , 
 
 Sepsis . . . . . 
 
 Placenta. 
 
 Spontaneous .... 
 Manual extraction 
 
 Expressed 
 
 Manual extraction 
 
 Expressed 
 
 Manual extraction 
 
 Spontaneous 
 Broken up . . 
 Expressed . . . 
 Spontaneous 
 Broken up . . 
 
 Manual extraction 
 
 Broken up 
 
 Expressed 
 
 Spontaneous . . . . 
 
 Curettage. 
 
 Instrumental 
 
 Instrumental 
 
 Instrument, and dig. 
 
 Instrumental 
 
 Instrument, and dig- 
 Instrumental 
 
 Instrument, and dig. 
 Instrumental 
 
 Instrumental 
 
 Duration of 
 
 Symptoms. 
 
 Few hours. 
 2 days. 
 Iday. 
 
 3 days. 
 2 days. 
 Few hours. 
 
 4 days. 
 1 day. 
 Few hours. 
 
 8 days. 
 3 days. 
 
 Note. — Winckel and Stumpf in their 115 cases of late abortion found 
 that manual detachment of the placenta was strictly indicated in 8 cases 
 only, or 6.95 per cent.; the placenta was delivered spontaneously in 77 
 cases, expressed in 17, removed or attempt at removal made by an outside 
 physician in 7 cases, removed manually by their own phj^sicians in 8. 
 
 Of their 115 cases, 6 w^ere fatal in consequence of immature labor, 
 
196 REPORT OF THE SOCIETY OF THE LYING-IN HOSPITAL. 
 
 5 of sepsis, 1 of lui?niorrluige. Three of the four cases of fatal sepsis had 
 been subjected to manual removal of the placenta, giving a mortality for 
 manual interference of '20 per cent., and for expectant or symptomatic 
 treatment of only 2 per cent. 
 
 Thev also claim a morbidity from sepsis under an expectant treatment 
 of l-t.a }>er cent., and under operative interference of -iO per cent.; but 
 they do not inform us what proportion of their cases were septic when 
 seen, and what pro]wrtion became so under an expectant treatment. To 
 quote their own words, '* On the strength of these figures one might 
 well, and with a clean conscience, defend and advocate a symptomatic 
 treatment as oj^posed to the operative." In 35 of their cases the third 
 staire was allowetl to continue over six hours. 
 
 Treatment and Results in Early and Late Abortions in the Several 
 Months of Gestation. 
 
 Eakly Abortions. 
 
 Cases. 
 
 Second month G9 
 
 Third month 165 
 
 Unknown S 
 
 Total "2^2 
 
 Of the above 242 cases belonging to the first three months, 233 showed 
 no fel)rile symptoms when first seen by the Hospital official, 9 showed 
 feljrile symptoms when first seen. 
 
 Tekmixatiox of 233 Cases ]^on-Febkile when First Seen. 
 
 Cases. 
 
 Subjected to immediate curettage 131 
 
 Allowed to run a spontaneous course 1()2 
 
 Of 131 subjected to immediate curettage: 
 
 Cases. 
 
 Fever-free puerperium resulted 120 or 91.60^ 
 
 Fever resulted 11 " 8.39^ 
 
 Total duration of fever in 11 cases was 17 days; average duration, one 
 and one-half days. 
 
 Of 102 cases of early al)ortion allowed to run a spontaneous course, 
 fever-free puei']»('rium resulted in all 1(>2 cases. 
 
 TiK.MI.NATIoN OF 9 CaSES FkiJRILK WIIKN l^'l ItST SeEN. 
 
 Cases. 
 Snbj('ct(!d to iinmcdiato curettage 8 
 
 Allowed to run a spontaneous course 1 
 
 Of the 8 curettage cases, fever lasted 15 A days in 7 cases; 1 case no 
 record ; average duration, 2 days. 
 
THE PREMATURE INTERRUPTION OF PREGN^VNCY. 197 
 
 Late Abortions. 
 
 Of 88 cases belonging to the fourth months 76 showed no febrile symp- 
 toms when first seen by the Hospital official, 12 showed febrile symptoms 
 when first seen. 
 
 Termination of 76 Cases JSTon-Febrile when First Seen. 
 
 Cases. 
 
 Subjected to immediate curettage 54 
 
 Manual extraction of the placenta 7 
 
 Allowed to run a spontaneous course 15 
 
 Total 76 
 
 Cases. 
 
 Fever-free puerperium resulted 72 
 
 Fever resulted 4 
 
 Termination of the 12 Cases that were Febrile when First Seen. 
 
 Cases. 
 
 Subjected to immediate curettage 12 
 
 Allowed to run a spontaneous course 
 
 Of the curettage cases, fever lasted 16^ days in 12 cases; average dura- 
 tion of fever, 1.30 days. 
 
 Of 37 cases belonging to the fifth mo7ith, 36 showed no febrile symp- 
 toms when first seen by the Hospital; 1 showed febrile symptoms when 
 first seen. 
 
 Termination of the 36 Cases of Fifth Month, ISTon-Febrile when 
 
 First Seen. 
 
 Cases. 
 
 Subjected to immediate curettage 1-1 
 
 Manual extraction of placenta alone 3 
 
 Allowed to run a spontaneous course 19 
 
 Total 36 
 
 Of the immediate curettage cases, fever lasted four days in one case. 
 
 Termination of the one case of the fifth 7nonth that was febrile when 
 first seen — subjected to immediate curettage. Fever in this case lasted 
 four days. 
 
 Of 50 cases belonging to the sixth month, 46 showed no febrile symp- 
 toms when first seen by the Hospital. Four showed febrile symptoms 
 when first seen. 
 
198 REPORT OF THE SOCIETY OF THE LYING -IX HOSPITAL. 
 
 Termixatiox of the -iO Cases of the Sixth Month, Xox-Febkile when 
 
 First Seen. 
 
 Cases. 
 
 Subjected to immediate curettage 
 
 IManual extraction of placenta alone 10 
 
 Allowed to run a spontaneous course 30 
 
 Total 40 
 
 Cases. 
 
 Fever-free ])uer]>erium resulted 38 
 
 Fever during- puerperiuni resulted 8 
 
 Termination of the 4 Cases of the Sixth Month that were Febrile 
 
 WHEN First Seen. 
 
 Cases. 
 
 Subjected to immediate curettage 3 
 
 Allowed to run a spontaneous course 1 
 
 Of the immediate curettage cases, fever lasted 3^ days in 3 cases ; 
 average duration, 1.13 days. 
 
 Of cases of interrupted pregnancy in which month of gestation was 
 unknown, sliowed no febrile symptoms when first seen by the Hospital. 
 None showed febrile symptoms when first seen. 
 
 Termination of the cases of unknown month, non-febrile when first 
 seen — sul^jected to immediate curettage, 0. 
 
 Of tlie primary curettage cases, fever-free puerperium resulted in 
 cases; fever during puerperium resulted in cases. 
 
 Resume of our 417 Caiita of Early and Late Ahoj'tions, toitli Percentage 
 of Ties nits. 
 
 Of the total 417 cases, 388 showed no fel)rile sym])toms when first seen 
 by the Hospital; 29 showed febrile symptoms when first seen. 
 
 Termination of the 388 Cases that were Non-Febrile when First 
 
 Seen. 
 
 Cases. 
 
 Subjected to immediate curettage 203 or 48.08,^ 
 
 Manual extraction of placenta '25 '' 5.99j^ 
 
 Expression of ])hicenta 17 '' 4.07j^ 
 
 Not noted 8 '' 1.91^ 
 
 Allowed to run a s])ontaneous course 135 " 32.37^ 
 
 Total 388 
 
 Of the immediate curettage cases, fever during piici'iH^rium resulted in 
 15 cases, or 3.59ji^. 
 
 Of the manual extraction of tlio ])hicenta cases, fever (hiring ])uer])e. 
 rium resulted in 5 cases, or 1.19^. 
 
THE PREMATURE INTERRUPTION OF PREGNANCY. 199 
 
 Termination of the 29 Cases that Showed Febrile Symptoms when 
 
 First Seen. 
 
 Cases. 
 
 • Subjected to immediate curettage 25 or 86.2^ 
 
 Allowed to run a spontaneous course -i " 13.8^ 
 
 Total numl;)er of cases out of the 417 abortions that were non-febrile 
 when first seen, but developed fever in the service of the Hospital, 37. 
 
 Table of Total I^fmber of Cases out of Our 417 Abortions that 
 Showed Febrile Symptoms either when First Seen by This Hospital 
 or Subsequently, with Treatment. 
 
 Xon-febrile when first seen, 
 Expectant treatment, 
 13 cases. 
 
 66 cases of fever 
 among 417 abor- 
 tions, or 15.83^. 
 
 8 cases. 
 Febrile when first seen, 
 5 cases. 
 
 Active interference, 
 
 ^Non-febrile when first seen, 
 29 cases. 
 53 cases. ] Febrile when first seen, 
 
 24 cases. 
 
 Treatfuent of Sj^ontaneotis Premature Labor. 
 
 The treatment of spontaneous premature labor in our service has prac- 
 tically been the same as that of labor at term, as is indicated in the follow- 
 ing table: 
 
 Treatment in 218 Premature Labors. 
 
 Cases. 
 
 Instrmnental curettage only 6 
 
 Digital curettage only 2 
 
 Intrauterine douche only 27 
 
 Expectant treatment purely 183 
 
 Total 218^ 
 
 Although we have already set forth under Prognosis the manner of 
 placental delivery, still we give the table here : 
 
 Placental Delivery in 218 Premature Labors. 
 
 Cases. 
 
 Spontaneous deliver}'" 47 
 
 Expressed 145 
 
 Manually removed 20 
 
 No record 8 
 
 Total 220 
 
 Regarding the apparently large number of placentae manually removed, 
 it must be remembered, as stated in another place, that there were eight 
 cases of placenta prsevia among the 218 cases of premature labor. 
 
200 
 
 REPORT OF THE SOCIETY OF THE LVING-IN" HOSPITAL. 
 
 Fever in Ol'R 218 Cases of Spontaneous Premature Labor. 
 
 Of our 218 cases of s})(mtaneous premature labor, the histories show 
 febrile symptoms either at the time the cases Avere first seen by the Hospi- 
 tal officials, or subsoiiueiitly, in 42 instances, or 19.27'^.'. 
 
 The following table inilicates the causes of the fever in these -42 cases : 
 
 Causes of Fever in Spontaneous Premature Labor. 
 
 Cases. 
 
 Fever due to sepsis 20 or 9.27j^ 
 
 " " mastitis 4 
 
 " " consti])ati()n 3 
 
 *' " pneumonia 3 
 
 " " mastitis and sepsis 2 
 
 " " abscess of breast 1 
 
 " '' tuberculosis (pulmonary) 1 
 
 " " eclampsia 1 
 
 " " unknown cause 7 
 
 Total 42 
 
 Tlie following table indicates the duration of fever, the day of highest 
 temperature, and cause of the fever in the 42 cases that Avere febrile either 
 Ijefore or after being seen by this Hospital : 
 
 Fever in Spontaneous Premature Labor. 
 
 C.N. 
 
 150 
 
 161 
 
 257 
 
 311 
 
 357 
 
 388 
 
 393 
 
 418 
 
 446 
 
 657 
 
 688 
 
 885 
 
 889 
 
 942 
 
 1.026 
 
 1,308 
 
 1,639 
 
 1,723 
 
 2,206 
 
 2,573 
 
 2,695 
 
 Duration 
 
 of 
 
 Fever. 
 
 30 days. 
 
 12 " 
 
 4 " 
 
 2 " 
 
 4 " 
 
 1 " 
 
 1 " 
 
 6 " 
 
 2 " 
 2 " 
 2 " 
 
 1 " 
 
 2 " 
 
 1 " 
 
 2 " 
 
 1 " 
 
 2 '• 
 
 7 " 
 
 1 day. 
 
 2 " 
 
 Day of 
 
 Highest 
 
 Temp. 
 
 2d day. 
 
 4th " 
 
 4th " 
 
 4th " 
 
 4th " 
 
 .•}d " 
 
 6tli " 
 
 4th " 
 
 :}d " 
 
 3d " 
 
 3d " 
 
 L. " 
 
 L. " 
 
 2d " 
 
 iHt " 
 
 3d " 
 
 r.tli " 
 
 7th " 
 
 4th " 
 
 4th " 
 
 3d " 
 
 Cause of Fever. 
 
 Sepsis. 
 
 Pneumonia. 
 Unknown cause. 
 Mastitis. 
 Pneumonia. 
 Sepsis & Ma.stitis. 
 Mastitis. 
 
 Sepsis. 
 Constipation. 
 
 Sepsis. 
 
 Sepsis & Ma.stitis. 
 
 Sepsis. 
 
 Pneumonia. 
 
 Sepsis. 
 
 C.N. 
 
 3,030 
 3,058 
 3,324 
 3,661 
 3,854 
 4,235 
 4,800 
 5,223 
 5,357 
 5,582 
 5,945 
 6.128 
 6,148 
 6,423 
 6,880 
 7,070 
 7,167 
 8,303 
 8,643 
 9,287 
 9,753 
 
 Duration 
 
 of 
 
 Fever. 
 
 1 day. 
 1 '' 
 1 " 
 
 2 days. 
 2 "■ 
 6 " 
 2 " 
 2 " 
 
 1 day. 
 
 1 day. 
 4 " 
 
 I day. 
 I " 
 1 " 
 1 " 
 
 Day of 
 
 Highest 
 
 Temp. 
 
 2d day. 
 
 1st " 
 
 1st " 
 
 L. " 
 
 2d " 
 
 1st " 
 
 2d " 
 
 5th " 
 
 4th " 
 
 5th " 
 
 3d " 
 
 7th " 
 
 1st dav 
 
 2d ••■ 
 
 2d " 
 
 L. " 
 
 3d " 
 
 4th " 
 
 4th " 
 
 3d " 
 
 Cause of Fever. 
 
 Constipation. 
 Unknown cause. 
 Sepsis. 
 
 Unknown cause. 
 Abscess of breast. 
 Sepsis. 
 
 Mastitis. 
 
 Phthisis. 
 
 Simple rise. 
 
 Sepsis. 
 
 Cause unknown. 
 
 S<'i)sis. 
 
 Eclampsia. 
 
 Sepsis. 
 
 Cause unknown. 
 
 S(^l)sis. 
 
 Unknown. 
 
 Total, 42 casRH of ftivor. or 10.27 per cent, of 218 cases. 
 
THE PREMATURE INTERRUPTION OF PREGNANCY. 
 
 201 
 
 Types of Early and Late Aboktions and Spontaneous Premature 
 Labors, with Symptoms, Treatment, and Results. 
 
 Case I. 
 
 Earhj ahoHloii ; mistaken diagnosis ; profuse hcemorrhage ; digital curet- 
 tage^ followed in five days hy instrumental curettage ; fever hefore latter 
 curettage^ none after j good recovery. 
 
 C. N. 6,223.— Second month of gestation; first seen May 18tli; thought 
 at this time to be a case of complete abortion ; mistaken diagnosis; upon 
 May 22d, four days after, a profuse haemorrhage occurred, which thre^y the 
 patient into coUapse, causing her to lose consciousness, and necessitating 
 the free use of stunulants; the embryo and decidua were digitally removed 
 at this time; upon May 2Tth, the fifth day of the puerperium, the uterus 
 was thoroughh^ curetted with both sharp and dull curettes, ether being 
 used, and a quantity of foul- smelling decidua removed; the uterus at this 
 time was packed with gauze ; this patient suffered from persistent headache 
 throughout the puerperium (syphilis ?) ; after being under observation for 
 fifteen days, and the lochia having ceased, the patient was discharged. 
 
 r 
 
 DATE 
 
 
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203 
 
 REPORT OF THE SOCIETY OF THE LYIXG-IN HOSPITAL. 
 
 Case II. 
 
 Incomplete early abortion; louif-continved hemorrhage; sepsis; curet- 
 tage ; good recover ij. 
 
 C. i^. 781. — Incomplete abortion; third montli; duration of symptoms 
 three weeks; profuse hiemorrhage ; temperature when first seen, 103.5 de- 
 crees; immediate instrumental cui-etta^e and uterine irrigation; tempera- 
 ture immediately after operation, 103.2 degrees; normal temperature and 
 pulse on third day after operation; ])atient left her l)ed on the sixth 
 day, and was discharged in gootl condition on the seventh day. (See 
 Tem])erature Chart.) 
 
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 Cask IN. 
 
 Early inr.oraplete abortion; severe hcemorrhage ; hnmediate curettage; 
 metriti>f ; subseqiient labor at terra. 
 
 C. N. 1,153. — Third montli of gestation; one ])reviouB abortion; first 
 seen by the Hospital, December 31, IsiM: pati<'nt at this time was very 
 weak from uterine hajmorrhagc; wlndi li:i<l coiiliniicd foi- foin-djiys; history 
 of an incomi)l(!U! abortion two <lays previous; tempei-itiu'c; when seen, 
 101.2 degrees; ])ulse, llo; os admits oidy one fing(!i'; immediate instru- 
 mental curettage; pieces of (lc(i(lii;i rriiio\('(l; siil)liinate iit(^i'ine irrigation ; 
 
THE PREMATURE IXTERRUPTION OF PREGNANCY. 
 
 203 
 
 temperature aftei- operation, lul. 4 degrees; pulse, 112; painful uterus on 
 first and second days; foul lochia on fourth day; uterine irrigations on 
 first, second, and fourth days; bowels acted onireely with Epsom salts; 
 sthnulated with whiskey and given quantities of milk because of anaemic 
 condition; discharged on sixth day. (See Temperature Chart.) 
 
 This ]3atient was subsequently delivered of a living child at term. No 
 history of subsequent interrupted pregnancies. 
 
 a: 
 
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 Case IY. 
 
 Incomplete late cibortion ; sepsis; iwofxise licemorrhage ; curettage; 
 syphilis ; cardiac disease. 
 
 C. N. 3,803. — Month of gestation, third and one-half; when first seen, 
 temperature, 101.2 degrees ; pulse, 110 ; foetus had come away half an hour be- 
 fore, accompanied by profuse hiemorrhage; placenta was found plugging the 
 OS, which latter admitted two fingers readily ; placenta w^as removed by digi- 
 tal traction; uterus curetted instrumentallv, and uterine sublimate douche 
 
204 
 
 REPORT OF THE SOCIETY OF THE LYING-IX HOSPITAL. 
 
 given; very little lia?inorrbiige after operation; twenty -four hours after 
 operation, temperature, 100,0 degrees; pulse, 10i2. This ease was suffering 
 at the time from syphilis, with ulceration in the fauces. 
 
 Chronic cardiac disease and emphysema were also present in this case 
 as complications. V\Mm the third day of the pueri)ei'ium the patient 
 refused further treatment, and was, consequently, discharged. 
 
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 Case V. 
 
 Late abortion ; sepsis ; profuse hmmoi'rhage ; periuterine injUmimation ; 
 curettafje / partial rcrovery. 
 
 C. X. 1,177. — Fourth month of gestation; lii-st seen .lanuaiy 4, 1892, 
 by this IIos))ital; liistory at this tim(> of uterine h{i}morrhage for several 
 days past, for whicli, two days ])reviou.sly, vagina had he(!n t;ini])on("(l hy a 
 j)rivat€ physician; when Jirst seen, temperature, 1()4 degrees Fahrenlieit; 
 pulse, 120; no lia>morrhage; hot, <hy skin; hejuhulM- tympanitis; abdoin- 
 
THE PREMATURE INTERRUPTION OF PREGNANCY. 
 
 305 
 
 inal pain and tenderness; pain, tenderness, and swelling in left broad 
 ligament ; vagina filled with foul-smelling clots ; os the size of a five-cent 
 piece. Treatment consisted in cleansing vulva and vagina, thoroughly 
 curetting uterus with sharp curette, and irrigating with j-^^ sublimate 
 solution, applying hot applications over abdomen, and in administering 
 calomel, one-half grain every half hour for four doses. 
 
 Much foul-smelling dehris was removed from the uterus, and the tem- 
 perature and pulse after operation were lOtt degrees and 106 respectively. 
 
 DATE- 
 
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 Uterus remained very sensitive for eight days; slight discharge after 
 operation; abdominal tenderness and tympanitis continued for three days; 
 tongue remained coated for five days, then cleared; well-marked parame- 
 tritis and vaginitis (gonorrhoeal?). 
 
 The bowels were fully moved after the calomel with salts ; morphine 
 was given for the severe pain, and the patient was supported with quinine, 
 whiskey, and milk. 
 
 Patient discharged on ninth day, the parametritis in left broad liga- 
 ment still giving some pain. 
 
206 
 
 REPOKT OF THE 80C1ETV OF THE LVING-IN HOSPITAL. 
 
 Case VI. 
 
 Late abort ion ; incomplete', acute sepsis ', moderate hoBmorrhage ; curet- 
 tage; cessation of fever ; aJhuminuria. 
 
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 C. N. 2,755. — Montli of gestation, fiftli and one-lialf; wlion first seen, 
 temperature, lo4.<; degrees; pulse, 120; ineoinplete id)ortion with retained 
 and adherent ])hicenta; moderate haemorrhage; placenta was immediately 
 e.xtracted manually, and in so doing was broken up into many ])ieces; 
 uterine suljlimate douche was tiien given; the temperature chart shows that 
 the fever continued Un- foui- days, and that the lochia was foul u])on the 
 tliird and fourth days; u])on the fourth day of the ))uer))erium insti-innental 
 curettage wa,s perfornuxl, and several small pieces of ])lacental tissue re- 
 movetl from the uterine cavity. As will be seen in the accompanying chart, 
 there was jjractically my f(;ver after the curettage; the curettage was 
 followed l)y the usual sublimate uterine douche; albimiinuria. 
 
THE FKEMATURE INTERRUPTION OF PREGXAjSCY. 
 
 207 
 
 Case VII. 
 
 Late abortion ; long-continued hcemorrhage j uterine douche j otherwise 
 expectant treatment. 
 
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 C. IN". 4,198. — Abortion, sixth month; symptoms began ten clays before 
 being seen, at which time an abortion was threatened; in addition there 
 was a history of an intermittent haemorrhage for seven weeks previous ; 
 when first seen by the Hospital the foetus was found presenting at the os 
 uteri ; a vaginal tampon was applied for one and a half hours ; at the end 
 of that time foetus was expelled and placenta came away spontaneously, 
 but broken up into several pieces ; duiration of third stage was ten minutes ; 
 foetus was hydrocephalic and placenta markedl}" fatty; no curettage; single 
 rise of temperature (101.8) on first day; at this time, also, a single piece of 
 placenta was expelled ; the membranes were incomplete, the retained por- 
 tions being subsequently found in the vagina; we beHeve this fever was of 
 septic origin ; there were no mammary symptoms, nor tenderness of uterus. 
 
208 
 
 REPOKT OF THE SOCIETY OF THE LVING-LN HUSFITAL. 
 
 Case YIII. 
 
 Early abort ion ; profuse hcemorrhage • digital curettage and smooth 
 curette; jjeriuterine inflammation ; fever for eleven days ; labor at term^ 
 fourteen months after. 
 
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 0. X. 4,1<;1. — Third numtli of n(>st;itioii ; luodorate haemorrhage liad 
 been present for eight days, ;iinl i^'olusc Jia-mon-luigefoni lew hours pi-cvi- 
 ous to hoing seen by tliis Hospital; ovmn was loiuid in tho os and removed, 
 the uterus then Ijeing curetted diiiitally and with smooth cui-cttc; tliis Avas 
 followed by the usual intrauteriiii' < louche; on the foiirlh. lifth, sixlli. and 
 seventli days of the puerpoi-inm, ah(h)iii(Mi was tciuhM- to ])ressuro and tym- 
 panitic; fr('(; catharsis and hot applications to the abdomen nsi^d : on the 
 nintli day pain and tenderness is recorded in Itoth Fallopian tubes; tem])er- 
 ature reached nontial ])ointon twclt'th day; no fever tluM'eaftei-. no uterine 
 treatment was used after tlie curettage; patient discharged on the sixteciuth 
 day, in only fair condition, there being sym])toms at this liuu' of j)ara- 
 metritis. 
 
 This patif'Ut was delivci-ed of a living child at term, rourtceii inoiiths 
 (August, la'M) after the fonjgoing abortion. 
 
THE PKEMATUKE INTERRUPTION OF PREGNANCY. 209 
 
 Case IX. 
 
 Premature labor ; mo rhid adhesion of jjlacenta ; fever ; manual extrac- 
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 C. ]Sr. 6,880. — Primipara; montli of gestation, seventh; first seen in sec- 
 ond stage of labor, which lasted nine hours; temperature when seen, 101.2 
 degrees; pulse, 107; placenta, adherent and markedly fatty, was torn in the 
 manual extraction ; duration of third stage, thirty minutes ; pieces of pla- 
 centa left in uterus digitally removed as far as possible ; twentj^-f our hours 
 later temperature, 103 degrees ; pulse, 120 ; chloroform ; external genitals and 
 vagina cleansed with lysol (5 per cent.) and sublimate solution (ro'Fo)j 
 uterus curetted with dull curette ; pieces of placenta and membranes brought 
 away; uterus irrigated with sublimate solution (yoto^) ^^^ packed with 
 gauze; chill immediately after operation ; temperature, 104 degrees; pulse, 
 120 ; temperature, 101 to 103 degrees for four days ; gauze removed on second 
 day; examination showed uterus bound down, and parametritis; no foul 
 lochia ; discharged on tenth day ; culture from uterus showed absence of 
 organisms before operation. (See Bacteriology.) 
 14 
 
210 REPORT OF THE SOCIETY OF THE LYING-IN HOSPITAL. 
 
 BiBLIOUKAPHY. 
 
 1. Ahlfeld: Archiv f. Gyniikologie, viii., p. 194. 
 
 2. Winckel: Text-book of :Mi(l\viforv, rhila(lel])liia, 1890, p. 51. 
 
 3. Stumpf : Miincliener mediciiiische AVoc-bonsehrift, 1S8S, p. 403. 
 
 4. Chailly: Practical Treatise on ]\[idwirerv. Am. edition, 1846. 
 
 5. ^[aunsell: Dublin Practice of ]\[id\viferv, Am. edition, 1842. 
 
 «'.. Cliuivhill: On the Theory and Practice of Midwifery, Am. edi- 
 tit>n. {>''>''>. 
 
 7. Haushalter: Arcliives de Tocologie, 1890, xvii. 
 
 S. De Marbaix: La CeUule, 1892, Yiii. ; Fortschritte der Medicin, 
 1893. No. 5. 
 
 II. AVidal: Bulletin de FAcad. de Med., 1888, xix. 
 Iti. Punim: Centralbl. f. Gyniik., 1892, No. 9. 
 
 11. Gartner: Archiv f. Gyniik., xliii. 
 
 12. Fritsch: Deutsche med. "Wochenschr. , 1891, xvii. 
 
 1:k Williams: Aincr. Journ. of Med. Sciences, July, 1893. 
 
 14. Si))i)L'll: Deutsch. med. Wochenschr., 1894, No. 52. 
 
 15. AVilliams: Johns Hop. IIosp. Reports, 1892, vol. iii. 
 
 16. Cullen: Johns IIoj). TIosp. Eeports, 1895, vol. iv., Nos. 7 and 8. 
 
 17. Diihrssen : Archiv fiir GyniikoL, xxx., 161, 1887. 
 
 18. Schroeder: Lehrbuch der Geburtshilfe. 
 
 19. Spiegelberg: Lehrbuch der Gelmrtshilfe. 
 
 21. Klein: Zeitschrift f. Geb. u. Gyniik., bd. xxii., p. 247. 
 
 22. Ekstein: Prager Med. Woch., Nos. xvi., xvii., 1892. 
 
 23. Kiirstner: Arch. f. Gyn., xviii. 
 
 24. Fritsch: Handb. f. Frauenk., i., p. 980. 
 
 25. Schroeder: Handb. der Krankh. des weib. Korpers, 1886. 
 
 20. AVinckel: Lehi'buch d. Frauenk., 1880. 
 
 27. Porak: Pul. et mem. de la Soc. Obstet, et Gynecol, de Paris, 1889, 
 p. 1 '.»:.. 
 
 28. Lehmann: Berlin klin. AVochen., June 25, 1894. 
 
 29. Hirschfeld and Schmorl: Prit. Med. Journ., abstract, June 6, 
 1891, ])ar. 5(i5. 
 
 30. Mornnv's " System of Genito-Urinavy Diseases, Syphilology, and 
 Dermat<;logy,"" vol. ii., p. 269. 
 
 31. Hehrer: Archiv fiir Gyniik., vol. xlv., pt. 3, 1894. 
 
 32. Priestly: Liiiiil(i;iii Lectures, p. 88. 
 
 33. "Williams: .loliiis Hop. IIosp. Reports, a'oI. iv., No. 9. 
 
 34. .M<-ng(': Zcit. f. (icb. u. (iyii., xxx., 323-305, 1S95. 
 
 35. Matthews Duncan: Lancet, Oct. 30 and Nov. 0, 1880. 
 30. AhllVld: Zcit. f. TJcb. u. Gyniik., 1S93, bd. xxvii., lit. 2. 
 
 37. P>unini: .\ivliiv f. (Jyniik., IM)!, bd. xl., lit. 3. 
 
 38. von l''ran(|ii«'-: Zcit. f. (ieb. u. (tVU., 1S93, xxv., p. 277. 
 
 39. WilliaiM.s: Anier. Jouni. of :\Ied. Sci., July, 1893. 
 
 40. Mayrliofei-: Monatssdi. f. ( icbiirtslcinide, iSfir), xv., ]). 112. 
 
THE PREMATURE INTERRUPTION OF PREGNANCY. 211 
 
 41. Pasteur: Comptes Rendus cles Seances de I'Acad., 18S0, p. 1038. 
 
 42. Doderlein: Arch. f. Gyn., 1891, xL, p. 99. 
 
 43. KOiiig: Centralblatt f. Gyniik., Feb. 25, 1893. 
 
 44. Flexner: Bulletin of Johns Hopkins IIosp., 1893, p. 12. 
 
 45. Ileyse: Deutsche med. Wochenschrift, 1893, ISTo. 14. 
 
 40. Semmelweiss : " yEtiologie, Begriff und Prophylaxisdes Kindbett- 
 fiebers," Buda., Wien, Leipzig, 1861. 
 
 47. Doderlein: " Das Scheidensekret, " Leipzig, 1892. 
 
 48. Mermann: Centr. f. Gyniik., 1893, p. 177. 
 
 49. Leopold: x\rchiv f. Gynak., 1891, xL, p. 439. 
 
 50. Doderlein: Archiv fiir Gynak., xxxi., 1887, p. 412. 
 
 51. Bumni: Centralblatt f. Gynak., 1892, No. 9. 
 
 52. Rindfleisch: Lehrbuch, Ite Aufl., p. 204. 
 
 53. Recklinghausen: Centralbl. f. med. Wissenschaften, 1871, p. 713. 
 
 54. Waldeyer: Arch. f. Gynak., 1872, iii., p. 293. 
 
 55. Klebs: Arch. f. exper. Path., bd. v. p. 417. 
 
 56. Orth: Virchow's Archiv, Iviii., p. 441. 
 
 57. Spillman: Zeit. f. klin. Med., 1880, p. 408. 
 
 58. Friinckel, quoted by Lomer: Zeit. f. Geb. u. Gyn., x., 366. 
 
 59. Winckel: Yerh. d. '^Deutschen Ges. f. Gyn., 1886, p. 78. 
 
 60. Bumm: Centralbl. f. Bacter., 1887, ii., p. 343. 
 
 61. Winter: Zeit. f. Geb. u. Gyn., 1888, xiv., p. 443. 
 
 62. Brieger: Charite-Annalen, 1888, xiii. , p. 198. 
 
 63. Czerniewsky: Archiv f. Gynak., 1888, xxxiii., p. 73. 
 
 64. Fehling: Yerhand. Deut. Ges. f. Gyn., Freiburg, 1889. 
 
 65. Hagler, quoted by Fehling: " Phys. u. Path, des Wochenbetts," 
 Stuttgart, 1890. 
 
 66. Kuliscioff : Gazetta degli Ospitali, 1886, N"o. 77. 
 
 67. Kehrer: Miiller's Handbuch der Geburtshiilfe, 1888, i., p. 545. 
 
 68. Kaltenbach: Yer. d. Deutschen Ges. f. Gynak., Freiburg, 1889. 
 
 69. Gonner: Centralbl. f. Gyn., 1887, p. 444. 
 
 70. Thomen: Archiv f. Gyn., 1889, xxxvi., p. 231. 
 
 71. Widal: Gaz. des Hop.*^, 1889, p. 565. 
 
 72. Witte: Zeit. f. Geb. u. Gyn., 1892, xxv., p. 8. 
 
 73. Bossowsky: Wiener med. Wochen., 1887, I^os. 8 and 9. 
 
 74. Welch: Amer. Journ. Med. Sci., ISTov., 1891. 
 
 75. Kronig: Deutsche med. Wochenschr., 1894, I^o. 43. 
 
 76. Bumm: Lancet (N. Y.), 1895, Iso. 8, p. 263. 
 
 77. Menge: Lancet (N. Y.), 1895, No. 8, p. 266. 
 
 78. Hofmeier: Miinchener med. Wochenschr., 1894, No. 42. 
 
 79. Yahle: Zeitschr. f. Geburts. u. Gyn., bd. xxii., ht. 3. 
 
 80. Walthard: Archiv f. Gyn., bd. xlviii., ht. 2. 
 
 81. Wertheim: Centralblatt f. Gynak., 1895, No. 26, p. 699. 
 
 82. Brion: Etude critique sur 530 cas d'avortement, G. Steinheil, Paris, 
 1892. 
 
 83. Misrachi: Nouvelles Archives d'Obstet. et de Gyn., 1889, pp. 195, 
 497. 
 
212 REl'ORT OF THE SOCIETY OF THE LYING-IX HOSriTAL. 
 
 S4. Leopold : Beitnige ziir Yerhiitimg des Kindbettliebers. Deutsche 
 meii. Wochensohrift, Xo. !25, 1887; Xo. 20, 1888. 
 
 85. 8tiiin})f: Munclioiior med. AVocheiischrift, 1888, p. 463. 
 S6. Porak: l^ull. et uu'iii. do la Soc. Ohst. et Gynec. de Paris. 
 
 87. Rochet: Traiteiueiit deravorteiuent incomi)let. Joiirn.d'accouche- 
 ments, Lit-ge. 181)2, xii., pp. 109, 181. 
 
 88, Goldschiuidt: These de Strassboiirg, 1854. 
 
 80. Enge: Zur ^Etiologie und Anatomie der Endometritis. Zeitschr. 
 f. Geb. und Gyn., v., h. 2. 
 
 00. Olshausen: UebiT cliron. hy]>erplas. Endometritis des Corpus 
 Uteri. Arch. f. Gyn., vii., p. 121. 
 
 01. Bischotf : Die sog. Endom. fungosa. Correspondenzbl. f. Schweizer 
 yErzte, 1878. 
 
 02. Brennecke: Zur ^Etiologie der Endometr. cet. Arch. f. Gyn., xx., 
 p. 455, 
 
 03. Diihrssen: Zur Pathologic und Tlierapie des Abortus. Arch. f. 
 Gyn., 1887, xxxi., ]). KU. 
 
 04. Fritsch: Die Krankheiten der Frauen, Berlin, 1889, p. 226. 
 
 05. Henricius: Ueber die chron. hyperpl. Endometr. Arch. f. Gyn., 
 xxviii. 
 
 9t;. ^lartin: Pathologic u. Therapie der Frauenkrankheiten, Wien u. 
 Leipzig, lss7, p. 2o4. 
 
 97. Kiistner: Beitriige zur Lehre von der Endom., Jena, 1883. 
 
 08. Pu]i|'>e: Untersuchungen uber die Folgezustande nach Abortus. 
 Inaug. Dissert., Berlin, 1890. 
 
 99. Bibot: Arch, de TocoL, Xo. 5, 1894. 
 
 100. Lepage: Precis d'oljstetrique, Paris, 1893. 
 
 101. Yeit: Miiller's Ilandbuch der Geb., bd. ii., p. 54. 
 
 102. Winter: Centralblatt f . Gyn., 1890, p. 111. 
 
 103. Klein: Zeitsclirif t f. Geb. u. Gyn., bd. xxii., ]>. 247. 
 
 104. Boetus: Centralblatt f. Gyn., 1877, p. 352. 
 
 105. Czobos, Karl: Zur Behandlung des Abortus. Central))], f. d. 
 gesammte Therapie, Vienna, 1884, ii.,p. 529. 
 
 100. Sclnvarz, E. : Zur Behandlung der Fehlgeburt. Samml. klin. 
 Yortr., Gyniik., p. 241, 1884, Leipzig. 
 
 107. AVeekbecker-Sternfeld : Ueber die Anwendung des scharfen Loffels 
 in der Geburtsliiilfe. Arch. f. Gyn., Berlin, 1882, xx., p. 230. 
 
 1<»8. Diihrssen: Zur Pathologic und Therapie des Abortus. Arch. f. 
 Gyn., XXXV., ]>. 101, Berlin, 1887. 
 
 1(»9. AVinckcl: ^Muncliencr med. Wochonschr., 1888, p. 463. 
 
 110. Stiiiiipf: Zur .Kliologie u, Beliaiidhmg der Fehl- u. Friihgeburt. 
 ^liindi. iii<(l. Woclienschr., 1892, Nos. 43 and 44. 
 
 111. ZwcilVl: LeliH)Ucli dor Gc])., ISSO. 
 
 112. Auvard: Cas d'avortcment oil le cni'age de ru(('rns ctait seul de 
 Kiuvor la femme. Arch, de TocoL, Paris, .Ian., isito, |). ci. — Avortement 
 de <|Uatro niois caus«* ])ar une lu'inorrliagic; utt'-i-iplaccntairc; hrmorrlmgie 
 dm- vraiseniblablcinent a un traumatismc indirect. Arch. d. TocoL, Paris. 
 
THE PREMATURE INTERRUPTION OF PREGNANCY. 213 
 
 1887, p. lUoO. Also Uull. et iiieiii cle la Soc. Obst. et Gynec. de Paris, 
 1887, p. 258. — Avortement due n une excitation reflexe provoquee par un 
 ascaride. Gaz. hebd. de med. et de chirur., Paris, 1878, p. 754. 
 
 113. Brehm, II. von: Ein casuistischer Beitrag zur Ilmgehung der 
 kiinstlichen Friihgebnrt. St. Petersburger med. Wochenschr., 1890, No. 
 9, p. 77. 
 
 114. Prochownik: Yolkmann's Samml. klin. A'ortr., 1881, No. 3. 
 
 115. Spondly: Zeitscbr. f. Geb., ix., 1893. 
 
 IIG. Yoltz:'CentralbL f. Gyn., No. 52, 1883, p. 835. 
 
 117. Charles. N. : De la delivrance dans I'avortement. Journ. d'ac- 
 conchements, Liege, 1890, xi., p. 77. 
 
 118. Porak, M. : Prolapsus de I'uterus et Allongement hypertrophique 
 du col compliquant la grossesse ; avortement au 4e mois ; retention du pla- 
 centa; delivrance artiiicielle. Bull, et mem. Soc. Obst. et Gynec. de Paris, 
 1891, p. 7. 
 
 119. Audebert: De rintervention dans I'infection puerperale post- 
 abortive. Arch, de TocoL, Paris, 1890, xvii., No. 9, p. 651. 
 
 120. Winckel: Miincli. med. Wochenschr., 1888, p. 463. 
 
 121. Stumpf: Miinch. med. Wochenschr., 1892, Nos. 43 and 44. 
 
 122. "Winter: Zur Behandlung des Abortus. Beilage zum Centralbl. 
 f. Gyn., Leipzig, 1890, xiv., p. 111. 
 
 123. Tarnier: De la delivrance dans Tavortement. Revue pratique 
 d'obstet. et de pediatric, Dec, 1892, p. 353, and Jan., 1893, pp. 1, 
 33, 97. 
 
 124. Boetus: Zur Behandluno- der Blutuno^en nach Abort. Centralbl. 
 f. Gyn., Leipzig, 1877. 
 
 125. Fehling, H. : L'eber die Behandlung der Fehlgeburt. Arch. f. 
 Gyn.. Berlin, 1878, xiii., p. 222. 
 
 126. Hartwig, Marcell: Znr Behandlung des Abortus. New Yorker 
 med. Presse, 1885-1886, i., p. 243.— Hoav Shall We Manage Abortion? 
 Buffalo Med. and Surg. Journ., 1885-1886, xxvi., p. 241. 
 
 127. Felseureich: Die Auskratzuno- des Uterus zur Entfernuno- von 
 Eiresten. AUg. Wiener med. Zeitung, 1885, xxx. , p. 499. 
 
 128. Moses: Einundsechzig Fiille von Abort aus der geburtshilflichen 
 Universitats-Poliklinik zu Breslau, mit Bemerkungen liber ^Etiologie, 
 Symptomatologie und Therapie. Inaug. Dissert., Breslau, 1884. — Cen- 
 talbl. f. Gyn., Leipzig, 1884, viii., p. 272. 
 
 129. Braun, C. Y. : Abortus mit Yerbleiben der Placenta im Litems; 
 consecutive Blutungen. Allg. Wiener med. Zeitung, Dec, 1882, p. 534. 
 
 130. Pick, P. : Ueber die Anwendung des scharfen Loffels in der Geb- 
 urtshiilfe, vornehmlich bei Blutungen post Abortum. Deutsche med. 
 Woch., Berlin, Dec, 1883, ix., No. 50, p. 732. 
 
 131. Schvrarz, E. : Zur Behandlung der Fehlgeburt. Centralbl. f. d. 
 ges. Therapie, Wien, 1884, ii., p. 529.— Sammlung klin. Yortr.. Leipzig, 
 1884, p. 1715. 
 
 132. Dahlmann. Franz: Zur Behandlung der Fehlgeburten. DerFrau- 
 enarzt, 1886, i., p. 113. 
 
214 REPORT OF THE SOCIETY OF THE IA'INCt-IX HOSPITAL. 
 
 133. Diihi-ssen, A. : Zur Patbologie iind Tlierapie "des Abortus. Arch, 
 f. Gyn.. Berlin, ISST, xxxv.. p. 101. 
 
 134. Dodorlein, AlbtM't: Die Bebandhmg der inutungen bei Abortus, 
 Placenta prcevia uud Atouia Uteri postpartum. Miincli. ined. Wochenscbr. , 
 May, 1S02. xxxix.. No. lHi, p. 339. 
 
 135. Eckstein, Eniil: Zur Behandlung der Feblgeburt. Prager med. 
 Wochenschr., 1892, xviii., Xos. IC, 17. pp. 177-186. 
 
 130. Bonifield, C. L. : The Treatment of Abortion. Amer. Journ. 
 Obst., isiti\ XXV., p. 49. 
 
 137. Locke, H. G. : The Treatment of Incomplete Abortion at Roosevelt 
 Hospital. ]^[ed. Record, Xew York, lSit2, xli., p. 78. 
 
 138. Kuppenheim, Rudolf: Zur Thera])ie des Abortus. Deutsche med. 
 Wochenschr., Leipzig u. Berlin, Dec, 1891, p. 14*23. —Centralbl. f. Gyn., 
 1892, xiv. 
 
 139. Chaleix, !Maxime: Curage digital de T uterus dans un cas d'hemor- 
 rhao-ie o-rave consecutive a un avortement de trois mois. Arch, de TocoL, 
 Paris, 1891, xviii., p. 14. 
 
 140. Bibot, M. : Contribution a Tetude du traitement de Tavortement 
 embryonnaire. Societe beige de Gyn., Bulletin, 1893, iv., p. 147. 
 
 141. Goltz, von der: Zur Behandlung des frischen Abortus. Medicin. 
 Monatsschr., Xew York, 1889, i., p. 305. 
 
 142. Borel: Du curettage uterin dans les accidents consecutifs a I'ac- 
 couchement et a la fausse couche. Arch, de TocoL, 1890, xvii., p. 89. 
 
 143. Kiistner, Otto: Decidua-Retention ; Deciduom; Adenoma Uteri. 
 Arch. f. Gyn., Berlin, 1881, xviii., p. 252. 
 
 144. Charles: Journ. d'accouchements, Dec, 1891. 
 
 145. Braun-Fern\vald, Egon V. : Zur modernen Therapie des Abortus. 
 Allg. Wiener med. Zeitung, 1890, xxxv., p. 4s3. 
 
 140. Lauros, K. X.: Behandlung der Xachgeburtsperiode. Allg. 
 AVienermed. Zeitung, 1892, xlvii., pp. 537-548, 501-590. 
 
 147. Stratz: Xederlaudsch Tijdschrift voor Geneeskunde, 1x1. xxix., 
 b. 5, 0. 
 
 148. Demelin : Traitement de la retention de I'arriere-faix dans I'avorte- 
 ment au 3e et au 4e mois de la grossesse. Revue gen. de clinique et de 
 Thera])euti(jue, 1889, iii., p. 375. 
 
 149. Velitz, II.: l>eitrjige zur Frage der ]^>e(leutung und Therapie von 
 zuriickgebliebenen Kihautresten. Internationale klin. Rundschau, Mar. 
 8, IV.H, v., p. 400. 
 
 150. Doleris, J. A.: ("onduite a tenir dans I'avortement; curage et 
 ecouvillonage de ruterns ])our I'extraction du ])lacenta retenu dans la mat- 
 rice. Xouv. Arch. (FObst. et de Gyn.. Paris, issO, ])p. 1, 282, 318.— lluit 
 cas d'avortements, traites par la dilatation i-a|)i(l(' <hi col, le curage de la 
 iiiatrice, h-s in j<*ctionsantisepticjues. Ann. <l('(iyn., Paris, ISSO, xxv., p. 300. 
 
 151. Misrachi, AI. : A i)rf)]X)s du ti-aitenu^nt de Favortement par hi 
 quinine. Annales de Gyn.. Fails, Isss. xxx., p. 120. — Fn dernier mot 
 sur le triitement (hi Favortement incomplet. Xouv. Arch. (l'()l)st. et (hi 
 Gvn.. F^^l>. iv.. 1). 497. 
 
THE PREMATURE INTERRUPTION OF PREGNANCY. 215 
 
 152. Porak: Bull, et mem. de la See. Obst. et Gyn. de Paris, 1889, p. 
 195. 
 
 153. Annschat: ]\[ittheiliing-en aiis der Praxis: zur Behandlung des 
 Abortus. Deutsche ]\[edizinal-Zeitung-, Berlin, 1885, No. 4, p. 512. 
 
 154. Balin, J.: Ein Fall von '"Missed Abortion." Centralbl. f. Gj^n., 
 Leipzig, 1890, xiv., p. 237. 
 
 155. Batuaud, J.: Tlierapeutique de Tavortement. Gaz. de Gyn,, 
 Paris, 1887, ii., p. 110. 
 
 15(). Bloch: Ueber die Behandlimg von Metrorrhagien, bedingt durcli 
 Retention von Abortusresten, Centralbl, f, d. gesammte Therap,, Wien, 
 1888, p, 193, 
 
 157. Brannan, John W. : The Treatment of Retained Secundines after 
 Abortion. Boston Med. and Surg. Journ., 1884, ex., p. 147. 
 
 158. Budin, P. : Eclampsie au septieme mois de la grossesse chez une 
 multipare; guerison de la mere; mort de P enfant 48 heuresplus tard; expul- 
 sion d'un oeuf complet, cinq semaines apres la mort du foetus. Le prog, 
 med., 2e serie, t. iv., iS'o. 37, Sep. 11, 1886, p. 755.— On the Mode of Con- 
 duct in a Case of Retention of Placenta after Abortion. Transl. fr. Le 
 Prog. med. by Dr. W. H. Wenning, N". C. Med. Jour., Mar., 1887, 
 19, 20. 
 
 159. Bureau: Dangers de I'intervention prematuree dans un cas de 
 retention placentaire (avorteinent de 3 mois et demi). Jour, de med., 
 Paris, April 3, 1892, p. 175. 
 
 160. Cecil, John G. : Management of the Secundines in Abortion. 
 Amer. Pract. and l^ews, Feb. 16, 1889, vii., No. 4, p. 97. 
 
 161. Cosentino, Giovanni: Ricerche ed osservazioni in ostetricia. 
 Annali di ostetricia e ginecologia, Milano, June, 1893, xv., p. 449. 
 
 162. Crow, Walter A. : The Treatment of Abortion, and Some of the 
 Complications Incident Thereto. An. of Gyn, and Paediatry, May, 1892, 
 v., p. 473, 
 
 163. Crowell, H, C, : Treatment of the Uterine Ca\nty in Abortions. 
 Med, News, April, 1891, No, 17, p, 460, 
 
 164. De Fresnay, L, Hamon: Traitement preventif des avortements a 
 repetition, Soc, de med, d'Anvers, Annales et bulletin, 1890, lii., p. 123. 
 
 165. DevUliers, C. : Avortement provoque. Nouveau Diet, de med. et 
 Chir. prat., 1867, iv., p. 329. 
 
 166. Doleris, J, A, : Traitement et restauration du col de I'uterus pen- 
 dant la grossesse, Nouv, Arch. d'Obst. et de Gyn., Paris, 1887, ii., pp. 
 427-445. 
 
 167. Fasola, Emilio: 82 aborti nel triennio 1883-85. Annali di oste- 
 tricia, Milano, 1887, p. 1. 
 
 168. Ferguson, Frank C. : Curetting the TTterus after x\.bortion. Indi- 
 ana Med. Jour., 1890, ix., p. 108. 
 
 169. Ferrand: Contribution a I'etude clinique de certaines fausses 
 couches. Soc. med. de I'Yonne, 1886, xxvii., p. 46. 
 
 170. Fischer: Meine Erfahrungen iiber FrtihgeburtsfaUe. Zeitschr. f. 
 "Wundarzte u. Geburtshelfer, Hegnach, 1888, xxxix., p. 332. 
 
216 REPORT OF THE SOCIETY OF THE LYIXGJX HOSPITAL. 
 
 171. Foei*stei', I'laiK-is: Abortion as an Etiological Factor in Gynae- 
 coloii-v and its Treatment. The Post-Graduate, May, 1891. ix., i). 
 
 17:^. Gallard, T. : De ravortement an i)i)int dc vue uu'dieo-legal. Paris, 
 J. 13. Baillicre et Fils, 1878. 
 
 173. Hart, D. Berry: The Anatomy and Mechanism of Early Abor- 
 tion. Laboratory Reports, Eoy. Col. of Physicians, iii., p. 261. 
 
 174. I^a^vlev, A. C. : A Case of Abortion Avith Seqnehr. Med. and 
 Surg. Pep., 18'.>0, Ixii., p. 449. 
 
 17.">. llaynes, Francis L. : Two Cases in whit-li the Uterus was Per- 
 forated by a Curette, Both Pecovering. Amer. Jour. Obst., Xov., 1890, 
 xxiii,, p. 1193. 
 
 176. Hegar, Alfred: Beitriige zur Pathologic des Eies und z.um Abort 
 in den ersten Schwangerschaftsmonaten. ^Monatschr. f. Geburtsk. u. 
 Frauenkr., Berlin, 1863, xxi., p. 1. 
 
 177. Ileitzmann, J.: Der protrahirte Abortus und seine Behandlung. 
 Central))!, f. d. gesammte Therapie, Wien, 1888, vi., ]). 65. 
 
 178. Ilenrichsen, K. : Zur Behandlung der Blutungen nach Abort. 
 Central bl. f. Gyn., Leipzig, 1886, x., p. 353. 
 
 17'.'. Herman, G. E. : Decidua vera and Reflexa from a very Early 
 Abortion. Trans. Obst. Soc. of London, xxxii., 1890, p. 272. 
 
 180. Iloffnum, Joseph: Premature Labor. Trans. Amer. Assoc, of 
 Obst. and Gyn., 1889, ii., p. 358. 
 
 181. Johnson, Joseph Taber: Abortion and its Effects. Maryland 
 Med. Jour., ^May Ki, 1890, xxiii. 
 
 182. Kelly, J. K. : The Treatment of Abortion, Glasgow Med. Jour., 
 Nov., 1891, p. 321. 
 
 183. Klein, Gustav: Entwickelung und Rtickbildung der Decidua. 
 Zeitschr. f. Geb. u. Gyn., Stuttgart, 1891, xxii., p. 247. 
 
 184. Klein wiichter, Ludwig: Die kiinstliche Unterbrechung der 
 Schwangerschaft, Leipzig u. Wien, 2te Aufl., 1890, Urban und Schwarz- 
 enberg. 
 
 185. Lambert: Traitement preventif et curatif de la fausse couche base 
 sur les indications. Soc. de med. d'Anvers, 1888, 1., p. 11. 
 
 ls(;. Lecmans: l"]tude sur le traitement de Favortement. Soc. de med. 
 d'Anvers, Ann. et buU., 1888, L., p. 81. 
 
 187. Legrand, H. : Avortement gemellaire; retention du placenta; 
 deux injections intrauterines avec solution de Sublime an y,)^^; hydrar- 
 gyrisHie aigii; mort; autopsie; examen histologique. Bull, de la Soc. Anat- 
 omicjue de Paris, 5e serie, 1889, iii., p. 321. 
 
 iss. Loiitr, J. AV. : The Curettage after Laboi- ;nid Aboi-ticm. N. C. 
 Med. .lour., .hdy, 1890, ]». 4(;i. 
 
 ISi). Lycett, J. ^y.■. The Pathology and Treatment of Abortion. 
 Birmingham Med. Uev., 1887, xxii.. ]). 2o3. 
 
 190. Maygrier-Demelin : l!ltu<le cliniciiK^ siir ravortement multiphi et 
 en ])arti( ulier snr Tavortement gemellaire. Arch, de Toeol. et de (ryn., 
 Paris, Feb., 1892, xix. 
 
THE PKEMATUKE INTERRUPTION OF PREGNANCY, 217 
 
 191. McKee, E. S. : Ilcibitual Abortion, Amer, Jour. 01)st., 1892, xxv., 
 pp. T75-780. 
 
 192. Merle, Leon: De I'avortement gemellaire, Paris, 1892, Oilier 
 Ilenr}'-, pj). 196, 8vo. 
 
 193. Miller, Alex. : Kotes on a Case of Recurring Miscarriage from an 
 Unusual Cause. Glasgow Med. Jour., Dec, 1889, p. 459. 
 
 19-1:. Napier, A. D. Leith: Statistical Note on "Habitual" Abortion. 
 Satellite of Sajous' Annual, 1889, ii., p. 181. 
 
 195. Olivier, Ad. : Note sur un cas d'avortement. Annales de la 
 poliolinique de Paris, 1891, i., p. 211. 
 
 190. Oui, M, : De F intervention dans les cas d'avortement lent. Arch. 
 Clin, de Bordeaux, 1892, i., p. 435. 
 
 197. Polacco, Roniolo: Contributo clinico ed istologico alio studio 
 dell'aborto interno. II Morgagni, 1887, xxix., p. 783. 
 
 198. Priestly, TV, O, : The Lumleian Lectures on the Pathology of 
 Intrauterine Death, Brit, Med, Jour,, 1887, i,, pp, 660, 714, 
 
 199. Pogge, H. : Curette eller ikke curette ved placentarrester efter 
 abort. Tidsskr, f, d, norske Lgegefor., Christiania and Copenhagen, 1892, 
 xii., pp, 68-72, 
 
 200. Eoss, Geo, T. : Missed Abortion, Canada Med. Record, Montreal, 
 Dec, 1889, xviii., p. 49. 
 
 201. Schuhl: De I'avortement a repetition et des moyens d'y remedier. 
 Ann. de Gyn., Paris, May, 1891, xxxv., p. 337. 
 
 202. Shauta: Therapeutics of Abortion. Med. Chir. Centralbl., Nov. 
 26, 1893. Also, Arch. Gyn., Obst., and Pediatrics, 1893, p. 452. 
 
 203. Shollenberger, Chas. P.: Spontaneous Abortion. Denver Med, 
 Times, 1889-90, ix,, p. 332, 
 
 204. South wick, G, R, : The Treatment of Abortion at the Fourth or 
 Fifth Month, with Retained Placenta, Amer. Jour. Obst., 1885, xviii., 
 p. 932. 
 
 205. Stratz, C. H. : Over graviditas extrauterina. Nederl. Tijdschr. 
 V. verlosk. en gynaec, Haarlem, 1890, ii., pp. 124-139. 
 
 206. Stumpf, Max: Zur ^tiologie und Behandlung der Fehl- und Fruh- 
 geburt, Miinch, med, Wochenschr,, Nov,, 1892, xxxix,, p. 780, 
 
 207. Ter-Grigoriantz : Beitrage zur Abortbehandlung, Centralbl, f. 
 Gyn., Leipzig, 1891, xv., p, 865, 
 
 208. Thomas, T, Gaillard: Abortion and its Treatment, from the 
 Standpoint of Practical Experience, A special course of lectures delivered 
 at the Coll, of Phys, and Surg,, New York, session of 1889-90. 
 
 209. Tintelin, Felix-Prosper: De I'avortement des 5e et 6e mois de la 
 grossesse considere surtout au point de vue de la delivrance, Nancy, 
 1888, 80 pp,, 4to, No. 278. 
 
 210. Yeit, J,: Miiller's Handbuch der GeburtshtiLfe, bd. ii,, 1888, 
 Stuttgart, pp, 1-220. 
 
 211. Vibert, Louis: Contribution a I'etude du traitement de la re- 
 tention du placenta dans I'avortement. Paris, 1891, 52 pp. 4to, G. 
 Steinheil. 
 
5il8 REPORT OF THE SOCIETV OF THE LYIXG-IX HOSPITAL. 
 
 212. AYanl, Sttinlev M. : Abortion — its Proper aiul Improper Manage- 
 ment. Amer. Gynecol. Jour., 1802, ii., p. 5(30. 
 
 213. AVarner, Helen F. : The ]\ranagement of Abortion. The Med. 
 Age, 1885, iii., p. 433. 
 
 214. Watson, -T. A.: Treatment of Abortion. X. C. Med. Jonr., 
 May, 1892, p. 250. 
 
 215. AVing, Elbert: Re]>ort of a Case of Abortion in tlie Third Month 
 of Gestation, Avith detention of the Placenta for Five Months without 
 Sepsis. Chicago Med. Jour, and Exam., 1888, Ivi., p. 334. 
 
 216. AVinckel, F. : Ueber den A^'erlauf und die Behandlung des Abortus 
 und Partus immaturus. "Miinch. med. AVochenschr. , 1888, xxxv., p. 463. 
 
OBSTETKICAL ASEPSIS AND THE KESULTS OF SIX YEARS' 
 OUTDOOE SERVICE. — MORBIDITY AND MORTALITY 
 STATISTICS OF 10,233 CASES. 
 
 By Samuel W. Lambert, M.D. 
 
 Obsteteical Asepsis in the Outdook Service, 
 
 The foUoTving pages will describe the methods of applying the princi- 
 ples of surgical cleanliness to the needs of the outdoor service of this 
 Hospital. The details are a result of the combined efforts of the members 
 of the Medical Board, and no personal claim is made of priority or author- 
 ship. The routine work of the Hospital is done in the same manner every 
 week of the year, without regard to the personal views of the attending 
 physician who may be on duty. Of course this routine has been a thing 
 of growth, and changes hav^e at times been frequent, and often of a radical 
 nature. But no change has been made without a previous discussion by 
 the Medical Board and without the approval of a majority of the five 
 attending physicians. 
 
 The outdoor service of the Lying-in Hospital has been described in 
 previous Reports often enough to need no repetition at this time. It is a 
 tenement-house service in the most densely populated district in the world. 
 The application of the principles of surgical asepsis in such a service is a 
 complex problem, which may be considered under three chief subdivisions: 
 I. Asepsis of apparatus. 
 II. Asepsis of operator. 
 
 HI. Asepsis of patient. 
 
 Asepsis of Obstetrical Instruments and Apparatus. 
 
 The Labor Bag. — This Hospital depends upon its tenement-house 
 patients to furnish at the time of their lying-in only a large pail for waste 
 douche, a basin for hand washing, and a plentiful supply of hot water. 
 All other apparatus which may be needed is taken to the case from the 
 Hospital. The outdoor service employs twenty-four labor bags, one of 
 which goes to every case. Each bag contains all the utensils needed for 
 
220 
 
 REPORT OF THE SOCIETY OF THE LYIXC-IN HOSPITAL. 
 
 the delivery of a normal case of labor. 
 ins: list of articles: 
 
 Kubber tj-oods : 
 
 Lying-in Hospital pad i^Keily). 
 Douche bag. 
 
 Agate ware: 
 
 Nest of three basins. 
 
 In glass bottles: 
 
 Soft rubber catheter. 
 Tape for cord. 
 Linen for cord. 
 Linen for eye wipes. 
 
 Drugs : 
 
 Acetic acid. 
 
 Alcohol. 
 
 Ergot. 
 
 Starch. 
 
 Solution of silver nitrate, Ifo. 
 
 Compound cathartic pills. 
 
 Bichloride of mercury tablets. 
 
 Its contents includes the follow- 
 In glass boxes: 
 
 \'ascline. 
 
 Soap. 
 In copper or brass cans: 
 
 Douche tubes. 
 
 Yulva pads. 
 
 Cotton wipes. 
 
 Nail brush. 
 
 Other articles: 
 
 Pelvimeter. 
 
 Eye dropper. 
 
 Scales. 
 
 Scissors. 
 
 Tape measure. 
 Blanks: 
 
 Miniature labor and child charts. 
 
 Ile})ort blanks. 
 
 Ijirtli certificate. 
 
 Small blank pad. 
 
 These bags are made of leather and lined with leather. They are lY x 
 0x9 inches in size; they open wide at the top, and one when filled weighs 
 20 pounds. One of them is represented in the accompanying cut (Fig. 1). 
 
 A room is sjiecially devoted to the use of the outdoor department as a 
 laboratory and is fitted U]) Avith the necessary glass tables, supply shelves, 
 sinks, and sterilizers. The preparation of the dressings, the sterilization of 
 the instruments, and the cleaning and refilling of the bags needed in the 
 service are done in this room. A general view of the room is given in the 
 accomjmnying ])late (Fig. 2), and the special arrangement of the apparatus 
 is shown in the plan on page 221 (Fig. 3). 
 
 The waslitub (3) is of porcelain, and the dripboard (2) of glass. The 
 tables are of sim))le consti'uction and have glass t()j)s. The table nuirked 
 11 in the |»l;iM li;is ;i cciili';!! sliclf ( \-J\ on wiiich the stock bottles for solu- 
 tions and a rcsei've siip])ly of drug bottles are kept, for renewing brok(Mi 
 articles when tlie bags are refilled. The sluOves (17) over table (1<») are 
 foi- the st<jrage of the co))p('r cans of wipes, pads, douche tubes, and nail 
 l)rushes. The remaining relerences to the ])lan <'xplain themselves. 
 
 Tlie Brainhall-I)e;ine stei-ilizers ai'e arranged to expose their contents to 
 the action of steam under a pressure of ten pounds. The a])])aratus is a 
 eylin<ler ojx'n at one end, and the steam is genei-ated from watei' in the 
 bottom, lieated by a liunsen flame nmh-i-neatli. The ai'ticles to be steril- 
 ized are placed u|)on a rack ovei- the boiling wafiM-. Thei'e is a, steam- 
 gauge and safety-valve, which latter is set at hn pounds pi-essure (Fig. 4). 
 
 The work is done b}' the nurses, two of wlioni ai-c on duty during the 
 
Fig. 1. — Labor Bag. 
 
 Fig. 4. — Steam Stehilizer. 
 
ASEPSIS, MORBIDITY, AND MORTALITY, 
 
 231 
 
 day. They leave the whole number of bags in condition for immediate 
 use when going off duty each night, and it is a very unusual thing for the 
 supply of clean bags to be exhausted by morning. The refilling of one of 
 these labor bags involves a considerable amount of sterilization and clean- 
 ing, but a supply of articles already prepared is kept on hand, and the 
 process is therefore much facilitated. When a bag is returned from a case, 
 it is emptied of its contents, and is then wiped out with a cloth dampened 
 
 Fig. 3. Plan of Nueses' Labokatoky. 
 
 1, 1. Bramhall-Deane Sterilizers. 
 
 2. Glass table. 
 
 3. Porcelain washtub. 
 
 4. Glass table. 
 
 5. Towel Rack. 
 
 6. Range. 
 
 7. Boiler. 
 
 8. Soiled linen hamper. 
 
 9. Instrument case. 
 
 10. Glass table. 
 
 11. Glass table. 
 
 12. Central shelf. 
 
 13. Glass table. 
 
 14. Stock closet. 
 
 15. Shelves for bags. 
 
 16. Vestibule, separated by iron rail. 
 
 17. Shelves for copper cans. 
 
 with bichloride of mercur}^ solution. It is filled immediateh^ with a fresh 
 supply, and is frequently used twice in twenty-four hours. Each of the 
 varied list of articles contained in these bags demands a different treat- 
 ment in order to render it surgically clean. The object of the system of 
 preparation detailed below is to furnish for each confinement the necessary 
 supply of aseptic dressings and apparatus. 
 
 The Lying-in Hospital bed pad is modified from the model of Dr. 
 Kelly in such a way that the seams are less numerous and the pad more 
 
222 REPORT OF THE SOCIETY OF THE LYING-IN HOSPITAL. 
 
 dill-able (Fig. •r>V One of these pads is used at every confinement to protect 
 the bed from the bk)oil and liquor amnii, and, what is eipially important, to 
 protect the patient fi'om the infective bedding Avhich is a constant accom- 
 ]ianiinent of the t)utdoor service. The j)ad is also used instead of a douche 
 pan to receive the postpartum vaginal douche and convey the overflow to a 
 pail on the floor. These pads are cleaned by washing with soap, water, 
 and brush, and sterilized by scrubbing with carbolic sohition (5 per cent.). 
 Kubber does not stand the action of corrosive sublimate nor of heat either 
 dry or moist. The life of a pad under this routine is twelve months. 
 
 The douche bag used is the ordinary four-quart fountain syringe, which 
 is also made of rubber, and is cleaned and sterilized in the same manner as 
 the rubber pad (Fig. 5). These bags are used exclusively for the giving of 
 bichloride of mercury douches in normal labor cases. A bag under this 
 care will last six months. 
 
 The three agate basins in the bag form a nest, for easy packing (Fig. 0). 
 The larger two contain a })int, and the bichloride tablets are of such a 
 strength that one in a })int makes a solution 1 to 2,000; these basins are 
 used to hold the bichloride solution. One will be used for disinfecting 
 the hands, and the other to contain the necessary amount of concentrated 
 solution of corrosive su1>limate to be added to the douche. The shallower 
 basin is used to hold the scissors and tape for the cord and some of the eye 
 wipes. These articles are placed upon the basin just before the end of the 
 second stage, where the}'' will be convenient when needed. These basins 
 are sterilized by washing with sapolio and corrosive sublimate solution 1 to 
 1,000. 
 
 The douche tubes which are used for normal cases are straight vaginal 
 tubes of glass (Fig. 13). A routine postpartum vaginal douche is given, and 
 these tubes are used to diminish the chance of the douche being delivered 
 into the uterus. The tubes have in the past been carried in glass cylinders 
 Avhich are shaped like large test tubes. Their blind end is perforated, and 
 when in use both ends are plugged with absorbent cotton. These cylinders 
 and their contents are sterilized in the pressure steam drums. It has been 
 voted l)y the Medical Board to change these glass cylinders for those of 
 brass, similar to the copper cylinders descril)ed below as b(>ing used for the 
 dressings and n;iil brushes. Such a cylinder is shown in Fig. !> l)elow. 
 The original c(jst (^f the brass is somewhat more than that of the glass, 
 but the loss by breakage is practicall}' nothing. Experience has shown 
 also that the brass is better than the copper, because solid brass tubing can 
 be ))urchased, while the co|>pei' must have a longitudinal seain along the 
 side. The brass will therefore outlast the copper. The lirst cans were of 
 nickel-plated zinc, but they did not stand the frequent exposure to steam, 
 as the plating wore olf and the zinc became oxidized. 
 
 Tiie soft rubber catheter is the onlv foriu used in the oiiLdooi' service. 
 It is sterilized by boiling in water, ami is kept in :i coi-kcd bottle immersed 
 in saturated boracic acid solution. The tjipc nscd for tying the umbilical 
 cord is bol;liin, one-(juarter inch wide. This is cut in lengths of twelve 
 inches, and six such pieces arc placed in a screw-to}) b(jttle. Small pieces 
 
^mmFmri^^i,~-s^si^ssB^^i^^^^^ism^?^^miT^i 
 
 Fig. 5.— Bed Pad and Douche Bag. 
 
 Fig. 6. — Agate-waee Basins. 
 
Fig. 7. — Bottles for Catheter, Tape, Dry and Wet Gauze. 
 
 Fig. 8. — Drugs Contained in Labor Bag. 
 
 Fig 9.— Copper Cans for Cotton, Vulva Pads, and 
 Nail Brush. Brass Cylinder for Douche Tubes. 
 
ASEPSIS, MORBIDITY, AND MORTALITY. 223 
 
 of gauze two inches square are used to surround and protect the stump of 
 the cord. These pieces of gauze are placed in a dry, four-ounce, salt- 
 mouth glass bottle. These bottles containing tape and gauze are sterilized 
 in the Bramhall-Deane sterilizer. Small squares of gauze similar to those 
 used on the cord are kept immersed in an excess of saturated solution of 
 boracic acid in a foiu'-ounce, salt-mouth bottle. They are also sterilized, 
 and are used to wipe out the baby's mouth and eyes immediately after 
 birth (Fig. 7). 
 
 The list of drugs kept in the bags is a short one. The bottles are four- 
 ounce tincture bottles. Ergot and dilute acetic acid are for use in case of 
 hgemorrhage. Solution of nitrate of silver of one per cent, strength is to 
 drop in the baby's eyes after birth, and tablets of bichloride of mercury, 
 compound cathartic pills, starch, and alcohol complete the list. Soap and 
 vaseline are carried in one-ounce ointment jars. The vaseline is used only 
 to anoint the new-born baby, and never to lubricate the examining finger or 
 hand. The ordinary yellow vaseline and commercial green soap are bought 
 in 25-pound jars, and are transferred to the small service jars, which are 
 then sterilized in the steam sterilizers (Fig. 8). 
 
 Absorbent cotton is bought in rolls of one pound. Two grades are pur- 
 chased; the better is used for the surgical dressing of wounds and for the 
 application of pressure to engorged breasts. The cheaper grade is used to 
 make the absorbent vulva pads and to sponge and cleanse the genitals of 
 the parturient and postpartum patients. This cheaper form of cotton is 
 known in the trade as " cotton waste; " it is equally absorbent and clean, 
 but does not lie in the lap so smoothly as does the better grade. It also 
 contains small, hard masses of matted cotton. The roll of waste is cut 
 into sections four inches long, and is then unrolled and divided into pieces 
 about four inches square and half an inch thick. Two of these squares 
 rolled in a piece of absorbent gauze to make a flat package 1x2x8 
 inches form the vulva pad of the outdoor service. 
 
 These pads are packed in cylindrical copper cans three inches in diam- 
 eter and six inches long. The ends of the cans are closed by perforated 
 covers, which are attached by brass chains to the cylinder. The holes in 
 the covers of the copper cans are protected, from the entrance of dust and 
 germs by a layer of absorbent cotton, and the pads are placed within these 
 caps. These cans are then sterilized in the steam -pressure sterilizers. A 
 number of the pieces of cotton waste are packed in a similar but slightly 
 larger copper can (8x3 inches) and sterilized in the same manner ; they are 
 used as " sponges " at the confinements (Fig. 9). 
 
 The nail brushes which are used are inexpensive ; the back is of wood 
 and the " bristles " are wooden fibres. They are placed in copper boxes 
 like those just described, but smaller (3 x 1 x | inch), in which they are 
 sterilized in the same manner. While in use the nail brush is kept in one 
 of the basins of bichloride solution. The life of a nail brush under this 
 treatment is about eiffht weeks. The scissors are sterilized at the time of 
 using by being immersed in corrosive sublimate solution 1 to 2,000. The 
 life of a pair of scissors is longer than one might expect — about one year 
 
•^>-^>4 REPORT OF THE SOCIETY OF THE LYIXG-IN HOSPITAL. 
 
 — under such treatment. The })elvinieter and scak^s are kept clean, but 
 receive no special disinfection. 
 
 The Lahor Bti1.—\\\ normal cases of labor are delivered on their o^vn 
 beils. The motlitieil Kelly })ad of rubber is used to protect the bed from 
 the blood ami discharges incident to the labor, and to protect the patient 
 and the accoucheur's hamls from the bod and bedding. In order to render 
 the beds less infective, freshly Uiundered linen is s})read whenever the patient 
 possesses such a luxury. Sometimes it is j^ossible to use an enamelled cloth 
 untler the bed sheet as a greater j-yrotection to the mattress; but it is often 
 necessary to dehver the patient upon the dirtiest of bedding and in the 
 most unsteady of double bedsteads. The side position is invariably 
 insisted upon at the time of delivery, because it raises the jjatient's genitals 
 from the bed and renders less likely uncleanliness both of the patient and 
 of the attendant. This side position allows a better observation of the 
 perineum during the birth, and permits the necessary exposure of the bnt- 
 tockf At the same time more of the patient's shoulders and legs are cov- 
 ered than is ])ossible in the dorsal posture. 
 
 Instrument Table. — It is usually impossible to find an aseptic surface to 
 serve as an instrument table in the homes of our patients. The bedrooms 
 are often so small tliat the Ijed takes \\\\ three-fourths of the floor space. 
 It is our custom, therefore, to use the aseptic materials brought from the 
 Ilos])ital directly from the original packages, and never to spread them out 
 on a table, which, although more convenient, would nullify the previous 
 care given to their aseptic preparation. The douche bag is hung on some 
 convenient hook, and the end of the douche tube is kept in the bag itself. 
 immersed in the solution. The tape and scissors are laid upon the shallow 
 basin, and the nail brush, when not in its proper case, is kept in the basin 
 of antiseptic solution Avhich is used for the hands. The linen for the eyes 
 and that for the ccjrd, the soap and vaseline, the cotton wipes and vulva 
 pads, are used directly from their respective glass and copper receptacles. 
 These basins and cans and ]:)ottles are ])lace(l on some table, or frecpiently a 
 wooden chair is taken for an " instrument table." 
 
 The application of the principles of asepsis to the para})h('niali;i nec- 
 essary to handle operative cases, denumds an extension of the methods just 
 described. In all operative cases a larger number of persons must render 
 their hands aseptic, and a greater amount of obstetric dressings must be 
 u.sed than at normal cases. The contents of the labor bag which is detailed 
 U) an ojierative case must be reinforced by additional cans of cotton wi])es, 
 by extra nail bruslies and soa|) jars. It is oui' custom, also, to isolate the 
 field of operation IVdin sun-omidiiig sources of possiblr inlcctioii hy \\r;i|)- 
 ping the legs and covering th(; abdomen niid the K'elly |i;i<l <>ii which the 
 patii.'Ut lies witli stei'ilized towels. 
 
 These towels are 2<» by l-'t inches in size. Tiiey m-e made of smooth 
 huckaliack, and finished by a sim|)le hem at each end. I'aclcages of six, 
 wraj)ped and .securely ]»inned in a seventh towel, an; stei-ilized in the steam- 
 pressure apparatus (Fig. lo). Patients are removed IVom theii- low beds 
 after Ijeing anaesthetized and are brought into the lai-gest and lightest room 
 
1 
 
 
 
 
 . 1 
 
 
 m 
 
 ^.M«;2^^~.....fl#*!2j| 
 
 "^- ' ■ .T^^iBiWSKi^SftiS:^ 
 
 
 Fig. 10. — Bundle of Stekilizkd 
 Towels. 
 
 Fig. 11. — Pehineorrhaphy Set 
 IN Glass Cylinder. 
 
 Fig. 13. — Sutdre Material. 
 
 Fig. 13. — Vaginal and Intr.\uterine Douche Tubes. Glass 
 Cylinders for Gattz.e or Tubes 
 
ASEPSIS, MORBIDITY, AND MORTALITY. 225 
 
 their tenement affords; they are placed upon a talile, and after the opera- 
 tion, again phiced in their bed. These operating' tables are improvised by 
 covering a kitchen table with some old woollen comforter or blanket and 
 placing the rubber Kelly pad on the end. Most operative deliveries are 
 done Avhile the patient is in the dorsal position. An instrument table is 
 furnished by covering a small table with one of the sterilized towels. 
 
 The different operations require a longer or shorter list of instruments, 
 which are sent from the Hospital in a sterile condition, in order to avoid 
 the transportation of an instrument sterilizer, and to economize the expen- 
 diture of time. Sets of the necessary instruments for the minor operations 
 of curettement and perineorrhaphy are kept in readiness for immediate use. 
 Special preparation is necessary to prepare for a forceps operation or any 
 more elaborate procedure. 
 
 The instruments and additional dressings are taken from the Hospital 
 to the case in special operation bags, which are like the labor bags, but 
 somewhat smaller. 
 
 A perineorrhaphy set consists of: 
 
 Three curved needles. 
 Thumb forceps. 
 Two clamps. 
 
 Needle holder. 
 Scissors. 
 Suture material. 
 
 The instruments are taken apart and wrapped in absorbent cotton, to pre- 
 vent rusting; they are then packed in a glass cylinder, which is plugged with 
 cotton, and the whole sterilized in the steam-pressure apparatus (Fig. 11). 
 The suture material is either catgut for lesser operations, or silkworm gut 
 for those of greater degree. The silkworm gut is sterilized by the Hospital 
 by putting the strands in test tubes plugged with cotton and exposing it to 
 steam under pressure for twenty minutes. These tubes are re-sterilized in 
 the steam sterilizer each time they are opened for the removal of a portion 
 of their contents. The catgut is prepared by a process of boiling in abso- 
 lute alcohol after it has been soaked and washed in ether. Each strand is 
 sealed in a separate glass tube immersed in absolute alcohol. The tube 
 is broken, and, in order to soften it and render it more flexible, the catgut 
 is wet in an aqueous solution of some antiseptic before using. Silk can be 
 prepared in the same manner (Fig. 12). 
 
 All instruments are sterilized in the steam drums, except in the unusual 
 oases, when a portable boiler is carried to the patient's home. The instru- 
 ments are first wrapped in a towel and securely pinned; they are then 
 exposed to the steam, and the bundle is not opened until they are needed. 
 Such bundles, containing the obstetric forceps or the necessary outfit for 
 curetting, are kept ready for use, at short notice, in the instrument case 
 in the outdoor department laboratory. The curettement set consists of 
 curettes, volsellum, vaginal speculum, cervical dilator, and intrauterine 
 douche tube. 
 
 The woven silk bougie which is used for the induction of labor, and the 
 catheter of the same jnaterial, with its metal stylet, used for replacing a 
 prolapsed cord, are sterilized by scrubbing with soap, water, and nail brush, 
 15 
 
226 REPORT OF THE SOCIETY OF THE LYIXG-IX HOSPITAL. 
 
 foUoweil bv similar treatment with carbolic solution. These instruments 
 are taken to the place of oi)eration. wrapped in sterile gauze. 
 
 The more serious operations, such as cranit>t()niy, symphysiotomy, and 
 Cesarean section have been performed successfully in this service. The 
 ase]nic ])rei)aration of apparatus recpiires a careful extension of these same 
 principles. Soft rubber trays for instruments, and larger su})i)lies of towels, 
 jars of sterile water, and sui)])lies of instruments from the indoor service 
 are transported to the patient's home. Portable instrument sterilizers are 
 often usetl on such occasions. Since the opening of the indoor service, 
 patients requiring such severe operations are usuall}'^ brought to the Hospi- 
 tal and oi>erated upon there. 
 
 The lesser o])erations of catheterization, packing the vagina or the uterus 
 with gauze, anil the giving of enemata are of such frequent occurrence that 
 the resident staif must be constantly ready to carry them out. The mem- 
 ber of the house statf who is acting as instructor to the students on labor 
 dutv carries with him on his visits a bag which contains a nail brush, soap, 
 and bichloride tablets for his hand washing, also a catheter, an enema 
 syringe, and the instruments for packing the uterus. 
 
 The passiuii' of a catheter is alwavs done bv sight, and never bv touch 
 alone. The labia majora are separated by one sterile hand, Avhile the other 
 first bathes the exposed vestibule with bichloride solution and then inserts 
 tiie soft rubljcr catheter into the meatus and l)ladder. If a s})ecimen of 
 urine is wanted, it is caught and saved in the bottle which originally held 
 the catheter. Of course this bottle must be rinsed free of the boracic acid 
 solution before being used for the urine. 
 
 The instruments for packing the uterus are: 
 
 A uterine dressing forceps. 
 
 A volsellum. 
 
 A speculum. 
 
 A (juantity of gauze in a glass cylinder. 
 
 The necessary instruments are wrapped in a towel and are then ster- 
 ilized by the steam a])paratus. The iodoform gauze is packed in one of the 
 glass cylinders formerly used for the douche nozzles, and this is also exposed 
 Ui the heat of steam under ])ressure. These cylinders are 11 by 1^ inches 
 in size, and contain a strip of gauze tAvelve yards long and two inches wide. 
 
 The method <.f packing the vagina or uterus is to place the patient upon 
 her back and across the bed; to insert a vaginal retractor; to grasp the 
 anterior lip of the cervix with tlie volsellum and draw the uterus down until 
 the OS externum is in full view ; then to introduce the gauze directly from its 
 rjriginal glass i'('c<'])tacle intf) the uterus (Fig. i;>). One hand of tlie opera- 
 tor holds tin' dressing forceps, and the other the volsellum. An assistant 
 holds the retractor in one hand and the gauze receptacle in the other. 
 Tiie r)j)eration can be done aseptically witliout an assistant by em])loving a 
 self-retaining speculum. The glass cylindei- is hehl l)etwecn the knees, or 
 in the hand which holds the volsellum. If the uterus is to be packed, the 
 first portion of tin* gauze is carried well up to th(? fundus, and the uterine 
 cavity is filled gradually downward from the fundus. "When the uterus is 
 
ASEPSIS, MORBIDITY, AXD MORTALITY. 227 
 
 fully packed, the vagina may be treated in like manner. The gauze is 
 carried by the dressing forceps into the fornices of the vagina and packed 
 around the cervix, then over the cervix; and, finally, the vagina is tilled 
 while the speculum is withdrawn slowly. 
 
 Bacteriological examinations of the various articles prepared in the 
 manner descriljed have been frequently made. The results of these tests 
 have shown that the methods in use were efficient. 
 
 A recent report is given in detail : 
 
 Dressings from Obstetrical Bag, Xo. 18. 
 
 Bag had l^een on the shelf five days before examination. 
 
 Bacteriological examination : 
 
 Glass catheter, sterile. 
 
 Yaginal douche tube, sterile. 
 
 Nail brush, sterile. 
 
 Yulva pad, sterile. 
 
 Cotton, sterile. 
 
 Dry cord dressings, a gas producing bacillus in every way resembling 
 bacillus coli communis. 
 
 Cord tape, sterile. 
 
 Starch, bacillus coli communis. 
 
 Silver nitrate solution (1 per cent.), sterile. 
 
 Eye wipes in boracic acid (saturated solution), sterile. 
 
 A subsequent examination of another sample of dry cord dressings 
 showed these to be sterile. 
 
 An older report on one of the obstetric bags showed all articles sterilized 
 by steam under pressure to be sterile. But articles not so treated, the 
 rubber pad, cord taj^e, and cord dressings, which had been treated with 
 milder measm^es, contained various species of staphylococci and bacilli. It 
 was as a result of such reports from the bacteriologist that the sterilization 
 by steam was extended to the treatment of nearly all the contents of the 
 labor bag. 
 
 Asepsis of Accoucheur. 
 
 A prophylactic abstinence from contact ^vith infectious matter of all 
 kinds, and especially with infectious patients, is demanded of the medical 
 attendants who give the routine care to the patients of this Hospital. The 
 student, it is true, comes to the work from we know not what ; but during 
 his first twenty-four hours he is watched and directed during all his 
 attempts to disinfect himself, and after that period he is under careful 
 oversight, as outlined in another article in this report. From the time he 
 comes on duty until his two weeks' service is finished, he cannot become 
 infected from any work of the Hospital, and he is not allowed to undertake 
 any other work of a medical nature. 
 
 In order to care for both normal and infected cases, the service is divided 
 into a regular ser^ace and a septic ser^^ce. If symptoms of a suspicious 
 nature occur in any patient, she is isolated from the care of the student, 
 
228 REPORT OF THE SOCIKTV OF TPIE LYING-TX HOSPITAL. 
 
 and is attended bv the sej)tie de})ai'tnient, as described below. The resi- 
 dent statf of physicians <.lo not come in contact Avith infectious cases, 
 except in the earlier stages of suspected infection. As soon as a case 
 develops fever and signs of infection, it is given into the hands of one par- 
 ticular member of the resident stalf, ^vho is detailed for septic work. lie 
 makes the rontine ])ostpartum calls, and carries out the treatment for all 
 such cases under the direction of the septic attending physician. This 
 septic subdivision of the service takes charge of all cases of conjunctivitis, 
 of suj>]mrating umbilicus, and of postpartum fever. The members of the 
 resident statf ])erform this duty, serving in rotation for periods of one 
 month each. 
 
 The attending physicians and their assistants are engaged in private 
 jM'actice as well as in the work of the IIos])ital. They cannot always be 
 free from the care of private cases of a suspicious nature. These members 
 of the IIos]utal staff, however, appreciate the ]iarticular need of extra care 
 in their antiseptic ])recautions, and can be relied u])on to disinfect their 
 hands \vith an intelligent application of the routine procedures. The IIos- 
 ])ital does not demand, even of its officers, however skilful in ase]>sis, that 
 they do aseptic and septic work in its service at the same time. The 
 attending ])hysicians serve in rotation for periods of one month. During 
 the month following their month of regular service, they become the septic 
 attending physician. This officer and his assistant and the se])tic member 
 of the resident staff form the septic department of the Hospital. 
 
 A further means of preventing infection is to limit the number of vagi- 
 nal examinations in each case. A number of observers have recently 
 claimed that normal labor should be conducted with no internal examina- 
 tion, and have presented series of cases so treated in whom a lower percent- 
 age of morbidity was observed than in similar cases Avhere examinations 
 were allowed. The percentage of fever, it is claimed, is proportional to 
 the numljer of such examinations. The following list gives the ])ublished 
 morbidity records of a number of institutions. In every case 100.4 degrees 
 Fahi-enheit (38 degrees Centigrade) is assumed as the limit of normal tem- 
 perature. 
 
 AIoiiniDnv Statistics ok Different Ot.stktrk! Schools. 
 
 Schools allowing students to examine the patients: 
 
 r^ Fever from 
 
 Cases. 
 
 all Causes. 
 
 1. University Frauenkliuik, TIcrlin, 1S8S-1S95... 8,528.. 25.5^(39.1^) 
 
 2. T'niversity Fraucnklinik, Dorjxit, 1888-18U3 . . 889.. 14.39^ 
 :;. ('niversity Obstetric Clinic, Prag, 1887-1895. . 8,924. . 13.54^ 
 
 4. Tniversity Fraucnklinik. Lcip/.in-. isitc, 5115.. 2T.U(),< 
 
 5. Mai.son d'Accouchements Ijaiideioccjuc, Taris, 
 
 1895 2,043. . 19.18^ 
 
 Infection Fever. 
 
 6. University Friiucnkliiiik- (I'dikliiiik i. Doi-pnl. 
 
 1893 l.'jno.. 14. Im;^' 
 
ASEPSIS, iMORBIDITY, AND MORTALITY. 229 
 
 Fever from 
 all Causes. 
 
 7. University Frauenklinik, TViirzburg 3,000. . 9.2^ 
 
 8. Konigliche Frauenklinik (Dresden), 1893: 
 
 a. no douche + examination a. 71. .a. 4.3^ 
 
 I. + douche + examination h. 300. .h. IS. 67 fo 
 
 e. + douche + examination e. 419. .c. IS.Sfo 
 
 Series of cases conducted without internal examination : 
 
 Fever from 
 v-^ases. n /-I 
 
 ail Causes. 
 
 9. University Frauenklinik, Leipzig, 1896 1,034. . 25.26^ 
 
 10. Konigliche Frauenklinik, Dresden, 1893: 
 
 a. no douche; no examination a. 336. .a. 5.95^ 
 
 I. + douche; no examination b. 100. .1. ll.Ofo 
 
 c. 4- douche; no examination c. 381. .c. 12.3,^ 
 
 1. Zur puerperalen Infection. Koblanck, Zeitschrift fiir Geburtshiilfe unci Gynae- 
 kologie, 1896. 
 
 6, 2. Ber-ichte und Arbeiten. O. Kiistner, 1894. 
 
 3. Bericlit liber die Morbiditats- und Mortalitats-verhaltnisse auf der Geburtshiilf- 
 lichen Klinik von Prof. Pawlik, etc., in Prag. Pipek, Monatsclirift fiir Geburtshiilfe 
 und Gyna3kolog'ie, 1896. 
 
 9, 4. Bakteriologie des weiblicben Genitalkanales. Menge und Kronig, 1897. 
 
 5. Fonctionnement de la Maison d'Accoucbements Baudelocque. Lepage, 1896. 
 
 7, Die Verliiitung des Kindbettfiebers in den geburtshilflicheu Unterricht anstal- 
 ten. Hofmeier, Kliniscbe Vortrage, 1897. 
 
 8, 10. Untersuchung liber die Entbehrlichkeit der Scbeidenaussplilungen bei ganz 
 normalen Geburten und liber die Sogenannte Selbstinfection. Leopold. Arcbiv fiir 
 Gynaekologie, 1894. 
 
 This agitation has had the beneficial effect of enlarging the field of 
 external manipulation and of abdominal palpation. It is the custom of 
 this Hospital to lunit the indications for vaginal examination to the single 
 rule that some good come of the proposed procedure. The Hospital 
 demands of its pupils a report concerning the condition of the patient and 
 the progress of the case at least every two hours. Each such report requires 
 a vaginal examination to render it complete. The first object of this service 
 is to teach, and it is the unanimous opinion of the Medical Board that a 
 student must make frequent examinations of women in all stages of labor 
 and pregnancy in order to learn to appreciate the normal and abnormal 
 phases of any particular case. The students are not given an uncontrolled 
 freedom to examine the patients, but are taught that frequent examination 
 increases the danger of infection, and that one long examination is less 
 dangerous than two short' ones. They are taught also the advantage and 
 practice of external examination. The table given above shows that the 
 morbidity record of this Hospital compares favorably with that of any of 
 the services which include a similar number of cases, whether the material 
 is used for teaching purposes or not, and whether internal examination is 
 limited, omitted, or practised freely. 
 
230 REPORT OF THE SOCIETV OF THE LYING-IN HOSPITAL. 
 
 The statistics concerning vaginal examinations have been recorded in a 
 can'ful manner in a number of oases. These figures are detailed in the 
 statistical synoj)sis of tlie jjatients. The summarv shows that the pui)ils 
 liave made 27,093 examinations in the first stage of labor on 5,109 women, 
 an average of over five examinations in each case. It shows, concerning 
 the second stage of labor, that the ])upils made 22,<')2T vaginal examinations 
 on 5,843 cases, an average of nearly four examinations of each parturient 
 woman. In spite of this extensive use of the material for instruction, the 
 morbidity jjcrcentage is 12.20 per cent., and the inortality record of all 
 cases dying of sepsis is 0.14 per cent. 
 
 The ])ersonal disinfection of tlie obstetrician involves the questions of 
 dress and of hand washing. This Hospital does not furnish an o})erating 
 gown for the use of those avIio conduct the normal cases of labor in the 
 (jutdoor service, though a gown is sometimes worn when an operation of 
 considerable importance is to be performed. On such occasions a gown of 
 the annexed ])attern is borrowed from the indoor service (Fig. 14). For 
 the regular work, the accoucheur removes his coat and rolls up both shirt- 
 sleeves above the elbow. The same preparation is made both to examine 
 pregnant women, to attend those in labor, and to care for the ])ostpartum 
 cases. His remaining efforts are applied to the care needed to cleanse and 
 ])re])are the hands. 
 
 The students are not allowed to attend the patients of this hos})ital when 
 their hands are the seat of any suppurating wounds. The following details 
 a])]ily to the preparation of the hands of the attending physicians and other 
 officers of the Institution. The care given to tlie hands at all times is an 
 important element in rendering them easy of disinfection when desired. 
 All wounds sliould be so treated that they will heal (luickly. If small 
 lesions suppurate and it is necessary for one to o})erate, the hands are ren- 
 dered aseptic by cauterizing with liquefied carbolic acid and the use of extra 
 precautions in cleansing. Slight wounds Avliich are heahng in a cleanly 
 manner are protected from infection by a collodion dressing, Avhich permits 
 of tlie use of the disabled hand. The wound is first cleansed with bichloride 
 solution and then covered with a solution of iodoform in ether. After this 
 has eva])orated, a very thin layer of al)sorbent cotton is ])laced over the 
 wound and tlie whole surface is ])ainted witli collodion. This di'ies in the 
 meshes of the cotton, and th(! wliolo mass makes a tough waterproof pellicle, 
 wliich can be scrubbcfl with a nail brush without dishKlmno- it and without 
 irritation of the wound. The fingci- nails are the most dilficult parts of the 
 hand to Ix; made aseptic, and thcii- prophylactic care is of considerable 
 iniportaiK-c. The fold of skin at the base of the nail and the reentering 
 angh* uiidcr the frci; border demand the most attention. The best ti'eat- 
 ment for this fold of skin is to kee[) it ])ushed \y.\ck I'loni the nail and to 
 remove all liang-nails and roughnesses. The )>olislied surlace of the nail is 
 kept free from tin; thin (^pidci-nial layers which ^row u))on it from the basal 
 fold. This is done by scra]»in<^- the inoistenc(l linger witii a sliarj) stick or 
 quit(! dull metal |)oint. Tare is taken not to sci-atch the sui-face and thus 
 make a lodging i)lace for germs. The fold is jtushed back several times a 
 
Fig. 14. — Operating Gown. 
 
ASEPSIS, MORBIDITY, AND MORTALITY. 331 
 
 day, when the hands are washed ; and the scraping is done thoroughly, but 
 not oftener than once in ten days. The free end of the nail is a natural dirt 
 collector ; it is best cleaned by the use of a nail brush, soap and water, and 
 subsequently of a soft wooden point. A soft towel or linen handkerchief 
 is used for this purpose, pushing the cloth under the nail with a nail of 
 the other hand. Metal scrapers are avoided, because they scratch the nail 
 and make crevices which collect dirt more readily and render the nails more 
 difficult of mechanical cleaning than they were before. The ideal condition 
 is one in which the under surface and edge of the free end of the nail are 
 as smooth and polished as the exposed surface. The following rules apply 
 to all attendants, including the students: 
 
 Before beginning to disinfect the hands, any rings should be removed 
 from the fingers, the coat should be laid aside, and the shirt-sleeves rolled 
 up, as already described. The routine procedure of this Institution for 
 preparing the hands is as follows : 
 
 1. Wash with hot water, green soap, and nail brush for at least three 
 minutes. 
 
 2. Rinse in clear water, and remove from under the nail all visible dirt 
 by means of a towel, handkerchief, or wooden point. 
 
 3. Wash again with a fresh supply of hot Avater, green soap, and nail 
 brush for at least two minutes. 
 
 4. Rinse ofl the soap, and scrub the hands with a solution of bichloride 
 of mercury of a strength of 1 to 2,000, using nail brush for at least three 
 minutes. 
 
 5. While using the nail brush, the fingers are separated and particular 
 attention is given to the nails. 
 
 6. The finger or hand is brought into contact with the female genitals 
 while wet with the bichloride solution, and no lubricant is used. 
 
 In case the hands of the operator are known to have been recently 
 infected, extra antiseptic precautions are used. A thorough scrubbing with 
 brush and alcohol is interposed between procedures 3 and 4 on the list just 
 given. This has been shown by a number of investigators to be very 
 effective.* Sometimes a scrubbing in a solution of permanganate of pot- 
 ash, followed by a decolorizing wash in oxalic acid solution, is used between 
 procedures 2 and 3 of the regular list. These extra procedures are used 
 by the attending staff when they are conscious that they have been exposed 
 to any infectious material. 
 
 The preservation of the hands in an aseptic condition after they have 
 been prepared is a question of habit. A single touch by the hand of some 
 unclean article may render the work of the past ten minutes entirely worth- 
 less. The habit of refraining from such contaminations is acquired only by 
 continued practice. It is equally important that an operator may know 
 when his aseptic hand has inadvertently touched some suspected article, be 
 it some piece of furniture or some part of his own dress or of himself. It 
 is not uncommon to have to stop some student from making an examination 
 
 * Versuche tiber die Desinfection der Haude. Poten. Monatschrift ftir Geburts- 
 liiilfe und Gynajkologie. 1895. 
 
!>3-2 REPORT OF THE SOCTETV OF THE LYING-IX HOSPITAL. 
 
 until he shall have resterilized his hand because he has handled the chair 
 lie will sit in or has readjusted his eyo-g-lasses, or has done some equally 
 unclean act. 
 
 Bacterioloo^ical examinations of the hands of students which have been 
 ])rei)ared in this manner have ii'iven in certain cases rather unsatisfactory 
 results. In one series of eight liamls the cultures from one only remained 
 sterile; six showed the presence of sta])li}l«x'Occus albus; and those from 
 two showed the ]>resence of staphylococcus citreus. During the period 
 when this particular test was made, the outdoor service was running 
 smoothly, and the cases were particularly free from infection and other 
 fevei*s. 
 
 Asepsis or Patient. 
 
 The work of Doderlein* and Kronigf has proved that the normal 
 secretion of the vagina will not only prevent the growth of pathogenic 
 o-erms, but also destroy those artificially introduced. This Hospital treats 
 its ])atients in accordance with this truth and submits them to no routine 
 ]n-oi-)hvlactic antisepsis until labor has begun. Preventive treatment is 
 applied, however, in special cases. All pregnant women who ])resent any 
 inrtammation which could cause infection at time of labor are treated. Any 
 sup])iirative disease in the region of the genital tract receives the necessaiy 
 antiseptic treatment, and an effort is made to cure such local inflammations 
 as early during pregnancy as possible. Inflammations of the vagina, blad- 
 der, urethra, vulva, and neighljoring glands, whether gonorrhoeal or septic 
 in nature, require sucli interference. Abscesses are opened and dressed 
 antisepticallv. Vaginitis and cystitis are treated with disinfectant or 
 astringent irrigation, and syphilis is treated by specific medication, botli in 
 the intei-est of the mother and of the child. 
 
 The regular bathing of the whole body and the ])roper regulation of 
 the bowels are sadly neglected by the dwellers in New York tenements. 
 In the (outdoor service these lapses in the rules of ordinary hygiene must 
 usually be corrected during or after labor. The application of aseptic 
 l)rinciples in the outdoor department also meets with the practical limita- 
 tion that a considerable number of our patients do not apply for aid until 
 labor has begun. Those who may apply during pregnancy are thoroughly 
 examined, and, if found to be healthy, they are protected from a sul)se- 
 quent '•• auto-infection '' so-called, by the rules pertaining to vaginal exam- 
 inations. AVhcncver internal examinations of pregnant women are made 
 in this Hospital, the same precautions in cleansing the liands ai-o enforced 
 as wlum a case in labor is to be examined. 
 
 The routine j)re])a)"ition of a ])atient for noi'uial laboi- is limited to 
 external disinfection. As soon as the \m\n\ ;ii rives at the case, and before 
 any ))liysical examination is ma<l<', tlic vulva and the mons veneris, the 
 anal rcnon and jx'rincuni are washed with soa]) suds, Avatcr, and absorbent 
 cotton; the same attention is given t(. llx- folds of the nates, the groins, 
 
 *I)!iHS.-licid«-iiH<'kn't unci sfiiic Bfdfiitmitr fiii- das rncr))('i-iilli('l)cr. DodoHoin, 1892. 
 t BakUii'iologie des weiblicheu Genitalkaualcs. Men{,^e uixl Kr<)ni{r, ]K1)7. 
 
ASEPSIS, MORBIDITY, AND MOETALITY. 233 
 
 the inner parts of the thighs, and the lower part of the abdomen. The 
 hair of the hibia majora and raons veneris is not cut in normal cases, 
 except for special reasons (excessive length or matted dirt). The soap is 
 washed off -with clean water, and the whole region is rubbed with a cotton 
 wipe and rinsed off with bichloride of mercury solution. If necessary, the 
 vulva is held closed while the antiseptic solution is being poured over it. 
 Such a disinfection is repeated, if the patient should have a passage from 
 the bowels, or in prolonged labor, at intervals of six hours. The healthy 
 internal genitals receive no antiseptic treatment whatever, and for two 
 reasons : first, it is unnecessary, and, secondly, it does positive harm. The 
 removal of mucus and the constringency of the vagina resulting from an 
 efficient disinfection increase the liability to abrasions of the mucous mem- 
 brane and to perineal lacerations. In cases where the vagina is already 
 infected, a mechanical or chemical disinfection is rarely a possibility within 
 the time limit of a first stage of labor, and the lesions resulting from a too 
 free scrubbing will give the germs Avhich may be present a better eviron- 
 ment for their growth. Internal disinfection is a doubtful expedient after 
 labor is begun, and has been discarded in our outdoor service. 
 
 The art of bringing the sterile hand into contact with the vagina after 
 the patient has been washed is easily acquired. The hands are prepared 
 as already described, and are introduced into the vagina while still wet 
 with the bichloride solution, and without lubricant. The patient is exposed 
 by some assistant sufficiently so that the vulva may be seen and the hands 
 reach it without touching either bed clothes or patient's garments, thighs, 
 or perineam. With the thumb and forefinger of one hand the labia majora 
 are separated until the introitus vaginae is seen. The fore and middle fin- 
 gers of the other hand are placed in this opening and inserted into the 
 vagina. The introduction of the finger into a vagina by touch alone, 
 under the bed sheet, is a surgically unclean act. 
 
 During the final act of expulsion, the patient demands the constant 
 attendance of the accoucheur. As alread}^ explained, the patient is placed 
 on her left side, and the attendant controls the advance of the occiput 
 and the stretching of the perineum with aseptic hands. The hands are 
 rinsed frequently in the sublimate solution, and are brought into contact 
 only with the vulva and perineum and with the neighboring parts which 
 have been disinfected. As soon as the presenting part has reached the 
 perineum, all reason for internal examination has ceased to exist. It is 
 during this stage that frequent examinations and the introduction into the 
 vagina of astringent chemicals will be especiall}^ liable to cause tears of 
 the soft parts. The labor can be finished by external manipulations alone. 
 The third stage of labor will frequently terminate spontaneously ; if not, 
 the delivery of the placenta may be effected by expression, after the manner 
 known as that of Crede. 
 
 The immediate postpartum treatment consists of a hot vaginal douche 
 of bichloride of mercury, 1 to 8,000. The fundus of the uterus is held for 
 one hour before any abdominal bandage is applied. The external genitals 
 are cleansed, with the antiseptic solution, of all visible blood stains, and a 
 
234 REPORT OF THE SOCIETY OF THE LYIXG-IN HOSPITAL. 
 
 viilva pad is placed on them. This vaiiinal douche is given as routine, not 
 so much because of its antise})tic qualities, but because it lessens the chances 
 of hivmorrhage from the uterus. The vulva })ad used in the out-patient 
 de])artment is a small flat dressing, and cannot be described as in any sense 
 an "occlusive antise])tic dressing." The pads must be loosened by the 
 ])atients themselves whenever they pass urine; they collect a samj^le of 
 the lochia for the instruction of the student attendant, and prevent only 
 imperfectly the access of germs to the external genitals. 
 
 All |)atients are visited twice daily for three days after labor, and once 
 daily after the third day until discharged. At these postpartum visits the 
 stutient uses the same precautions for his personal disinfection that are 
 required at the coniluction of a labor. He washes the external genitals of 
 the wonuui with absorbent cotton and antiseptic solution (bichloride of 
 mercury, 1 to 2,(»oo); he changes the v^ulva pads; he washes the chiUrs 
 mouth and eyes Avith boracic acid solution, and he dresses the stuni]) of the 
 umbilical cord or the umbilical wound with fresh gauze and sterilized 
 starch powder. The rest of his duties are detailed elsewhere. They are 
 concerned with the patient's general condition, and are not to be classified 
 as "antisepsis.'' The internal genitals receive no douches or other 
 routine treatment. The general rnle that postpartum asepsis is limited 
 exclusivelv to external cleanliness has no exceptions but for special cause. 
 
 In complicated laljor the immediate antepartum preparation is usually 
 more thorough than it is in normal cases. The external genitals receive 
 a careful scrubbing with soa]) and water and nail l)rush, and the ])udendal 
 hair is cut short or even shaved. After such a scrubbing, the routine rins- 
 ing with corrosive sublimate solution is repeated. Such an antiseptic toilet 
 is thorough enough to be distinctly painful, and is usually done after the 
 patient is under the influence of an anajsthetic. Even in these operative 
 ca.ses, the internal genitals are not given any speciflc treatment, but all 
 intra vaginal and intrauterine manipulations are undertaken in or through 
 the normal vagina. 
 
 The aseptic use of instruments during operations and the prevention of 
 infection at the field of operation require, in a tenement-house service, a per- 
 fect familiarity with the environment on the part of every one who may 
 take an active ])art in the pro])osed procedure. AVhenever an operation is 
 necessary in tlu? outdoor service of this Hospital, tlie members of the 
 attending ;ind i-csidcMit staffs alone take part in the active Avork; tlie jnipils 
 are deposcij to the position of s])ectators, or, at most, to j)assive assistants, to 
 hold a leg or douche bag. The instruments are spread out on the towels in 
 which th«;y were sterilized. The ])atient is ana>sth(^tized and ])laced uj)on the 
 improvised (Operating table. iShe is then subjected to the antisej)tic })repa- 
 ration alrcaxly described, and the field of operation is surrounded with the 
 towels which were brought in a sjiecial sti^'ilized bundle. The legs and 
 feet, the upper ])art of the abdonuMi, and th(5 table beneath the ])atient's 
 butttxiks are covered with these sterilized towels. All efforts are concen- 
 trated on tliese three elements — the opcjrator, the |)aticnt, and tlic; instru- 
 ments — and tlie more remote surronntUngs arc ign<jr<;d <'ntirely. The Hos- 
 
ASEPSIS, MORBIDITY, AND MORTALITY. 235 
 
 pital is very ]mrticular to see that all patients receive plenty of good, 
 nourishing food to assist them to recover from the strain of childbirth. A 
 small diet kitchen, run in connection with the Hospital, is a great assistance 
 to prevent a serious ending to many operative cases. 
 
 The immediate postpartum treatment of patients who have been oper- 
 ated upon is changed from that given the normal cases onl}^ in the addition 
 of an intrauterine douche immediately after the delivery of the placenta. 
 This douche acts as a stimulus to uterine contraction as much as it is an 
 aseptic measure. The external genitals receive the same care as in routine 
 cases. The postpartum care of operative cases presents practical peculiari- 
 ties of asepsis in only a few cases. When the uterus has been packed with 
 gauze, it is emptied, as a rule, within three days, or as soon as the woman's 
 temperature and pulse would indicate an absorption of septic material. 
 When a perineorrhaphy has been done, the patient may require catheteriz- 
 ation at intervals of eight hours for two days or longer. Such cases may 
 suffer from retention for a variable period, and they may not get out of bed 
 because of the wound in the perineum, hence the catheterization may be 
 required for a longer period. The stitches are removed from the perineal 
 wound on the eighth to tenth day. The passing of a catheter in normal 
 cases is a last resort and rarely needed. Such patients are allowed to sit up 
 and empty the bladder without assistance. The aseptic method of passing 
 a catheter as practised in this Hospital has been described above. 
 
 Morbidity Statistics. 
 
 The last Medical Report of this Hospital, published in 1893, contained a 
 study of those cases of the preceding three years which were complicated 
 by febrile symptoms. The following analysis is founded upon a six years' 
 service in the Hospital's outdoor department, and includes the period cov- 
 ered by the report of 1893. The definition of fever which was arbitrarily 
 assumed in that Report will be adhered to in this, and every rise of tem- 
 perature above 100.4 degrees Fahrenheit is included as of pathological 
 significance. The temperatures are all taken beneath the tongues of the 
 patients by a self -registering thermometer, which is left in situ for a full 
 five minutes. 
 
 During these six years the Hospital has treated 10,233 women in their 
 homes, of whom 1,255 have presented a febrile complication; a total fever 
 or morbidity percentage of 12.26 per cent. This is a better showing than 
 was made in the 1893 Report, where this figure was noted as 15.81 per 
 cent. This improvement is due in part to the fact that the early period of 
 1,454 cases described below now makes up a lesser part of the total num- 
 ber of cases. It is partly due also to improved methods of asepsis in hand- 
 ling this service. The six years are easily divided into three periods, accord- 
 ing to the varying conditions of the service. 
 
236 REPORT OF THE SOCIETY OF THE LYTXG-IX HOSPITAL. 
 
 Table I. 
 
 THREE PERIODS OF SERVICE. 
 
 I. JiUKutri/ 18, 1S90, to Mapch 1, 1892. 
 
 Patients aclmitted to treatment in all stages of puerperal period, \vliether 
 infected or not. Service entirely out-initient; 1,45-1 cases gave 310 cases 
 of fever, or 21.78 per cent. 
 
 II. MarrJi 1, 18'.t2, to FSnianj 18, 1895. 
 
 Patients admitted to treatment only ante])artnm, or when, unattended 
 in labor, they have applied ^vithin 12 hours of delivery. No postpartum 
 infected cases taken. Service entirely out-patient; 0,45() cases gave 732 
 Ciises of fever, or 11.33 per cent. 
 
 III. Fihruarij 18, 1895, to Ajjrll 1, 1896. 
 
 Out-patient service the same as in the second period; but the indoor ser- 
 vice was open, and many severer cases were transferred from the outdoor 
 to the indoor service. The cases, therefore, in this period, have been less 
 complicated than in second period; 2,323 cases gave 207 cases of fever, or 
 8.91 per cent. 
 
 The percentage given above for the first period differs from the same 
 
 ratio as given in the last Report of the Hospital. Since the date of the 
 
 last Ileport the original histories have been subjected to a careful review, 
 
 with the result that a number of cases of fever of lesser degree have been 
 
 discovered and added to the list. The morbidity percentage for the 1,45-4 
 
 cases of this period has been increased from 20.70 percent, to 21.73 per 
 
 cent. The difference in the percentages for the second and third periods, 
 
 and the influence of the indoor service upon the morbidity percentage of 
 
 tlie (jutdoor statistics, will be appreciated after a glance at the following 
 
 table, which presents a list of the severer cases transferred from the latter 
 
 service to the indoor wards. 
 
 Table II. 
 
 Cases. 
 
 Manual dilatation and version for placenta praevia 3 
 
 Version for shoulder ])resentation 2 
 
 Deca]>itation for shoulder presentation 1 
 
 Craniijtomy for contracted pelvis 1 
 
 Craniotomy for liydrocephalus 1 
 
 Forceps for posterior occipital position 1 
 
 Forceps for breech presentation 1 
 
 Postpartum case for endocarditis 1 
 
 IVjstpartuin cases for oclani])sia 2 
 
 Posti)artuni cases lor i-iipturc of utci-us 2 
 
 In addition a number of cases wliicli presented the possibility of opera- 
 tive jirocedure at the time of their a])])li(;;ition have been enrolled on the 
 indoor books at once;, without tlie formality of an outdoor service registry. 
 The list just given represents the cases actually transferred after laboi* liad 
 begun. A number of |»rimi|)ar;e also have l)een 1 rai)sfeiTe(] t,i> tin; ward 
 
ASEPSIS, MORBIDITY, AND MORTALITY. 237 
 
 service, which represents a combined primipara and operative service. The 
 following table will demonstrate more clearly the percentage proportion of 
 fever occurring in successive periods of the service. In this list the 10,233 
 cases are divided into series of 1,000 cases, and the nmnber of fever cases 
 and morbidity percentage for each period is appended : 
 
 Table III. 
 
 FEVER PERCENTAGES BY SUCCESSIVE 1,000 CASES. 
 
 First thousand, 209 cases of fever, or. 20.9^ 
 
 Second " 199 " " 19.9^ 
 
 Third " 160 " " 16.0^ 
 
 Fourth " lOr " " 10.7^ 
 
 Fifth " 85 '' " 8.6fo 
 
 Sixth " 112 '' " 11.2^ 
 
 Seventh " 83 " " 8.3^ 
 
 Eighth " 100 " " 10.0^ 
 
 Ninth " 92 " " 9.2^ 
 
 Tenth " 89 " " 8.9^ 
 
 233 cases 19 " " 8.15^ 
 
 10,233 cases 1,255 " '' 12.26^ 
 
 The morbidity percentages thus obtained vary during the more recent 
 periods between 8.3 per cent, and 11.2 per cent. These variations do not 
 seem to follow any rule when viewed from this basis of successive series of 
 one thousand cases. The influence upon the morbidity of using a mater- 
 nity ser\^ce for the instruction of medical students can be estimated in some 
 measure from the following table. Most of our pupils are busy at their 
 medical schools from October 1st to April 1st, and are comparatively free 
 from required work during the summer six months. They come to this 
 Hospital during the latter period to take the practical work in midwifery, 
 which is for theju an optional course. The twelve months can be divided, 
 therefore, into two six-month periods, according to the number of pupils 
 on duty. During the winter months the pupils are comparatively few in 
 number, and the majority of the patients are cared for b}^ the trained 
 physicians on the house staff. During the summer months the patients are 
 used for teaching purposes to their fullest possible extent. 
 
 In the following table the number of students on duty, the number of 
 patients delivered, the number of fever cases occurring in these cases, and 
 the morbidity percentage are given for the first period of nine months and 
 for each six months' period thereafter, beginning with the date of opening 
 of the outdoor service. This table shows plainly that the morbidity is not 
 proportional to the number of students instructed, and therefore not to 
 the use made of the service for their instruction. It shows the same 
 influences at work as already pointed out in Table I., but it would seem 
 to indicate, further, that the parturient woman was more susceptible to 
 febrile complications during the cold months of the year. Such a fact 
 would have been dwelt upon by earlier observers more than it will be by 
 
238 
 
 REPORT OF THE SOCIETY OF THE LYING-LN HOSPITAL. 
 
 the inoilern obstetrician, who thinks more of the souires of septic infec- 
 tion than of climatic intluonces. Tlie reason for snch a condition in this 
 sernce can be found in the unhygienic dwellings and the herding of peo})le 
 in the Polish quarters of New York-— factors which operate to supply our 
 patients with poorer food and more vitiated air in winter than in summer, 
 when fuel need not be purchased, and when all the windows may be kept 
 constiintly open. The fact renuiins that there is more fever among our 
 patients during the winter months, when the sources of infection are 
 diminished in number, tlian during the warm weather, when the clinical 
 material is used for instruction pur})Oses to the fullest possible extent. 
 
 Table IV. 
 
 RELATION OF NUMBER OF STUDENTS TO PERCENTAGE OF FEVER. 
 
 Period. 
 
 Jan. 8, 1S90, to Sept. 30, 1890, 9 months 
 
 (Jan. 8th to Mar. 31st onlv 15 cases treated.) 
 
 Oct. 1, 1890, to Mar. 31, 1891, 6 months 
 
 Aiu'il 1, 1891, to Sept. 30, 1891, " . . . . 
 
 Oct. 1, 1891, to Mar. 31, 1892, " . . . . 
 
 A]n-il 1, 1892, to Sept. 30, 1892, " . . . . 
 
 Oct. 1, 1892, to Mar. 31, 1893, " . . . . 
 
 April 1, 1893, to Sept. 30, 1893, " . . . . 
 Oct. 1, 1893, to Mar. 31, 1894, " . . . . 
 
 April 1, 1894, to Sept. 30, 1894, " .... 
 
 Oct. 1, 1894, to Mar. 31, 1895, " . . . . 
 
 April 1, 1895, to Sept. 30, 1895, " 
 
 Oct. 1, 1895, to Mar. 31, 1896, " . . . . 
 
 Totals, 6 years 3 months 
 
 
 
 cc 
 
 
 
 <s> 
 
 
 
 w 
 
 u: 
 
 
 . <A 
 
 -4-J 
 
 
 oo 
 
 6 g 
 
 xA 
 
 ^l! 
 
 ^'3 
 
 ^1 
 
 > 
 
 Xfl 
 
 O 
 
 Ph 
 
 53 
 
 130 
 
 25 
 
 ♦)2 
 
 201 
 
 49 
 
 145 
 
 470 
 
 96 
 
 140 
 
 819 
 
 176 
 
 204 
 
 1,046 
 
 176 
 
 105 
 
 1,071 
 
 130 
 
 143 
 
 1,144 
 
 95 
 
 GO 
 
 1,025 
 
 114 
 
 206 
 
 1,331 
 
 121 
 
 77 
 
 831 
 
 80 
 
 224 
 
 970 
 
 88 
 
 126 
 
 1,195 
 
 105 
 
 1,545 
 
 10,233 
 
 1,255 
 
 
 19.23 
 
 24.37 
 
 20.42 
 
 21.48 
 
 16.82 
 
 12.13 
 
 8.30 
 
 11.12 
 
 9.09 
 
 9 . 62 
 
 9.07 
 
 8.78 
 
 12.26 
 
 The following tables of the presentations and of the operations done 
 in the service during the period reported upon, reproduce the figures from 
 the statistical syno])sis, and will give a clear a})preciation of the character 
 of the .service. 
 
 Table V. 
 
 TAIU.K OK PRESENTATIONS. 
 
 Vertex 8,4!>5 cases, or 1.71'^ of ol)served cases. 
 
 Face, 3«; I 
 
 lirow, \ r 42 " " 0.47;^ " " " 
 
 Ear, 2 ) 
 
 Breech VA\ '' " 3.80^ " " "■ 
 
 Shoulder 91 " " 1.02^" " " 
 
ASEPSIS, MORBIDITY, AND MORTALITY. 239 
 
 Tablk yi. 
 
 TABLE (W OPERATIONS AND SEVERER COMPLICATIONS. 
 
 Placenta prasvia 31 cases, or O.SOfo of all cases. 
 
 Eclampsia 14 " "0.13^ " " 
 
 Abortions 417 " " 4.07^ " '' 
 
 Forceps 204 " "2.99^ " " omitting abortions. 
 
 Version 212 " " 2.1G^ " " " " 
 
 Perforation and decapita- 
 tion 5 " " 0.05^ " " " " 
 
 Symphysiotomy 6 '•' " 0.06^ " " " " 
 
 Csesarean section 2 " "0.02^ " " " '' 
 
 Manual extrac. of placenta, 182 " " 1.95^^ " " " " 
 
 It is an accepted fact that priraiparfe are more liable to febrile compli- 
 cations after labor than multipara are, and it is of interest to note in this 
 connection that there were 2,157 primiparge out of 10,094 cases in whom 
 the number of the parturiency was noted. This is a percentage of 21. Of 
 the 1,255 cases presenting febrile symptoms, 403 were primiparae and 852 
 were multipara. The 2,157 primipar^e represent only 21 per cent, of all 
 cases, but furnish 403 fever cases, which is 32.11 per cent, of all fever 
 cases. These 403 fever cases represent 18.68 per cent, of all primiparge, 
 and the 852 fever cases occurring in multiparse represent only 10.54 per 
 cent, of all multiparae. These figures mean that the ratio 10.54 to 18.68, or 
 1 to 1.77, represents the relative frequency of postpartum fever in multiparae 
 and primiparee. This ratio is given by Kleinwachter as 3.7 to 6.8, or 
 1 to 1.83, which is nearly identical with the above result. 
 
 It has been decided to divide the 1,255 cases which present febrile com- 
 plications according to their prominent etiological factor into seven classes 
 similar to those adopted in the last Medical Report. This has been done in 
 the following table : 
 
 Table YII. 
 
 classification of fever oases accordina to chief causes. 
 
 Cases. Of fever cases. Of all cases. 
 
 Class I. Breast temperatures 171 13.63^ 1.67^ 
 
 Class II. Constipation temperatures. . 276 21.99^ 2.70^ 
 
 Class III. Combinations of I. and II. 90 7.17^ 0.88^ 
 
 Class lY. Puerperal infection 331 26.38^ 3.23^ 
 
 Class Y. Complications which are \ 
 
 not puerperal sepsis and not in- V 82 6.53^ 0.80^ 
 
 eluded in Classes I. to lY ) 
 
 Class YI. Single rise of temperature ] 162 12.91^ 1.58^ 
 
 on labor day j (217) (17.29^) (2.12^) 
 
 Class YII. Temperatures of nn- ^^^ 
 
 known oriffm 
 
240 
 
 REPORT OF THE SOCIETY OF THE LVIXG-IN HOSPITAL. 
 
 Class I. Cases in ^VHICH the Breasts aveke Hard and Tender, and 
 TUE Temperature Became Normal upon Relief of this Condition. 
 
 As recorded in Table VII. there were 171 cases. To these cases there 
 must be added one case of abscess of the breast, in which the abscess fol- 
 lowed a curetl uterine sepsis. 
 
 Analysis of the 17l' Cases of Breast Temperature. 
 
 Table YIIL 
 
 table of maxi:mrm temperatures. 
 
 Cases. 
 
 Maximum temperature between 100.5" and 101.4° S3 
 
 '- " " 101.5° " 102.4° 41 
 
 '' " " 102.5° " 103.4^ 28 
 
 " " " 103.5° " 104.4° IT 
 
 " " " 104.5° " 105.4° 3 
 
 Table IX. 
 
 TABLE OF NUMBER OF DAY POSTPARTUM OF ONSET OF FEVER. 
 
 Cases. 
 
 Fever began on 1st day postpartum 9 
 
 " 15 
 
 ' " 39 
 
 29 
 
 " 20 
 
 16 
 
 ' " 12 
 
 13 
 
 i a ^ 
 
 ' " 
 
 
 a 
 
 2d 
 3d 
 
 
 
 4tli 
 
 
 
 5th 
 
 
 
 6th 
 
 
 
 7th 
 
 
 
 8th 
 
 
 
 9 til 
 
 
 
 loth 
 
 
 
 nth 
 
 
 
 21st 
 
 
 
 32d 
 
 Table X. 
 
 TABLE OF DURATION OF TEMPERATlIiK. 
 
 Cases. 
 
 Fever lasted 1 dav 110 
 
 2 days 
 
 19 
 
 8 
 
 Fever lasted 5 davs , 
 
 Cases. 
 6 
 
 1 
 
 2 
 1 
 
 Of these 172 eases of teHi])erature due to changes in the breasts, 12 
 developed an al)Sfess. To these 12 cases, \) other cases of abscess of the 
 breast must be added, in 8 of which the abscess formation was not accom- 
 ])aniod by any febrile symptoms, and 1 case in which the aljscess of the 
 brcjLst was ])ya;mic in character. These 21 cases of purulent inflammation 
 of the mammary gland make up only 0.2 per cent, of the total numl)er 
 of cas<^?s treat(;d. This number is reduced to 0.15 ])er cent, if we remove 
 from the total 21 the pyicmic ca.se aiul I otluir cases w Iiidi <)ii;^ii);it('(l fiom 
 an infection of th(,' ni]i]»les bcfr)rf' l;il)()i' l»c^;in. 
 
ASEPSIS, MORBIDITY, AND MORTALITY, 
 
 241 
 
 The following table gives some interesting facts concerning these cases : 
 
 Table XI. 
 
 
 . 
 
 r^ 
 
 
 
 
 
 
 
 1 ^ 
 
 r- 
 
 
 
 
 
 
 
 CD ie 
 
 -^^ i^ 
 
 0,3J 
 
 
 
 M3 
 
 
 
 a CO 
 
 1^ 
 
 a; o 
 
 g 
 a 
 
 ci 
 
 
 
 
 
 
 S8 M 
 
 .g 
 
 -t-i 
 
 be 
 
 a) 
 
 
 pq 
 
 « 
 
 PmO 
 
 £ 
 
 ^ 
 
 M 
 
 ^ 
 
 Abscesses without fever . 
 
 2 
 
 6 
 
 4 
 
 3 
 
 5 
 
 ■1 
 
 4 
 
 ' ' with fever .... 
 
 2 
 
 10 
 
 1 
 
 3 
 
 9 
 
 6 
 
 6 
 
 Pyaemic abscess 
 
 
 
 1 
 
 1 
 
 
 
 1 
 
 
 
 1 
 
 Totals 
 
 4 
 
 17 
 
 6 
 
 6 
 
 15 
 
 10 
 
 11 
 
 
 
 Class II. Cases in which the Bowels were Constipated, and the 
 Temperature Became Kormal upon the Exhibition of Cathartics. 
 
 There are 276 cases which come under this heading. 
 
 Analysis of the 276 Cases of Constipation Temperature. 
 
 Table XII. 
 
 TABLE OF maximum TEMPERATURES. 
 
 Cases. 
 
 Maximum temperatures between 100.5" and 101.4° 139 
 
 " " " 101.5° " 102.4° 82 
 
 " " " 102.5° " 103.4° 37 
 
 " " " 103.5° " 104.4° 16 
 
 " " " 104.5° " 105.4° 2 
 
 Table XIII. 
 
 TABLE OF NUMBER OF DAY POSTPARTUM OF ONSET OF FEVER. 
 
 Cases. 
 Fever began on 1st day postpartum 52 
 
 2d 
 
 3d 
 
 4th 
 
 5th 
 
 6th 
 
 7th 
 
 8th 
 
 9th 
 
 10th 
 
 11th 
 
 14th 
 
 15th 
 
 52 
 
 69 
 
 40 
 
 23 
 
 19 
 
 5 
 
 7 
 
 3 
 
 3 
 
 1 
 
 1 
 
 1 
 
 16 
 
242 
 
 REPORT OF THE SOCIETY OF THE LYIXlMN HOSPITAL. 
 
 Table XIY. 
 table of duration of temperature 
 Cases. 
 
 Fever lasted 1 tlay 197 
 
 • -J (lays 49 
 
 • ^5 - 17 
 
 Cases, 
 Fever lasted 4 days 9 
 
 U ii K i( 2 
 
 Class III. Cases in which Both the Breasts and the Condition of 
 THE Bowels Demanded Treatment, and the Temperature Became 
 Xormal upon Believing These Conditions. 
 
 There are 9o cases of which this statement is true. 
 
 Analysis of the 90 Cases of Combined Breast and Bowel 
 
 Temperatures. 
 
 Table XV. 
 
 TABLE OF MAXIMUM TEMPERATURES. 
 
 Cases. 
 
 Maximum temperature between 100.5° and 101.4° 26 
 
 '' " " 101.5° " 102.4° 37 
 
 " " " 102.5° " 103.4° 17 
 
 " " " 103.5° " 104.4° 7 
 
 " " " 104.5° " 105.4° 3 
 
 Table XYI. 
 
 TABLE OF NUMBER OF DAY POSTPARTUM OF ONSET OF FEVER. 
 
 Cases. 
 
 Fever began on 1st day postpartum 11 
 
 11 
 
 2d 
 3d 
 4th 
 5 th 
 Gth 
 7th 
 Sth 
 9th 
 loth 
 11th 
 
 20 
 12 
 9 
 11 
 6 
 G 
 1 
 1 
 2 
 
 Cases 
 
 Fever lasted 1 day 44 
 
 " ** 2(hiys L>o 
 
 •• :; •• II 
 
 Taiuj.; XVII. 
 
 TABLE OF I)rHATK)N OF TEMPERATURE. 
 
 Cases. 
 Fevei- lasted 4 chtys 7 
 
 " " f; " 3 
 
ASEPSIS, MORBIDITY, AND MORTALITY. 
 
 243 
 
 Class IV. Cases in which the Temperature Seemed to be Due to 
 THE Action of Micro-Organisms which had Invaded the Body 
 
 THROUGH the PaRTURIENT WoUNDS. 
 
 There are 331 cases of puerperal infection, Avliich give the following 
 analysis tables: 
 
 Analysis of the 331 Cases of Septic Infection. 
 
 Table XYIII. 
 
 table of maximum temperatures. 
 
 Cases. 
 Maximum temperatures between 100.5° and 101.4° 56 
 
 " 101.5° 
 
 
 102.4°.... 
 
 ...66 
 
 " 102.5° 
 
 
 103.4°.... 
 
 ...64 
 
 " 103.5° 
 
 
 104.4°. . . . 
 
 ...72 
 
 " 104.5° 
 
 
 105.4°. . . . 
 
 ...57 
 
 " 105.5° 
 
 
 106.4°. . . . 
 
 . .. 14 
 
 " 106.5° 
 
 
 106.9°... . 
 
 ... 2 
 
 Table XIX. 
 
 
 
 
 TABLE OF NUMBER OF DAY POSTPARTUM OF ONSET OF FEVER. 
 
 Cases. 
 
 Fever began on labor day 60 
 
 1st day j)Ostpartum 56 
 
 " 49 
 
 " 48 
 
 " 41 
 
 20 
 
 " 19 
 
 8 
 
 8 
 
 " 8 
 
 " 5 
 
 " 4 
 
 " 1 
 
 '' 3 
 
 " 1 
 
 
 1st 
 
 
 2d 
 
 
 3d 
 
 
 4th 
 
 
 5th 
 
 
 6th 
 
 
 7th 
 
 
 8th 
 
 
 9th 
 
 
 10th 
 
 
 11th 
 
 
 12th 
 
 
 13th 
 
 
 14th 
 
 These 331 septic cases may be divided into two groups — those which 
 remained in the care of the Hospital until the end of the disease, and those 
 which sought other attendance during their illness. Of the first class, 272 
 recovered and 9 died ; 37 cases sought the aid of outside physicians ; the 
 results in 34 are doubtful ; 3 others have been traced, and the final result 
 recorded in the histories. The remaining 13 were transferred to other 
 hospitals and their record is given below. 
 
 The tables of duration of temperature are given separately for each 
 subdivision. 
 
244 
 
 REPORT OF THE SOCIETY OF THE LYING-IX HOSPITAL. 
 
 Taule XX. 
 
 TABLE OF DURATION OF TEMPERATURE IN 272 CASES OF GROUP I. "WHICH 
 
 l^ECOVERED. 
 
 Fever lasted 
 
 Cases. 
 
 1 (lay •'.»> 
 
 2 (lays 47 
 
 :) •• 38 
 
 4 '• 42 
 
 o •' 2o 
 
 r. " IS 
 
 7 •• 12 
 
 5 •• 7 
 
 Cases. 
 
 Fever lasted days 4 
 
 " " 10 '' 5 
 
 '^ 11 " 1 
 
 " " 12 " 2 
 
 " " 13 " 2 
 
 " 15 " G 
 
 '' " 19 " 2 
 
 " " 30 " 1 
 
 Table XXI. 
 
 TABLE OF DURATION OF TEMPERATURE OF 9 CASES OF GROUP I. WHICH DIED. 
 
 Fever lasted 3 days 
 
 " " 5 ''^ 
 
 Cases. 
 
 2 
 2 
 
 1 
 1 
 
 Cases 
 
 Fever lasted 8 days 1 
 
 " " 11 " 1 
 
 " " 35 " 1 
 
 Table XXII. 
 
 TABLE OF THE OBSERVED DURATION OF TEMPERATURE IN 3Y CASES OF GROUP II. 
 AVHO CALLED IN OTHER PHYSICIANS. 
 
 Cases. 
 Fever observed 1 day 3 
 
 " '• 2 days 4 
 
 " •• 3 '• 10 
 
 II ii 4 " 9 
 
 << «< 5 >' 2 
 
 Cases. 
 Fever observed 6 days 3 
 
 u a 7 " 9 
 
 " " 8 " 1 
 
 " '< 9 " 2 
 
 " '< 12 " 1 
 
 Of the 13 cases referred to (ttlicr liospita Is for treatment, 9 recovered 
 and 4 died. Tlic duratioji of fcvci- in these cases is sliown in tlic followin*^- 
 table: 
 
 Taijlk XXIII. 
 
 STATEMENT OF OBSEKVKH IirilAlIoX OV 'II;M I'KliA'IT IvK I\ 13 CASES OF (JUoUl' II. 
 TRANSFERRED To OlIIKIi IK (SITIALS. 
 
 Fever was observed for two days in two cases, for live days in two cases, 
 and for six, seven, eleven, tliirt(!en, and twenty-oiu; days res])ectivcly in 
 one case each ; these nine recovered. Fever was observed for six days in 
 three ca.ses, and for seventeen days in one ease; these four died in hospital. 
 
 .\ THon- drtaijcd aiialvsis is ^n veil bch)W coiicci'iiin^' the fatal cases. 
 
ASEPSIS. MORBIDITY, AND MORTALITY. 245 
 
 Class Y. Cases in which the Temperature was Evidently Due to 
 Some Complicating Pathological Condition Other than a Puer- 
 peral Septicemia. 
 
 There are 82 such cases in the series under consideration, and they may 
 be grouped as follows : 
 
 Analysis of the 82 Cases of Complicating Diseases. 
 Table XXIV. 
 
 GROUP I. NON-SEPTIC DISEASES. 
 
 Cases. 
 
 Pneumonia 16 
 
 Epidemic influenza without pneu- 
 monia 4 
 
 Bronchitis 16 
 
 DiT pleurisy 1 
 
 Cases. 
 
 Phthisis 11 
 
 Malaria 3 
 
 Intestinal colic 2 
 
 Alcoholism 1 
 
 Starvation 1 
 
 GROUP II. SEPTIC DISEASES OF NON-PUERPERAL ORIGIN 
 
 Cases. 
 
 Facial erysipelas 4 
 
 Cystitis 1 
 
 Abscess of gluteal region 1 
 
 Abscess of thig-h 1 
 
 Cases. 
 
 Cellulitis of wrist 1 
 
 Burns from douche and hypoder- 
 mic abscess 1 
 
 Tonsillitis 4 
 
 GROUP III. PUERPERAL DISEASES OF NON-SEPTIC ORIGIN. 
 
 Cases. 
 
 Eclampsia 8 
 
 Suppression of urine after ether 1 
 
 Retention of urine 1 
 
 Anaemia after haemorrhage 4 
 
 To these there should be added one case of phthisis who died without 
 presenting febrile symptoms, one case of tonsillitis in a patient who had 
 previously been cured of a puerperal sepsis, and ten cases of pneumonia 
 which complicated septic processes. 
 
 Adding these duplicate or additional cases, the following list gives the 
 corrected statistics : 
 
 Cases. 
 
 Pneumonia 26 
 
 Phthisis 12 
 
 Tonsillitis 5 
 
 Class YI. Cases in avhich a Single Pise of Temperature Occurred 
 During or Immediately After Delivery. 
 
 There are 162 cases in this subdivision of the subject, but there are 55 
 other cases which presented a similar rise during or immediately after labor, 
 and also a subsequent temperature due to some other cause. These 217 
 
246 REPORT OF THE SOCIETY OF THE LYIXG-IX HOSPITAL. 
 
 cases are grouped for purposes of statistics. Sixty aiklilional cases pre- 
 sented a temperature on the day of delivery which was tlue to a true se})- 
 ticannia: these are considered under Chiss IV. only. 
 
 The etiological factor in this class of cases is, that labor is accompanied 
 by an inci-eased muscular exertion, with a diminished activity of the lungs 
 and skin.* 
 
 Analysis ok tuk :^17 Cases of Labor Day Temperatures. 
 
 Table XXY. 
 table of causes of seooxd fever ix 55 additional cases. 
 
 Cases. 
 
 Fever due to breasts 11 
 
 '' " constipation 20 
 
 " " both breasts and Ijowels 10 
 
 u 
 
 sepsis 
 
 " " unknown causes . < 
 
 Table XXYI. 
 
 table of height of temperature, 
 
 Cases. 
 
 Temperature between 100.5° and 101.4^ 182 
 
 " " 101.5° " 102.4° 30 
 
 " " 102.5° " 103.4° 3 
 
 " " 103.5° " 104.4° 2 
 
 Class VII. Cases in which no Accountable Cause for the Temperature 
 
 WAS Obvious. 
 
 There are 143 cases of this class. 
 
 Analy'sis of the 143 Cases of Temperature of Unknown Origin. 
 
 Table XXVII. 
 
 TABLE OF maximum TEMPERATURES. 
 
 Cases. 
 
 Maximum tem])eratui-e between 100.5° and 101.4° 90 
 
 " 101.5° " 102.4° 41 
 
 " " " 102.5° " 103.4° 10 
 
 " " " 103.5° " 104.4° 2 
 
 Table XXA^TIT. 
 
 TABLK or DtKATlON OF J K.^U'ERATURE. 
 
 Cases. 
 
 Fever lasted 1 day 118 
 
 " " 2 days 2<> 
 
 '' " 3 " 1 
 
 " " 5 ^' 1 
 
 * Fieber in der Geburt., Winter. Zeitscliiift fiii' < Jchurlshiilfc uiid Gynaikologie, 
 xxiii. 
 
ASEPSIS, MORBIDITV, AND MORTALITY. 
 
 247 
 
 Table XXIX. 
 
 TABLE OF DAYS OF PUEKPEKIUM ON WHICH RLSE OF TEMPERATURE OCCURRED. 
 
 Cases with temperature on one day only, total 118. Cases. 
 
 Rise of temperature occurred on 1st day postpartum 31 
 
 2d 
 3d 
 4th 
 5th 
 6th 
 7th 
 8th 
 9th 
 10th 
 13th 
 
 9 
 15 
 14 
 17 
 
 7 
 
 14 
 
 6 
 
 2 
 2 
 1 
 
 Cases with temperature on two days, total 20. Cases. 
 
 Kise of temperature occurred on labor day and 1st day postpartum . . 5 
 
 u- u u u g^]^ cc u 
 
 " 1st and 2d davs 
 
 1st 
 
 ' 5th " 
 
 2d 
 
 ' 3d " 
 
 2d 
 
 ' 8th " 
 
 3d 
 
 ' 4th " 
 
 3d 
 
 ' 5th " 
 
 3d 
 
 ' 8th " 
 
 5th 
 
 ' 6th " 
 
 5th 
 
 ' 7th " 
 
 Case with temj)erature on three days, total 1. 
 
 Rises of temperature occurred on labor day, 1st and 3d days postpartum. 
 
 Cases with temperature on four days, total 3. 
 
 Rises of temperature occurred on 1st, 2d, 3d, 4th days postpartum in 
 1 case. 
 
 Rises of temperature occurred on 1st, 2d, 3d, 9th days postpartum in 
 1 case. 
 
 Rises of temperature occurred on 3d, 4th, 5th, 6th days postpartum in 
 1 case. 
 
 Case wath temperature on five days, total 1. 
 
 Rises of temperature occurred on 2d, 3d, 4th, 5th, 6th days postpartum. 
 
 Mortality Statistics. 
 
 The total mortality among the 10,233 cases amounts to 42 cases. This 
 is a total mortality percentage of 0.41 per cent. Another death must be 
 added to this list, although it did not occur in one of the 10,233 deliveries. 
 
248 
 
 REPORT OF THE SOCIETY OF THE LYING-IX HOSPITAL. 
 
 This patient died oi advanced cardiac disease in tlie early part of tlie sev- 
 enth month of ]>regnancv. If this case be inchided in estimating the ratio, 
 this is not materially altered, bnt is sim])ly increased to 0.42 per cent. 
 
 If tliese deaths are tabulated in accordance Avith the subdivision of the 
 service as recorded in Table I., page 23G, the following table results: 
 
 TAm.E XXX. 
 
 
 No. of 
 Cases. 
 
 No. of Deaths 
 from .Sepsis. 
 
 Pr.Ct. 
 
 No. of Deaths 
 
 from 
 
 all Causes. 
 
 Pr.Ct. 
 
 1st Period. 
 
 Jan., "iM.)-Mar.,'92 
 2d I*eriod. 
 
 Mar.,'92-Feb.,'95 
 3d Period. 
 
 Feb.,'95-Apr.,'96 
 
 1,454 
 
 6,457* 
 
 2,323 
 
 8 
 5 
 2 
 
 0.08^ 
 
 14 
 
 26 
 3 
 
 0.96^ 
 0.40^ 
 . 12,^ 
 
 Totals 
 
 10,234 
 
 15 
 
 . 14,'^ 
 
 43 
 
 ()A2fc 
 
 
 
 Tlie mortality percentages in each successive thousand cases is shown in 
 the following table: 
 
 Table XXXI. 
 
 
 No. of 
 
 
 No. of 
 
 
 
 Deaths 
 from 
 
 Per Cent. 
 
 Deaths 
 from all 
 
 Per Cent. 
 
 
 Sepsis. 
 
 
 Causes. 
 
 
 First Thousand 
 
 6 
 
 . Ofc 
 
 10 
 
 1 . Ofc 
 
 Second '' 
 
 2 
 
 0.2^ 
 
 6 
 
 . ('4 
 
 Third " 
 
 () 
 
 < 1 . ( K^ 
 
 2 
 
 0.2^ 
 
 Fourth " 
 
 (_) 
 
 n.();f 
 
 5 
 
 0.5fo 
 
 Fifth " 
 
 (.» 
 
 OAKi 
 
 3 
 
 0.3^ 
 
 Si.xth " 
 
 3 
 
 o.nfc 
 
 8 
 
 0.8^ 
 
 Seventh " 
 
 
 
 o.<»^ 
 
 2 
 
 0.2^ 
 
 p:iglith " 
 
 2 
 
 0.2^ 
 
 3 
 
 0.3^ 
 
 Ninth " 
 
 1 
 
 0.1^ 
 
 1 
 
 0.1^ 
 
 Tenth " 
 
 (1 
 
 O.i^'^c 
 
 
 
 0.0^ 
 
 233 cases 
 
 1 
 
 0.4^ 
 
 2 
 
 0.8^ 
 
 Antepartum case .... 
 
 
 
 0.0^ 
 
 1 
 
 
 
 10,234 cases 
 
 15 
 
 0.14^ 
 
 43 
 
 0.42,^ 
 
 These percentages are subject to the criticism that certain of our cases 
 souglit otl)er assistance after l)ecoming ill, and may have died subsequently 
 from the effects of the puerperal inlVn-tion. l-'ifty |)atients are of this chiss, 
 but of these thirteen were sent to othci- hos|>itals. and the results in all ai-e 
 
 * Th<' ;iiitfi»:irtiiiii dcilli fi-om lic;ir( iliHoa.sf^ is ;ii|(|cil (o lliis series. 
 

 d pelvis Hfgli t 
 
 
 ■"hysldno:! 
 
 
 ■ )l,.B'.A.t 
 
 
 
ASEPSIS, MORBIDITY, AND MORTALITY. 251 
 
 known and included in tliese statistics. Four of the thirteen died. Thirty- 
 seven cases sought the care of private physicians. The hospital has traced 
 three of these; one recovered and two died, and are included in our records 
 (C. jN". 5, 799, C. N. Y,538). The records also include a case of surgical 
 kidney following cystitis and vesico-vaginal fistula, who died many months 
 after her discharge from the service. The remaining thirty -four patients 
 who sought other medical care were discharged while still septic, but the 
 severity of their sepsis varied very materially. It is safe to infer that a 
 large majority of them recovered. The following table gives their tem- 
 peratures at the time of discharge: 
 
 Table XXXII. 
 
 TEMPERATURE AT TIME OF DISCHARGE OF 34 CASES SEEKING- OTHER MEDICAL 
 
 ATTENDANCE. 
 
 Temperature at time of discharge below 100.5° 
 
 3 
 
 " " " " " between 100.5° and 101.4" 5 
 
 " " " " " " 101.5° " 102.4° 6 
 
 " " " " " " 102.5° '' 103.4°.... 11 
 
 " " " " " " 103.5° " 104.4°.... 5 
 
 " " " " " above 104.5° 4 
 
 If all these cases are included as deaths, the total mortalit}^ would be 77 
 fatal cases in 10,233 cases, or 0.75 per cent. Of course this is manifestly 
 an over-estimate; nevertheless even this figure compares favorably with the 
 figures of other obstetric schools. 
 
 Table XXXIII. 
 
 MORTALITY PERCENTAGES OF VARIOUS SCHOOLS. 
 
 Cases. Mortality. 
 
 1. University Frauenklinik, Berlin, 1888-95 8,528 1.93^ 
 
 2. Maison d'Accouchements Baudelocque, Paris, 1890-95 . 10,861 .... 0.66^ 
 
 3. University Obstetric Clinic, Prag, 1887-95 8,924 0.85^ 
 
 4. University Frauenklinik, Dorpat, 1888-93 889. .. . 1.57^ 
 
 5. University Frauenklinik Poliklinik, Dorpat 1,267. . . .2.2^ 
 
 6. University Frauenklinik, "NVurzburg 3,000. . . .0.7^ 
 
 1. Ziir puerperalen Infection. Koblanck, Zeitsclirift f . Geburtshiilfe nncl Gynae- 
 kologie, 1896. 
 
 2. Fonctionnement de la Maison d'Accouchements Baudelocque. Lepage, 1896. 
 
 3. Bericht iiber die Morbiditats-verhaltnisse, etc. Pipek, Monatschidft fiir 
 Geburtshiilfe mid Gyna?kologie, 1896. 
 
 4. 5. Berichte und Arbeiten. O. Kiistner, 1894. 
 
 6. Die Verhiitung des Kindbettfiebers in den geburtsbilflichen Unterrichts- 
 austalten. Hofmeier, Khniscbe Vortrage, 1897. 
 
 These 43 fatal cases have been arranged in the order of their occurrence, 
 and a brief statement of each case has been given in the statistical synopsis 
 printed above. In the table Xo. XXXIY. the same cases are arranged 
 in groups, according to the chief cause of death. 
 
253 
 
 REPORT OF THE SOCIETY OF THE EVIXC-IX IIOsriTAL. 
 
 The l\»llo\ving table shows the cause of death in the 2S fatal cases which 
 died from other causes than })uer})eral infection, and the mortality per 
 cent, for each cause. All these cases wei-e delivei-ed l)y the Hospital. 
 
 Table XXXV. 
 
 hilaiiiiisia 
 
 Antepartum ha'uiorrliage 
 
 Postpartum hiemorrhage 
 
 Placenta ]>rie\'ia j 
 
 Eu]>ture of uterus ■ 
 
 ]*neumonia 
 
 Phthisis 
 
 Heart disease i 
 
 Suppression of urine from ether 
 
 Erysipelas, facial 
 
 Surgical kidney following vesico-vaginal| 
 fistula, 1 year postpartum ' 
 
 11 
 2 
 
 2 
 
 2 
 
 4 
 •> 
 
 1 
 1 
 1 
 1 
 
 Xo. Cases 
 of Com- 
 plication 
 
 Observed. 
 
 ]\Iortality 
 Per Cent. 
 
 YS . 67 fc 
 
 6.45^ 
 
 12.5,'^ 
 
 8.33$^ 
 11.11^ 
 
 100^ 
 
 The followino- ta1)le presents a further analvsis of the deaths from 
 septicaemia : 
 
 Table XXXVI. 
 
 
 Delivered 
 
 Midwife, 
 etc. 
 
 DELIVERED BY HoSPrj'AL. 
 
 
 
 Operative 
 Delivery. 
 
 Spontaneous 
 Birth. 
 
 Total. 
 
 First tliousand 
 
 Second *' 
 
 Si.xth " 
 
 Eighth " 
 
 Ninth '' 
 
 Eleventli '' 
 
 3 
 1 
 
 
 
 
 
 
 2 
 
 1 
 1 
 1 
 1 
 
 1 
 1 
 2 
 1 
 
 
 
 6 
 
 2 
 3 
 
 2 
 
 i 
 
 1 
 
 Totals 
 
 4 
 
 ('. 
 
 5 
 
 15 
 
CONGENITAL CYSTIC KIDNEYS. 
 By Martha Wollstein. M.D. 
 
 The specimen wns removed at autopsy from a female infant (C. N. 132), 
 born at term, who lived twelve hours. Delivery had been by forceps after 
 a labor of fifteen hours; the position was right occipito-posterior. The 
 child's respirations were delaj^ed, and when finally established they 
 remained irregular and shallow until death. The body was that of a well- 
 nourished child, with a marl^edly prominent abdomen which was resistant 
 to the touch and gave no evidence of fluctuation. There were no skin 
 lesions and no oedema. Upon opening the cranial cavity, the pia mater 
 was found hyperaemic over the entire brain ; there was no extravasation of 
 blood, and the brain substance was normal. In the lungs there were large 
 atelectatic areas in both lower lobes, the anterior border of both upper 
 lobes being emphysematous; there was marked congestion. The pleura, 
 pericardium, and peritoneum were normal ; the heart w^as normal, as were 
 the pulmonary artery and the aorta. The liver, spleen, pancreas, stomach, 
 and intestines showed no change from the normal; nor did the uterus, 
 Fallopian tubes, ovaries, and vagina. 
 
 When the intestines were removed, two large masses were seen to fill 
 the entire space between vertebral column and lateral body walls. These 
 proved to be the kidneys, each measuring twelve centimetres in length, by 
 six in breadth, and four in thickness. The suprarenal capsules were nor- 
 mal in size and position, capping the upper border of the kidnej^s. The 
 ureters were traced from pelvis to bladder, which was very narrow, small, 
 and empty. It was cylindrical in shape, showing no bulging at the 
 fundus ; the trigonum was readil}^ found, the openings of both ureters and 
 of the urethra being present, but very small. The urachus was not pervi- 
 ous, and the umbilical vessels were entireU^ normal. The kidneys, supra- 
 renal bodies, bladder, and uterus were removed e?i masse, and w^eighed 375 
 grammes. 
 
 The following anatomical description applies to both kidneys, as their 
 condition was practically identical. They had a distinctly%oggy feel ; on 
 being opened, the cut surface presented a peculiarly cribriform effect, due to 
 the dilatation of the renal tubules everywhere throughout the cortex and 
 medulla. These were not distinct, the one from the other, except in a few 
 places, where the cortex measured one centimetre in depth. For the rest, 
 
254 REPORT OF THE SOCIETY OF THE LYING-IX HOSPITAL. 
 
 the Itoiintlary zone between cortex and medulla was entirely lost. The 
 tuhnles were all more or less dilated, aiul a very few cysts, none larger than 
 a small pea, were present in the interior: on the kidney surface, beneath the 
 capsule, there were no cysts larger than one to three millimetres in diam- 
 eter. The capsule was thickened and adherent. The appearance of the 
 pelvis, calices, and jiapilkv was very striking. The Avail of the pelvis Avas 
 smooth, grayish-red in color, and very much thicker than the correspond- 
 ing ]>ortion of a normal kidney; the papilltx? were not free, as is usual, in 
 the calices, but their outline as ajnces of the ]VIal[)ighian pyramids was lost 
 on account of their close adlierence to the thickened Avail of the kidney 
 peh'is. Of the nine or ten pyi'amids jiresent, no one could be raised out of 
 its calix, as in the normal kidney. The uj)})er end of the ureter was a mere 
 solid cord, two millimetres in thickness; at a point about two or three 
 centimetres below the pelvis, the ureter became somewhat Avider, and Avas 
 pervious throughout the rest of its course. There Avas no urine in either 
 pelvis, ureter, or bladder. The normal fcetal lobulation of a kidney at l)irth 
 Avas entirely lost; a condition Avhicli may be ex])lained by the stretcliing of 
 the organ, due to the distended tubules and increased stroma l)etween them. 
 Figure 1 is a ])hotograph of the gross specimen, and shows all the points 
 enumerated in the description. 
 
 The blood sup})ly, also symmetrical, varied from the nonnal in that tAVO 
 renal arteries Avere given off sej^arately from the aorta on either side, about 
 one centimetre apart; the}' branched but little l)efore entering the hilus. 
 The renal veins Avere single, emptying into the inferior A^ena cava. 
 
 Microscopical examination of sections cut through the entire depth of a 
 Mal])ighian pyramid shoAV an extremely interesting and unusual condition. 
 The kidney cajisule is sevei'al times thicker than normal, and is comj)osed 
 of fibrous connective tissue containing comparatively few s])indle-shaped 
 cells. Two things are strikingly suggestive in the kidney substance — the 
 large amount and irregular folding of e]nthelial bands and masses, and the 
 (juantity of (iljrous connective tissue, rather less cellular tlian is normal in 
 the newly b(ji-n. Tlie glomeruli vary much in siz(;, some being smaller, 
 others lai'ger than normal, that is, dilated. They contain either the usual 
 caj>illary tuft, or a mass of flattened epithelial cells, oi' tliey are emi)ty. 
 They are present throughout the cortex, even close und(M* the capsule, 
 avIk'I-c some renal tulniles can be seen to bend and coil, others to illustrate 
 the lirst entrance of the capillary tuft into their blind extremities. None 
 show any increase of connective tissue at tlie ex])ense of their epithelial or 
 vascular elements. 
 
 There are very few renal tubules \\ho.s(! epithelium resembles that in the 
 normal convoluted tuljes, and still less which can be classed as the arms of 
 Ilenle's loo]); as for the collecting tul)ul('s. tlici-e ai-e scarcely any which 
 retain their noniial nha, slui])e, and lining. The; r<Mnainder of the tubules 
 in the specimen.s are cylinders of epithelial cells, sonn; hollow, some solid, 
 the majority having no distinct membrana propria. ImiI lying directly upon, 
 or rather within, the conncc-tive tissue stroma, to which they are rather 
 loosely a])plied. 
 
a 
 
 r 
 
 d" 
 
 Fig. 1. — a, riglit kidney ; &, left kidney ; c, suprarenal capsules ; d, bladder ; e, ureters ; /, two 
 renal arteries on left side ; g, two renal arteries on riglit side ; Ji, renal veins; i, vena cava 
 inferior ; /, aorta ; Ic, cysts ; I, a calyx showing thickened wall and adlierent papilla ; tn, 
 uterus ; ?t, vagina ; o, narrowing of right ureter before entering pelvis of kidney ; p, opening 
 of ureters in bladder. 
 
Fig. 2. — a, folding or convoluting of the tubes ; i, large cysts, empty, lining gone ; c, dilated 
 glomerulus ; d, normal glomerulus ; e, projections into lumen of tubules ; /, glomerulus 
 filled with epithelial cells ; g, collecting tubes, compressed ; h, stroma. 
 
CONGENITAL CYSTIC KIDNEYS, 255 
 
 Many of the folded strands give the impression of l^eing tuljules forced 
 to double on themselves for lack of space in which to elongate (see Fio-. 
 2, a), very much as the first bend is formed in the developing kidney tubules 
 (Minot^), when the capsule acts as a mechanical obstacle to further elonga- 
 tion. Xauwerck and Ilufschmid ' call attention to the aj)parent loosenino- 
 of the e])ithclium from the stroma, and point out the fact that in some cases 
 the membrana propria is thicker than normal; in others, normal; and in 
 others, again, has entirely disappeared. By far the greater number of 
 tubules in this specimen are minus a membrana propria. The same authors 
 also think it erroneous to attribute this loosened condition to artificial 
 causes, such as shrinking in hardening, etc. ; it is certainly too universal 
 and too constant to make the explanation plausible, or at least acceptable, as 
 the only factor. Furthermore, were the epithelium unfolded, it would be 
 found to be much too long a band to fit into the cavity outlined by the 
 stroma immediately outside. That there are coiled and recoiled epithelial 
 cylinders is evident, and that this condition can only be explained by an 
 mmsual proliferation of the epithelium in excess of the stroma, is also plain. 
 The hollow cylinders are lined wath a single row of beautifully clear, cubical 
 cells, whose nuclei stain deeply ; in addition to these there are, in places, 
 masses of clearer, regular polygonal cells, whose nuclei stain less deeply 
 than the others. They resemble exactly the nests described by JSTauwerck 
 and Hufschmid, and fill not only the cylindrical tubes, but the globular 
 glomeruli as well, Karyokinetic figures can be demonstrated in the epi- 
 thelial cells in many places. 
 
 While no branched papillary outgrowths were found in any one of the 
 sections, there are many small projections of the cj^st w^all into the lumen, 
 carrying the lining epithelium with them. There are also numerous exam- 
 ples of the solid branches of tubes (Sprossenbildung) pictured by JSTauwerck 
 and Hufschmid,^ some of which show" their origin distinctly. jS'ear the 
 apex of a Malpighian pyramid there are small tubules, w^hose epithelial 
 lining is a row of low columnar cells, resembling a compressed and inactive 
 collecting tube. The connective tissue in this region is greater in amount 
 than in any other portion of the kidney. 
 
 The wall of the pelvis is greater in actual depth than the kidney cap- 
 sule; no trace of a lining epithelium remains, and the papillarj^ apex is 
 united to the pelvis by a distinct zone of round cell infiltration, evidently 
 inflammatory in origin. The blood vessels are normal as to the structure 
 of their walls, and are neither increased nor diminished in number. Some 
 of the tubules and cysts contain a small quantity of fine granular material, 
 but nowhere any colloid substance. 
 
 This condition of the pelvis and papillae would seem, at first, to illustrate 
 to a nicety the theory of Yirchow ^ as to the formation of congenital renal 
 cysts — assuming a foetal nephritis, in reality a pyelonephritis, causing 
 atresia of the papillary orifices and dilatation of the renal tubules in conse- 
 quence of their compression by connective tissue. But this explanation 
 clears up only a part of the specimen, leaving the epithelial proliferation 
 entirely unelucidated. Evidently, instead of remaining passive and becom- 
 
256 REPORT OF THE SOCIETY OF TllK LYIXG-IN HOSPITAL. 
 
 iiif moiv ami more riattenocl as the tuluile walls beeame ilistemled, the epi- 
 thelimii here took an active i)art in the process, giving rise to a comlition 
 distinctly adenomatous in character. 
 
 Xaiiwerck ami lliit'schmid' have endeavored to prove that these cystic 
 kidnevs are to be classed as multilocular adenocystomata, explaining the 
 inflammatory zone between the kidney and pelvis as analogous to the 
 romul cell infiltration almost constantly found at the periphery of epithelial 
 tumors, and the inflammatory jirocess in the pelvis and kidney substance 
 as the result, not the cause, of the cyst formation (pressure). Arnold^ 
 lias shown conclusively that a in'imary fa3tal nephritis does occur, but the 
 specimen he so described Avas an atrophic kidney with microscopic cysts 
 only. Viivhow ' still ui)lK)lds his original theoiy, and emphatically denies 
 the neo}»lasmic origin of this condition. Chotinsky-"' and Brigidi and 
 Severi,* though conservative, are yet inclined toward the neoplasmic view. 
 and Phillipson ' considers it an open question whether the proliferating 
 epithelium is really a beginning adenoma, or merely a compensatory 
 hypertrophy. Bland-Sutton^ takes a view radically different from any 
 other observer, in that he considers cystic kidneys, both foetal and adult, as 
 retention cysts of persistent Wolffian (mesonephritic) tubules, and thus 
 classes i^aroojihoron cysts, kidney cysts, and innocent cysts of the testicle 
 as identical, under the teratomata. 
 
 Congenital cystic kidneys have been recorded which were so large as to 
 seriously interfere with delivery (Ortli) ^^ or to cause death in a few hours 
 or days, as in the present case, through interference with respiration by 
 })ressure u|>on the dia]ihragm. On the other hand, the condition has 
 remained unsuspected until found at the autopsy in adult life. It is quite 
 common to find other malformations coexisting. As reported above, the 
 only other defect ])resent in this case was that of the bladder, and how 
 much its lack of size (dilatation) was due to the absence of the mechanical 
 factor of urine distension can only be surmised. 
 
 Two exj)lanations of this specimen ai'e ])ossil)le — either there was a 
 foital pyelonephritis accompanied by marked e])ithelial hyj^erti-ophy, or 
 else a foetal cyst-adenoma with resulting ])eripheral inflammation. The 
 etiology of both conditions is equally dark. Microscopic study, however, 
 ])oints to the latter as the more tenable hypothesis, in that it covers all the 
 changes noted. Beyond the pajnllary zone, no evidences of nephritis exist. 
 
 lhi!i.i<i(;i{Ai'Hv TIeferrki) to IX TJiK Tkxt. 
 
 1. Nauwerck and Ilufschmifl: rcbci- das Mnltilocnlare Adenocystom 
 der Xiere. Zeighn-'s Beitriige, bd. xii. 
 
 2. Vircliow: Uebej- liy(h'ops Kciium Cysticus Congenitus. Virchow's 
 Archiv, bd. xlvi. 
 
 'i. Arnohl: Cchf-r Angcbf>renc eniseitige Nierenschrnmpl'ung mit Cys- 
 tenbilduug. Ziegler's I>eitriige. bd. v. 
 
 1. Vircliow: n<'rliin'r klinis< In- W'ochcnscliiif't. lid. xxix. 
 
CONGENITAL CYSTIC KIDNEYS. 257 
 
 5. Chotinsky: Ueber Cystenniere. Inaug. Dissert., 1882. 
 (). Brigidi e Severi: Contributo alia patogenesi clelle cisti renale. Lo 
 Sperimentale, 1880. 
 
 7. Phillipson: Anatomische IJntersucliungen iiber Nierencysten. 
 Virchow's Archiv, bd. iii. 
 
 8. Eland-Sutton: The Lancet, 1887. 
 
 9. Minot: Human Embryology. 
 
 10. Orth: Lehrbuch der Speciellen Pathologischen Anatomic, bd. ii. 
 17 
 
DEFORMED PELVES, 
 
 By Austin Flint, Jr., M.D. 
 
 The statistics on which this article is based, include cases already 
 reported in a pajier entitled "Observations on Pelvic Deformities," read 
 before the Xew York State Medical Association, October 16, 1895. The 
 observations then made were mainly for the purpose of determining the 
 frequency with Avhicli pelvic deformities occurred ; and in most of the cases 
 the deformity was very slight. AVhen the Hospital first began its Avork, 
 the cases were in some res]")ects imperfectly recorded; and, as many instances 
 of minor pelvic deformity were undoubtedly overlooked, the first 2,000 
 histories \vere not included in the statistics, and the figures were obtained 
 in 0,000 consecutive cases, from numbers 2,000 to 7,000 inclusive. The 
 observations now recorded include the 2,(H)0 ])reviously omitted and the 
 6,000 previously v('])orte(l. and have been studied with reference more par- 
 ticularly to instances in wliich deformity is well marked. In addition to 
 this. 2,23;j women have since been confined, making a grand total of 10,233 
 observations. 
 
 Alth(High the object in rejiorting these cases is to ascertain the results 
 in instances of mai'ked deformity, before tabulating and analyzing these, 
 some general facts in regard to the frequency of pelvic deformity in all 
 degrees will he of interest. 
 
 It is necessary, as a preliminary, to deline what is meant by pelvic deform- 
 ity; and to do this, some staiid;ird of size must be ado})ted, below which 
 pelves may l)e called •• <l(roiiii('(l." As in the cases reported in the previ- 
 ous article, observations liii\e still been recoi'ded accoi'ding to the limits of 
 contraction asdefin<'d by Litzmann and followed by the majority of German 
 writers, in which all cases with an external conjugate of eighteen centi- 
 metres or less, or 7.2 inches, wen; regarded as contracted; but these statis- 
 tics include; onlv cases in which the (•oniu'>at(? measured seven inches or 
 less. As regards the nuc conjugate, Litzmann inclndcd as contracted all 
 ca.ses witli a measurement of I*^ centimeti'cs or ;!.s inciies. Disi-egarding, 
 for the moment, tlie true conjugate, which ninst he eslinialcd from the 
 diagonal, I include as contracted all cases with a diauonal ineasnicnient of 
 4.i ImcIh'S, or an estimated true conju^'-ate falling sli^li11\ hch)w tiiis limit. 
 
 Lnder this <l<'linition of pelvic debjrmity, in a total of 1(),2.'>3 cases 
 ohservetl, contniction was j»resent in 85f'> cases, oi- x.'W \n'A' cent. C'om])ar- 
 ing tliis ])ercentuge with statistics fi-om Kuro])ean sources, it will he noticed 
 
DEFORMED PELVES. 259 
 
 that it is quite markedly less. Thus: Michaelis, in 1,(»00 cases, obtained a 
 percentage of 13.1; Litzmann, 14.9. Winckel believes that from 15 to 20 
 per cent, of women liave contracted pelves; Kaltenbach, 1-1 to 20; 
 Schauta, 20. The report from Leopold's clinics for 1805 records a fre- 
 quency of 24.3 per cent. It has already been stated that in the first 2,000 
 cases recorded at the Hospital, many instances of minor deformity, accord- 
 ing to these measurements, were omitted, and consequently the first 2,000 
 were disregarded. In the previous investigations, the histories numbered 
 from 4,000 to 0,000, and from 6,000 to 8,000, showed a frequency of 249 
 and 251 respectivel}^, or 12.4 and 12.9 per cent, respectively; and these 
 percentages are correct if we accept the definition of deformity which has 
 been described, rather than the percentage of 8.36 in 10,233 cases. A 
 conclusion that may be drawn is, that in 'New York, with its large foreign 
 population, pelvic deformities occur with about the same frequency as in 
 Europe, under the same standard of measurements; but, as will be shown 
 later on, pelvic deformity in which the obstruction is serious enough to be 
 noticed, does not occur with the same frequency here as abroad, even when 
 compared with the conservative estimate of Winckel. A more careful 
 observation and a larger experience in the treatment of these cases has con- 
 vinced me that, when the external conjugate diameter is the only one which 
 falls below the standard, contraction does not necessarily exist. 
 
 As a part of the routine of the Hospital, all applicants are carefully 
 examined and measured. These measurements are made by students, under 
 the direct supervision of the resident staff of the Hospital and the Board 
 of Assistant Attending Physicians. To insure more accurac}^ of observa- 
 tion, whenever a case with any of the measurements falling below the 
 standard is found, it is referred for diagnosis to the assistant attending 
 physician on duty in the examining-rooms for that day. In other 
 words, external measurements are no longer relied upon, but internal meas- 
 urements, made by a skilled observer, are made before the case is recorded 
 as one of deformity. This plan, it is believed, will render future observa- 
 tions much more accurate and uniform. 
 
 Of the 856 cases of deformity recorded, in 710 deformity was very 
 slight, or, possibly, did not exist. The external conjugate measured seven 
 inches or less in all, but labor was not modified, mth the exception, per- 
 haps, of being prolonged; and nearly all the deliveries Avere spontaneous. 
 In this number there were 14 forceps deliveries in which pehdc deformity 
 was mentioned in the account of the operation. In none of these cases, 
 however, was the diagnosis of contraction borne out by pelvic mensura- 
 tion, so that they have been included in the 710 doubtful cases, and not in 
 the well-marked cases. 
 
 In 146 cases deformity Avas marked. This means a frequency in 
 10,233 of but 1.42 per cent., Avhich is insignificant as compared with the 
 ordinary European statistics, and very moderate as compared Avith the 5 
 per cent, of serious obstruction estimated by Winckel. 
 
 The foUoAving is a synopsis of the 146 instances of marked pehdc 
 deformity : 
 
2tiO 
 
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DEFORMED PELVES. 
 
 263 
 
 All anal3'sis of this Table of Deformed Pelves shows the following 
 As regards etiology, the record of nativity is important: 
 
 Russia 110 
 
 United States 
 
 Austria 10 
 
 Poland 7 
 
 Germanv 5 
 
 Ilnngaiy . 
 Ireland . . . 
 Italy 
 
 jS'ot noted 
 
 2 
 1 
 1 
 1 
 146 
 
 A glance shows that the great majority of the patients were Russians. 
 There are one hundred and thirty-six foreign born and but nine natives, 
 disregarding the one case in which the nativity was not noted. This great 
 preponderance of foreign over native women exists not only in cases of pel- 
 ^ac deformit}", but also in the general statistics, and very nearly in tlie same 
 proportion. 
 
 Thus, in a total of 10,233 cases, the nativity in 163 cases was not noted, 
 910 were native, and 9,180 were foreign born. 
 
 GENERAL STATISTICS. 
 
 ]S"ative, 910 ; foreign, 9,180. 
 projDortion of 1 to 10.08. 
 
 A 
 
 DEFORMED PELVES. 
 
 Native, 9 ; foreign, 136. 
 portion of 1 to 15.11. 
 
 A pro- 
 
 About one-third less in the deformed pelvis cases than in the general 
 statistics. The majority of all the foreign-born patients were also Rus- 
 sians, 6,885 in a total of 9,180. 
 
 It is still worthv of note that only nine cases of marked pelvic deformity 
 were observed among nine hundred and ten Avomen of American birth. 
 
 As regards the age of the patients, the majority were between twenty 
 and twenty-five. 
 
 Age of Patients. 
 
 Cases. 
 
 Under 20 7 
 
 Between 20 and 25 67 
 
 " 25 " 30 U 
 
 " 30 '' 35 20 
 
 The para is recorded as follows: 
 
 Paka 
 Cases. 
 38 
 
 Cases. 
 
 Between 35 and 40 
 Xot noted 
 
 Total 146 
 
 I 
 
 II 
 
 III 
 
 lY 
 
 Y 
 
 YI 
 
 24 
 
 22 
 24 
 17 
 10 
 
 YII . . . . , 
 
 YIII 
 
 IX 
 
 X 
 
 Xot noted 
 
 Cases. 
 
 5 
 2 
 2 
 1 
 1 
 
 Total 146 
 
 Even a marked pelvic deformity does not seem to act as a bar to bring- 
 ing up quite a large famil}^ of children. One hundred and eight of the 
 women were multipar£e. 
 
264 
 
 REPORT OF THE SOCIETY OF THE LYING-IN HOSPITAL. 
 
 Month of Gestation 
 Cases. 
 
 7^ months in 
 8 
 
 Cases. 
 
 9 to 10 months in 143 
 
 Xot noted 1 
 
 It is interesting to note that the pelvic deformity had api)arently no 
 effect whatever, as far as the pregnancy was concerned. Nearly all were 
 deliveretl at full tei'm. 
 
 A'akiety of Defokmity. 
 
 Cases. 
 
 Simple flattened pelvis 79 
 
 Justo-minor ])elvis 39 
 
 Flat, generally contracted, pelvis 19 
 
 Naegele's oblique pelvis 3 
 
 Contracted outlet 2 
 
 JSpondylolisthetic 1 
 
 Cases. 
 
 Scolio-rachitic 1 
 
 Male type (transversely con- 
 tracted outlet ) 1 
 
 Karrow pubic arch 1 
 
 Total 140 
 
 The simple flattened type predominated, occurring in more than one- 
 half of the cases. It is unfortunate that the histories are not sufficiently 
 clear to enable me to separate the rachitic and non-rachitic varieties with 
 any degree of accuracy. 
 
 The degree of deformity is perhaps of more importance than the type, 
 and a table has been made as follows : 
 
 Conjugata Yeea. 
 
 Inches. 
 
 ^ 
 
 3^ 
 
 3i to 3f 
 
 H 
 
 H 
 
 3 to 3]^ 2 
 
 Cases. 
 
 . 79 
 . 24 
 
 20 
 9 
 
 Inches. 
 3t . . . . 
 3f . . . . 
 
 Cases. 
 1 
 1 
 3 
 
 Not noted 12 
 
 Total 14(3 
 
 I have ])ut down the conjugata vera exactly as it was recorded in the 
 history, in each case. In scjme instances no conjugata vera was I'ecorded 
 when the diagonal measured 4-^ inches, and in such cases I have estimated 
 tin; vera as 3|, irres])ective of the height of the syui])liysis or tlie inclina- 
 tion of the pelvis. For this reason. 3^ make up about half of the cases. 
 
 Of the twelve cases in which no conjugata vera is recorded, two were 
 cases of Nacgeh; oblicpie jKilvis ; one was a case of conti'acted outlet (3^ 
 inciies l*etween the ischial spines); two were cases of " rigid coccyx: " one 
 was a case of " narrow ]nd)ic arch ; " one was a consultation case in wliich 
 no measurements were taken; and seven were cases in uliicli, Avhile deform- 
 ity was present, as sliown by the nieeli;inisni of the labor, no conjugate Avas 
 re<;or(le<l. In these last cases, the fault was in recoriling tin? history; so 
 that, although impossible to classify, llxy must be inehaled as " defoi-med." 
 
DEFORMED PELVES. 
 
 265 
 
 In the one hundred and forty-six cases in the table, the following- 
 operations were performed : 
 
 Forceps 24 
 
 Attempted forceps (followed by version) 6 
 
 Podalic version (G cases after forceps) 33 
 
 Cephalic version , 1 
 
 S3nn])hysiotomy 6 
 
 Extraction of breech (1 case twins) 6 
 
 Accouchement force 
 
 Csesarean section 
 
 Manual extraction of head 
 
 Induced labor 
 
 Conversion brow to vertex 
 
 Craniotomy on after-coming head 
 
 Total 86 
 
 These eighty-six operations were done on sixty-seven cases. In the 
 remaining seventy-nine delivery was spontaneous. In none of the sponta- 
 neous cases was the conjugate less than 3^ inches, although the conjugate 
 was so recorded in seven instances. 
 
 Complications. 
 
 Cases. 
 
 Fracture, child's skull (forceps) 1 
 
 " Depression," child's skull (version) 3 
 
 Fracture humerus 3 
 
 Prolapsed cord 7 
 
 Albuminuria 5 
 
 Lacerated perineum (requiring suture) 8 
 
 " cervix " " 4 
 
 Extension after-coming head 1 
 
 Uraemia 1 
 
 An analysis of position and presentation shows the following: 
 
 Position. Cases. 
 
 L. O. A 89 
 
 E. O. A 26 
 
 L. O. P 7 
 
 E. O. P 8 
 
 L. Sac. A 3 
 
 E'. " P 2 
 
 E. '' A 1 
 
 L. Scap. A 1 
 
 E. " A 1 
 
 L. M. P 1 
 
 l^ot noted 7 
 
 Total 146 
 
 Presentation. Cases. 
 Vertex 130 
 
 Shoulder . 
 Brow .... 
 Left ear . . 
 
 Face 
 
 Breech . . . 
 Not noted 
 
 Total 146 
 
266 REPOKT OF THE SOCIETY OF THE LYING-IX HOSPITAL. 
 
 The general result as regards mortality in the one hundred and forty- 
 six cases is as follows: 
 
 Maternal deaths 3 
 
 Children still-born 19 
 
 who subsequently died 7 
 
 Of the three maternal deaths, one was in a case of albuminuria, death 
 occurring the first day i)()sti)ariuni, with fever. The second death occurred 
 three weeks j)osti)artum. from sepsis, and the third fatal result was due to 
 uraMuia also, al)()Ut three weeks after the delivery. This case was a for- 
 ceps delivery indicated by a sharjtly curved and rigid coccyx, and is included 
 among the twelve cases of irregularly deformed pelves. 
 
 The results in the various degrees of contraction are of such impor- 
 tance, that I repeat the table of measurements, dividing the cases into four 
 classes : 
 
 Cases. 
 
 Pelves measuring 3f inches or more 79 
 
 3^ " and less than 3| 27 
 
 " '• 31 " '' 3i 23 
 
 3 '' '' SI 5 
 
 Total 134 
 
 These, with the twelve cases of irregular contraction, make a total of 
 
 Taking up the first seventy-nine cases, in which the conjugata vera 
 measured 3;| inches or more: 
 
 Cases. 
 Delivery was spontaneous in 53 
 
 by forceps in 16 
 
 " by a manual extraction of a breech presentation 
 
 in 4 
 
 " was ])remature in 1 
 
 '* by version for a shoulder presentation in 1 
 
 " " after symphysiotom}^ in 1 
 
 " " for prolapse of the cord in 3 
 
 Total 79 
 
 Rt^^sultf*. — Among these cases there was one maternal death, a forceps 
 delivery in a case of all)uniinuria and fever, death occurring on the first 
 day prjstpartum. 
 
 There were also ten fo-tal deaths, as follows: 
 
 Cases. 
 In a sponUineous delivery (no cause assigned) 1 
 
 After a forcej)s delivery 5 
 
 " version delivery and |»rola|»s('tl cord 2 
 
 ** premature delivery 1 
 
 ** pn)long('d labor aud cxf rcuic moulding of tlic head 1 
 
 ToImI K) 
 
DEFORMED PELVES. 267 
 
 CoNJUGATA Vera Measuring 3^ Inches and Less than 3f. 
 
 The twenty-seven cases in this class terminated as follows: 
 
 Cases. 
 
 Delivery was spontaneous 11 
 
 " "by version 13 
 
 " " " forceps 2 
 
 " " "a manual extraction of breech 1 
 
 Total 27 
 
 The forceps cases were uncomplicated. 
 
 In eleven of the cases delivered by version, the operation was com- 
 plicated as follows : 
 
 Cases. 
 By previous attempts to deliver with forceps, one of these 
 
 also having a prolapsed cord 4: 
 
 By a symphysiotomy 1 
 
 By a prolapsed cord 2 
 
 By an ear presentation 1 
 
 By so-called ' ' accouchement force " 2 
 
 By extension of the head at the brim 1 
 
 Total 11 
 
 It is interesting to note that in one of these version cases a living child 
 was extracted through a pelvis which had required the operation of sjan- 
 physiotomy at a previous confinement. 
 
 JResuUs. — In this grou]) there likewise occurred a maternal death, the 
 woman dying of sepsis three weeks postpartum. The conjugate measured 
 3-| inches, and version was performed after a manual dilatation of the 
 cervix. 
 
 There were seven still births, and one subsequent death of the child. 
 
 1 still birth was after a forceps delivery. 
 
 2 after version operations that were uncomplicated. 
 
 1 after a version, attempted forceps, and prolapsed cord. 
 1 " " and prolapsed cord. 
 
 1 " " in which the mother also died. 
 
 1 " " in which the extended head was arrested at the 
 
 brim. 
 
 The subsequent death of the child followed a delivery by version after 
 forceps had failed. 
 
 Of these cases, which were not what might be called very highly con- 
 tracted, eleven were spontaneous deliveries. In the sixteen operative de- 
 liveries, delivery by forceps was attempted six times and was successful in 
 but tAvo instances; and in the fourteen remaining cases, the child was 
 extracted bv the feet. 
 
268 REPORT OF THE SOCIETY OF THE LYTNO-IX HOSPITAL. 
 
 This seems to prove tlmt a head can be tlragged through a contracted 
 brim more successfully when it is made to engage by tlie smaller " wedge- 
 sha])eil " base than by the more rounded vault. AVhether the ultimate 
 result for the child is as favorable, taking into account the probable delay 
 in the extraction of an arter-coming head, is (juostionable. 
 
 CoNJCGATA Vera Measuring H Inches and Less than 3^. 
 
 There were twenty -three cases iii this class. 
 
 Cases. 
 
 Delivery was spontaneous 1<> 
 
 '' " by forceps 1 
 
 " *' '' following a cephalic version ... . 1 
 
 '< *• "a manual extraction of the breech after 
 
 an induced lalxu- 1 
 
 " " " version 10 
 
 Total 23 
 
 It will l)e seen that in this series nearly one-half were s])ontaneously 
 delivered, although the contraction was marked. In the remainder, deliv- 
 ery bv forceps was attempted in tliree and was successful in but two 
 instances. In eleven cases the child was extracted by the feet. Of the 
 ten cases in which podalic version Avas done, symphysiotomy was neces- 
 sarv in two instances, and the choice of version, rather than of forceps, 
 indicated in two others by ])rolapse of the coi'd. AVhat has been said of 
 the advantages of version over force]is in slightly larger ])elves, seems to 
 be more markedly demonstrated in tliis series, in which the contraction is 
 more ))ronounce(l. 
 
 Jii.'»nlt.s. — There wei'c no maternal deaths and live still birtlis — one in the 
 
 forceps case, another in the induced labor case in wliicli the l)i'eech i)]'c- 
 
 sented, and three folhjwed delivery by version. Of the later three, one 
 
 was macerated, and two had a depression of the skull. One of these had 
 
 been sul>jected to an ineffectual effort to deliver by high forceps, and the 
 
 fracture in the otlicr case was due to efforts to extract the after-coming 
 
 head. 
 
 Co.NjrGAT.v Vera Measuring 3 Inches and Less than 3^. 
 
 There were l)iit live sucli cases, and the delivery was by — 
 
 Case. 
 
 Forceps 1 
 
 Sym])hysiotoniy aii<l vci-sioii 1 
 
 Version 1 
 
 Cicsarean socli(»n 1 
 
 A^'ersion fulloucd l»\- a craniotoinN' on t ln' al'tci'-coniing Ik 'ad 1 
 
 litnultM. — No inat<!rnal deaths. 
 
 Two fo'tal deaths in the vei'sion cases, in one of which there Avas a 
 depression of the elilNrs skull, resulting Ironi the ell'oi'ts to extract through 
 a conjugate of but three inches. In the second, extraction was performed 
 with great ditiiculty aftei- pnfoi-atin^'- and ciiishin;:' tlu! aftei'-coining head. 
 
DEFORMED PELVES. 269 
 
 All of tlio fatal cases, both foetal and maternal, occurred in these cases 
 which have been described in detail, with the exception of the delivery of 
 one still-born child by forceps, in consultation in a case in Avhich no meas- 
 urements were obtained. 
 
 An analysis of these cases brings up several points of interest which 
 might be discussed at length. 
 
 First. — The question of frequency, both in regard to cases of moderate 
 deformit}^ and cases in Avhich deformity is well marked. 
 
 Second. — The influence of the deformity on labor in the various degrees 
 of contraction. 
 
 Third. — The best means of extraction in the various degrees, and the 
 results. 
 
 Under the tirst heading, regarding the frequency, but little remains to 
 be added to a plain statement of figures. Deformity of all degrees may 
 be met with in practice, in about 12^ per cent, of all cases, according to 
 the standard of measurements used in foreign statistics. This result was 
 obtained, not in the whole number of cases observed, but in four thousand 
 consecutive cases. Deformity serious enough to materially influence labor 
 and demand active operative interference may be met with in about 1^ 
 per cent, of all cases. 
 
 In comparison with foreign statistics, deformity marked enough to 
 form a serious obstacle to delivery occurs in about one-third as many 
 instances, and slight deformity with about the same frequency. 
 
 Statistics from the Boston Lying-in Hospital give a frequency of two 
 j)er cent, in native women and six per cent, in foreign women (Reynolds). 
 
 Under the second heading, the influence of the various degrees of con- 
 traction on labor, it may be said that a large proportion are delivered 
 spontaneously, even when the obstruction is apparently formidable. In 
 cases that demand interference, the choice of operation depends more on 
 the size of the child's head, the character of the labor pains, and malpres- 
 entations or positions, than on the degree of contraction itself. This is 
 illustrated by abundant facts in the tables. As examples may be mentioned 
 the case requiring symphysiotomy, with a conjugate of 3f inches, and the 
 spontaneous deliveries in cases of 3^ inches. When the contraction is 
 marked, and delivery is not spontaneous, the operations that are required 
 are, as a rule, the more difficult major operations. 
 
 Third. — The best means of extraction in the various degrees. 
 
 It is difficult to make rules to govern the treatment, except when the 
 deformity is very marked — under 3^ inches. With a conjugate of about that 
 diameter, spontaneous delivery is possible in a larger proportion of cases 
 than is ordinarily supposed. 
 
 When the disproportion between the size of the head and the size of 
 the canal is not marked enough to prevent extraction by the natural pas- 
 sages, the choice lies between forceps and version. 
 
 Delivery by forceps has been successful mainly in the cases where a 
 waiting plan has been adopted, the head has moulded and delivery by 
 forceps has failed when attempted earlier. 
 
270 
 
 REPORT OF THE SOCIETY OF THE LYIX(;-1X HOSPITAL. 
 
 The results for the mother in either operation should be the same, if it 
 is done or attem})ted bv one wlio is familiar \\ith its dangers and is ordi- 
 narily skilful. 
 
 In the whole series of one hundred and forty-six cases, forceps were 
 applie<l twenty-four times, and ])odalic version was pei'formed thirty-three 
 times. 
 
 The tiiirty -three version operations include six cases in which forceps 
 had been attempted and had failed. The results of these operations can be 
 seen by comparing forceps with version in parallel columns. 
 
 Forceps. 
 
 Version. 
 
 clConJ. 
 SS Vera. 
 
 Mother. 
 
 ChUd. 
 
 Remarks. 
 
 1 
 
 Conj. 
 Vera. 
 
 Mother. 
 
 Child. 
 
 Remarks. 
 
 1 ? 
 
 Recov'd. 
 
 Rec'ov'd. 
 
 Fractured child's skull. 
 
 3i 
 
 Kecov'd . 
 
 Recov'd. 
 
 Prolapsed cord ; lacer- 
 
 2i 3» 
 
 
 " 
 
 Ceuhiilic vei-siou lor 
 snoulder pres. 
 
 
 
 
 
 ated ]>erineum. 
 
 
 
 
 
 2 
 
 3} 
 
 " 
 
 " 
 
 After syiiH)liysi(itomy. 
 
 3 
 
 3-3i 
 
 " 
 
 " 
 
 Liicei-ated i>erineura. 
 
 3 
 
 3i 
 
 " 
 
 " 
 
 After s'ymphy.siotuiuy ; 
 
 4 
 
 :H 
 
 " 
 
 " 
 
 
 
 
 
 
 perinoorrliapliy. 
 
 3 
 
 
 " 
 
 " 
 
 Allnimiiuiria 
 
 4 
 
 3 
 
 " 
 
 " 
 
 After synipliysiotumy ; 
 
 6 
 
 3» 
 
 Did .... 
 
 " 
 
 .Vlbuniiiiuria and fever. 
 
 
 
 
 
 fractured humerus. 
 
 7 
 
 3J 
 
 Recov'd. 
 
 '• 
 
 
 o 
 
 3i 
 
 " 
 
 Died . . . 
 
 After forceps. 
 
 8 
 
 3f 
 
 " 
 
 " 
 
 Trachelorrhaphy. 
 
 G 
 
 3M 
 
 " 
 
 Kecov'd . 
 
 Prolapsed cord. 
 
 S* 
 
 3t 
 
 •' 
 
 " 
 
 
 7 
 
 3} 
 
 
 " 
 
 
 111 
 
 ? 
 
 " 
 
 Still 
 
 Consultation case. 
 
 8 
 
 3J 
 
 " 
 
 " 
 
 After symi)hysiotomy. 
 
 n 
 
 ■n 
 
 " 
 
 Died .... 
 
 Occiput posterior. 
 
 9 
 
 3* 
 
 " 
 
 " 
 
 *' " 
 
 lu' 
 
 ■H 
 
 
 Kecov'd . 
 
 
 10 
 
 3i 
 
 " 
 
 " 
 
 2 yeare after symphysi- 
 
 i:j 
 
 ■H 
 
 
 Still.. .. 
 
 " 
 
 
 
 
 
 otomy. 
 
 14 
 
 3| 
 
 
 Died .... 
 
 
 11 
 
 3} 
 
 " 
 
 " 
 
 ShoiiMcr prcscMtatidii. 
 
 15 
 
 31 
 
 
 Kecov'd. 
 
 12 
 
 3i 
 
 " 
 
 " 
 
 Face prcscntaiidii. 
 
 16 
 
 3» 
 
 " 
 
 .« k> kk 
 
 13 
 
 ? 
 
 " 
 
 " 
 
 Contracted oiillet; sym- 
 
 i: 
 
 3» 
 
 
 Still 1 
 
 
 
 
 
 physiotomy; brow; pe- 
 
 18 
 
 31 
 
 " 
 
 Kecov'd . 
 
 
 
 
 
 
 rineorrh.; attempted 
 
 1« 
 
 31 
 
 
 " 
 
 
 
 
 
 
 forceps. 
 
 a> 
 
 31 
 
 
 " 
 
 
 
 
 
 
 
 21 
 
 3» 
 
 
 
 Manual dilatation of 
 cervi.\. 
 
 14 
 115 
 
 3i 
 3i 
 
 " 
 
 4k 
 
 Perineorrhaphy. 
 Trachelorr.; perin. 
 
 22 .Tf 
 
 
 Still 
 
 Occiput posterior; man- 
 ual dilatation. 
 
 ir 
 
 3 
 
 ;: 
 
 Died .... 
 
 Depression child's skull. 
 
 B 3» 
 
 ** 
 
 " 
 
 Occiput posterior. 
 
 IS 
 
 3} 
 
 " 
 
 Recov'd . 
 
 Attempted forceps. 
 
 24 
 
 31 
 
 " 
 
 Recov'd . 
 
 
 19 
 
 ■ii 
 
 " 
 
 " 
 
 *' " 
 
 
 
 
 
 
 20 
 
 4 
 
 Died .... 
 
 Still 
 
 Fever. 
 
 
 
 
 
 
 21 
 
 3} 
 
 Recov'd . 
 
 
 
 Prolajisod oonl ; at- 
 tem|it('(l forceps. 
 
 
 
 
 
 
 22 
 
 3i 
 
 
 
 AtteniptiMl forecps ; de- 
 pi'cssion cliild's skull. 
 
 
 
 
 
 
 23 
 
 31 
 
 ** 
 
 " .... 
 
 Prolaiiseil cord. 
 
 
 
 
 
 
 24 
 
 3 
 
 
 
 Ci-aniotomy, after-com- 
 ing' lieiiii. 
 
 
 
 
 
 
 25 
 
 3* 
 
 " 
 
 ** 
 
 Depression child's.skidl. 
 Child maeerated. 
 
 
 
 
 
 
 2H 
 
 •a 
 
 *' 
 
 " 
 
 
 
 
 
 
 27 
 
 31 
 
 " 
 
 Liviiiff . . 
 
 Prolapsed cord. 
 
 
 
 
 
 
 28 
 
 3i 
 
 " 
 
 Still ..... 
 
 E.vtended after-coming 
 head. 
 
 
 
 
 
 
 29 
 
 31 
 
 " 
 
 
 
 Prolapsed cord ; frac- 
 turol humerus. 
 
 
 
 
 
 
 30 
 
 3* 
 
 " 
 
 " 
 
 Prolapsed cord 
 
 
 
 
 
 
 31 
 
 3^ 
 
 " 
 
 " 
 
 
 
 
 
 
 
 32 
 
 3» 
 
 " 
 
 •' 
 
 
 
 
 
 
 
 33 
 
 
 Died .... 
 
 Living- .. 
 
 Urteniia; rifid coccy.x. 
 
 The results shown by the preeciding tabic are as follows: 
 
 TliHM; deatlis of mothers. 
 
 Twenty-one deaths of children. 
 
 The cau.ses of tlic^ maternal <leat]is need not be re])eated, as tliey have 
 alre^idy Imm-u descrihed in detail; and, with the ('xi'e])tion of one, they 
 could not have been caused by the operation. 
 
 Of the twfnty-one deaths of cliildrcii, seven were after forceps and 
 fourti^en after version operations. 
 
 It JH necessary to go into details in order t<. explain sncli an apparent 
 sujieriority in the results al'tei- forceps. The iiHiviised iimidiei' of deaths 
 
DEFORMED PELVES. 271 
 
 iri the version column may be partially explained by the fact that there 
 were nearly one-third more version operations. Again, six of the versions 
 were undertaken after forceps had been tried and had failed, and three of 
 the deaths were of these six. In one of these, death was distinctly due to 
 forceps, it having been found that the cord had prolapsed and was pinched 
 between the head and forceps blade. 
 
 It is significant, also, that deformity was more marked in the version 
 cases than in the forceps cases. In the former, twenty-six had a conjugate 
 below 3^ inches, Avhile only five such cases occurred in the forceps deliv- 
 eries. In other words, nearly all the forceps deliveries were in moderately 
 deformed pelves as compared with the cases of version deliveries. 
 
 If the column of ' ' Remarks ' ' be examined for a probable explanation 
 of a still birth, in each instance it will be found that there were no com- 
 plications in the forceps cases other than occiput posterior positions, which 
 were present in five of the seven. Of the still births after version, death 
 Avas due to causes other than the version, as follows : 
 
 1. Depression of child's skull in three cases, with a conjugate of 3 
 inches in one case, and 3^ in another (complicated with forceps), and 3^ in 
 a third. 
 
 2. Prolapse of cord in three cases. 
 
 3. Arrest of the head necessitating a craniotomy in a case in which the 
 pelvis measured but three inches. 
 
 4. A macerated child in still another case. 
 
 Taking into account the accidental complications, and the more pro- 
 nounced pelvic deformity, the results as regards the child are more favor- 
 able after version than after forceps. 
 
 Given a case of deformed pelvis in which the disproportion is not suffi- 
 ciently great to preclude the possibility of extracting a living child, in the 
 majority of instances version is the better operation from all points of view. 
 
 I do not think that it would be occupying an extreme position to say 
 that forceps should never be applied to the head when it is movable above 
 the brim, in cases of pelvic deformit}^. There is only one condition that 
 might be an exception to this rule. When the patient is seen after the 
 mehibranes have ruptured, the amniotic fluid drained away, and the uterus 
 is tightly contracted about the child, cautious attempts may be made to 
 engage the head with forceps. Failing in this, delivery can only be 
 accomplished by a difficult version or a more radical operation. Such a 
 condition can only occur Avhen the disj^roportion is great. 
 
 Such varied conditions may be present in any given case, that no rule 
 can be made that is absolute. For the general practitioner, version is 
 safer, is easier, and gives better results in cases of pelvic deformity than 
 forceps. For the practitioner skilled in midwifery, the same rule will hold 
 good in the majority of cases. Face to face with other complications, he 
 should be capable of making rules for his own guidance. 
 
 Special training and experience will often enable an operator to over- 
 come difficulties insurmountable to another, whether the operation be for- 
 ceps or version. 
 
CiESAREAX SECTION IN A EACIIITIC DWAKF. 
 By James W. Markoe, M.D. 
 
 Previous History. 
 
 C. X. o.oOC).— The patient, a primipara, thirty-four years of age, Avas 
 born in Pohind, and came to this country but three months ago. She states 
 tliat when nine months old she first began to walk, and was perfectly well 
 and strong until reaching the age of two years, when she was badly 
 scalded upon the left arm and side. From the description of what fol- 
 lowed, rickets evidently developed, she being unable to walk again until 
 her seventh year. Since that time, she has always been well, except for 
 deformitv. ^Menstruation began at fourteen, and has always been normal 
 
 in character and duration. 
 
 Examination. 
 
 Dr. T. Ilalsted Myers examined the patient and reported as follows: 
 ''A rachitic dwarf, fifty inches in height, with marked rotary lateral 
 curvature of tlie dorso-lumbar spine. The vertebrge from the ninth dorsal 
 to the fifth lumbar were markedly deformed. The lateral deviation 
 amounted to one inch, and this brought the ribs on the right side against 
 the iliac crest, while on the left they were two inches above it. The pos- 
 terior rotation of the lower ribs as the patient stooped forward was two 
 and a half inches. The lumbar spine showed less than the normal lordosis, 
 The sacrum seemed very flat, and its anterior concavity less than normal. 
 The inclination of the ])elvis to the horizontal plane was 50^ degrees. 
 
 Measurements of l:*EL^'ls. 
 
 Inches. Cent. 
 
 Anterior superior s])ines 9^ 24 
 
 Crests 10 26 
 
 External ()l)liques (both) 8 20| 
 
 con ju^'-atc of l-J-J 
 
 Diagonal c<jnjiigato 4 10 
 
 True conjugate 8 7^ 
 
 Height of symphysis 2 5 
 
 " The racliitis had jjrrulnccd a ps('U(lo-))aralysis lor a longtime, therefore 
 the lower limbs were but little deCormed. IJotli Icuioi-a, showed some ante- 
 rior curvature, and there was slight knock knee and Hat foot on the left 
 side. The up|x;r extremities were well fonned. buldwarfed." 
 
Case of CissAREAN Section. 
 C. N. 5,506. 
 
Case of Cesarean Section. 
 C. N. 5,506. 
 
CESAREAN SECTION IN A RACHITIC DWARF. 273 
 
 After consultation Avitli the other members of the attending staff, 
 Cjesarean section was decided upon as the only chance for the mother and 
 child. As she was in the ninth month of pregnancy, nothing was to be 
 gained b}^ operating immediately. AVhen labor should commence was 
 chosen as the time for the operation. 
 
 It is but fair to state that every effort was made to induce the patient 
 to go to a hospital, the advantages being explained to her most carefully, 
 but to no avail. 
 
 Operation. 
 
 December 24, 1893, in the front room of third-floor apartment of a 
 tenement at 84 J^orfolk Street, Sanger's operation was performed. 
 
 jSTo attempt was made to clean the room, but as perfect asepsis as possible 
 was observed with everj^'thing that came directly in contact with the patient. 
 
 Ether was started at 11.25 a.m. ; uterus lifted out of abdominal cavity, 
 11.51: ; child and placenta delivered, 11.56. Last suture in uterus, 12.16 
 P.M. ; last abdominal suture, 12.56. Operation lasted 1 hour and 11 minutes. 
 Silk was used for all sutures; sterilized water for washing and irrigation 
 purposes. Dressed with strip of iodoform gauze, then sterilized gauze held 
 in place by firm binder. 
 
 Patient rallied quickly from ether, but on following day developed severe 
 cough with profuse purulent expectoration. On the night of the fifth day, 
 her temperature reached 101.2 degrees; pulse, 121; respiration, 28. Bowels 
 were moved by enemas, and the cough controlled by small doses of code- 
 ine and muriate of ammonia. On the sixth day, as temperature remained 
 up, it was thought advisable to dress the wound, and, upon doing so, a small 
 drop of pus was pressed from second lower stitch. This was, therefore, 
 removed and well washed. Temperature, one hour later, 101 degrees, 
 largely due to the very nervous condition of the patient. 
 
 On the seventh day the lochia was scant, and composed of mucus and 
 pus. All the abdominal sutures were removed, and an intrauterine 
 douche given of weak bichloride solution. Patient being very unruly and 
 complaining of pain in right chest, physical signs showed simply an 
 extensive bronchitis. On the eighth day a small stitch abscess at the site 
 of third stitch was opened with scissors, and irrigated with peroxide of 
 hydrogen. Patient's general condition satisfactory, appetite very good, and 
 sleep much improved. Cough is troublesome, and expectoration purulent 
 and profuse. From this time on, patient steadily improved. Douches were 
 given every day, and her general condition built up with cod-liver oil and iron. 
 
 At the end of four weeks, patient walked to the Dispensary perfectly well. 
 
 The child was bottle-fed from the beginning, but was a remarkably 
 healthy baby until the summer of 1895, when it died of some diarrhoeal 
 disorder, the mother failing to notify the Hospital , until after its death, 
 some local physician having been called in. 
 
 An examination of the mother two and one-half years after the opera- 
 tion reveals uterus of normal size, drawn well up in the pelvis by adhesions 
 to the anterior abdominal wall. Menstruation is regular, and her only trouble 
 seems to be the loss of her child and an inability to become pregnant again. 
 18 
 
PREGXAKCY AXD LABOR FOLLOWING ALEXANDER'S 
 
 OPERATION. 
 
 By James W. Markoe, M.D. 
 
 Previous History. 
 
 C. N. 1,705. — An English woman; age 29 years; III. para; married; 
 fii'st menstruation at twelfth year; always regular; after the fourteenth 
 year accompanied with pain; general health was otherwise very good 
 until she married, when there developed a leucorrhoea, to relieve which 
 she entered a hospital and was operated upon; thereafter her symptoms 
 improved. Iler history since marriage shows one miscarriage before the 
 o]ieration, and one after. The dates of these or the duration of preg- 
 nancy were not ascertained. 
 
 History of Present Pregnancy. 
 
 Last menstruation on June 27, 1891; first felt foetal movements in the 
 latter part of September; on October 6, 1891, she applied to this Hospital 
 for care daring her coming confinement. The examination at this time 
 revealed two scars two inches long, directly over the inguinal canal ; uterus 
 (h-awn forward, witli greatest diameter transverse; measurements of pelvis 
 normal; jxitient's general condition good, Imt complained of dragging pains 
 radiating ujjward from scars. General condition amumic and weak. 
 
 Record of Lauok. 
 
 Regular ])ains l)on;an about 11 o'clock i-.m., April 14, 1892, and were 
 very severe from the beginning; face presentation; position L. M. P.; at 
 2 o'clock A.M., A])ril 15th, the membranes ru])ture(l sj^ontaneously; chloral 
 hydrate and moi-phine wei-e given to control the excessive pain, which she 
 referred to tlie course o I' round ligaments. Api-il IC, 1892, at 12 o'clock 
 P.M., forceps were applied above the brim, but with considerable force no 
 advance cf)uld l)e made; tliey were removed, and podalic version per- 
 formed under ether to surgical decree. 
 
 Tlie cliibl, a male, weighing jil)out eiglif .-uul one-half jiounds, was deliv- 
 ered without much <limculty; but althounli its heart beat for some time 
 afterwanis, respiration was never established. Tiic mother made an unin- 
 terruptc*] recovery. 
 
YERSION. 
 By Austin Flint, Jr., M.D. 
 
 Among the 10,233 cases delivered by the Hospital, exactly 20Y were 
 delivered after a version operation. 
 
 This is a frequency of one in 49.43 cases. Among the 207 cases observed, 
 twins occurred 15 times, making a total of 222 children delivered. In some 
 instances cephalic version was done during pregnancy ; in one instance it 
 was performed twice, and the case finally delivered after a podalic ver- 
 sion. Including twin cases and the instances in which version was per- 
 formed more than once, there were 214 operations performed. Of these, 
 14 were cephalic and 200 podalic versions. 
 
 All of the cephalic versions were done by the external method, with one 
 exception, done by the combined method, and nearly all the podalic ver- 
 sions were done by the internal method. These operations were performed 
 in tenement houses, often in desperate cases, and under the worst possible 
 surroundings. Many of them had previously been under the care of mid- 
 wives, or of physicians not connected with the Hospital, and had been sub- 
 jected by them to manipulations and operations which had not been suc- 
 cessful. In each instance, careful antiseptic precautions were observed, but 
 the patients were without the advantages of skilled nursing subsequent to de- 
 livery, which has such an important influence on the ultimate results. This 
 is especially noticeable in the results for the children, many of whom would 
 undoubtedly have survived had they been born in a well-appointed hospital. 
 
 The operations were performed for a great variety of causes, and in 
 cases presenting complications, including almost all of the more common 
 accidents in midwifery. 
 
 I have made a table of all the version cases, which contains so much that 
 cannot be shown to advantage in any other way, that it is published as it is. 
 (See pages 277-278.) 
 
 In the 214 cases tabulated, the presentation and position are recorded 
 
 as follows: 
 
 Presentation. 
 
 Cases. 
 
 Shoulder • 86 
 
 Yertex 102 
 
 Transverse 4 
 
 Face 7 
 
 Breech 4 
 
 Brow 2 
 
 Cases. 
 
 Ear 1 
 
 Arm, foot, and cord 1 
 
 Transverse, feet and cord 1 
 
 Not noted, including twins 14 
 
 Total 222 
 
276 
 
 REPORT OF THE SOCIETY OF THE LYIXGIX HOSPITAL. 
 
 POSITK^N. 
 
 Cases. 
 
 L. O. A 63 
 
 L. Scap. A 25 
 
 R. Soap. A 1^5 
 
 R. O. A IS 
 
 R. Scai>. P 13 
 
 R. O. V 13 
 
 L. Scap. P 11 
 
 L. M. P 4 
 
 Cases. 
 
 L. O. P 2 
 
 L. Sacrum P 2 
 
 L. Sacrum A 1 
 
 R. M. P 1 
 
 L. M. A 1 
 
 R. M. A 1 
 
 Xot noted, including twins 42 
 
 Total 222 
 
 The complications, as can be seen by referring to the large table, are 
 SO numerous, that it is difficult to tabulate them or to separate them from 
 the indications. In many cases, the most serious of the conditions pres- 
 ent is put down as the indication, and the less serious condition under the 
 head of '* Complications."' For example, a placenta pr^evia complicated by 
 a shoulder ])resentation and a prola])se of the cord has occurred several 
 times. To this miglit be added a slight pelvic deformity as a complica- 
 tion, if it were slight, or as the indication, if it were serious. 
 
 A list of indications and complications has been made, but this might 
 be changed by one who considered the complication of more importance 
 than the indication, or vice versa. 
 
 Bef(jre tal>ulating the complications and indications in the cases of 
 podalic version, a brief summary of tlie cases of cephalic versions will 
 render the tabulation of tlie others more sim])le. 
 
 There were fourteen such operations. The indications and results were 
 as follows: 
 
 1. For shoulder presentation, followed hy forcei)s, which were unsuc- 
 cessful, and the case was finally delivered hx podalic version. 
 
 2. For shoulder presentation performed twice during pregnancy, after 
 which the coi-d |)rolapsed, and delivery was accomplished after podalic 
 version. 
 
 3. For transverse presentation, followed by pi-olapso of the cord and 
 podalic version. 
 
 4. In a twin caso, the second child Ix'ing changed from a breech to a 
 vertex. 
 
 5. Also for a breech presentation in a twin case. 
 
 0. Twin case, cephalic versicm atteini)ted, delivery by podalic version. 
 
 7. Ih'eech presentation, changed to vei-tex. 
 
 8. Twins, second eliild transverse, changed to vertex. 
 
 0. Fr)ra slioulder pi-esentation in a Xaegele ])elvis, followed l)y forceps. 
 
 10. For a slioiddei" |)reseiitation in a case of placenta })rievia, followed 
 by iKxlalic version. 
 
 11. For a shoulder presentation, done six weeks antepartum. 
 
 12. For a transverse presentation, changed to a vertex. 
 
 13. Breech presentation changed to vertex. 
 
 With ca.se nundxT two counting as two operations, cephalic version was 
 
XIV.-VERSION (PODALIC AND CEPHALIC). 
 
 R. Scat). P. 
 R. Scap. A. 
 L, Scap. A. 
 
 R. Scap. P, 
 B. Scap. A, 
 
 1,103 > 
 1,175 
 1,M I 
 
 1,253 
 
 1,280 - 
 
 1.331 ti 
 
 1,424- 
 
 1,475 
 
 1,554 
 
 1,573 
 
 Breech 
 
 j Vertex. 1st | 
 I 2d twin. " f 
 
 R. Scap. P. 
 
 R. O. A. 
 R. Scap. P. 
 L, Scap. A. 
 
 L. S. A. 
 
 L. M. P. 
 L. Scap. P, 
 
 SlioulUer . . 
 
 Brow 
 
 \''ei-te.v . . . . 
 
 Shoulder"!! 
 
 foot, ' 
 
 L. Scap. P, 
 L. a*A' 
 
 L. O. A. 
 H. O. P. 
 L. O. A. 
 
 R. Scap. P. 
 
 Ij. O. A. 
 L. Scap. A 
 I,. O. A. 
 
 ii. Scap. A 
 
 Shoulder ; placenta prfEvia ; prolapsed cord . 
 Shoulder presentation 
 
 Shoulder; prolapsed an 
 Shoulder : prolapsed ar 
 
 Forceps failed 
 
 Shoulder presentation . 
 
 Placenta praevia and hjemorrhage , . , 
 
 Prolapsed cord 
 
 Prolapsed cord, second child 
 
 Shoulder presentation 
 
 Prolapsed cord ; contracted pelvis — 
 
 Prolapsed cord, second twin 
 
 Placenta prtevia 
 
 lapsed cord 
 
 Shoulder presentation 
 
 Prolapsed cord; head not engaging. - 
 Shoulder and right hand. 
 
 Prolapsed cord ; pulsation feeble . 
 
 Shoulder and breech 
 
 Shoulder presentation , 
 
 Breech ; displacement of fcetal part 
 
 Second twin, prolonged labor 
 
 No advance 
 
 Shoulder presentation 
 
 Prolapsed cord (forceps) 
 
 Midwife case 
 
 Placeutii pi-ievia 
 
 Perineum torn (forceps tried) 
 
 Jlidwife and outside physician had failed to deliver case 
 
 Cephalic and forceps, contracted pelvis. .'. 
 
 Mother suffered from hiemorrhage and shock from I 
 growths on cervix f 
 
 Right arm and leg extended ; prolapsed cord 
 
 i, immature 
 
 Hydraranion 
 
 Phthisis; twins 
 
 Prolapsed feet and cord 
 
 Contracted pelvis ; forceps failed . 
 "" ' ' to pulsate' " 
 
 Hex head . 
 
 Ruptured I 
 Cephalic vc 
 
 prolapsed hand . 
 prolapsed cord .. 
 
 Second child 
 No record.. 
 Shoulder pr 
 
 Position persistent ; 
 
 Mother in collapse; pr( 
 
 Albuminuria 
 Exhaustion ; t 
 \ Prolonged i 
 
 Prolapsed cord and ruptun 
 
 Shoulder prt _ 
 
 Prolonged labor; brow pr 
 
 ' r''eak pains ; prescntiit 
 
 R. S. P ; and arm prol 
 
 Prolapsed cord 
 
 Shoulder presentation; \<\. 
 
 Shoulder presentation; pia^ 
 
 Contracted pelvis 
 
 Severe pains; no advance.. 
 
 Metliod of Extraction of After-coming Head, 
 
 ) pulsate before 
 
 Both feet seized ; right hand . 
 Left foot seized ; " "■ . 
 
 Right hand _ 
 
 Right hand and left foot seized. 
 Delivered by podalic version . , 
 Right hand and left foot 
 
 Left foot 
 
 Heads pulled off by grasp of ce 
 
 Left foot . . . , 
 
 Right foot 
 
 Both feet ; left hand 
 
 Right foot ; right hand 
 
 ■ity. 
 
 1 twice, after which, podalic . 
 
 Both arms and head extended 
 
 Cephalic version, followed by podalic. . 
 
 Pi-olapsed cord 
 
 Both arms extended 
 
 .p,„jn„ j Fii-st, shoulder; podalic versior 
 iwint, ( Second, breech ; cephalic versic 
 
 Prolapsed cord 
 
 "'wins ; one delivered by manual » 
 breech ; and the other by cephalic \ 
 
 Cephalic \ 
 
 n, followed by podalic 
 
 High forceps and previous Alexander's operatic 
 ' Right arm partially extended; placenta pro 
 
 cord prolapsed during extraction 
 
 Placenta pniivia ; arms extended 
 
 Prolapsed cord : arms extended 
 
 Asphyxia in child 
 
 No record (tedious) 
 
 One leg and arm extended. 
 
 Arms extended 
 
 Legs e.vtended ; arm^'M'Ti 
 
 Induction of labor 
 
 Extended arm 
 
 Extended arms 
 
 Arms extended 
 
 extended . 
 
 s extended.. 
 
 As indicated 
 
 apsed arm ; shock, two hours postpartun 
 
 Occipito-posterior position 
 
 Weak pains (second twin) 
 
 Shouluer presentation 
 
 Contmcted pelvis (symphysiotomy), , 
 
 Prolapsed arm 
 
 Placenta pitevia 
 
 No record 
 
 Shoulder presentation 
 
 Shoulder presentatinu 
 Hremorrhage (seve 
 
 Placenta pn_ 
 
 Deformed pelvis; prolapsed cord, . . 
 
 Prolapsed cord; pulsations weak. , . 
 
 Placenta pi"a?via and hemorrhage 
 
 Right ar 
 Right an 
 
 ' First child, R. O. A.; second child, face ; attempt to flex caused prolapse of cord. 
 
 Ha2morrliat;i;f^i;vc'ro .. 
 Twins; forceps; albuu. 
 
 Prolapsed arm 
 
 Failure forceps 
 
 I,eft ar 
 Fractn 
 
 ; occipito-posterior pus. 
 
 I ; suspended a 
 ito-posterior position. . 
 
 Living; temperature 101" Liv 
 
 " fever Lstil 
 
 well 'l,iv 
 
 Living ; well 
 
 recovery 
 
 Died 5 houra postparti 
 Living; well 
 
 Right tiand ; left f 
 
 Right hand ; right foot . 
 
 Left hand 
 
 Bight hand 
 
 Left hand 
 
 Forceps to after-coming head 
 
 trnal cephalic version and binder. 
 
 One leg 
 
 E.\ternal cephalic 
 
 ,. followed by forceps. 
 
 s.; rupt. uterus; right hand; both feet 
 
 Right hand ; both feet. . 
 
 Left hand; right foot 
 
 Died 3ti hi*s. postp.; 
 Living; fever 
 
 Died 4 hours postparti 
 
 well... 
 
 . Cord pulsiiting. 
 . Not heard. 
 
 . Still-boniiE 
 . Li\nng.... 
 ,. Still-born , 
 
 . Living 
 
 , Both living . 
 
 . Still-born... 
 , Both living . 
 
 . Heard in Iststage, 
 
 Died a') m 
 . Living... 
 . Still-born 
 
 t Attended for two hours before labor by midwife. 
 
XIV.-TEKSION (PODALIC AND CEPHALIC).-(CoN 
 
 
 L. O. A. 
 [.. Scap. j\ 
 
 III. 
 
 s 
 
 
 
 II 
 
 
 xiri. 
 
 ;« 
 
 IX. 
 
 It, 
 
 V, 
 
 "« 
 
 1. 
 
 III 
 
 III. 
 
 
 11. 
 
 28 
 
 
 
 TI, 
 
 :«l 
 
 IX. 
 
 h 
 
 IV. 
 
 M 
 
 VIII. 
 
 a 
 
 IX. 
 
 ir 
 
 IX. 
 
 
 III. 
 
 21 
 
 III. 
 
 -'■1 
 
 Shoulder presentatioo ; prolapsed cord J 
 
 Placepta pnevia 
 
 Prolapsed cord 
 
 Contracted pelvis; failure forceps 
 
 Shoulder presentation 
 
 " " prolapsed core 
 Contracted pelvis ; symphysiotomy. , 
 Slioulder presentation 
 
 lapsed liand 
 
 ilapsed cord 
 
 Shoulder presentation . 
 
 Shoulder presentation . 
 
 Shoulder presentation 
 
 Prolapsed cord 
 
 Deformed pelvis ; weak fcEtal heart . , 
 
 Hydrocephalus 
 
 Deformed pelvis 
 
 Prolapsed cord 
 
 Deformed pelvis 
 
 Rclampsia ; prolapsed cord 
 
 -Shoulder presentation 
 
 Deformed peh 
 Prolapsed con 
 Prolapsed u 
 
 ine inertia and eclampsia 
 
 Shoulder presentation , 
 
 Prolapsed arm ; weak UaUii beart 
 
 other; weak foetal hear 
 
 'lii: 
 
 
 'i 
 
 
 
 
 III. 
 1. 
 
 lio 
 XI 
 
 9 
 
 
 
 
 11. 
 
 :;7 
 
 
 VII 
 
 
 
 VI. 
 
 :iK 
 
 i) 
 
 vn. 
 
 '■'■' 
 
 " 
 
 Deformed pelvis; prolapsed eord 
 
 Shoulder presentation 
 
 Face presentation 
 
 Brow presentation; deformed pelvis. 
 
 iiiipendinfj asphyx 
 
 Prolapsed cord 
 
 Shoulder presentation; prolapsed' cord ^! 
 
 ]''ace presentation , 
 
 Fliit pelvis; failure uterine force 
 
 IV. 
 
 1. 
 
 
 8 
 
 X, 
 
 » 
 
 
 II. 
 
 n 
 
 
 X. 
 
 
 
 V. 
 
 I. 
 
 3 
 30 
 
 9 
 il 
 
 Ill 
 
 :'.-. 
 
 
 IV. 
 
 
 
 II. 
 I. 
 
 30 
 
 
 Deformed pelvis 
 
 Placenta pnevia 
 
 Shouldor presentation . . . 
 
 Small pelvis; failure to d 
 
 Feet and cord prolapsed . 
 Shoulder presentation ... 
 
 Deformed pelvis (flat).!.! 
 
 rb^* forceps.. 
 
 Symphysiotomy . 
 Induced labor 
 
 Arras e.xtendcd. 
 
 Method of E; 
 
 of After-coming Head. 
 
 Combined (bipolar) cephalic . 
 
 irrhage; prematurity.. 
 
 x^ALr. «. ..io, iituivii . iinec, 1.1 ttiii.ii; threatened eclampsi; 
 
 Fractured humerus in child 
 
 Postpartum hferaorrhae'e; oceipito-posterior position 
 Prolapsed hand and arm ; developed pneumonia 
 
 Oceipito-posterior position 
 
 Deformed pelvis 
 
 Oceipito-posterior position ; exhaustion in mothei 
 
 Left arm extended ; mother exhausted 
 
 Mother intoxicated 
 
 Oceipi to- poster 
 
 Prolonged labor {! 
 
 Plural births (twins). , 
 
 Deformed pelvis. . 
 
 ; raembranesTiipturedSday 
 
 x; iiEemorrhagi 
 n second) 
 
 Ruptured i 
 
 Symphysiotomy !..........!...!! 
 
 Prolapsed arm ; hBemorrhage ; prematurity 
 
 Symphysiotomy in previous pregnancy, 1893. .'.'.'.'.'... 
 Extended arms ; left arm fractured ... .... 
 
 Deformed pelvis (justo-minor); mother pneumonia , 
 
 Flat pelvis; extended arms 
 
 Symphysiotomy (attempted forceps) 
 
 Extended legs aiii 1 :ii- ■ - 
 
 Armsext.t no pruyress; liiiclurt^d burner 
 
 Prolapse of cord and left hand 
 
 Twins ; prolapsed arm 
 
 Fracture of arm '" 
 
 1 Failure of forceps to cause head to e'u''. 
 
 1 extended ; oceipito-posterior positionr 
 
 Prematurity ; rigii't arm extended '.'..'.'.'.'" 
 Prolapsed cord and hand 
 
 Prolapsed arm; prematurity! 
 Prolapsed cord ; hosmorrhage 
 
 Arms extended ; both clavicles f 
 I'ight iliac fossa, bead i 
 xtended; rishtlege 
 
 Breech i 
 
 Left a 
 
 Left arm displaced belTind back" 
 
 1 labor two days . 
 
 . Still-born 
 . Living . . 
 
 Living: died postparti 
 
 Both feet . 
 Right foot , , 
 Both feet . '. 
 
 . Died postpartum: ho3m.. 
 
 . DicdSodaysp.p.; pneum.. 
 
 External cephalic during pregnancy. . 
 Temperatureof mother 103° 
 
 . Died 7 hours postpartun 
 
 . Died 6th day postpart 
 
 . Forceps failed ; right a 
 
 . Died at Bellevue ♦ 
 
 . Died 6th day postpartun 
 
 Died 2d day postp.; feve 
 
 Died 3 days postpartum. , 
 
 Died 6 houre postparti 
 
 . Died 3d day postpart 
 
 ► Died at Bellevue 23 days postpartum, or 14 days after discharge 
 
VEKSION. 
 
 279 
 
 performed fourteen times ; in seven deliver}^ followed naturally, and in the 
 other seven delivery was accomplished by means of some other operative 
 procedure. 
 
 What has seemed to be the chief condition present has been recorded 
 as the indication in the following cases in which podalic version was per- 
 formed : 
 
 Indications. 
 
 Cases. 
 
 Shoulder presentation 82 
 
 Placenta praevia 13 
 
 Prolapse of the cord 35 
 
 Deformed pelvis 27 
 
 Transverse presentation 3 
 
 Hydrocephalus 2 
 
 Attempted forceps (failure) 4 
 
 Attempted forceps after cephalic 
 
 version 1 
 
 Attempted forceps in a face pres- 
 entation 1 
 
 Face presentation, inconvertible. 1 
 Vertex, no indication recorded . . 1 
 Face, posterior position of chin . 1 
 
 Collapse, attempted forceps 1 
 
 Albuminuria, threatening symp- 
 toms 2 
 
 Eclampsia 4 
 
 Cases. 
 Exhaustion of patient, arm pro- 
 lapsed 1 
 
 Ruptured uterus 2 
 
 Brow presentation 2 
 
 Weak pains, and spontaneous 
 
 change from vertex to shoulder 1 
 Presentation of arm, foot, and 
 
 cord 1 
 
 Vertex, no advance 4 
 
 Haemorrhage 2 
 
 Prolapsed arm (twins) 1 
 
 Failure induction labor (weak 
 
 pains) 1 
 
 Prola])sed hand and arm 3 
 
 Exhaustion, weak pains 3 
 
 Face presentation, no progress . . 1 
 
 Total 200 
 
 Under the head of " Complications," the following conditions are tabu- 
 lated. It will be noticed that many of the complications are identical 
 with conditions recorded as indications in other cases. 
 
 Complications. 
 
 Cases. 
 
 Prolapse of the cord 30 
 
 Extended arm or arms 29 
 
 Prolapsed arm 30 
 
 Haemorrhage and shock 20 
 
 Twins 15 
 
 Attempted forceps 9 
 
 Occiput posterior position 7 
 
 Immaturity 6 
 
 Leg or legs extended 5 
 
 Previous cephalic version 5 
 
 Symphysiotomy 6 
 
 Fracture humerus 6 
 
 Placenta praevia 12 
 
 Midwife cases 4 
 
 Cases. 
 
 Deformed pelvis 8 
 
 Ruptured uterus 3 
 
 Forceps to after-coming head ... 3 
 
 Pneumonia 3 
 
 Hand displaced behind head .... 2 
 Prolonged labor (more than 3 
 
 days) 2 
 
 Patient alcoholic 2 
 
 Shoulder impacted (dry labor) . . 2 
 
 Leg prolapsed 2 
 
 Hydramnion 2 
 
 Deep laceration of cervix 2 
 
 Extreme rigidity of ring of Bandl 1 
 
 Prolapsed arm and leg 1 
 
280 
 
 REPORT OF THE SOCIETY OF THE LYING-IN HOSPITAL. 
 
 Complications. — (Confiu iiecl. ) 
 
 Cases. 
 
 Phthisis 1 
 
 Face presentation 1 
 
 Head extended 1 
 
 UiUMuia 1 
 
 Craniotomy, after-coming head . 1 
 
 Child's skull fractured 1 
 
 Albuminuria and threatened 
 
 eclamjisia 2 
 
 Cases. 
 
 Induced labor 1 
 
 Rigid cervix (undilatable) 1 
 
 Incision of cervix 1 
 
 Anencephalus 1 
 
 Hydrocephalus 1 
 
 Total L>30 
 
 No complication other than the 
 indication 45 
 
 More than three-quarters of all cases were complicated, 230 complica- 
 tions occurring in 162 deliveries, and but -15 cases that were not complicated. 
 This has, of course, a very important bearing n]wn the mortality rate, 
 not only for the mothers, but for the children. 
 
 There were fourteen maternal deaths, divided as follows: 
 
 Cases. 
 
 From rupture of the uterus 3 
 
 Shock and haemorrhage 7 
 
 Pneumonia 1 
 
 Eclampsia 
 Sepsis .... 
 
 Cases. 
 ... . 1 
 
 <■>, 
 
 Total 14 
 
 Of the 222 children, 149 were born alive, 65 were still-born, and 8 died 
 during the puerperium. 
 
 Cause of Death in Still-Bokn Children Delivered 
 
 Version. 
 
 AFTER PODALIC 
 
 Table No. 
 Cases. 
 
 Prolapsed cord 20 
 
 Shoulder presentation (uncompli- 
 cated) 6 
 
 Shoulder presentation, arm dis- 
 placed ]iosteriorly 2 
 
 Shoulder presentation, extended 
 
 arms 1 
 
 Shoidder ])resentation, hajmorrlL . 1 
 Deformed pelvis 7 
 
 Deformed pelvis and haemorrhage. 1 
 Deformed pelvis and fractured 
 
 skull 1 
 
 Deformed pelvis and craniotomy, 
 
 after-corning head 1 
 
 Deformed pelvis and ruptured 
 
 uterus 1 
 
 Placenta j^rajvia 4 
 
 Cases. 
 Placenta praevia and immaturity 
 
 (one case of twins) 3 
 
 Placenta i)r£evia and extended 
 
 arms 1 
 
 Eclam])sia (one case of twins) .... 4 
 
 Attem})ted high forceps ... 2 
 
 Forceps, after-coming head, and 
 
 extended arms 1 
 
 Ruptui'ed uterus 1 
 
 Haemorrhage 1 
 
 Iliumorrhage and prematurity ... 1 
 
 After cei)lialic version 1 
 
 Hydrocephalus 2 
 
 Anence])lia]us 1 
 
 No cause assigned 2 
 
 Totid 65 
 
VERSION. 281 
 
 In inan}^ of these cases the child Avas dead before operating. No foetal 
 heart could be heard in 85 instances, or in more cases than the total num- 
 ber of still births. The cause of still birth can be assigned to accidents in 
 every instance, excepting two. 
 
 Cause of Death in Children Dying During the Pueepeeium, Delivered 
 
 BY PoDALic Version. 
 
 There were seven, the circumstances of which are as follows : 
 One died six hours postpartum, a premature child, in a case of placenta 
 praevia. 
 
 One died after a few moments, in a placenta prsevia case. 
 " " 25 minutes postpartum, in a placenta prasvia case. 
 " " 3 days " in a case of deformed pelvis. 
 
 " " 5 days " " prolapsed cord. 
 
 " " 2 " " " face presentation. 
 
 " " • 6 " '' no cause assigned. 
 
 Among these cases, also, the fatal results can be ascribed to accidents 
 in delivery, in all but one instance, and w^ere not due to the operation itself. 
 
 Placenta prsevia is a condition important enough to demand special 
 consideration. 
 
 The cases which appear in this table, however, are included in a- special 
 article elsewhere in the report, so that the results need not be repeated. 
 
 Prolapse of the cord is a condition which complicated the delivery 64 
 times. There were undoubtedly other cases in the service of the Hospital, 
 which do not appear among version operations. 
 
 The routine treatment in such cases is reposition where the conditions 
 are favorable. When conditions are unfavorable, by reason of complica- 
 tions, or when attempts to replace the cord fail, version is usually done. 
 
 Although shoulder presentation or placenta prasvia frequently occurred 
 among these 64 cases, 42 children survived, 20 were still-born, and 2 died 
 during the puerperium. 
 
 To tabulate the complications in the 42 cases of living children would 
 involve useless repetition. A table of the complications in the 20 cases of 
 still births has been made, with an idea of explaining the fatal results. 
 
 Still Births in Cases of Prolapsed Cord. 
 
 Cases. 
 
 Complicated by shoulder presentation 5 
 
 ' ' a deformed pelvis 4 
 
 ' ' extended arms 3 
 
 " ruptured uterus 2 
 
 " depression child's skull 1 
 
 " forceps to after-coming head 1 
 
 No complications 4 
 
 Total 20 
 
282 REPORT OF THE SOCIETY OF THE LYIXG-IX HOSPITAL. 
 
 The death which occurred on the lifth day after delivery, in a case of 
 prolapsed cord, could not be traced to any special cause. 
 
 Such a summary of cases in which version was performed develops 
 nothiuo- new in re^iard to the treatment. 
 
 The operation, its causes, and the results for the mother and child are 
 submitted in the form of a statistical report. In the opinion of the writer 
 it proves the fact that it is possible to obtain good results under unfavor- 
 able surroundings, when care is taken to observe antiseptic precautions in 
 operating. Among all the cases, but one maternal death ca.n be ascribed 
 to sepsis. Two others were unavoidable, and had no bearing on the oper- 
 ation whatever; namely, the cases of pneumonia and eclampsia. The 
 remainder were caused by shock, haemorrhage, and ru])tured uterus. 
 
 It is but fair to again tlirect attention to the fact that man}^ of these 
 cases did not come under the care of the Hospital until late. Everv 
 obstetrician can recall the desperate nature of cases sent to hospitals as a 
 last resort, and neglected up to the time that they are admitted. 
 
 The mortality rate from all causes, in cases of version, was G^ per 
 cent. 
 
 I do not wish to be understood as advocating treatment of serious cases 
 in the tenements rather than transferring them to a properly equipped hos- 
 pital. Such a course would needlessly sacrifice many lives. On the other 
 hand, when it is impossible to operate under favorable surroundings, good 
 results may be expected under even the most unfavorable conditions, in a 
 great majority of cases. 
 
 The results, whatever they may be, depend directly upon the ability to 
 carry out antiseptic princi})les and api)ly them to obstetric surgery. 
 
FKACTURES IN THE NEW BORN. 
 By Churchill Carmalt, M.D. 
 
 Among the liistories of 10,233 deliveries in the Lying-in Hospital and 
 Dispensary, delivered by 1,631 men (1,545 students, 86 staff — the staff, 
 however, responsible for all fractures recorded), there are histories of 40 
 infants suffering from 42 fractures. Five craniotomies and embryotomies 
 are included in that number. This is a ratio of one fracture to each 250 
 deliveries and to each six accoucheurs, a frequency much greater than 
 ordinarily noted. 
 
 Of these injuries the writer has personally seen twenty-three, some of 
 them not included in the statistics here presented, but in all the diagnosis 
 rested upon the joint opinion of the attending surgeon, at least two mem- 
 bers of the Hospital staff, and one or more students. Like all statistics, 
 these are only approximately correct; as cases individually they may be 
 useful. The preponderance, mentioned by most writers, of fractured 
 humeri is apparent in the following table: 
 
 Fractures of the skull Living children 5 
 
 " " " . Dead " 2 
 
 Craniotomies and embryotomies . . " " 5 
 
 Fractures of the jaw " child 1 
 
 " " clavicle Living children 2 
 
 " " humerus " " 18 
 
 " " " Dead " 6 
 
 '^ " forearm, scapula, 
 
 ribs, sternum, 
 
 pelvis 
 
 " " femur Living children 1 
 
 Multiple Fractures : 
 
 Fractures of both clavicles Living 1 
 
 Fractures of skull and humerus ... " 1 
 
 The relation of fractures to operative procedures is shown in the fol- 
 lowing table. In cases of abortion no position is recorded, so that these 
 statistics in regard to the fcetus refer only to those that have reached at 
 least seven months' development. As the number of still births in any hos- 
 
284 
 
 REPORT OF THE SOCIETY OF THE LYIN'G-IN HOSPITAL. 
 
 pital statistics diminishes, there Avill ])robably be au increase in the fcBtal 
 ilamas:e or the number of induced hxbors. 
 
 Totals 
 
 Low forceps 
 
 High forceps 
 
 Attem])ted high forceps 
 
 and vei'sion 
 
 Embryotomy and era 
 
 nioclasm 
 
 Podalic version 
 
 Breech presentation . . , 
 Sh( (ulder presentation , 
 
 Phiral births 
 
 Vertex 
 
 
 
 
 
 
 X 
 
 i . 
 
 
 6 
 
 M 
 
 u 
 
 
 «3 
 
 5 
 
 «5 
 
 
 
 
 3 
 
 S 
 
 !i 
 
 
 w 
 
 f-l 
 
 
 • l-< 
 
 o ^ 
 
 o} 
 
 1— 1 
 
 O 
 
 
 f=H 
 
 pq 
 
 
 +2 
 
 =4-1 
 
 l+H 
 
 =fH 
 
 
 w 
 
 
 
 
 
 O bi 
 
 o 
 
 O 
 
 §3 
 
 
 
 B 
 
 O 
 
 M CC 
 
 13 O) 
 
 5^ 
 
 9 
 
 
 Xi 
 
 p 
 
 2 
 
 tsS 
 
 Vs 
 
 nd >-; 
 
 ^ 
 
 :3 
 
 S . 
 
 1 
 
 1— 1 
 
 
 y 
 
 ^ 
 
 o 
 
 15 ^ 
 
 ^1 
 
 o 
 
 
 ^ 
 
 W 
 
 ^ 
 
 Ph 
 
 <1 
 
 P 
 
 P 
 
 [^ 
 
 P^ 
 
 10,233 
 
 359 
 
 110 
 
 218 
 
 417 
 
 215 
 
 ? 
 
 13 
 
 24 
 
 240 
 
 29 
 
 2 
 
 1 
 
 
 
 
 ? 
 
 
 
 1 
 
 141 
 
 16 
 
 
 
 
 
 
 
 
 ? 
 
 4 
 
 
 
 13 
 
 T 
 
 
 
 
 
 
 
 1 
 
 5 
 
 
 
 1 
 
 5 
 
 5 
 
 1 
 
 1 
 
 
 
 
 
 3 
 
 (5) 
 
 
 
 148 
 
 35 
 
 11 
 
 3 
 
 
 
 9 
 
 14 
 
 2 
 
 11 
 
 341 
 
 59 
 
 27 
 
 7 
 
 
 
 31 
 
 ? 
 
 2 
 
 9 
 
 91 
 
 23 
 
 1 
 
 
 
 
 2 
 
 y 
 
 (1) 
 
 (5) 
 
 161 
 
 35 
 
 7 
 
 3 
 
 
 
 35 
 
 2 
 
 (1) 
 
 (1) 
 
 8,495 
 
 211 
 
 5 
 
 
 
 
 126 
 
 ? 
 
 (4) 
 
 (10) 
 
 O 
 
 (1) 
 
 1 
 
 2 
 
 (1) 
 
 
 (2) 
 
 All of these fractures were due to manual interference in delivery 
 under conditions that would have sacrificed the child and perhaps the 
 mother without such interference. Nevertheless, o])erative ignorance on 
 the ])art of the obstetrician has been an etiological factor. Caused by 
 ignorance, I would class those fractures of the skull due to pressure 
 through the alxlominal wall in efforts to express the after-coming liead, a 
 large number of the fractures of the humerus in breech extractions, and 
 multi])le fractures in cases where symphysiotomy or Ctesarean section 
 should have l>een chosen, instead of some more usual obstetric jirocedure 
 violently performed. There were 34 fractures among 506 breech ex- 
 tractions and presentations, against 8 fractures among all other modes of 
 delivery. 
 
 Fractures in the new Ijorn diflfer from other fractures only in their 
 etiology, rapid repair, perhaps tlu; infrequency of com[)lications, and in the 
 application of apparatus to such small bodies. 
 
 Definition (/>/•. Stiinson). 
 
 "A fracture is a solution of contimiitv in the more solid connective 
 tissues, bone and cartihige, such occurring ' s))ontaneously ' in healthy 
 tissues, or 'pathologically' in diseased tissues; not a very technical, but 
 convenient, statement." 
 
FRACTURES IX THE NEW BORN. 285 
 
 Classification {Stimson). 
 
 Incomplete (comnion in infants): 
 
 a. Fissured (leading to periosteal infection), 
 
 h. Green stick (deformity of a long bone with fissure). 
 
 G. Depression (no macroscopic solution of continuity). 
 
 d. Separation of splinter or apophysis. 
 Complete, divided as to: 
 
 a. Direction of line of fracture (usually transverse in infants). 
 
 h. Seat of fracture anatomically (epiphyses, shaft, etc.). 
 
 c. Relation to joints (intraarticular are not common). 
 
 d. Mode of production (direct violence, etc.). 
 
 e. Number of fractures (multiple are common in real intrauterine 
 
 fractures). 
 Compound : 
 
 a. "With ordinary wound of skin. 
 h. Gunshot (all so far reported in new-born, dead). 
 Displacement may be transverse or lateral, angular, rotary, by over- 
 riding, impaction, crushing, or direct longitudinal separation. 
 
 Etiology. 
 
 Etiology will be studied more particularly under the head of fractures 
 of the individual bones. Usually these fractures are the results of manual 
 or instrumental interference, undertaken to change the position of a dis- 
 placed limb or head of a foetus in utero, to supplement the insufficient 
 expulsive power of the uterus, or to hasten delivery in conditions menac- 
 ing the life of the mother or the child. 
 
 Whether in instrumental interference or by uterine force, strain, supe- 
 rior to the resistance of foetal bone, exerted from without, through a 
 comparatively short period of time and with varying leverage, is the cause 
 of all these fractures. 
 
 Fractures by violence of uterine force alone, when a limb is caught 
 between the hard parts of the mother and the body of the child, are very 
 rare ; but three cases are cited by Hamilton, and the mechanism is carefully 
 explained by Reynolds. Fractures of the skull pushed by uterine force 
 alone through anomalous pelves are reported by Rosinski. 
 
 The resistance or elasticity of foetal bone studied under the dissimilar 
 conditions of life, death, time of pressure, point of pressure, differing 
 kinds of force, and long and short leverage, is hard to estimate. It is 
 partially decided for adult bones to be about that of cast-iron. In experi- 
 ments on the dead foetus, now undertaken at this Hospital, these elements 
 shall be studied for a future report. A force of about twenty pounds 
 applied for one minute on the humerus of a still-born male child, with a 
 leverage of one and one-half inches on each side of a fixed point, fractured 
 the humerus transversely. (Experiment of writer, December 2, 1896.) 
 
 Uterine force is estimated at from six to three hundred pounds. In 
 difficult labors, as in nearly all of those deliveries in which fractures occur. 
 
286 REPORT OF THE SOCIETY OF THE LYING-IN HOSPITAL. 
 
 the force exerted by the uterus ou u circle lour auil one-half inches in diam- 
 eter — the dilated os uteri — is at least sixty pounds. If deflected, by the 
 pi-essure of the accoucheur's linger or instrument, against a point on a limb 
 or a flat bone lixed in the uterus or pelvis, such a force is more than sufli- 
 cient to fractui'e that bone. Any nuinipulation of insignificant force itself, 
 permitting point of support as a fulcrum for lever made of foetal bone, 
 mav cause a breaking pressure to be exerted against the arms of such 
 lever. Experiments as to uterine force are vitiated for the most part by 
 the difficulty in estimating the resistance to be overcome. Haughton's 
 ]>urelv theoretical calculations are immensely too large, as shown by Mat- 
 thews Duncan, whose estimate of sixty pounds has not been disproved. 
 Proofs of the truth of these estimates, it is hoped, will be ready for the 
 next Report. 
 
 Predisposing Causes of Fracture. 
 
 We/'(//if of Child. — As shown by this series, the larger children — all but 
 one over Of pounds at birth — are much more liable to fracture than their 
 leaner fellows. 
 
 Se.c of Child. — As a corollary to the above, the weight of males aver- 
 ages somewhat greater than that of their sisters, and on that account 
 males are more liable to fractures. Also, the children of multiparse are 
 larger than those of primipara?, and, therefore, more liable to injury. 
 
 Early os><iJi<:ation of bones, particularly the skull, predisposes to frac- 
 tures. The cause of this condition is unknown, unless chronic periostitis 
 may lead to it. Pare diseases, myositis ossificans multiplex progressiva, 
 might cause fractures. 
 
 Si/philis renders the nutrition of Ijones ])oor, l)ut the children are usu- 
 ally small and their delivery easy. If syphilis causes hydrocephalus, that, 
 of coui-se, might demand craniotomy, and sy]ihilitic osseous dystrophy or 
 osteopsathyrosis may cause a separation of e])iphyses. 
 
 Rachitic (rare in the new born) may ]^redispose to fractures. It is 
 claimed to be the most common cause of real intrauterine fracture. jSIyx- 
 cedema or cachexia struinipriva in the mother (Kocher) renders the child 
 liable to rachitis, and so possibly more liable to fracture. As Avith syphilis, 
 these children are usually pooi'ly nourislied, and their delivery is accom- 
 ])lished with little dilliculty. Intrauterine cretinism, associated as it is with 
 rachitic malnutrition and malformed skulls, would ]u-ol)ably predispose to 
 fracture. Ilaig asserts that even an iiilici-ited tendency to tlie uric acid 
 diathesis would render bones brittle. 
 
 Poxiilon of the fdun in iitero, i)r('ech presentation, transverse ])osi- 
 tions, and any condition requiring podalic version, Avith its consecutive 
 l)reech extraction, seems a special menace to the integrity of the child's 
 lim])s and vertebrte (84 cases among HoO such ])ositions). Pelvic deformi- 
 ties and uterine inertia, in conditiiMis necessitating tin; use of forceps, are 
 more liabhj to fracture the skull, thorax, and i)elvic girdle. 
 
 Thr rlniiiixfry of fitftl hotir aud the ]»atliology of such conditions as 
 early union of sutun; lines, carlv ossili(;it i<»n. iIk- inlluence of tlu^ h3'po- 
 
FRACTUEES IN THE NEW BORN. 287 
 
 physis cerebri, tlie thymus and thyroid glands on bone nutrition, are at 
 present too obscurely understood to indicate anything save possible defects 
 in present pathological teachings. 
 
 Bibliography. 
 
 Uterine force. 
 
 Haughton: Dublin Quart. Jour. Med. Sciences, 1870, xlix., p. 459. 
 
 Duncan : Contributions to the Mechanism of Natural and Morbid Par- 
 turition, 1ST5, p. 108. 
 
 Kehrer: Beitriige zu Yergleich und Experiment. Geburts Kunde, ii., p. 
 119. 
 
 Schatz: Archiv flir Gynak., 1872, s. 64. 
 
 Cocq, Archiv de tocologie et de gynecologie. Paris, 1894, p. 335. 
 
 Strain of Infant Bone. 
 
 Joulin : Traite Complet des Accouchements, p. 447. 
 
 Tillman's Principles of Surgery and Surgical Pathology (translated by 
 Rogers and Tilton). N. Y., 1894, p. 569. 
 
 Pepaie. 
 
 Malgaigne (1840) in his clinical lectures said that " bone for bone and 
 fracture for fracture, repair in children requires only half so much time as 
 it does in adults. ' ' All subsequent writers agree with him, as do the his- 
 tories of cases here recorded. "Breaks of lower limbs take more days in 
 healing than those of upper limbs ; of the latter more than of the skull ; 
 of midshaft more than of epiphysis; of bone with permanent displace- 
 ment or mobility more than of fragments in accurate apposition." (Stim- 
 son, p. 113.) 
 
 The reasons for such active repair are the greater proportionate blood 
 supply to infant bones, the greater thickness of the osteogenetic layer 
 (twice that of adult bone, according to Cohnheim) of the infant's perios- 
 teum and the weaker musculature of the foetus, causing little spasm and 
 small tendency to displacement. 
 
 Bibliography. 
 
 Zeigler: Text-book of Special Pathological Anatomy, ]^ew York 
 (translation from eighth German ed.), 1896, p. 161. 
 
 Signs. 
 Ohjective : 
 
 Deformity— angular, longitudinal. 
 
 Abnormal mobility. 
 
 Crepitus (not easily made out in infants). 
 
 Spasm (not common), muscular twitching. 
 
 Loss of function; pseudo-paralysis. 
 Subjective : 
 
 Tenderness. 
 
 " Night cry " (very common). 
 
288 REPORT OF THE SOCIETY OF THE LYIXG-IX HOSPITAL. 
 
 After repiiir has taken place, the limb may be shruuken, muscles wasted 
 and feeble, skin ilrv, with tendency to congestion and desquamation, stiff- 
 ness in neighboring joints (adhesions?), callus, deformity, paralysis. These, 
 liowever, dis;\]i])ear so ra])idly in infancy that at the end of two or three 
 months even a marked deformity may entirely disappear, as in a fracture 
 of the skull, in a case cited below. 
 
 In diagnosis from malformations, defects, and paralysis, Rontgen pho- 
 tography may prove a great help, although the EOntgen photographs pre- 
 sented on pages 297 and 303 are not very satisfactory. More familiarity 
 with the fluoroscope will probably obviate this defect. 
 
 Treatment. 
 
 Of recent yeai's immobilization in some retentive apparatus has been 
 the almost universal practice in treatment of fractures. It is accom- 
 ])lished with considerable difficulties in children, where points of fixation 
 are few, pressure irritates the skin, and the dressings are continually wet 
 from urine or careless bathing. These appliances are made from plaster 
 of paris (gy])sum), silicate of soda, wrapjiing-paper in la3^ers moistened 
 with glue, heavy cardboard fastened with adhesive plaster, preparations 
 which become pliable on the application of heat or moisture, celluloid in 
 acetone (lately much lauded). The last two are not always within easy 
 reach, and the celluloid is inflammable. 
 
 It appears to be satisfactorily established through the writings of 
 Lucas-Cliampionniere, 1SS9, in France; Landerer, 1891, in Vienna; and 
 Kendal Franks, 1891, in Dublin, that massage as practised in Egypt, 
 Arabia, and India for centuries (Slatin Pasha) "promotes comfort, and at 
 least expedites restoration of function when there is little displacement of 
 fnigments, when the skin is uninjured, and when the bone is not too thickly 
 covered with muscles, as in the neighl)orhood of joints." (Stimson in 
 Sajous's Annual, 1895.) This would indicate that fixation apparatus may 
 be removed daily and the child cleansed Avithout the resulting harm often 
 claime<l. Because many untreated cases ([)roljaljly the majority) recover 
 with perfect function and without deformity, such removal of dressing 
 may ])(i advised under ])roper restrictions. Massage increases the amount 
 of callus, but certainly maintains the nutrition of muscles. 
 
 Complications. 
 
 Permanent deformiiy (common only in frontal depressions apparently). 
 
 Exuhcrant and jM'inful callus (due to malposition of fragments, inter- 
 fK)sition of soft parts, syphilis, scurvy, rachitis (?), when the embryonal 
 bf>ne stage persists) is a common complication, but disappears rapidly with- 
 out treatment. 
 
 pHevflarfhroHw^ very rare in these fractures. (Bruns.) 
 
 Inrhiiotm of nerven hi callus and ])aralysis due to injury <jf nerves are 
 reporte<l by I)r. Weir ^litchell (Injury of Nerves, p. 104). 
 
FRACTURES IN THE NEW BORN. 389 
 
 Sarcoma in callus is reported by Bruns (only case reported). 
 
 Stiffness of joints and limbs and atrophy in segments above and below 
 the fracture, noted by Gosselin, are certainly very uncommon in the 
 fractures of infants. 
 
 Ilcemorrhage, exceedingly common on account of infant's thin arterial 
 walls, the special danger of fractures of the skull. 
 
 J^at emholisin (no case reported). 
 
 (Edema and thromhosis seem to be moderately common, but disappear 
 rapidly. 
 
 Diminished growth from so-called epiphyseal injury is more probably 
 due to chronic osteitis or osteomyelitis, with early ossification. 
 
 Acute ej)ij)lnjsitis^ Dr. C. B. Poore maintains, is often an infection of 
 unrecognized fracture from a suppurating umbilicus, infected pin-prick, 
 etc. 
 
 Gangrene^ especially common in the 3^oung, so that pressure from ban- 
 dages must be carefully watched. (Stimson, Fractures, p. 141.) 
 
 Tuherculosis of hone in the 3^oung seldom, if ever, follows a fracture, 
 as the injury is productive of such active cell prolification that this very 
 activity will hold in abeyance the pathogenic action of tubercle bacilli. 
 (Yolkman, quoted by Senn.) 
 
 Nervous delirium^ quite like the milder types of delirium tremens in 
 adults, must be moderately common, as the writer has seen two cases in 
 children, following fracture. 
 
 The literature of complications is very meagre, and in the discussion 
 following Dr. Lovett's paper in Boston in 1893, most of the men denied 
 having seen any complications. 
 
 Bibliography on Fractures in the Kew Born. 
 
 Parvin: in Keating's Cyclopaedia of Diseases of Children, 1889, vol. i., 
 p. 258. 
 
 Lovett: Boston Medical and Surgical Journal, 1893, March 30. 
 
 Kuestner: Die Typischen Verletzungen die extremitaetenknocken des 
 Kindes durch den Geburtshelfen, Halle, 1887. 
 
 Brothers: Infantile Mortality during Childbirth (W. F. Jenks, prize 
 essay), Philadelphia, 1896. 
 
 Gurlt: Lehre von Knocken bruchen, Berlin, 1862. 
 
 Stimson : Treatise on Fractures, New York, 1878. 
 
 Hamilton: Fractures and Dislocations. 
 
 St. Germain: France Medicale, Paris, 1879, xxiv., 89. 
 
 Plunlvett (J. D.): IS'ash^alle Jour. Med. and Surg., 1879, xxiv., p. 69. 
 
 Delove: Diet. Encj^cl. de sc. Medicale, Paris, 4 s., iv., p. 201. 
 
 Leutze: Berliner Klin. Wochenschrift, 1880, xvii., 740. 
 
 Dubreuil: Gaz. Hebd. de sc. Med. di Montpellier, 1883, v. 241. 
 
 Keed: Brit. Med. J., London, 1881, p. 639. 
 
 Korber (G. J. L.): Die Knocken verschadegungen der Fruchte wahrend 
 die Schwangerschaft wahrend und nach der Geburt., Svo, "Wurzburg, 1835, 
 19 
 
290 REPORT OF THE SOCIETY OF THE LYING-IN HOSPITAL, 
 
 Cieslewicz (J.): \'erletzungen des Fa^tus diircb ileii Geburtshelfer, 
 8vo, Halle (187(»). 
 
 Diicournoau (J. E.): Contribution a retiule des lesions des foetus dans 
 les presentations spuutauees de Textremite pelvienne et dans la version, 
 4to, Paris, 1:S70. 
 
 Iledinger {C. F.): rel)er die Knocken-verletzungen bei Keugebornen 
 in niedic-inisb gericbt licber-IIuisicbt, Svo, Tubingen, 1833. 
 
 Lapitzondo (M.): De quelques cas le lesions trauniatique eprouvees par 
 le ftvtus ])endant raccoucbenient, 4to, Paris, 1867. 
 
 Pajot (C.) : Des lesions trauniatitpies que le foetus peut eprouver pendant 
 accouchement, 8vo, Paris, 1853. Also in bis Trav. d'obstet. et de gynecol. , 
 Svo, Paris, 1882, p. 201-424. 
 
 Von Sassen (O.): Ueber ^'erletzungen des Kindes durcb die Wendung 
 und Extraction oder Expression bei Beckenendlagen, Svo, Berlin, 1874. 
 
 Seitfert (A.): Ueber Todesensacken du Kinder wahrend der Geburt., 
 Svo, Berlin, 1873. 
 
 Little: London Lancet, 1S61, ii., p. 378-380. 
 
 Oebler: U. Ztschr. f. Geburtsh., Berlin, 1836, iii., 383-396. 
 
 Piedagnel: Bull. Acad, de Med., Paris, 1840, v., 203-215. 
 
 Fkactuees of the Skull. 
 
 The photograph and tracing (Figs. 1 and 2) sliow the conditions exist- 
 ing in the child (C. N. 26); age two years. Now, after five years, the 
 conditions remain unchanged. The drawings (Figs. 3 and 4) indicate more 
 fully than the history, the autopsy of C. N. 255 (indoor history) and 
 C. N. 37S (indoor history). 
 
 The lettered cases are noted for peculiar features. The cases from 
 the indoor histories and later outdoor cases are preliminary to the next 
 report. None of these cases are included in the statistics. 
 
 Locality of the Fractures. 
 
 Parietal depression ainong the new born, Matthews Duncan and 
 Rosinski sav, is more common than all other fractures of the skull. In 
 the .seventeen infant skull fractures seen by the writer (two not in this 
 series) eleven had ])arietal depression. As the head descends with the long 
 diameter transverse to the pelvis, the parietal bones are exposed to pressure 
 from the short conjugate, and, low in the pelvis, to pressure from forceps 
 blades. 
 
 Frontal (hjn-rxxion^ Jennings says, persists if untreated. This record 
 confirms this assertion, one case thirty years old still showing marked de- 
 pression, one after live years, and one aftei" two, while no purely frontal 
 depH'ssion corrected itself jus did the ])ai-i('tal, occi])ital, and temporal 
 di'pressions. The frontal arch, with its buttressed base, is less subject to 
 change of shape, after depression, frcjni intr;ui;inial or extracranial pres- 
 sure than the parietal or occi|>it;d rcgioiis. On account of the disfigure- 
 
■ 
 
 
 
 « 
 
 
 Numt«;r 
 
 Iteconl. 
 
 Previoua 
 Cbildreil. 
 
 10 
 
 Para. 
 
 
 
 
 Shorn iillve 
 
 
 
 
 
 s'luri. 
 
 10 
 
 I. 
 VI. 
 
 
 H.IIW 
 
 r„illvc.... . 
 
 
 ,,,:„ 
 
 rmilvo 
 
 10 
 
 IX. 
 
 
 5,« 
 
 Provloim 
 liilii.rtluii. 
 
 10 
 
 1. 
 11. 
 111. 
 
 
 n.,l,j..i' 
 
 
 10 
 10 
 
 IV. 
 
 li 
 
 
 1 
 
 "I'f! j.'w.' 
 
 M,._ AllB. 
 
 
 10 
 ICO 
 
 1. 
 
 I. 
 
 I. 
 
 
 rn... Ill HIT 
 
 
 
 II. 
 V. 
 
 
 Jtlmm.i'i; 
 N. V. II. 
 
 IlllVOWltll 
 
 iiliortliiiij 
 
 1 llKui. 
 
 10 
 
 ,, 8t:up. A. 
 
 im 
 
 iMHu 
 
 1 UllU 
 1 ullv 
 
 i- 
 
 1,11,,., 
 
 .0 
 
 V. 
 
 Jugate, 
 4 J tnclies. 
 
 JllKUtC, 
 li in. 
 
 inches. 
 
 11 " 
 
 Placcntii pncviu 
 
 via ; displacc- 
 
 montol'oliild. 
 
 TwliiB louItoU (y; 
 
 Jutting lu'omoii' 
 tijry. 
 
 Juttlntr promon- 
 tory; ulbumi- 
 
 Jiittingpromoii' 
 
 Jutting promon^ 
 yiHinall pel- 
 Jutting promoii- 
 
 Oliliqno polvia; 
 Il8|iliic<'il ciilli 
 
 Podnilc version 
 brcucli exti-ac- 
 lion. 
 
 Symjiliyaiotomy 
 
 Pod. voi-sion; iic 
 couclium. forefi 
 
 bind bead. 
 
 Firatclilid caugbt 
 against second, 
 
 irms and logsc.v 
 
 Narrow pelvis.. 
 Tetanic 
 
 Recovery 
 
 rigid vagini 
 NoneC?) 
 
 None(?) 
 
 Smnli pelvis and 
 
 Arms and leg ex- 
 tended i ereat 
 
 Female 
 Mule, 
 
 Deatb; 6op- 
 HecovQi'y . 
 
 Good.. 
 Good.. 
 
 Female 
 Male, 
 
 on tion; ilntrers iu 
 
 -IDeluy in deiivcrylGoo.i., 
 
 Miilpiisltloii I'cc 
 Sniiill polvlH 
 
 Breech extraction 
 
 1IIb:1i forceps un- 
 verBion; breecli 
 
 Arms extended; 1 
 
 uterine tetanus. 
 
 See under Pmctures or Tibia and Fibula. 
 
 nm rce-|PodnI!o version slTotanic 
 
 1.1 It. 0.1*. Kllinohes.lJnUliiiTpnmn 
 
 toi'y: niiilpti 
 
 I tlon fiutiis. 
 
 ,-|niKli forceps lUi-IArms. nftorwnrdslUcco vc 
 - suvccssrni: pod. funis, pro.; arms veryslo 
 ver.; breech ex.; slipped by bead; septic 
 fillet ou feet. condition of pa- mla. 
 
 Weight 
 of 
 Child 
 
 pounds 
 
 Bitemporal, 3 inches . 
 
 Bipurietai, 4i inches ; bi- 
 tempoiiii, 3i inches. 
 
 3f; bimnstoid, 2]; bitem- 
 poral, 3j ; bimolar, 31 in. 
 
 Head 51easuremenls of 
 
 [Ictween depressions, 3 
 inches ; behind depres- 
 sion, 3i inches, 
 lipai'ietal. 4 inches; bi- 
 terapornl, 31 inches. 
 
 Ditempontl, 3 Inches.. 
 
 tACTUllES OF THE SKULL. 
 
 Cause of Fracture 
 
 Pressure of brow \ 
 
 Pressure of band upon soft 
 
 bones of head. 
 
 thro, abdomen up. 
 
 on hcadat'ainstpr 
 force in extract, li 
 
 n-e through abdomen 
 
 Pi-essure of forceps blade 
 and promontory. 
 
 Foetal bones 
 
 noted before opoiati 
 Expression throu^'b j 
 men of head against 
 
 Dnigging of head tbrougb 
 
 Expression of bead througl 
 abdomen against prnm- 
 
 Apparently pressure of for- 
 
 Apparently pressure ol 
 
 Fronto - parietal region 
 shaft of right humerus. 
 
 Left parietal, 3 by 3 inches 
 but not deep, 
 
 3 in. below sagittal suture 
 by upper anterior bordei 
 of temporal bone. 
 
 Right temporal region (?).. 
 
 Rupture of coronal suture 
 
 Left parietal anteriorly ; 
 ight side between parie- 
 11 & temporal dei)i'ess!on 
 
 parietal bones. 
 
 Parietal region; right side. 
 3byiby2in.; shaft r' 
 
 [lirht''"fvnnto-parietJil 
 giun, Ibylbyj inch. 
 
 tiglit frontal region ( 
 eye, Ibylbyl inch. 
 
 throii^Ii abdo- Left parietal Delayed rcspimti 
 
 g and cceliyn 
 
 facial paralysis from 1 
 
 Delayed respiration ; dc 
 pression on fifth daj-. 
 
 Delayed respiration 10 min, 
 cut in temporal rcgioi 
 just above ear down t 
 
 Delayed respiration : ceph- 
 alhii'mntoma ; pnlsntmL' 
 
 tjoth sides an 
 
 h freces. 
 Cold to head . . 
 
 ■eathed only a few times. 
 
 Delayed vospimtion ; facial 
 paralysis; convulsions. 
 
 'anilvsis llexnr nuiseles 
 lefr, arm. apparently due 
 
 Convulsions (?).. 
 
 Immediate Tr 
 
 None for skull 
 
 Fmcture not noted t 
 
 
 rtiflcial respiration. 
 
 Cupping(?) 
 
 iVrtitlcial respiration . 
 
 Inimedi- 
 
 snlt to" 
 Child. 
 
 Good.. 
 
 Death... 
 Death, 2d 
 Good.... 
 
 -Two sncceedioff ohildreu killed 
 
 Soft; premature 
 
 . Depro9slo__ __ 
 mained 1 year 
 Inter; arm O. K. 
 
 FRACTURE OF JAW. 
 niction on jaw in deliveryLl 
 
 1 of 2d a 
 ' shoulders In e 
 
 Right clavicle ; ( 
 Both clavicles; 
 
 bothlBieeding from mouth ;| 
 
 crepitus; deformity; ab- 
 
 ] normal mobility. | 
 
 Crepitus : deformity; 
 layed respiration. 
 
 Crepitus ; deformity . . . 
 
 ii| [Small ITraction 
 
 leg; upper i; ecchy-ICrepitus ; deformity. 
 
 ihTftai 
 
 . ISpIints and temp, dressing ;|Good .... [Normal No 
 
 long splint from sacrum to 
 I heel and perineum to heel. I I I 
 
 □buia from both epiphj-- 
 
 bral symptoms, 
 le pression dlsap- 
 
 Dcp ression disap- 
 peared iu 1 month. 
 
 Wound infected 
 fith day, 
 
 II 30th day ;" iiopaV- 
 
 . Tnmoi-a disappeared 
 onSOf • 
 
 I day fjithor toolc baby out of 
 ^nobothoapit 1 1 isto j egi 
 
 ulsloiis coul 1 bo b gilt on 
 
 By pressuro on the 
 Autopsy. 
 
 Depression disnp- 
 schartred inth <lay. 
 
 Autopsy ; Fig. 3, p. L'UO. 
 Fig. i. p. 200. 
 , year later 
 
 
 i left. 
 
 . Now depression remains, JWyi 
 since delivery; man reini 
 " " ■ :ht pfiv " ■ 
 
 I Operation to relievo depii?sslon 
 ' and doformity ; found cyst be- 
 neath, on opening which child 
 went into collapse and died. 
 
 s T.UI day goiid union; i 
 , No further report. 
 
 shortening (?). 
 .1 Autopsy. 
 
 II solid ; function good; 
 
Fig. 1.— C. N. 26. 
 
 Fig. 2.— C. N. 26. Tracing Taken at Level Marked (1) in Fig. 1. 
 
Fig. 3.— C. N. 255, Indoor History. 
 
 Fig. 4.— C. N. 378, Indoor History. 
 
FRACTURES IX THE NEW BORN. 293 
 
 inent, these frontal depressions are less often overlooked than the others. 
 They are usually caused by pressure of forceps applied in the pelvic curve 
 of the mother to the head of the foetus when above the In-im of the pelvis. 
 Even in the hands of good operators this accident may occur. The cephalic 
 application of high forceps, if otherwise safe, would avoid it. 
 
 Occipital clepressions occur in the same wa}^ as do frontal, from pressure 
 of "high forceps operations." Owing to the proximity of the medulla, 
 these fractures would more surely cause death than any of the other forms. 
 If the child lives, the depression usually corrects itself. 
 
 Whether the base of the skull in a child living after delivery is ever 
 fractured is still a mooted question. Cases of facial 23aralysis are usually 
 due to pressure of the forceps blade on the branches of the facial (seventh) 
 nerve where those branches cross the mandible. Such cases recover in a 
 short time. There are, however, one or two cases reported (Jolly) of per- 
 manent unilateral facial paralysis, infantile in origin, accompanied by unilat- 
 eral deafness on the same side, also permanent, an occurrence strongly 
 suggestive of fracture through the temporal bone. 
 
 Rupture of a suture line, as in C. N. 5,854, of course has the same 
 dangers to the child as a fracture of the skull, with all the additional 
 danger of meningocele. 
 
 BiBLIOGKAPHY. 
 
 Jolly: British Medico-Chirurgical Journal, 1889, June. 
 
 Stephen: Medical JN'ews, January, 1889. 
 
 Dauchez: British Medical Journal, October 31, 1891. 
 
 Hewett: Holmes's System of Surgery (Am. ed.), vol. i., p. 627. 
 
 Prognosis. 
 
 Rosinski reports 44 cases, with 16 recoveries; Shroeder, 65 cases, with 
 33 recoveries (22 born dead, and 10 dying within a few days). Among the 
 17 cases seen by the writer, there are 10 recoveries. 
 
 That the depression is not always injurious, witness the now thirty -years' 
 old, deep, frontal depression of D. E., an instructor in a New York college, 
 and C. ]Sr. 26, at five years old, a very bright child. The new-born corti- 
 cal brain cells are not developed (Edinger, His, etc.) save in the motor 
 area, therefore the delicacy, noted by Jacobi, of the blood-vessels in child- 
 hood is not so great a danger as among similar injuries to adults. In 
 giving a prognosis, one must be guided by the locality of the fracture, 
 the accompaniment of injuries to the skin, the depth and area of the 
 depression, the time taken in delivery, the time needed to resuscitate, the 
 symptoms present after delivery or developing later. The after history of 
 these cases is so often lost that an accurate study of their course is only 
 made by the collected observations of different men, not always agreeing 
 as to signs noted. 
 
 Complications. 
 
 All the dangers of fracture of the skull depend upon the complications, 
 generally haemorrhage, as the depression itself is usually not sufficient to 
 
294 REPORT OF THE SOCIETY OF THE LYIXG-IN HOSPITAL. 
 
 impinge dangerously uj^on cranial content^^. If the fracture occurs from 
 the use of instruments, the haemorrhage is usually outside the dura mater, is 
 slight in extent, and of little consequence; if, however, there is much over- 
 lapping of the cranial l)ones, or a very deep depression, there may be a 
 hirire-sized ha?matoma in the cortical substance sufficient to cause death. 
 iSuch a hanuatoma, l)eneath frontal de})ressions, indenting u})on no vital 
 centres, may, according to Dr. ]\r. Allen Starr, remain as a cyst. (See case 
 fi-om Recoitls of New York Hospital, lettered '' f.") Operations upon such 
 de])ressions and cysts are very dangerous, from change in intracranial 
 pressure on removing the cyst fluid ; an indication, therefore, for early 
 0}3e ration, if any is to be undertaken. 
 
 The fractures of the skull due to breech deliveries and podalic version 
 are usuallv accompanied by much cerebral congestion, and, therefore, often 
 by hcemorrhage. The spastic paraplegias, idiocy, microcephalus, epilepsy, 
 cerebral palsies, and insanity, as the result of difficult deliveries, and due to 
 cerebral injuries, are noted in only one case of the lt»,238 here considered. 
 A child (C. X. 3,394) of healthy parents had an arm fractured in delivery, 
 but no cerebral injury was noted at Ijirtli. One year later this child is a 
 microcejihalic idiot. 
 
 Infection from scalp wound and compound skull fractures, of course, 
 predispose to meningitis, encephalitis, epiphysitis, septicaemia, or pj^semia. 
 
 Etiology. 
 
 A jutting promontory, or exostosis jutting from the j^elvic wall, with 
 breech extraction, seems to be the cause of skull fractures more common 
 than anything, unless it be the perforator. 
 
 Pressure through the abdominal wall upon the after-coming head, in 
 difficult In-eech extractions, seems the next most common cause; even more 
 fre<|uent than the hasty or injudicious i:>ulling upon forceps applied at the 
 superior strait Ijefore moulding has time to take ])lace. These and the for- 
 cible a])proximation of the forceps blades (an uncommon cause, owing to 
 the wide cephalic curve of an ordinary instrument) of course can be 
 averted. 
 
 Pressure of tlio liead against a displaced fcx'tal limlj can only occur in 
 much defornx.'d pelves — a fi'acturc from such cause is reported; also a case 
 where a skull was fractured against a jutting promontor}'' by uterine force 
 alone (Tuckei-). Hamilton mentions sucli a case. Matthews Duncan 
 describes a <l<'pression ma<le by ])ressure of the accouclieui"'s fin<i'er in 
 att<impting t<j produce rotation. In |ii-eci])itate lal)ors infant skull frac- 
 tures are rejioi'tcd fi-om the fall of the child against the floor or the edge of 
 tlie vessel over which the mother was standing'. In an effort to )'esuscitate 
 the child by Schultze's method, the writci' has seen a cliild sli|) from the 
 r)|M'rator''s hands, and in the fall sustain a fracture of the skull. Lowen 
 and .Joullin have demonstrated that a coiM|»rcssiii^- force of loo pounds 
 applied for two or three minutes continuously will fracture the skull of a 
 normal ffjetus. 
 
FRACTURES IN THE NEW BORN. 295 
 
 Symptoms. 
 
 The deformities of the skull are apparent at delivery if haematomata 
 do not conceal thera. Crejoitation and abnormal mobility cannot be made 
 out. Muscular twitcliings or convulsions starting unilaterally, unilateral 
 paralysis, blindness or deafness, coma, subnormal temperature, delayed 
 respiration, irritability, sleeplessness, sudden death — all are indications of 
 cerebral haemorrhage, which may or may not be accompanied by fractures. 
 
 Diagnosis. 
 
 From cephalhaematomata, either early, when the depression may not be 
 noticed, or late, when the edge of the organized clot may be mistaken for 
 depression. From overlapping of cranial bones, particularly abnormal or 
 ' < Wormian ' ' bones. 
 
 Teeatment. 
 
 Dr. Irving W. Smith, Dr. McKennan, Dr. Jennings, each elevated 
 such depressions as we have noted, with recoveries in all the cases. If the 
 fracture is compound (unfortunately the forceps often make it), or if the 
 depression causes symptoms of compression — subnormal temperature, coma, 
 respiratory delay — as in Dr. McKennan's case, there would be no question 
 as to the propriety of elevating the depressed bone. Frontal depressions 
 are commonly permanent, therefore this would particularly apply in their 
 case. Parietal and occipital depressions usually correct themselves. How- 
 ever, in a deep parietal depression recently seen by the writer, after breech 
 delivery through a narrow conjugate, when respiration could not be excited 
 after twenty minutes, and the heart was becoming slow, it seemed as if, 
 had elevation been practised, the child might have been made to breathe. 
 
 Jennings summarizes active treatment thus: first, the use of cups 
 (among older writers condemned for the intracranial haemorrhages the cups 
 apparently caused ; unsuccessful, also, in a trial of their use seen by the 
 writer) ; second, elevation, itself not a dangerous proceeding, save for 
 possible infection. Jennings advises replacement of any pieces removed. 
 He urges immediate action if symptoms are present, even if the operation 
 has to be done with a boiled pocket-knife. Later interference he suggests 
 if the depression be more marked at the end of the second week. Because 
 loss in weight will of itself increase any depression in an infant's skull, 
 and an organized clot (Dr. M. Allen Starr) might have already assumed 
 the character of a cyst, such interference should be undertaken at birth or 
 within a day or two. 
 
 BiBLIOGEAPHT. 
 
 Eosinski: Zeitschrift filr Geburt u. Gynak., 1893, xxvi., 225. 
 Fritsch und Shroeder: Klinik der Geburtshiilflichen operat. auf,, p. 
 305. 
 
 Siche: Centralblatt fiir Gynak., 189tt, xxxv., p. 856. 
 
29G REPORT OF THK SOCIETY OF THE LYING-IM HOSPITAL. 
 
 Fen.vick: International Clinic, 1S93, p. 24S. 
 : Charlotte (X. C.) Medical Jour., 1S93, 17. 
 
 Xairel: International ^leil. Mag., 1S92, G70. 
 
 lieynultls: X. Y. Med. Jour. Gyn. and Obs., 1S92, 907. 
 
 Porak: Kev. Obs. et Gyn., 1S93, ix., 119. 
 
 Jennings: X. Y. Med. Jour.. Mar. 10, 1S94. 
 
 Tucker: Anns. Gyniec. and Obs. Jour., Sep., 1890, p. 279. 
 
 Bull. Soc. de Chirurg., Paris, 1857, p. 278. 
 
 Bull. Soc. de Chirurg., Paris, 1802, 2d, p. 159. 
 
 Larkin: Lancet, London, 1872, vol. i., p. 490. 
 
 Arnold: Boston ^Med. and Sur. Jour., vol. Ixxxvi., 352. 
 
 Mercier: Brit. Med. Jour., 1881, vol. 1., p. 847. 
 
 Sinkler: Med. and Surg. Keport, 1887, p. 675. 
 
 Lusk: :Med. anil Surg. Beport, 1887, p. 673. 
 
 West: Trans, of London Med. Chirurg. Soc, 1845, p. 397. 
 
 ]'>arin: Bull, de la Soc. Anat., vol. xlviii., p. 426. 
 
 Borges (G. II. L.): Ueber Schiidelrisse an einen neugeboren Madchen 
 und den Entstehung, 8vo, Mlinster, 1833. 
 
 Hirt: De cranii neonatorum fissuris ex partu natural! cum novo eorum 
 exampla. 4to, Lipsiae, 1815, i. 
 
 Ilorstmann (H.): De fissures in cranio neonatorum congenitis, 8vo, 
 Marburgi Cattorum, 1854. 
 
 Jayet: Des fractures des os du crane chez les enfants nouveau, 4to, 
 Paris,' 1858. 
 
 Jouslain (A.): Des enfoncements et fractures du crane produits chez le 
 nouveau-ne pendant I'accouchement, 4to, Paris, 1805. 
 
 De Xinbeck: Des fractures et des enfoncements du crane du foetus 
 pendant raccouchement, 4to, Strasburg, 1863. 
 
 Ileali (G.): Ueber die Behandhmg du angeborenen Schiidel und Riick- 
 gnitsbriiche, 8vo, Zurich, 1874. 
 
 Reis (G. R.): De capitis neonatorum laesionibus ex partu cum novo 
 earum examplo, 8vo, Gryphiswaldia?, 1860. 
 
 Rose (F.): Ueber die Schadelverletzungen die Xeugeborenen in gerichts- 
 iirzlichen Beziehung, Svo, Menden, 1880. 
 
 Schuralz (C, J.): De laesionibus ossium cranii inter partum factis, Svo, 
 Jenie, isoo. 
 
 Siegel (F.): De cranii neonatorum fracturis partu natural! effectis, Svo, 
 Dorpat, 1S34. 
 
 Abbot: JJoston M. and S. J., 1>;72, Ixxxvi., 351. 
 
 Adanikiewicz: Vrtljschr. f. gevvchtl. in off. Med. Berlin, 1864, n. F. I. 
 211. 
 
 Angobonn: iil. f. gerichtl. Anthrop, Ansl)ach, 1854, v. 4, lift. 63. 
 
 Ba.shain: London, M. and S. J., ls35-3(), viii., 187. 
 
 Becker: Ztschft. f. d. Staatsarznk., Erlang., 1833, xxvi., 245. 
 
Fig. 5.— C. N. 11.016. A Pix ix Ba>-dage, and Thumb 
 OF Nurse Holding Limb while Exposed to Eoxtgek 
 Rays are Shown. 
 
fractures in the new born. 297 
 
 Separation of EpiphysiSo 
 
 The radiograph (Fig. 5) here given was taken of a case (C. IST. 11,010) 
 to be fully reported in next series. It is supposed to be an epiphj^seal 
 separation. The epiphysis is apparently so cartilaginous that Rontgen 
 photogra})hy penetrates it the same as through other soft parts. 
 
 Gurlt, 1S62, reports three cases of separation of epiphysis at birth, 
 diagnosis verified at autopsy; one by traction upon feet, two by traction 
 upon arm or axilla. Hamilton mentions a case, while Bruns, in a series of 
 eighty-seven, mentions ten that occurred at birth. According to Gurlt, it 
 is difficult to separate an epiphysis by direct traction, l)ut very easy on 
 forced hyperextension or hyperflexion of joints, more particularly the 
 ankle, knee, elbow, and shoulder. C. 'N. 225 (indoor historj^) here 
 recorded, verified at autopsy, showed separation of the lower epiphyses 
 of both tibite, due to the use of a fillet around the ankles, the feet hjq^er- 
 extended in a difficult version. 
 
 If the child lives, early ossification of such separated epiphysis may 
 take place and growth of that bone cease. The limb will then be short- 
 ened. Such a case is said to be the arm of the present Emperor of 
 Germany. Arrest of growth from this cause must be rare, as stunted 
 growth may be induced by fracture of the shaft when chronic inflamma- 
 tion of the bone has followed. Bruns has pointed out that the line of 
 separation is more apt to be through the partially ossified portion of the 
 epiphysis (the most brittle), and the chondrogenetic, or growing portion, to 
 remain uninjured. 
 
 BiBLIOGEAPHY. 
 
 GurJ.t: quoted above. 
 
 Helferich: Fractures and Laxations, 1894, 
 
 Manquat: Sur les decoUements epiphysaires traumatiques, These de 
 Paris, 1877. 
 
 Bruns: Langenbeck's Archiv., vol. xxviii., p. 240, 1882. 
 
 Partridge: K. Y. Med. Jour., March 22, 1890. 
 
 Barr: Archives de tocologie de gynecologic, Paris, March, 1895. 
 
 Kuestner: quoted above. 
 
 Tillmans: quoted above. 
 
 Bitol: J. de Med. de Bordeaux, 1859, 2 s., iv., 5-19. 
 
 Godfrey (H. T.): Chicago M. Rev., 1882, v., iii. 
 
 Ghillini: Archiv. f. Klin. Chir. Berlin, 1893, xlvi., 8M. 
 
 Tubbey: Ann. Surg., Phila., 1894, xLx., 289-325. 
 
 Stunock: Edinburgh, Hosp. Report, 1894, 598-608 (after results). 
 
 Savage: Med. Rec, ]^. Y., 1895, xlvii., 690. 
 
 Missenbach: Med. Rec, K. Y., 1895, xlviii., 475. 
 
 Milliken: Arch. Pediatrics, K. Y., 1894, xii., 611. 
 
 Simpson (A. R.): Obst. Jour. W. Brit., London, 1880, viii., 553. 
 
•29S REPORT OF THE SOCIETV OF THE LYING-IX HOSPITAL. 
 
 Fractuke of the Jaav. 
 
 AVinckel alludes (citing a case of his own) to this clanger in the old 
 Sniellie -Veit method of deliveiy with finger in the mouth of the after 
 coming head of the ftvtus, as in the case here reported. Dr. A. B. Davis, 
 of this Hospital, in two breech cases Avhere the children were known to 
 lie dead, found it impossible by this method to fracture the mandible, and 
 the writer made the same observation in a tliird case. Parvin says a force 
 of fifty pounds, direct traction, Avill break the jaw. Dr. Lusk speaks of 
 having fractureil a jaw in an effort to convert a brow into a face presenta- 
 tion. 
 
 Heath points out that most of these cases are fortunately still-born, 
 and escape deformities in later life. A case at 8t. Mary's Free Hospital 
 for Children, operated u})on by Dr. Poore, the writer assisting, December. 
 1895, illustrates the possibilities. A boy, eleven years old, with atrophy 
 of the mandible, ankylosis of the mandibular joint, unilateral bony coales- 
 cence of condyle and zygoma, existing since infancy, and fed by suction 
 through gap between teeth where maxillary overlapped mandibular inci- 
 sors; with no scars, no trouble with teeth, no a]ipearance of tubercular 
 infection. The parents were dead, and the history obscure. The proba- 
 l)ility seemed that a breech delivery had been conijileted by Smellie -Veit 
 method, and fractures (perhaps compound, with ])eriostitis, causing dimin- 
 ished growth of the mandiljle) had taken place. Excision gave him good 
 movement of the })oorly developed jaw he had left. Paralysis of the 
 inferior dental branch of the fifth nerve might be a complication, as might 
 atrojiliv of the jaw and unecjual eruption of the teeth, or the occurrence of 
 dentigerous cysts. 
 
 Such a fracture could be held in position by a starch bandage around 
 tlie head or with a dental ])late, and the child fed by gavage through the 
 nose. 
 
 P>II{I,IOGRAl'IIV. 
 
 Heath: Injuries and Diseases of the Jaws, London, 1884. 
 Winckel: (Edgar's Translation) Text-Book of Obstetrics, Philadelphia, 
 1890, p. 689. 
 
 Duncan, Matthews: qucjted above (Champetier). 
 
 Fractures of the Vertebra. 
 
 These cases, save in one instance, liave not been included in the list of 
 fififtnres, as de{'a))itati(»n divides so much beside bone. In C. N. 9.'}*.), 
 pi-emature twins iiad l)oth heads pulled off at deHvery, and the heads after- 
 ward extracted with difficulty. C. N. 7,018 was a case of decapitation for 
 an impacted shoulcU'r ])osition. In C. X. 8,74.'. Ihe he;i(l was ])ulle(1 off l)y 
 Uh) zealous traction upon an impacted breech. 
 
 Several cases have been rej)orted due to Smellie- Veit mode of delivering 
 the after-coming he;i(l when the body <»!" \\\<- cliild h;is heen bent backward 
 
FRACTURES IN THE NEW BORN. 299 
 
 ov^er the symphysis of the mother to save a perineum. Because the ante- 
 rior spinal ligament, however, is weaker than other ligaments, it is more 
 apt to give way than the bone. The awkward use of Schultz's method of 
 resuscitation might fracture vertebra?, although no case has been reported. 
 
 If the child survived, fractures of the atlas might cause hypoglossal 
 paralysis. (Erb.) 
 
 Bibliography. 
 
 Winckel: quoted above. 
 
 Montgomery : Observations on Obstetrics. 
 
 Erb: In Zieinsen, 1876, vol. xi., p. 254. 
 
 Fracture of the Ribs. 
 
 No case in this series. 
 
 One fracture reported by Gebhard, where a rib penetrated the lung 
 after Schultz's method of resuscitation had been tried. Death of the child 
 resulted from haematothorax. Whether the method of resuscitation or 
 the delivery caused the fractures is not stated. 
 
 Bibliography. 
 
 Gebhard: Am. Jour, of Med. Sci., Phila., February, 1895. 
 Smith: Obst. J. W. Brit. (Amer. Supplem.), Phila., 1877, v. 6. 
 
 Fracture of Sternum. 
 
 No case in this series. Eauber has shown that in children the sternum 
 may be forced back to the spinal column without fracture. 
 
 Andree: J. f. Geburtsh., Frankfort a Main, 1828, viii., 101-107. 
 Tillmanns : quoted above. 
 
 Fractures of the Clavicle. 
 
 These fractures probably occur much more often than is generally 
 stated, because the injury causes an infant very little inconvenience, and 
 more cases of Erb's paralysis than of fractured clavicles are reported. 
 
 Etiology. 
 
 In the Smellie-Yeit method of delivering the after-coming head, or any 
 method of breech extraction, where two fingers are hooked over the 
 shoulders as point of traction, not only is there a possibility of tearing 
 away the cervical nerves from the roots, but of bending the clavicle 
 against the upper or outer cord of the brachial plexus, and even of fractur- 
 ing the clavicle, as in the cases here recorded. Cases are reported due to 
 Schultz's method of resuscitation. The force is one of torsion and bend- 
 ing, a combination requiring the least power necessary to accomplish a 
 fracture. Winckel mentions a case due to the arrest of a shoulder behind 
 
300 REPOHT OF THE SUCIETV OF THE LYING-IX HOSFFrAL. 
 
 tlie svmpliysis after a forceps delivei'v o^ a vertex. A similar occurrence, 
 but duo to uterine force aloiio. w Iumi in a vortex presentation the shoulder 
 caught behind the symphysis, has boon related to the writer by Dr. S. W. 
 Lambert. 
 
 Complications. 
 
 Erb's or brachial paralysis may coexist. It is usually not due to the 
 fracture, but to the same force which produced fracture. Kupture of the 
 lung by the shar[) end of a fragment is recorded by Schultz himself, in 
 describing his mode of artificial resuscitation. Heyderich mentions a simi- 
 lar accident. Puncture of the brachial cord is reported by Dr. Weir 
 ^litoholl, and of course it is possible that the fractured end might enter a 
 subclavial vein or artery. 
 
 Dr. Royal Whitman has recently pointed out that the shortening of the 
 cla^•icle, which repair in most cases brings about, might shorten the support 
 of the sca])ula sufficiently to promote a tendency to rotaro-lateral curva- 
 ture of the spine. 
 
 Symptoms. 
 
 Crepitus is usually felt in delivery at the time of fracture, a faint audible 
 snap. Tliis is sometimes misleading, because in a case whore the snap was 
 heard, the writer, after careful examination, could make out no fracture. 
 Deformity is as marked as in an adult, ])articularl_y when the fracture is 
 comi)leto. Tenderness, apparentlj^ is always present. Row significant it 
 is in childhood is still questioned. Pseudo-paralysis may be due to this 
 same tenderness, but may be confused with a true brachial paralysis. A 
 false point of motion, owing to the lax joints of infants, is difficult to 
 make out. 
 
 Treatment. 
 
 If the infant were a girl, and there Avere any doubt about future 
 deformity, the child should be stra])i)ed to a board or a Bradford frame, 
 with the shoulders back. Otherwise Sayre's strapping, as used for adults, 
 and a]»|»liod for ton days, is sufficient. If not treated, after two or thi'ee 
 months a careful examination will usually fail to reveal deformity. 
 
 Bibliography. 
 AVoir Mitclicll: Injury to Xerves. 
 (iibson: Principles of Surgery, Oth ed., vol. i., ]). 27. 
 Heydericli: Glasgow Med. Jour., July, 1890. 
 Sfhnltz: Auk Jour, of Med. Science, July, ls!»4. 
 llodgon: cjuoted by Pai'vin. 
 Knight: (juoted by Parvin. 
 
 FkACTUKES of ScAl'ULA. 
 
 There are none in this seri(!s. 
 
 AVagner reports one case with a somcwli.-ii olisciirc liistoiy in the Uni- 
 versity M<-d. \\:\<^.. I'liil;idr||i!ii;i. .\|.iil. ls;)4. 
 
XiaUursciiBy.. 
 lilrths. 
 
 'lovlniis In- 
 
 'I-CVIOUB 111. 
 
 uusy Inborai 
 f r. I'liiuiw In privnto pnic. 
 
 °l1?n**/ ^''; ^''»■'t<«' '" pi-lvato pnic- 
 «L-im """'" iU'loi' fmctm-es ol' 
 
 tlnUve;ltmui 
 
 Iscarrlugt't 
 
 rovioiifl la- 
 
 
 .Montb 
 
 of 
 
 Gestation, 
 
 Jt "It: lies. 
 
 L. Scup. P. 
 L. S. A. 
 
 R. U. A. 
 
 H. O. A. 
 
 L. S. P. 
 L. S. A. 
 
 Vertfx (?) 
 U. O. A. 
 
 It. S. A. 
 
 L. M. A. 
 
 L.Si-ii|..A. 
 
 L. ( ). P. 
 
 U. O. P. 
 
 formity (V) 
 rutting nroit 
 
 Jiisto-minor pelvis 
 nrnlapscd futijs. 
 
 prolapsed funis. 
 Pelvis small (?) 
 
 Pelvis small; pro- 
 
 AlbuminurJn : de- 
 formed pelvis. 
 
 Mnlpositlon fcetus.. 
 :)i3pliiccmeiit ol 
 Loeldnifof twins.., 
 
 .Tiisto-minor pelvis. 
 Pioliipsed funis unc] 
 
 PnilHpscd finiis; de- 
 
 Breccb extraction. 
 
 Difficulties of Open 
 
 Arms locked behind 
 
 Great force u 
 i extended. 
 
 Arras extended.. 
 
 (podiiHc version oi 
 iiiherclilld). 
 Breeeb extraction. 
 
 r\rms locked bebind 
 Left arm extended . 
 
 tended. torn; final 
 
 CO very. 
 ■Vrms extended Good 
 
 Length 
 Child. 
 
 Cbild's heart 
 
 Arms extended.. 
 
 Mnlpositlon of child Poi 
 
 Albuminuria: Jut- 
 ting promontory 
 
 Aecoucbflm'tforce; 
 nodnlio version 
 ui-eech extraction. 
 
 Itef used trc 
 ttfteropcnition; 
 
 SI"'":"" 
 
 FKACTUKES OF HUMERUS. 
 
 f Cbild. Cause of Fracture. 
 
 Male .... 
 Female. . 
 
 Female.. 
 Male .... 
 
 Male . . . - 
 Female.. 
 
 . Attempts to die- 
 lodge rigbt "" 
 
 Attempts to s 
 
 Position of Frac- 
 
 Kight sbaft. 
 per S. 
 
 Right sbaft., . 
 
 - Left abaft. . - . 
 . Left middle i . 
 
 . Small splints ; soft bandage. 
 
 . Crepitus; 
 
 held rigid ; J 
 
 . Extraction of lii-st I 
 xtcnded r 
 
 xtraction 
 xtendcd a 
 
 . Great force used in I 
 
 tended arm. 
 Unknown 
 
 . Extraction of i 
 
 across back 
 
 cbild. 
 . Extraction of i 
 
 purposely aci 
 
 baclt of cbild. 
 . Extraction of i 
 ross back 
 
 1 caught against 
 
 . Right shaft. 
 
 . Right e pi physist?) 
 probably not. 
 
 n Rightshaft; "pai-- 
 V tial dislocation o" 
 
 shoulder." 
 n Right shaft 
 
 . Early qss 
 
 skull. 
 . Brittled ( 
 
 Normal , 
 
 t parts greatly swollen. 
 
 - Facial paralysis from forceps; . 
 " temperature, 90"; pi "' 
 paralysis left side (?) 
 
 ) Fracture of skull as wt 
 
 ■s; pasteboard splints. 
 I across chest; soft band- . 
 
 delivered with 
 extracted with 
 
 extracted with 
 c through 1 
 peh-is. 
 
 tended arm. 
 . Extraction of i 
 . Extraction of 1 
 
 Left upper } 
 
 Left (?) middles. 
 Left upper J 
 
 Leftmiddlej... 
 
 Right upper 
 middle j. 
 
 Left shaft.... 
 Left lower i.. 
 
 Delayed respii'ation 
 
 deformity ; a 
 „ id ; crepitus mar 
 noted untUr)tli day 
 No crepitus; mobiil 
 direction only; ds 
 "green-stick." 
 Arm held rigid 
 
 . Crepitus 
 
 . Crepitus; mobility. 
 
 
 ages; pasteboard splin 
 
 Starch bandage around chest, 
 
 to which arm fastened with 
 
 stareb bandage. 
 
 , Starch bandage 
 
 :1 Soft bandage ; arm to si 
 
 c Smalt wood splints; 
 bandages. 
 
 .Splints; soft bandage; 
 
 .Splints: softbandngo; 
 
 lostorcase removed on 
 
 , Plaster case around h 
 1 bound to case. 
 
 . Splints for two days, then . 
 plaster case. 
 
 Arm across chest; splints; 
 soft bandages. 
 
 temperature, 97° ; S 
 
 - Notbrokenat birtii 
 but noticed 5 day 
 
 I Right upper J. 
 
 Right upper 
 i epiphysis (?) 
 
 , Left upper J ... 
 
 , Normal . 
 
 delayed respiration. 
 
 Night cry; pseudo-itaralysi 
 ;repilus; mobility. 
 
 3 oround thorax 
 
 . U " (?). 
 
 n swelled and plos- 
 
 Large callus; 
 
 weniy-Qrstday refractured; 
 ,wo months later position 
 md lunctiou good, 
 iill birth. 
 
 . Still birth, duo to delay in 
 
 . mouths lator position 
 and function good. 
 
 no year later child wasmi- 
 jroccphalic idiot ; no paraly- 
 
 . Good. 
 
 . Good Olio month at'tor. 
 
 , Said to bo "O.K." 
 
 sbortuning. 
 
 t'-Hirco days later po- 
 
 ty-thrco days Inter po- 
 sition ami function good, 
 
 luggcstcd, but refused. 
 
 right." 
 
 later 
 
 , Good, 
 
 Still birtli, due to dldlcu 
 , Slight deformity; goud I 
 
 Twenty-live days: good, 
 . Still-born, duo to delay ii 
 
 months later positim 
 function perfect; m 
 
 ad been delivered by midwife two days pre' 
 
 r fractures of skull. 
 
Fig. 6.— C. N. 12,027. Fracture of Humerus. 
 
Fig. 
 
 7 c. N. 12,027. Fkactuke op Humerus 
 
 Seventeen Days after Birth. 
 
fractrres in the new born. 303 
 
 Fractures of the Humerus. 
 
 The radiographs (Figs. 6 and 7) here shown of C. IST, 12,027, to be reported 
 in next series, although somewhat dull, indicate the ordinary overlapping of 
 the fragments. These pictures are opposed to Dr. Reynolds' assertion that 
 most of these fractures are ' ' green stick." Only one in this series of twenty- 
 six cases was of that character. The second picture shows the callus for- 
 mation after seventeen days. The arm is firm, and externally shows no 
 
 deformity. 
 
 Etiology. 
 
 In this list it will be noticed that in all but four citations a breech 
 had been extracted, either breech presenting or after podalic version. One 
 of the three is C. N". 780, delivered by midwife. The mechanism is 
 unknown. C. K. 5,723 should not be counted an accident; the arm caught 
 behind the symphysis, was purposely swept across the back, necessarily 
 breaking it, because the operator feared to delay in the interest of the 
 child's life. In delivery of the breech this is the danger always taught to 
 students, the inexcusable sweeping of arms behind the child's back, partic- 
 ularly the first arm to be delivered. Ifearly all the cases in the present 
 list were breech extractions in which the arms were extended above the 
 head. In narrowed pelves, under conditions when rapid delivery seems 
 essential to the life of either mother or child, the act of sweeping a child's 
 arms across its face is accomplished with great force. Pressure is exerted 
 as in a lever of the first class. The accoucheur's finger is a fulcrum, with 
 the child's forearm and lower half of its humerus as the long arm of the 
 lever against the whole uterine and abdominal pressure. The fixed uj^per 
 half of the humerus is the short arm. In such conditions breech extraction 
 endangers the child's arms. C. IS". 9,575 was extracted by hooking the 
 finger beneath the shoulder; a similar fracture of Gurlt's was made by a 
 blunt hook in the axilla ; and a fillet in the axilla broke an arm for Char- 
 pentier. All were vertex cases. 
 
 In Hamilton's "Fractures" Dr. Stephen Smith quotes a case of Dr. 
 Fanning, when in a vertex presentation the arm arrested behind the 
 mother's symphysis was broken by uterine force alone. If the arms are 
 extended beside the body of a child in a vertex presentation, while the 
 body is passing out of the vagina, around a symphysis which impinges 
 against the humerus, it is possible that the humerus might be fractured in 
 the same way that Reynolds has shown the femur may be broken. The lift- 
 ing of a child by one arm, as in C. ]S". 9,886, has long been known as a 
 cause of shoulder dislocation, of separation of the epiphysis of the 
 humerus or scapula, or of fracture of the shaft of the humerus. Sixteen 
 of these twenty-six children were males, all of them large, one weighing 
 fifteen pounds (the size apparently the sole cause for still birth and frac- 
 ture). All the cases were at full term, twenty-three in multiparee, in whose 
 children fractures of extremities seem more common than in children of 
 primiparae, perhaps because of the greater liability to large children. Some 
 operative interference was required in all cases but two. 
 
304 REPORT OF THE SOCIETV OF THE LYIXG-TN HOSPITAL. 
 
 CoMPLIOA'riONS. 
 
 Deformity is usually the result of improper treatment, but in time cor- 
 rects itself. Musoulo-spiral })aralysis has been noticetl, but, as Erb points 
 out, Russian children, with the arms tightly swathed to the body and 
 allowed to lie for a long time on one side, often suffer from musculo-spiral 
 paralysis without fractures. This paralysis may also take place from too 
 tight bandaging (Loviot), and has been due to the inclusion of a nerve in 
 callus. 
 
 No case of shortening from e]nphyseal separation or chronic osteitis 
 has apj)earetl as yet in this series, nor have any cases of epiphysitis. 
 
 Prognosis. 
 
 Two of the humeri in this series needed refracture, but the one which 
 refuseil treatment had very slight deformity two years later. Six cases 
 were still-born or died within forty-eight hours. Probably the deaths 
 were from other causes than the fracture, in view of the recovery of two 
 chiUlren with fracture of the skull as well as of the humerus. Unfortu- 
 nately no autopsies were to be had to prove this assertion. 
 
 AN'ithin seventeen days these fractures usually solidlv unite, although at 
 the ninth and tenth days many of them appear perfectly firm, notably 
 those near the ends of the shaft and those in good position. 
 
 Symptoms. 
 
 A snap is heard at the moment of fracture ; crepitus is often faint, and 
 like that of an (jld l)lood clot rather than that of adult bone. An abnor- 
 iiud ])oint of motion is usually easily made out. This may, however, be 
 oltscure if the fracture be under the deltoid muscle, or if the periosteum be 
 iKtt divided. DeJ'ormity is not often marked, as the muscles are too weak 
 to hold the bone in an abnormal position. The writer has found most of 
 these fractures com])lete (not "green stick"), the line of fracture nearly 
 transverse, with little or no splintering, in the upper one-third of the 
 shaft, about the insertion of the deltoid muscle. If fracture be un- 
 lutticed for some days, the large callus often developed may call atten- 
 tion to it. The children arc irrital)le and cry out at night in the same Avay 
 that osteosco])ic pains cause "night cry" in older children. The arm 
 hangs useless, and is tender on manipulation. 
 
 DiAfJNOSIS. 
 
 The physician shoidd distinguish a liiictiirc from Erb's paralysis with 
 its late disl(x;ations of shoulder j<»int; fi-om pseudo-])aralysis of syphilis 
 (osseous dystroj)jiy): from fa-tal malformation and fi-om dislocation. Tiruiis 
 has report«'d an intrauterine sarcoma of the humerus, which would be iiai-d 
 to distingui-sl) from the callus of an intrauterine fracture. The Rontgeii 
 photography will i.pobably iiclj) greatly in dillVivntiations. 
 
FRACTL'KES IN THE NEW BORN. 305 
 
 Treatment. 
 
 The writer believes that a gypsum (plaster of paris) case around the 
 chest, and the arm bound to the case after reduction of the deformity, 
 either with plaster, starch, or ordinary gauze bandage, meets all the require- 
 ments of immobilization. If not applied with care, this may impede 
 respiration. A towel folded over the chest and removed after the plaster 
 is hard, prevents that danger. This dressing may cause erythema, des- 
 quamation, and even erysipelatous-looking eruptions, which render the 
 patients exceedingly uncomfortable. Drying powder and white flannel 
 beneath the dressing usually eliminates this difficulty. If the arm be 
 bandaged to a well-padded case there will be no danger of gangrene or of 
 musculo-spiral paralysis due to pressure. It is well to caution the nurse 
 against permitting a child to lie on the injured side, even if weU protected 
 by a solid case. Splints are exceedingly unsatisfactory, because they slip 
 readily and cause permanent deformities, which may require refracture. 
 Such slipping ma}^ delay union, as in three cases of this list. If gypsum, 
 silicate, or starch bandages are not used, it is better to bandage the arm to 
 the side of the chest with cardboard at the inner side of the arm, because 
 then there is less liability to displacement than with splints. The enforced 
 absence of bathing does the child no harm, and may be a distinct advan- 
 tage. 
 
 These are ideal cases for the treatment by massage without retentive 
 apparatus, on account of the weak musculature, small liabiUty to spasms 
 or re]3roduction of reduced deformity, and on account of their rapid heal- 
 ing even without treatment. The child will hold a fractured arm approxi- 
 mately still, and displacement, therefore, can only take place by nursing 
 and handling. 
 
 BiBLIOGEAPHY OF FrACTURES OF HuMERUS. 
 
 General references above. 
 
 Hamilton: Sth ed., Philadelphia, 1891, p. 227. 
 
 Lowenhardt: Am. Jour. Med. Science, Philadelphia, Jan., 1841, p. 250. 
 Western Med. and Surg. Kep., St. Joseph, Mo., Jan., 1891. 
 
 Gerber: Der Kinder Arzt., Worms, May, 1893. 
 
 Loviot: Ann. de gynecolog. et obstet., Paris, June, 1895. 
 
 Berry (J. J.): Kew England Med. Month., J^ewtown, Conn., 1892- 
 93, p. 257. 
 
 Kleber (J. C): Handel v. h. Genersk. Genootsch., Amsterdam, 1777, 
 p. 251. 
 
 Fractures of Forearm. 
 ISTone in this series. 
 
 Fractures of Pelvis. 
 
 There are none in this series. As the pelvis in the foetus is relatively 
 smaller than the shoulder or cephalic girdle, and well covered, there is very 
 little danger of its breaking. Euge, however, reports three cases of rup- 
 ture at the sacroiliac joint. 
 20 
 
306 REPORT OF THE SOCTETV OF THE LYTXG-TX HOSPITAL. 
 
 nUiLIOGKAl'lIY. 
 
 Ruge: Ztschr. f. Geburts. u. Frauen Kr., Stuttgart, 1875-7(i, p. OS-90. 
 
 Fkactures of Femtij. 
 
 Etiohxfy. — In breech presentation or in jHxlalic version, if the child's 
 leg be extended behind its back, the leg is certain to be fractured or dislo- 
 catetl. In })(jdalic version or breech extraction, the leg should be flexed on 
 the tliijrh, and the flexed lind) rotated inward and extended across the abdo- 
 men. The second leg is prol)al)ly usually the one fractured. The mechan- 
 ism of fracture of the femur by uterine force alone is skilfully depicted by 
 Key nulds (Practical Midwifery, X. Y., 1892, p. 248) as follows: "In breech 
 presentation with the sacrum posterior, the mid point of the flexed femur 
 (leg extendetl) is pressed against the symphysis pul)is of mother with sufli- 
 cient force to break the infant l)one.''' ]\[ensinga reports a case fractured 
 l)y the use of the blunt hook as tractor in gi-oin; ]\ratthews Duncan one 
 when the tractor in groin was a flllet. If, as in the case in this series, the 
 ))i-<)nu3ntory jutted forward, traction on the foot would bend the femur 
 acr(jss such a ])ro)nontory, while the body of the child firmly held the 
 u])per part of the infant femur well behind the eminence, and a fracture was 
 as easil}' accomplished as if the bone ^vere broken across the knee. 
 
 Prognosis. 
 
 The prognosis is as regards life good, but not as regards shortening. 
 Shortening particularly a])pears if, as is usually the case, the fracture 
 fx?curs above the junction of the upper and middle third of the bones. 
 The uncompensated action of the psoas iliacus muscle tends to tilt forward 
 tlie upper fragment. The diagnosis is easy, save possibly from congenital 
 dishx-ation, later from shortening due to epi})liyseal separation, from bend- 
 ing of the neck of the femur (Whitman), or from the sciatic paralysis men- 
 tioned by Erb as occurring in breech deliveries with extended thighs or by 
 traction u))on tho foot. 
 
 Symptoms. 
 
 The symptoms are the same as in fractures of the luunerus, but the 
 anatomical [Kjsition modifies their relation, and the deformity is more 
 marked, owing to the stronger muscles in this part of the body. 
 
 Ti;i;A'r>rK\T. 
 
 A (loid)lo Liston s])lint fi-om Ijotli axillie to the hods, with a cross-bar 
 at the feet, separating the thighs, for convenience in dressing and cleansing 
 the child, or a Pradford franie arc good when the fracture is in the lower 
 half of the bone. Immobilization is tlnis more conveniently secui'cd than 
 by a single splint, plaster, or by sus])ension of the cliild by tlie legs. 
 
 In fractures in the upper thii-d. tlie method suggested by Di-. AVyeth 
 would probably give tlie best results; that is, the leg flexed upon the thigh, 
 and the thigh upon the lK>dy, until the fragnnMits of the Ijroken femur are 
 in accurate apfMjsition and so fixed by a gvpsiiin easeleft(»n b.i- twow<!eks. 
 
FRACTURES IX THE NEW BORN. 307 
 
 BlBLIOGRAPPIY OF FeMORAL FkACTURE. 
 
 Partridge: quoted above. 
 
 Mensinga: (|noted in Brit. Med. Jour., London, March 14, 1891. 
 
 AVyeth: N. Y. Med. Jour., July 4, 1891. 
 
 Gravel! : Med. Xews, Philadelphia, May 13, 1893. 
 
 Owings: Med. News, Philadelphia, Nov. 25, 1893. 
 
 Erb: Zierasen C3"cloptedia, 1876, xi., j). 567. 
 
 Breisky: Prag. Med. Wochenschrift, 1879, ix., 244. 
 
 Morton: Lancet, London, 1878, i., 223. 
 
 O'Farrell: Phila. M. Times, 1876-77, vii., 125. 
 
 Ten Eyck (A. P.): Med. Ann., Albany, 1880, i., 9-11. 
 
 Feactdees of the Tibia and Fibula, 
 
 There were no fractures of this character in the series. Such a case 
 occurred in the indoor service of the Hospital, however, and will be 
 reported in detail at some future time. See history e, C. N. 225 (indoor 
 history). 
 
 BiBLIOGEAPHT ON FeACTUEES OF THE TiBIA AND FiBULA. 
 
 Simpson: Obs. J. W. Brit., London, 1880, viii., 553. 
 
 Multiple fractures, not at once causing fatal issue, seem from these his- 
 tories to do better than in adults, in whom shock is a greater factor. Shock, 
 if occurring at all in infants, would probably be only a respiratory stim- 
 ulus. The child with both clavicles fractured and the one with skull and 
 humerus both did very well. 
 
 Summary. 
 
 Coston says the dangers of breech deliveries to a child are : pressure on 
 the cord, asphyxia, traumatisms to the head, intracranial haemorrhages, 
 slipping of an arm over the head, fractures of the humerus, contraction 
 of an incompletely dilated os uteri around the neck of the child. The 
 writer would add: fracture of the clavicle, Erb's paralysis from the Smellie- 
 Yeit method of delivery, fractures of the femur from extended legs, sciatic 
 paralysis, fractures of the tibia from the use of a fillet. 
 
 BiBLIOGEAPHT. 
 
 Coston: Therapeutic Gazette, Detroit, 1896, xxxv., p. 604. 
 
PLACENTA PREVIA. 
 
 By George E. White, M.D. 
 
 Amont, the first 10,000 cases delivered by the Hospital were 31 cases 
 of })lacenta pra?via, which are ])resented briefly in the table on opposite 
 page. 
 
 Definition. 
 
 This term was first used to designate a placenta that Avas supposed to 
 have become detached and gotten below the head of the child. At present 
 the term means an implantation of the placenta in the lower part of the 
 uterus covering more or less of the zone which must dilate during labor. 
 Before labor begins, this zone extends between 2^ and 3 inches above the 
 internal os. When the placenta occupies part of this zone, but does not 
 extend over the dilated cervix, the condition is called "placenta pra?via 
 marginalis; '" wlien the dilated cervix is covered partly with placenta and 
 partly with membranes, it is called "placenta pra?via partialis," and when 
 the dihited cei-vix is covered entirely ])y ])lacenta, it is called "placenta 
 praevia centralis." The latter term does not imply tliat the placenta is 
 directly central, as that is a condition rarel}^ met with. Many writers, 
 including Parvin and MuUer, make but two subdivisions, complete and 
 partial. 
 
 Frequency. 
 
 Tliis condition occurs 31 times in Jo.odo cases, or 1 to 322. This 
 number is somewhat higher than the normal ratio, since some of the 
 ])atients were consultation cases referred to the IIos])ital by outside physi- 
 cians an<l midwives. In over 800, OOO deliveries tiibiilated by IMiillci-, this 
 condition occurred about J to 1, ()()(»; and in (Kmijkh) cases tabulated 1)V 
 Parvin, it was present about 1 tf) l,2<-'0. 
 
 The distribution of our cases has been nov uneven. TJins t Iiei'o were (! 
 among tlie first 500 cases, wliile at anotliei- lime tlier<> were over 2,000 
 delivj-ries witli but a single case- of jdacenta, ])i-a'via. This une(|u;il distri- 
 bution is alsf> noted by Sa.xtorj)!! and by iS'iigle (K. Iligby, jMidwifer^', ]>. 
 504), who states that in some years ])lacental presentation is so frequent 
 that it seems as if it were almost epidemic. 
 
PLACENTA PREVIA. 
 
 309 
 
 
 
 
 
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3111 REPORT OF THE SOCIETY' OF THK LVIXG-IX HOSPITAL, 
 
 Re^J-aiiliii"- the friHjUOiu'V of tho ditVoi-ent implaiUatioiis, tliere is some 
 (litticultv in getting satisfactory statistics, as different metliods of classifi- 
 cation are adopteil. ^fiiller in 270 cases found 20 per cent, central. Town- 
 send (IJost. Med. and Surg. Jour., IS*.);}, p. 129) in his 28 cases found 15 
 nuirginal, S hiteral, 5 central, or IS percent, central. Boss (Med. Kec, 
 Feb. 1, 1S1>«'») in 13r> casos found 28 per cent, central, 01 per cent, partial, 
 and 11 percent, marginal. TJiese -lo;^ cases give about 22 per cent, cen- 
 tral. ( Uir statistics show 10 central (;>2.2 per cent.); 9 partial (29.2 per 
 cent.), and 12 marginal (88. per cent.). 
 
 UCCIKKENCE. 
 
 It is often stated tliat j^lacenta pra'via occurs most frequently in old 
 multipara^ with relaxed uterine walls. Thus ]Muller gives the ])roportion 
 of })rimi})ara^ as 1 to 0, but that is not far fi-oni the normal ratio of first to 
 subsecjuent ])regnancies, and it seems doubtful if uudtiple pregnancies have 
 anything to do with the occurrence of the condition. Townsend, among 
 28 cases at the Boston Lying-in Hospital, reports 11, or about io per cent. 
 of the ca.ses in ])rimi|)ara\ 
 
 Our cases are distributed as follows: 
 
 Cases. 
 
 The 1st pregnancy 4 
 
 ''2d " ' 9 
 
 "3d " 1 
 
 "4th •' 6 
 
 " 5th " 2 
 
 The 6th 
 
 " Sth 
 
 pregnancy .... 
 
 Cases. 
 
 2 
 
 2 
 
 " 9th 
 
 u 
 
 1 
 
 " 10th 
 
 u 
 
 3 
 
 " 13th 
 
 u 
 
 1 
 
 The second pregnancy furnishes 29 per cent, of our cases. 
 This distribution seems to be purely accidental. 
 
 ETior,()(;v. 
 
 The cause of the trouble is still unknown. Parvin attributes placenta 
 pra'via to a diseased endometrium, which is apt to cause frecpient al)ortions, 
 but anuing our cases only foui- had liad ])rcvious abortions. Man}' writei's 
 are of the o))iiiioii that it is simply due to a ]o\\' attachment of the pla- 
 centa. Ilofmein- (/iir Anatomic line .Ktiologic dcr i'lacenta l*ra>via, 1890) 
 and more rj'ccntly JvaltcMbach liave advanced iIk; theory that the choi'ionic 
 villi develop in ihc dccidiia icllexa as well as in the serotiiia, and the 
 refle.xa subsecjueiitly beconuis attached to th(^ vera, forming a ])art of the 
 placenta. If this process takes ))lace in the lower pole of the ovum, 
 the cervix is liable to be more or less covered. 
 
 Pljicentii succentnriata and the f)ther mallV)rmations are sup])Osed to be 
 formed by a similar pn^cess. Anu)ng our cases theiM? was one velamentous 
 insertion of the cord and one markedly lolnd placenta. No case of pla- 
 centa succenturiata was f(Mind. althou^-h it is not an nnc-ommon (-oniplica- 
 
PLACENTA PRiEVIA. 
 
 311 
 
 tion. In one case (729) the placenta covering the cervix was so very thin 
 and non-vascular that labor was terminated without any interference. 
 According to this theory, the condition is due to an anomaly of develop- 
 ment of the ovum, and the cause is foetal rather than maternal. Barnes, 
 Hart (Brussels Congress, 1892), Ahlfeld, and others oppose Hofmeier's 
 views and adhere to the theory of the low implantation of the ovum. 
 Hart asserts that it is no uncommon thing for the chorionic villi to grow 
 into tlie decidua retlexa, but they subsequently atrophy and do not form 
 part of the placenta. 
 
 Complications. 
 
 Faulty presentations of the child are of common occurrence, owing 
 undoubtedly to the placenta occupying the space usuall}^ filled by the pre- 
 senting part. 
 
 Shoulder presentations were seen in 9 of our cases, or in 29 per cent. 
 If these 9 are excluded, this presentation forms less than 0.8 per cent, of 
 the 10,000 cases. 
 
 The breech presented but once, and in that case the child was prema- 
 ture. It would seem that placenta preevia does not predispose to breech 
 presentation. 
 
 Twins occurred twice. 
 
 Symptoms. 
 
 The chief symptom of placenta prtevia is haemorrhage. This may come 
 on at any time after the placenta is formed, but rarely before the sixth 
 month. 
 
 Those who believe in the theory of the low implantation of the ovum 
 claim that it is a frequent cause of abortion. 
 
 Among our 31 cases the first hsemorrhage occurred as follows: 
 
 Cases. 
 
 In the 5th month 1 
 
 " 6th " 5 
 
 " 7th " 5 
 
 Cases. 
 
 In the 8th month 8 
 
 At or near term 12 
 
 Dilatation of the lower segment of the uterus during labor is one of 
 the causes of hasmorrhage, but not the only one, as hgemorrhage sometimes 
 takes place without any sign of labor, beginning perhaps while the woman 
 is asleep. This is probably caused by want of uniformity in growth of 
 the placenta and lower uterine zone. The placental site is supposed to grow 
 more rapidly than the placenta and tear open the uterine sinuses. 
 
 Haemorrhage occurring before labor usually comes on without any warn- 
 ing. The first attack, as a rule, is not severe, but is almost certain to be 
 followed by others, increasing in severity as pregnancy advances. Excep- 
 tionally, the first attack may be fatal. In other cases there is a constant 
 oozing of blood, which keeps on until the patient is exsanguinated. 
 
ol'.i REPORT OF THE SOCIETY OF THE LYING-IN HOSPITAL. 
 
 Diagnosis. 
 
 The (.liairnosis is made bv feelino- tlie placenta. This may sometimes 
 be done bv abdominal i)al[)ation or vaginal examination before labor 
 begins. 
 
 AVhen the cervix is dilated, the diagnosis presents no dirticulty, except 
 in some cases of marginal implantation, in Avhich the edge of the placenta 
 becomes detached from the lower zone and remains suspended in the cervix, 
 surrounded by blood clots. The examining linger may then be passed 
 around the entire lower zone of the uterus without feeling the placenta, and 
 one is a])t to make an error unless the entire surface of the presenting* 
 membranes be examined. 
 
 The diagnosis was not made in any of our cases before haemorrhage 
 began. 
 
 Prognosis. 
 
 The prognosis depends largely upon tlio time the patient is seen, the 
 method of treatment, and skill of the operator. 
 
 Miiller, in an analysis of 1,574 cases, puts the maternal mortality as not 
 less than 3<'> to 4(> ])er cent., and the fa^tal mortality as (U) per cent. 
 Ahlfeld ]nits the maternal morttdity at 2.") ])er cent. Winckel claims it 
 ought not to be over 5 to 1(» per cent., while the foetal mortality is seldom 
 less than 50 per cent., and often 75 per cent, or more. 
 
 Tkeatment. 
 
 No single operation will suffice for all cases, but treatment depends 
 u]ton the condition of mother and child and the location of the ])lacenta. 
 While stnne cases do well with a purely exjiectant plan of treatment or 
 early rupture of the membranes, others can barely be saved by most 
 prom])t an<l skilful opei-ative i)rocedure. 
 
 IVrliaps the oldest method of treating this condition is tliat known as 
 accouchement force. A satisfactory definition of this term is not easy to 
 find ; the dictionaries ])ara])hrase it in several languages, but do not define 
 it. Foster states that it is a forcible termination of labor by version or 
 force])s; l)ut this is a sense in which it is never used. Parvin (Am. Text- 
 I'o<;k of Obstet., ]). 5!m;) asserts that the term has undergone a change of 
 jueaning, whicli is undoubtedly the case. As used by the older writers, 
 it meant (h-igging a child through an undilated cervix. As used at the 
 Lying-in Hospital, the term means artificial termination of labor tlirougli 
 the natural passages, and includes manual dilatation of the cervix, rupture 
 of tlie membranes, and ra]>i(l extraction of the child by force])S or version, 
 or other operations. No force need be used. 
 
 Altliough this method is condemned by AVinckel, husk, i'arvin, and 
 most obstetrical writers, it is the irent nieiiL most in use at the Lying-in 
 Hospital, and at present is used almost e.xeiusively in IIh; severer cases in 
 
PLACENTA PR /R VI A. 313 
 
 wliicli the cliild is living-. The details of the o])eration are given in a sub- 
 sequent paragraph. 
 
 In the latter part of the last century the vaginal tampon was intro- 
 duced by Wigand and Leroux. The vagina was packed as soon as the 
 diagnosis was made, and the tampon left in place until it was expelled by 
 the advancing child. Wigand states that in a large obstetrical practice he 
 lost neither mother nor child; but other obstetricians have been less success- 
 ful, and the procedure is not in general use, except as a preliminarv to 
 other measures. Haemorrhage can be stopped at once by a well-applied 
 tampon, which may be left in place until ready to operate. There is but 
 little danger of severe hcemorrhage taking place above the tampon. Parvin 
 (Text-Book, p. 388) states that no case of the kind has ever been recorded. 
 Eecently Diihrssen (Deu. Med. Wochenschrift, 1894, p. 422) has reported 
 a fatal case of haemorrhage into the uterus after the vagina had been tam- 
 poned b}'' a midwife. 
 
 The tam])on is still a favorite method of treatment by Tarnier. As 
 low a maternal mortality as 1.7 per cent, is claimed by its use (Labus- 
 quiere: Ann. de gyn., Jan., 1896, p. 60). Three cases of placenta pr^evia 
 marginalis were treated by this method at tlie Lying-in Hospital, with 
 favorable results to all the mothers and two children ; the other child was 
 not viable. These were probably cases which would have done well with- 
 out any treatment. 
 
 Cohen's method consists in detaching the placenta from the lower zone 
 of the uterus and leaving the deliver}^ to nature. Haemorrhage often ceases 
 when the placenta is partially detached in this manner. This procedure 
 has been used in several of our cases, in addition to other means of treat- 
 ment, but never alone. 
 
 Braxton Hicks, in his work on combined external and internal version, 
 in 1864, made a great advance in the treatment of placenta pra?via. His 
 treatment consists in version by the method which bears his name, plug- 
 ging the cervix with the breech to prevent haemorrhage, and leaving the 
 child to be delivered by the natural forces. This method is in very exten- 
 sive use at the present day, and some obstetricians report excellent results 
 as far as the mother is concerned. Thus Duhrssen saved all but one 
 of twenty-two mothers, but onl}^ three children survived. The same author 
 states that the best statistics show a foetal mortality of at least 60 per cent. 
 Lusk's statistics show 178 cases treated by eleven operators, with only 
 eight deaths. Other obstetricians are not so successful with this method. 
 The hemorrhage does not always stop when the breech is brought down. 
 Speigelberg has pointed out that this is because the haemorrhage does not 
 come from the cervix, the part plugged by the child, but from a point 
 higher. 
 
 One case (398) of breech presentation was delivered bv this method at 
 the Lying-in Hospital, with favorable result to the mother; the child was 
 dead when the patient was first seen, and this operation was chosen, as 
 only the interests of the mother were considered. 
 
 The method most in use at present is often attributed to Barnes. It 
 
314 REPORT OF THE SOCIETY OF THE LVIXG-IX HOSPITAL. 
 
 consists in fully dilating tlie cervix Avitli Ihirnes's bays and delivering the 
 ihild by vei*sion or forcej)s. The results vary with the different ojierators. 
 Anionsr the best stiitistics arc those of Thomas (Trans. N. Y. Obst. Soc, 
 vol. i., j>. 2i'>2), 18 cases, Avith two deaths; one from sepsis and one from 
 ]»osti)ai-tum hannorrhagc. Murphy (Brit. Mvd. Jour., 1893) reports only 
 two deaths in (>2 cases. One of these was from se])sis, and one from 
 h;emorrhagc before assistance arrived. The children did not fare so Avell. 
 Onlv three lived out of a ])ossible nine. In his later re])ort the children 
 are not mentioned. DUhrssen, by using the Champetier de Ribes balloons, 
 lost but one mother in '2Ct cases. These statistics give but little idea of the 
 morlalitv by less skilful o})erators working under less favorable conditions. 
 
 At the Lying-in llos])ital the Barnes bags have been used live times 
 (Xos. 2<»2. 4.").'), 1.198, 8,4<)r), 0.231) — three times as a preliminary measure 
 for manual dilatation; once the ])atient refused treatment, and was dis- 
 charged undelivered; and in the fifth case the uterus was ruptured. The 
 case is given lu'ieflv as follows: 
 
 Xo. 1,198. — liussian ; \1. para ; 36 years ; six months pregnant. 
 AVhen lii-st seen the patient had been bleeding alwut twelve hours; the cer- 
 vix was <lilated a])()Ut the size of a silver quarter, and tlie ])lacenta was felt 
 attached low down upon the left side. A Barnes bag was inserted to dilate 
 the cervix; after it had been in place about ten uiinutes, it suddenly ru])- 
 tured. The cervix was dilated enough to admit the hand, and the child 
 was extracted by version. Upon introducing the hand again, a coil of 
 intestines was drawn out and the uterus found to be ruj^tured in the poste- 
 rior }>art. The placenta was extracted manually, and the wound in the 
 uterus packed with gauze. Tlie child was still-born, and the mother died 
 thirty-six hours after delivery. 
 
 Barnes's bags have not been much used at the Lying-in Hospital for 
 placenta pncvia. They are liable to ru])ture at a critical ])eriod and arc 
 <litlicult to make aseptic, unless they are put in the steam sterilizer, which 
 soon spoils them. Moreover, they are entirely unnecessary, as the iodo- 
 ff»i-m gauze tam])on and nuinual dilatation are much more satisfactory means 
 of dilating the cervix. 
 
 The balloons of Cham])etier de Ililjcs, wliicli are ])()))ular in many of the 
 continental clinics, have not been used for tliis condition. 
 
 None of the otlier methods of ti'catment described in the text-books or 
 recent literature has been tried. 
 
 ClIOICK. 
 
 The choice of Ihf; operations depends ciitii'dy npon ihv. conditions found. 
 The vaginal tampon suffices in many cas<!S, with marginal Implantation of 
 the ]»lacenta. Braxton llicks's method is useful if the child ])e dead or 
 nonviable. J'arnes's bags arc now rarely or never used. Accouchement 
 fonx- is employed in nearly all the severer cases, if the child is living 
 and viable. 
 
 Jewett states that patients wlio have lost nnich Mood stand operation 
 badly, and ad vi.ses an expectant plan of treatment, as follows: the life of 
 
PLACENTA PREVIA. 315 
 
 the child may be disregarded ; hiemorrhage checked hy a vaginal tampon ; 
 stimulants and a small quantity of ergot given; and delivery left to nature, 
 or done after the patient rallies. 
 
 Among our 31 cases, one (729) received no treatment; three were treated 
 by vaginal tampon only; one was delivered by pulling down a foot and 
 leaving the delivery to nature; in one case Barnes's bags were used and the 
 case left undelivered, and 25 were delivered by accouchement force. 
 
 The treatment as carried out at the Hospital depends upon the conditions 
 found. Cases of high marginal attachment of the placenta, in which the 
 lower edge becomes detached and causes hgemorrhage during the first stage 
 of labor, usually require no special treatment, as the haemorrhage is not 
 sufficient to cause alarm, and the descending head rarely fails to check it. 
 If, however, anj^ treatment be necessary, early rupture of the membranes 
 or a vaginal tampon is all that is required. If the patient is bleeding 
 from a placenta preevia, a vaginal tampon of iodoform gauze is inserted, 
 and kept in place until all preparations for the operation are made. In 
 cases in which the cervix has not begun to dilate, or is not readily dilat- 
 able, the cervix and vagina are packed with iodoform gauze, which is left 
 in place four hours or longer, and reinserted if the first tampon has not 
 dilated the cervix or softened it sufficiently to admit of read}^ dilatation. 
 The operation is carried out under the usual antiseptic precautions, the 
 details of which need not be mentioned here. 
 
 After giving an aneesthetic, the patient is placed in the lithotomy posi- 
 tion. A hand is passed into the vagina, and dilatation accomplished by 
 gradually working one finger through the cervix, then two fingers, and 
 so on, until the whole hand is admitted. Dilatation is then done rapidly 
 by doubling the hand into a fist while in the uterus and withdrawing it. 
 The operation is often very tiresome. In some cases, as soon as the cervix 
 will admit two fingers, both index fingers are inserted, and traction made 
 laterally in opposite directions. 
 
 When possible, the cervix is dilated thoroughly, as it offers considera- 
 ble resistance to the passage of a head after it will admit a fist. Hemor- 
 rhage is not profuse in the majority of cases, probably owing to the fact 
 that the lower uterine segment is but little disturbed until the cervix is 
 quite wide open. In some cases, however, profuse haemorrhage does occur, 
 and requires the dilatation and version to be done very rapidly. 
 
 In the writer's opinion, Diihrssen's incision would be indicated in cases 
 of rigid cervix in which the supravaginal portion is obliterated, and the 
 resistance is at the external os; but no case in our records has required that 
 operation. 
 
 After the cer\dx is dilated, the membranes are ruptured or the placenta 
 is perforated, if necessary, and a foot brought doAvn. Delivery is effected 
 as soon as possible, following the usual methods, being careful to prevent 
 the arms from becoming extended, as dela}^ from the after-coming head is 
 liable to be fatal to the child. 
 
 The placenta is extracted manually soon after delivery, as hgemorrhage 
 is apt to persist until it is removed. 
 
310 REPORT OF THE SOCIETY OF THE LYIXG-IX HOSPITAL. 
 
 The time of the o]>eratii>u varies greatly, owing to the condition of 
 the cervix. It was: 
 
 Cases. 
 
 55 minutes 1 
 
 30 •• 2 
 
 25 •• 2 
 
 15 •• 1 
 
 Cases. 
 
 10 minutes 2 
 
 5 '• 2 
 
 8 " ?> 
 
 The exact time was not recorded in tlie other cases. 
 
 The chiUlren ai-e fre(|uently ])rematnre, and if aspliyxiated are resnsci- 
 tateil l»y the most gentle measui-es. Continuous swinging and vigorous 
 treatment of any kind is a[)t to l)e fatal to these premature babies. 
 
 Results. 
 
 In considering tlie results, allowance must be made for the conditions 
 umler which the operations were performed. They were all done in tene- 
 ment houses, with most unsanitary surroundings, and often not seen for 
 several hours after ha^morrhao-e had beo-un. 
 
 There were four maternal deaths among our 3i> cases, or 13.3 per cent. 
 The causes of death were: Sepsis, ])ulmonarv oedema on the third day after 
 lalxjr, hiemorrhage before assistance arrived, and rupture of the uterus. 
 
 Of the 32 children, including two cases of twins, six had not reached 
 the age of viability, four were dead when first seen, four died during 
 labor, and three died soon after delivery. This gives a total mortality of 
 17, or 53.1 per cent. Excluding the nonviable and dead children, 15 were 
 siived out of a possible 22, or a mortality of 31.8 per cent. Of those 
 which dird during lal)Oi'. tlie death in most cases could be attributed to 
 delay bcl'oi-e opci-ating. Of those whicli died soon after delivery, one was 
 ])remature and died of atelectasis six hours after birth, and its death was 
 not due in any way to the method of operation. 
 
 AViiile tiiese results are not entirely satisfactory, they refute tlie state- 
 ment of Pacjuy (Gaz. med. de Paris, 03, Xo. 4!>) and others, that the fa'tal 
 mortality is so high that the life of the child should be disregarded. 
 
 In a w«'ll-e(juipjM'd hos])ital, where the cases can be seen early, the mater- 
 nal mortality <night to l;e mucii smaller than these statistics show% and our 
 mortiility of 31.8 i)er cent, of viable children reduced at least a half. 
 
REPORT OF THE CURATOR. 
 
 By Jabies W. Markoe, M.D.. and Martha Wollstein, M.D. 
 
 This report is intended to cover a period of nearly six years, but owing 
 to the impossibility of preparing and storing specimens during the first 
 years, when the work was performed in part at the Dispensary in Broome 
 Street and in part at the laboratory of the Embryologist, it was necessarily 
 incomplete. Thus many of the early specimens were lost, and it is only 
 within the past two years that they have been systematically prepared. 
 Even at the present time, the only place provided for the purpose is entirely 
 inadequate. 
 
 It can, therefore, be but an outline of the preparations at present 
 mounted upon the shelves of the Museum, together with the various 
 models. 
 
 The wet specimens are prepared either in alcohol or formaline, and 
 are arranged in such an order that they may be referred to during the 
 course of any lecture. 
 
 In addition to the wet specimens, wax models and similar preparations 
 have been purchased abroad, and have also been prepared by members of 
 the Medical Board. These form a very valuable addition to the depart- 
 ment. 
 
 Collection, 
 
 22 models of normal pelves, male and female. 
 
 22 models of deformed pelves. 
 
 2 rubber pelves. Tramond, Paris. 
 
 1 wax model of the female pelvis (median section), with a portion of 
 the vertebral column, showing the relations of bladder, uterus, and rec- 
 tum; also the external genitalia. Tramond, Paris. 
 
 1 ovology set, showing the formation of the ovule in the ovary, its 
 course in the tube, and its fecundation, allowing all the modifications that 
 the germ and its envelopes undergo to be followed from the first to the 
 thirtieth day ; that is, from the appearance of the oyuIq in the ovary to the 
 formation of the embryo. Auzoux., Paris. 
 
 1 wax model human uterus, pregnant. Three months' foetus in mem- 
 branes. Tramojul, Paris. 
 
 1 series of His models of human embrvos, comprising 8 models in the 
 first month of development. Ziegler, Freiburg. 
 
318 REPORT OF THE SOCIETY OF THE LYIXG-IX HOSPITAL. 
 
 1 series of His models of liunuin einbryus, foiiiprising S models in the 
 second month of development. Ziegler, Freiburg. 
 
 2 mo<.lels of the development of the human embryo (wax). Ziegler, 
 Freihury. 
 
 1 series of His models of chick embrvos, comprising 23 models, enlarged 
 fortv times the real size. The first 9 models show the development of the 
 fii*st and second days of ineubation; tlie next 4 models show tlie third and 
 fourth days; numbers 14 to 17 are bj-ain models; IS to 21, hearts; and 22 
 to 23 intestine. Z'n</h>i\ FreiJud'tj. 
 
 1 series of His models of the develo])ment of tlie human brain (wax), 
 com})rising S models from embryos of 4 weeks to 3 months. Zieyler, 
 Freihury. 
 
 1 series of Ecker models of the development of the convolutions of the 
 cei-ebral liemis])lieres in the human foetus, comprising 14 models which 
 show 7 stages of development in embryos from 12 to 36 weeks old. Ziey- 
 ler, Freihury. 
 
 1 series of ]^Ian/. models of the development of the e3^e in vertebrates, 
 comprising models. Ziegler^ Freihurg. 
 
 1 series of His models of the development of the internal ear (human), 
 P'our models in embryos 4 weeks to 2 months old. Z'teyler, Freihury. 
 
 1 series of Rose models of the development of human teeth. Six 
 models from embryos 2 to 30 centimetres in length; finally, the second 
 temporary and the first permanent molar, just prior to birth. Ziegler, 
 Freihury. 
 
 1 series of His models of tlie development of the human heart. Twelve 
 models from embr3'os 2 millimetres in length, to the fifth week. Ziegler, 
 Freihury. 
 
 1 scries of Born models of the development of the mammalian heart, 
 comprising 11 models, magnified sixty times the real size, showing 7 
 stages of development, including the aortic arches in 3. Zieyler, Freilmry. 
 
 1 series of Born models of the development of the human heart, com- 
 prising 3 models which show 2 stages (lieginning of the third and middle 
 of the sixth month) in the formation of the auricular septa anil valves. 
 Ziegler, Freihury. 
 
 2 models in clay of vagina. I)r. Luiuhert. 
 
 3 models of uterus: (1) unimpregnated; (2) first month of pregnancy; 
 (3) second month of pregnancy; natural size. />/•. Kdyar. 
 
 7 corrosive ])re])arations of placenta'. Dr. JJuiiiinyfon. 
 
 1 models, clccti-otypc, laceration of ])erineum with sutures in place. 
 Pla.ster covered willi thin layer of cojjpei-. />/■. F/yar. 
 
 2 normal skulls of fcetiis at birth. Truinond, Pai'is. 
 
 1 skull showing result of o('ripitf)-])ostei'ioi' ])osition. Trnmond, Paris. 
 
 2 normal skulls of younger einbiyos. I^uhiioik}. Paris. 
 
 1 skull of fd'tus at birth, showing (lee]) depression of left ])arietal Ixme, 
 made by forcops. 
 
 1 skull of ffX'tus at term, sliowiiiH^ li-ietin'e :iii(l over-i'idiiig of both 
 parietiil bones, tlie result of eniiiiotoinv. 
 
REPORT OF THE CURATOR. 319 
 
 Wet Specimens. 
 
 In addition to loO specimens mentioned in the previous Keports of the 
 Hospital, 32 in the first and 68 in the second, tliere are T-t which have 
 been prepared and classitied as follows: 
 
 Placenta and nnil)ilical cord, showino- calcareous deepen- 
 
 eration, twin, and other abnormalities 5 
 
 Umbilical cord, volvulus 1 
 
 '' " double knot 1 
 
 Monsters 5 
 
 H3^drocephalic 1 
 
 Anencephalic 2 
 
 Cretin 1 
 
 Diaphragmatic hernia 1 
 
 Twins 4 
 
 Embryos 30 
 
 Longitudinal median section, showing relations of all the 
 
 viscera 1 
 
 Longitudinal median section, showing all the serous 
 
 cavities 1 
 
 Foetus at term 3 
 
 Foetal organs 14 
 
 Heart, lungs, and thymus gland 4 
 
 Kidneys, ureters, and bladder 4 
 
 Brains (2 hydrocephalic) 5 
 
 Intestinal stenosis 1 
 
 Longitudinal section through thigh, leg, and foot, show- 
 ing diaphysis and epiphysis of femur and tibia, also 
 
 patella and bones of foot 1 
 
 Uterus of mother from cases of rupture, Cgesarean sec- 
 tion, etc 8 
 
 Total number 74 
 
 Some of the specimens are mounted, others are still in various stages 
 preparatory to a permanent mount in alcohol or formaline. 
 
 For several months past the method of Jores,* which aims to preserve 
 the natural color of the organs and tissues, has been used both for embryos 
 and viscera. The results thus far obtained have been eminently satisfac- 
 tory. 
 
 * Centralblatt fiir AUgemeine Patliologie unci Pathologische Anatomie, bd. vii., 
 No. 4. 
 
REPORT OF ORTHOPEDIC SURGEON. 
 
 Fro.ai April 1, 1893, to April 1, 189G. 
 
 By T. Halsted Myers, M.D. 
 
 Six thousand seven hundred and sixty cases of confinement were 
 attendeil Ijv the physicians of this Society during this j^eriod. 
 
 Sixtv cases of deformity were noted, wliich may be tabulated as 
 
 follows! 
 
 Cases. Cases. 
 
 AiK'ncepliahis 9 
 
 Absence of lingers and toes 1 
 
 right Jiand 1 
 
 Cleft palate 8 
 
 Deformity of hands and feet. ... 1 
 
 E])iithyseal se|)aration 1 
 
 Ilydrijcephalus 4 
 
 and ta]i])es varus. 1 
 
 Hare li). 8 
 
 I leforinity of genitals, su- 
 
 ])('i-nuinorary fingers and toes . 1 
 
 Imi»crf(»rate anus 3 
 
 Monster 2 
 
 Phimosis 2 
 
 Rudimentary tail 
 
 Spina bifida 
 
 Su])ernumerary fi n gers 
 
 " toes . . 
 
 fingers and toes . 
 auricle 
 
 Talipes varus and im])erfo]-ate 
 
 anus 1 
 
 Talipes varus 11 
 
 Teeth atbirtli 1 
 
 Weljbed toes 1 
 
 fint'-ers 1 
 
 .tal 
 
 r.o 
 
 Poh/thirti/IiKm. — The cases of siipciiniinciary lingers and toes presented 
 nearly all the varieties known, and the following are detailed as examjOes: 
 
 It was im))ossiblo in the first case to secure ])]iotogi'a])lis of the hands 
 an<l feet, therefore rough sketclu'S are given. 
 
 The riglit hand was norniiij. except that a I'udiinentaT-y tei-niinal ])lia- 
 lanx. with nail, was attached by a very thin pedicle of skin, one-eight li of 
 an inch long, t(^ the fifth finger, op])osite Hh' joint between the second and 
 third phalanges (Fig. I). 
 
 The left liand was normal, exce])t that a similar, but somewhat better 
 developed, terminal ]>halanx, with nail and cartilage, was attached b}' a 
 fleshy ])edicle to the fifth finger, opposite the middle of the thiid piialanx 
 0:\' 2). 
 
REPORT OF ORTHOPEDIC SURGEON. 321 
 
 The great toe of the right foot has t\vo terminal pliahmges, Avith sepa- 
 rate bones and partly divided nail, articulating with a single broader prox- 
 imal ])halanx. The second and third toes are Avebbed up to the terminal 
 phalanx ; the fifth has a double terminal plialanx, each with its nail, but 
 both articulate Avith the same proximal phalanx (Fig. 4). 
 
 The left foot presents a A^ery similar deformity, but in this case the 
 great and fifth toes have all their phalanges double. The sketches shoAV 
 the extent of the Avebbing in each case (Fig. 5). 
 
 The family history in this case is remarkable. This boy's grandfather 
 had six fingers and six toes on both right and left sides. The father had 
 six toes on each foot, but his hands Avere normal. One brother of the 
 father has polydactylism of hands and feet. Four other brothers of the 
 father Avere normal. Tavo of them Avere married and their children Avere 
 normal. This child is the sixth and last. Both the first and second of the 
 children, boys, had six fingers and six toes on each side. The third child, 
 a boy, had six toes on one foot, otherAvise Avas normal. The fifth child, 
 a girl, Avas normal. 
 
 The deformity in the second case is unusual: the right hand has a 
 double thumb with double metacarpal bones, and is Avebbed completel}^, 
 but has only one nail. The first finger is rudimentary throughout, and has 
 no power of flexion or extension. The second and third fingers are fully 
 dcA'eloped, but are Avebbed completely; the fourth finger is normal. The 
 prehensile poAver of the hand is good, and no operative measures are 
 adA^sed (Fig. 6). 
 
 The third case is an example of the simplest form of the deformity. 
 The other members of the family Avere normal, as far as Avas knoAvn ; the 
 extra finger, a poorly developed terminal phalanx, with its nail, Avas 
 attached by a long, narroAV pedicle to the proximal phalanx of the little 
 finger of the left hand (Fig. 3). 
 
 A number of the other cases presented deformities similar to those 
 already shoAvn. 
 
 Adactylisin. — Suppression of both fingers and toes. 
 
 Kight hand: thumb, metacarpo-phalangeal joint malformed ; phalanges 
 slightly adducted ; index and second fingers absent beyond the metacarpo- 
 phalangeal joint; little finger normal; third finger is flexed and adducted 
 at the joint, betAveen second and third phalanges (Fig. 1). 
 
 Left hand: thumb normal; first finger lacks first and second phalanges; 
 second and third fingers av ebbed completely; tAvo bones and two nails; 
 fourth finger normal (Fig. 8). 
 
 Right foot : great toe adducted ; second and third toes, including corres- 
 ponding metatarsal bones, absent; fourth and fifth metatarsal bones present, 
 but only one toe, Avhich seems to be the fifth, and this articulates Avith the 
 fifth metatarsal (Fig. 9). 
 
 Left foot: same deformity as in the right foot, but in this case it seems 
 to be the fourth toe which is present, and this articulates Avith the fourth 
 metatarsal. The parents say that the umbilical cord was found passing 
 over the points marked " x," but this explanation is probably incorrect, as 
 
322 REPORT OF THE SOCIETY OF THE LYIXG-IN HOSPITAL. 
 
 most authorities now thinlc these deformities are dependent upon changes 
 in the embryonal cell mass (Fig. 10). 
 
 TorticoUtK. — Two of the cases of torticollis illustrate different ways in 
 which this tleforniity may originate. In the lirst case the deformity was 
 notetl a few hom*s after birth and for the next two days. I saw the child 
 three and a lialf days after birth, and there was then no deformity of any 
 kijuh nor anv induration in the muscles of the neck. This is interesting, 
 as congenital torticollis is genei'ally believed due to an actual shortening of 
 tlie sternocleido mastoid, and cases where the deformity is seen just after 
 birth are commonly ascribed to the irritation of an ha^matoma in that 
 muscle, caused by some traumatism received at birth. In this case it 
 would a]>}iear to have been due to a temporary ])aralysis of the muscles 
 on one side of the neck, allowing their opponents to incline the head in the 
 opjMDsite direction. 
 
 The second case was a breech presentation. Xo deformity was noted 
 at birth. A tumor was first seen fourteen days afterwards in the sterno- 
 cleido nuistoid on the right side, at the junction of the middle and u])per 
 thirds of the muscle; the head could be inclined to the left normally, 
 but the rotation of the chin to the right was less by 30 than on the oppo- 
 site side. This case under massage and manual correction steadily improved, 
 and both the haematoma and the deformity entirely disappeared in a few 
 months' time. 
 
 JL(r> L'q). — One simple case with cleft on left side, involving soft parts 
 only, Avas operated upcju with excellent result. The stitches were removed 
 in five days; union Avas ap})arently complete, but during some violent fits 
 of crying the Avound was torn open. A secondary operation secured a very 
 fair result. 
 
 In a second case there was a douljle maxillary cleft and eversion of 
 pnemaxillary Ijone. The hard and soft palate were also completely cleft. 
 The child was ])uny, l)ut was able to nurse. She was when last seen three 
 months of age, but not in a condition to undergo the radical operation 
 indicated. 
 
 I I ndiinenUmj Tail. — This girl when she was four weeks old presented 
 the appearance roughly shown in the sketch; this, however, accui'ately 
 indicates the i-elative i)Osition and extent of the folds in the gluteal region 
 and tlie thighs, A tail-like process, 1^ inches long, with a slight indenta- 
 tion at its extremity, was attached to the gluteal region about 1^ inches to 
 the riglit of tlie central gluteal crease. This Avas excised two weeks later 
 and was found to be a mass of fibrous and fatty tissue attached to the 
 ])eriosteum covering the end of the coccyx, which was itself deflected to a 
 ]»osition at riglit angles with the last segment of the sacrum, and at this 
 ]K»int there wjus abnormally free movement. The anus was situated in the 
 deep fold immediately lielow this tail-like process, apparently \\ inches to 
 right of median line. The seconchiry gluteal fold on the right side. l)elo\v 
 the fold just mentioned, was of (-(lual (l<'i)tli and extent witli the latei'wl gluteal 
 crease on the left side, as shown in the sketch, ;iii<l was on the same hori- 
 zontal |»lane. Tln-re were noother ahnonnalitics noted in this case (Fig. 11.) 
 
Fig. I. 
 
 Fig.2. 
 
 K'^ 
 
 Fic/.3. 
 
 > 
 
 X 
 
 Flg.4. 
 
 Flg.5. 
 
Flg.S. 
 
 Fig, 9. 
 
 Flg.lO. 
 
 FigJL 
 
KEPORT OF ORTHOPAEDIC SURGEON. 323 
 
 Many of the severest cases of deformity, such as hydrocephalus, mon- 
 sters, etc., were still-born. 
 
 Club Foot. — Immediately after birth the physician, as a matter of rou- 
 tine treatment, instructed the mother or attendant how to manipulate the 
 feet so as to reduce the deformity as completely as possible. She was told 
 to do this at certain regular intervals, and was also shown how to apply 
 bandages to them when that was necessary. In the more severe grades of 
 the deformity simple retention splints were applied within a few days after 
 confinement. The first object was to overcome the varus. For this pur- 
 pose a light steel bar with cross-pieces at its extremities to embrace the toes 
 and the calf of the leg Avas strapped to the inside of the leg and foot after 
 being pro])erly padded. This brace was put on the foot in its deformed 
 position and gradually straightened, a change being made every two or 
 three days, until the foot was brought into a valgus position. The equinus 
 was then corrected by manipulation, or by applying a brace, similar to that 
 described, to the back of the leg and sole of the foot, direct pressure back- 
 wards being applied at the ankle by adhesive plaster. The brace was 
 applied in the position of deformity, as before, and the foot-piece gradu- 
 allv brought up to a right angle with the leg-piece. Owing to the very 
 early age at which treatment was begun, tenotomies were rarely neces- 
 sary. Eelapse is almost sure to follow, however, unless a correct position 
 or over-correct position of the foot is carefully maintained for at least a 
 year. Daily exercise to strengthen weak muscles must also be carried out 
 methodically in all these cases. 
 
 21 
 
('oxTrjp.rxiox to the topographical anatomy of 
 
 THE THOKAX IX THE F(ETUS AT TEEM AXD THE 
 XEW-BORX CHILD. 
 
 By George S. Huntington, M.D. 
 
 Thk following anatomical conditions, aside from those comiected with 
 the circulatory ai)paratus and dependent upon the placental type of respira- 
 tion, imi)ress their character most strongly on the arrangement of the 
 viscera in the foetal thorax, when contrasted with the form and contents of 
 the adult chest cavity. 
 
 1. Ditferences in extent and configuration of the lungs before and 
 after ])ulmonary respiration has been established. 
 
 2. Ditferences in the extent of the })leural sacs and of the complemen- 
 tary pleural spaces, especially the costophrenic sinus. 
 
 3. Presence of the thymus gland. 
 
 4. Relative large size of the foetal liver, influencing indirectly the 
 arrangement of the thoracic contents l)y determining tlie level of the dia- 
 )»liragin. 
 
 Tlie following nuMiioranda have been ct^mpiled tVom tlie examination of 
 the thorax and its contents in five foetus at term, four newly-born infants 
 who died witlnn a few hours after birth, and two foetus of 25 and 31 
 weeks (estimated) res))ectively. 
 
 The material has in all cases been prepared by the pvclimiiiarv injection 
 through tlie umbilical vein of a ten per cent, formaline solution, at a hydro- 
 stiitic pressure varying from one to three feet. This hardening fluid pos- 
 sesses jMjculiar value for the determination of the topographical relations 
 of the l>o(ly cavities .and viscera. In the strength above indicated the 
 (jedematous swelling at times observed with the use of weaker solutions is 
 entirely conlinwl to the subcutaneous connective tissues. The deeper ])arts, 
 es|>ecial]y tlie viscera, are hardened /// .ntn in such a manner as to ])reserve, 
 even whon removed from the body, their correct form, and to indicate most 
 accuratoly by the surface; markings their natural relationshii) to surround- 
 ing structures. The solution is eminently well adapted to the complete 
 hardening and ])reservation of the lung. The viscus appears of almost 
 rubber-like consisteney, and admits fi-eely of manipulation, without the 
 least impairment of ihc normal sli:ipe. iind without disturbing the relations 
 
ANATOMY OF THE THORAX IN THE FCETUS AT TERM, ETC. 325 
 
 to surrounding structures. The preparations which can be obtained by this 
 method are of the greatest value in determining the topography of the 
 tlioracic cavity. More especially is it possible by their aid to deal with 
 the mutual relations of the lungs and mediastinal contents from an entirely 
 novel point of view. The hardened lung reflects accurateh' its relation to 
 the thoracic parietes and to the structures contained in the mediastinum. 
 
 It is especially desirable to formulate a precise description of the thor- 
 acic organs in the foetus for comparison with the same structures in the 
 adult.* In the following communication this attempt has been made, and 
 although the material is not large, yet the uniform disposition of the more 
 important structures in all the preparations examined affords good ground 
 for regarding the conditions described as conforming to the normal type. 
 
 The lungs of the foetus and new-born infant are free from the disturb- 
 ing influences which in later life pulmonary disease so frequently exerts on 
 the disposition of the thoracic organs. For this reason the study of foetal 
 material possesses a special value in the regions in question. 
 
 The subject matter of these observ^ations may be arranged under the fol- 
 lowing headings: 
 
 I. Form and External Characters oe the Lungs. 
 
 A. Surfaces of the Lungs. 
 
 Each lung presents four surfaces — -the viscus having the form of a trun- 
 cated pyramid, with three unequally develooed lateral surfaces converging 
 to a blunt apex, the fourth surface forming the broad base by means of 
 which the organ rests on the convex upper surface of the diaphragm. 
 
 The general disposition of the side and basal surfaces is best obtained by 
 examining the hardened lungs of a foetus in the later months. 
 
 Figs. I to lY present the medial and lateral aspects of the right and 
 left lungs of a foetus esthnated to be in the twenty-fifth week, and Figs. Y 
 and YI give outline representations of the basal or phrenic surfaces of the 
 same lungs. 
 
 The sharp anterior margin (Figs. Y and YI, 2) admits readily of the 
 usual division into a lateral or sternocostal convex, and a medial or medi- 
 astinal concave surface. 
 
 AVhile this sharp differentiation exists along the entire well-defined 
 anterior margin of the lung, the arrangement of the posterior thick portion 
 presents, in the organ detached and removed from the bodj^, greater diffi- 
 culties. The correct appreciation of this portion of the lung depends U23on 
 exact reference to the mediastinal structures and to the part of the thoracic 
 wall with which the same comes into contact. 
 
 The examination of the basal outlines of these foetal lungs shows that 
 
 * While this paper was in press, Dr. J. A. Blake, of Columbia University, pre- 
 sented the results of similar investigations of the adult thorax to the Association of 
 American Anatomists at Washington in May of this year. His pa^jer will be pub- 
 lished in the Proceedings of the Ninth Annual Meeting of the Association, and will 
 form a very valuable sequel to the present communication. 
 
336 REPORT OF THE SOCIETY OF THE LYING-IN HOSPITAL. 
 
 each presents u east of its side of the thoracic cavity. The following sur- 
 faces cau be distinguished: 
 
 1. S^entOi'Ofifd/ ifinfare (Figs. V and YI, 1) extends transversely between 
 the sharp anterior margin (2) and the blunt posterior margin (0), fitted 
 against the concavity of the parietal i>leura lining tlie internal surface of 
 the thoracic wall from the posterior surface of sternum and costal cartilages 
 in front to the line marked superficially by the costal angles behind. 
 
 1'. Muliasiiiml surface (Figs. Y and YI, 3) is included between the 
 anterior (2) and internal margin (4), concave in main, directed inward and 
 somewhat forward in the posterior part, modelled upon the contents of 
 the anterior ])()rtion of the mediastinum, es})ecially upon portions of the 
 l^ericardium. thymus gland, and large vessels covered by the mediastinal 
 pleura. 
 
 3. Costovertehral surface (Figs. Y and YI, 5) directed })ack wards and 
 inwards, included between the internal (4) and posterior borders {(\). This 
 surface is a])plied to that portion of the parietal pleura which covers the 
 sides of the vertebral bodies and intervertebral disks, the heads of the ribs 
 and symjmthetic nerve strand, and the anterior surface of the necks and 
 ])odios of the ribs as far out as tlic ])oint -wliere the latter change their 
 orijrinal outward and backward direction to curve forward in the lateral 
 thoracic wall. 
 
 Tlie principle adopted in the above definition of the lung surfaces is 
 afforded by the direction of the surfaces, the presence of distinct margins, 
 and the relations to thoracic contents and walls. The mediastinal surface 
 is taken to include all that portion of the medial aspect of each lung which 
 comes indirectly, by means of the interposed mediastinal layer of the parie- 
 tal pleura, into contact and relation with the visceral, vascular, and ner- 
 vous structures contained in the mediastinal space. This is quite readily 
 apparent in the anterior ]mrts of this surface, where large impressions exist 
 for adai)tation to tlie bulky thymus gland and pericardium. In the pos- 
 terior portion of this area the relation to structures entering and lea^'ing 
 the lung at the hilus is well defined, from the intimate connection of these 
 parts with the j)ulmonary substance. But above, below, and behind the 
 hilus the mediastinal surface of the lung comes into contact with the pleura 
 covering va.scular and visceral sti'uctures which })ursuo in main a vertical 
 coui*se in the posterior mediastinum. 
 
 The publislied descriptions of the anatoni}' of tlu; lung separate a sterno- 
 c<:;sta] and mediastinal surface by the sharj) anterior margin, and state in 
 general that j)osteriorlv these pass into each other by means of a thick, 
 rounded posterior border. Even to take the posterior margin of the aortic 
 groove as separating tlif nu-diastinal from the parietal surface of the left 
 lung, and the jjosterior margin of the azygos furrow as sejmrating the cor- 
 responding j)ortions of the right lung, is not correct. In the detailed con- 
 .siileration of the relations of the mediastinal |)iiliiionarv surfaces, given 
 l>elow, it will be .seen that the character of this aica is eomj)lex, coming into 
 relation with successive structures as liny a|)i)roach or recede from the 
 poslf-rior part of tin- inrdinstinal plciiral leaf. 
 
ANATOMY OF THE THOHAX IX T]1E FQ'n'L'S AT TERM, ETC. 327 
 
 It seems, therefore, more in accordance with the actual conditions to 
 define the mediastinal surface as including that portion of the lung which 
 is in relation with the mediastinal })leural reflection covering the vascular, 
 glandular, visceral, and nervous structures of the mediastinal space. 
 
 This area is separated by wdiat we have termed the " internal " margin 
 from the surface in contact with the parietal pleura investing the walls of 
 the thoracic cavity. This internal margin, varying in distinctness in differ- 
 ent parts of its extent, is, therefore, the composite of the successive posterior 
 borders of a series of impressions which result from the relation of this 
 portion of the lung to the pleura investing the longitudinal vascular and 
 visceral contents of the. posterior part of the mediastinal space. The 
 details of this margin will be subsequently considered. 
 
 The surface of the lung in contact with the pleura covering the thoracic 
 parietes is generally convex, and in the foetal lung is quite evidently divided 
 into a lateral or sternocostal^ ^Jidi posteromedial or costovertebral surface. 
 
 The sternocostal surface is limited anteriorly by the sharp anterior mar- 
 gin, in w^hich it meets the mediastinal surface. The posterior limit is 
 afforded by a rounded but distinct border (Figs. Y and VI, 6), which fits 
 into the vertical groove formed by the succession of ribs and intercostal 
 spaces at the point where the former change their original outward and 
 backward direction to turn forward in conformity with the lateral curve of 
 the thoracic wall. 
 
 The costovertebral s'wrface extends between this posterior border and 
 the internal margin, as above defi.ned. As the name proposed indicates, 
 this surface comes into relation with the parietal pleura covering the lateral 
 aspects of the vertebral centres and disks and the portions of the ribs and 
 intercostal spaces which extend between the costovertebral line of articula- 
 tion and the line indicated superficially by the succession of the costal angles. 
 
 B. Changes in External Form During the Later Developmental Stages 
 of the Lungs. 
 
 In the earlier stages of development the posterior border is sharper, 
 and the costovertebral surface is directed obliquely backward and inward 
 (Figs. V and YI). As the lung develops, the increase in size affects pri- 
 marily the posterior portions. 
 
 Figs. YII to XII present the lateral and medial aspects and the out- 
 lines of the basal surfaces of the right and left lungs of a foetus of thirty- 
 one weeks (estimated). 
 
 It will be noted (Figs. XI and XII, 6) that the posterior margin is 
 more rounded, and that the costovertebral surface looks almost directly 
 inwards (Figs. XI and XII, 5). This change in direction produces a 
 diminution in the distinctness of the internal margin (Figs. XI and XII, 
 4) as seen from the basal surface, since the costovertebral surface forms a 
 more direct continuation backwards of that part of the mediastinal surface 
 which is in relation with the vertical structures occupying the posterior 
 mediastinal space. At the same time it will be presently seen that the 
 differentiation of the two surfaces, as indicated by the impressions pro- 
 duced, becomes more marked with the full development of the lung. 
 
328 REPORT OF THE SOCIETY OF THE LVINO-IX HOSPITAL. 
 
 Kig. XI 11 represents the basal aspect of the lungs of a foetus at term, 
 together with the inferior surface of the ))ericarclium and attached portion 
 of the diapliragin. The same relative chanues are t(^ l)e noted here. 
 
 The ///</'</</(• or baf<a/ i>-n/;f(/i'i' of both lungs is uniformly concave, moulded 
 over the convexity of the diaphragmatic cupolae. The varying propor- 
 tions in which the different lol)es contribute to the formation of this sur- 
 face will be considered in speaking of the course of the nuiin interlobar 
 incisures. 
 
 C Ju-femal l^ornt^ Fissures, Incisures, and Lohes. 
 
 The com})arison of the foetal lung in the earlier stages with the fully 
 develoj)etl organ at term shows some characteristic changes in form. 
 
 1. Lift Lutuj. 
 
 The lung rejiresented in Figs. Ill and IV (25 weeks, estimated) gives 
 the following picture: 
 
 Elongated, cone-shaped, the sternocostal, costovertebral and medias- 
 tinal surfaces narrowing uniformly and gradually to the apex, which pre- 
 sents a smooth, rounded lateral and slightly concave medial surface. 
 
 A slight dei)ression (Figs. Ill and lY, 2), differentiating the apex 
 ])roper from the posterior border, is produced by the proximal portion of the 
 anterior margin of the first rib. The anterior margin shows a similar 
 though slighter costal impression (Figs. Ill and IV, 3), separating it 
 from the apex. 
 
 The anterior margin appears crenated by a number of short incisures. 
 One of these, the anterior marginal incisure* (Figs. Ill and IV, 4), 
 extends somewhat more deeply upward and l)ackward on the medial sur- 
 face. A second more deeply marked incisure (Figs. Ill and IV, 5) 
 api)eai's to foreshadow the development of the typical cardiac curve. 
 Tliese secondary fissures represent rudiments of the occasional additional 
 lissure which in the adult at times extends backward from the deepest 
 portion of the cardiac incisure to meet, in extreme cases, the main inter- 
 lol>ar incisure, and thus re])eat the intermediate fissure of the right lung. 
 
 The lung shown in Figs. IX and X (31 weeks, estimated) exhibits, 
 when contrasted with the preceding, the tyi)ical changes occurring in the 
 further development of the organ. The most notal^le difference exists in 
 the up])or and apical ])ortions of the lung. The site of the original rounded 
 blunt apex of the cone is still discernible, Ijotli the posterior and anterior 
 margins exhibiting the first costal impression (Figs. IX and X, 2, 8). 
 
 The anterior marginal fissure (Figs. IX and X, 4) is well marked on 
 l>oth the lateral an<l medial sui-faces. TIk; extent of the U])])ei- lobe, mcas- 
 urwl along the anterior margin between 8 and 4, and along the ])osterior 
 border b<;tween 2 and the intersection of the main intei-lobar incisui-e, 
 indicates a very marked antero-|)osterior ex})aiision of this portion of the 
 lung. 
 
 • It has been considered advis.-ihlf to (lcsi;,''ii:itc lliis lissm-c of the left Iiiii^'' l)y a 
 Rpeciul U-rm. on ar<'oinit «»f its constaiit occunM-ncc in I lie cirlici- stages and {\n\ \r.\Yi it 
 plavH in tli(> jjrrKlurtioii of tin; in«»ro important lissui-al variations of the left lung' iu 
 the later Hluges. 
 
ANATOMY OF THE THORAX IN THE FCETUS AT TERM, ETC. 329 
 
 In the earlier stages (Figs. Ill and IV) the anterior margin slopes 
 uniformly and gradually downward and forward from the apex to the 
 anterior marginal fissure (4), at an angle of about 45 degrees with the ver- 
 tical long axis of the })Osterior border. In Figs. IX and X the same por- 
 tion of the anterior margin in the older lungs is seen to pass at first for- 
 ward from the apex, nearly at right angles with the line of the posterior 
 border. It then abruptly turns downward, and recedes somewhat to the 
 beginning of the anterior marginal fissure (4), developing a blunt, nearly 
 quadrangular superior marginal process, which overhangs the cardiac 
 incisure from above. 
 
 Below, the lingula is also produced forward and inward, resulting in 
 the hook-like inferior limit of the cardiac incisure. The formation of the 
 wide cardiac incisure is chiefly to be credited to the forward expansion of 
 the anterior portion of the upper lobe, between the apex and the anterior 
 marginal fissure. The anterior margin of the lung in the region of the 
 cardiac incisure presents the same crenated appearance, although the fis- 
 sures and indentations are relativel}^ smaller and of less depth than in the 
 first lung. 
 
 The changes affecting the loAver lobe are best appreciated by considering 
 the course of the main interlobar incisure, the extent of the medial surface 
 of the inferior lobe, and the position of the hilus. 
 
 In the first lung (Fig. IV) the main interlobar incisure runs a much 
 ra.ore vertical course on the sternocostal surface. Fig. IX indicates by 
 the more oblique course of this fissure that in the later stages the growth 
 has involved more especially the anterior and lateral portions of the infe- 
 rior lobe, resulting in a sagittal increase of the lower portion of the 
 sternocostal surface. Coincident with this, the relative extent of the 
 inferior lobe on the mediastinal surface is less. In the earlier lung (Fig. 
 Ill) the mediastinal surface of the lower lobe presents a broad triangular 
 area, forming approximately one-third of the entire mediastinal surface, 
 between the main interlobar incisure, the line of attachment of the lio-a- 
 mentum latum, and the medial margin of the phrenic surface. In the later 
 stage this area is reduced in extent, but much more prominent, forming 
 (Fig. X) a sharp triangular process (pericardio-cesophageal tuberosity), to 
 be subsequently considered in detail with the topographical relations of this 
 surface. It is, however, to be remembered that individual variations in the 
 arrangement of the main fissures and incisures are not infrequent. (See 
 below.) As already stated, reference to the outline tracing of the phrenic 
 surface (Figs. VI and XII) shows an expansion and rounding of the 
 posterior margin and a more sagittal direction of the costovertebral sur- 
 face. 
 
 The uncinate character of the lingular process, curving forward and 
 inward, is also to be noted in comparing the basal surface of the second 
 with that of the earlier lung. 
 
 The aortic groove becomes much more distinct in the later stage, and 
 in the view of the medial aspect (Fig. X) the beginning of the costover- 
 tebral surface dorsal to the groove is to be observed. 
 
330 REPORT OF THE SOCIETY OF THE LYING-IN HOSPITAL. 
 
 The liilus «»f the more lulvaiiced lung occupies a relatively greater area 
 on tlie meiliastinal surface. This is more esjiecially marked in the inferior 
 |K>rtion. i*esulting in a shortening of tlie ligamentnm latum. 
 
 In the further (levelo])ment of the external form of the left lung the 
 clianges inclicatetl above lead to the establishment of two quite distinct 
 ty])es. 
 
 Instances of these are given in Figs. XIV to XVII, representing the 
 sterno<.'ostal and mediastinal surfaces of two left lungs at term. 
 
 T>ij>e 1. Luinj u'ltli irrll-<leveloj)ed cardiac incisui'e (Figs. XIV, XV, 
 and XVIin. 
 
 The quadrangular form, noted as appearing in IX and X, is here still 
 further develo])ed, due to the great antero-posterior extent of the supe- 
 rior lobe and marked development of the anterior portion of the same 
 above the cardiac incisure. The quadrangular marginal process forming 
 the up))er limit of the latter is especially prominent. 
 
 The anterior marginal fissure is present and distinct, appearing both on 
 the sternocostal and metliastinal surfaces. 
 
 The cardiac incisure is deep, forming three sides of a rectangle, bounded 
 below by the prominent incurve of the hook-like lingula. 
 
 The main interlobar incisure on the sternocostal surface meets the 
 inferior margin at a point which would correspond to the vertical prolonga- 
 tion down^vard, across the root of the lingula, of the bottom of the cardiac 
 incisure. 
 
 On the mediastinal surface the inferior lobe presents an extensive area. 
 The course of the main interloljar incisure, in returning to the anterior 
 margin of the hilus, on the mediastinal surface, follows the type indicated in 
 the earlier stages in Fig. III. The incisure meets the anterior border of 
 the hilus nearly at the middle, and a large triangular area, belonging to 
 the mediastinal aspect of the inferior lobe, presents in its anterior and larger 
 part a concavity iav adajitation to the left sui'face of the pericardium, its 
 smaller posterior and inferior segment forming the prominent triangular 
 tt'sophageal surface. 
 
 Ti/jn- 2. Ahi«'/ifi' of cardiac incisure. Assimilation of external form, to 
 that of ri'jlif I II ml. 
 
 In strong conti-adistinction to the ])reccding form is the superficial con- 
 figuration of tlie lung shown in Figs. XVI and XVII. 
 
 The entire a])pearance of the lung suggests the structure usually encoun- 
 tered on tlie right side. The anterior margin is nearly vertical. There is 
 no cardiac incisure. The anterior marginal fissure is well developed and 
 crr>s.sf?s the sternocostal surface so as to nearly intersect the main inter- 
 lobar incisure. The anterior mai^gin turns with an obtuse angle into the 
 8U|KTior division, sloping slightly upward and backward to the apex. 
 
 The u])per lolje, compared with the first type, is slightly less Cjuadran- 
 gular. Possibly tlie abr.ence of the cardiac incisure, and the consetpient 
 increase in lung substance along the anterior and inferior marginal por- 
 tions of the lung, accounts for the somewhat smaller sagittal extent of the 
 upjKjr part of the su])erior lobe. 
 
ANATOMY OF THE THORAX IN THE FCETUS AT TERM. ETC. 331 
 
 The middle lobe, which is thus marked out on the sternocostal surface, 
 evidently corresponds to a very highly developed lingula. 
 
 On the mediastinal surface the main interlobar incisure follows the 
 course indicated previously in Fig. X. It does not quite reach the inferior 
 part of the anterior hilus margin. The mediastinal surface of the inferior 
 lobe is confined to the strongly developed triangular pericardio-oesophageal 
 tuberosity. 
 
 The anterior marginal fissure penetrates on the mediastinal surface 
 backward and upward, covering two-thirds of the distance between the 
 anterior lung- maro;in and the anterior border of the hilus. 
 
 The difference in the conformation of the left lung and of the cardiac 
 incisure exhibited by the above types appears to be independent of the 
 development of the thymus gland. In both cases a well-developed typical 
 thymus was present. The large size and pronounced character of the 
 cardiac incisure in the first form (Figs. XIV and XY) would appear to 
 negative the view expressed by some authors,* according to which the car- 
 diac incisure does not make its appearance until involution of the thymus 
 permits of greater expansion of the upper portion of the left lung. 
 
 2. PdgU Lung (Figs. I, II, Y, YII, YIII, XI). 
 
 The right lungs of the two younger foetus of 25 and 31 weeks are 
 represented in medial and lateral views and in projection outline of the 
 basal surface in the above figures. 
 
 The differences in the external form of the right lung in the earlier and 
 later stage are of the same character as on the left side, but less pro- 
 nounced. The right lung of the earlier foetus is less elongated than the left 
 lung of the same preparation, the greatest sagittal and vertical diameters 
 being more nearly equal. 
 
 The pointed apical portion of the earlier stages (Figs. I and II) is, 
 how^ever, again replaced by the more quadrangular form in the older lung 
 (Figs. YII and YIII), due to the sagittal expansion of the upper lobe. 
 The first part of the posterior margin, which inclines obliquely back- 
 ward and downward in the younger specimen, is directed almost hori- 
 zontally in the older lung, bringing the apex more into direct continua- 
 tion with the anterior margin. Later, at term, the expansion of the upper 
 and anterior segment of the superior lobe restores the apex to its position 
 as the upper rounded termination of the posterior margin (Figs. XIX, 
 XX, XXI, XXII). Between the apex proper and the beginning of the 
 vertical portion of the anterior margin, a superior marginal portion passes 
 forward with but a very slight downward inclination (Figs. XIX to XXII). 
 At times, apparently after pulmonary respiration has been inaugurated, 
 the beginning of the vertical portion of the anterior margin is marked on 
 the mesal aspect by a prominent rounded tubercle, w^hich imparts to the 
 superior segment of the marginal portion, between it and the apex, a 
 slight concavity upwards (Fig. XXIII, above 3). 
 
 A number of variations are presented in the arrangement of the inter- 
 lobar fissures of the rio'ht lung-. 
 
 * C. Gegeiibauer, Lelirb. d. Anat. d. Menschen, 1890, Bd. ii., p. 10-4. 
 
332 REPORT OF THE SOCIETY OF THE LYING-IX JIOSriTAL. 
 
 a. Stt'rnoc('-'<f(d sinface. 
 
 (1) The typical form, which corresponds to the usual achilt condition, is 
 representeil on the sternocostal surface by Fig. YII. The intermediate 
 fissure leaves the main interlobar incisure at an acute angle and passes for- 
 wartl over the sternocostal surface to the anterior margin, its direction 
 being nearly parallel to the course of the anterior part of the inferior 
 maririn. The outline of the sternocostal surface of the middle lobe is 
 nearly that of a ])arallelogram. 
 
 (2) In a second form, the middle portion of the intermediate fissure is 
 obliterated, ])artially or completely (Figs. XYIII and XIX), the fissure 
 developing only at its point of dei)ai'ture from the main interlobar incisure, 
 and again a short distance from the anterior margin. 
 
 (3) A third type is presented by the extension of the intermediate fis- 
 sure doi*sad of the main incisure (Fig. XXI). At times this is combined 
 with island formation at the anterior extremity (Fig. II). 
 
 The return of the main interlobar incisure of the right lung across the 
 lower ]K)rtion of the mediastinal surface again presents variations which 
 are similar to those encountered on the left side. 
 
 The usual arrangement is indicated in Figs. YIII, XX, XXII, and 
 XXIII. The termination of the fissure meets, or nearly meets, the ante- 
 rior inferior margin of the hilus, defining the anterior border of an irregu- 
 larly quadrangular field for apposition to the inferior vena cava (XX, 
 XXII, XXIII, 1). More exceptionally (Fig. I) the fissure returns on 
 the mediastinal surface to the inferior angle of the hilus, nearly excluding 
 the inferior lobe from ]XTrtici]iation in the composition of the mediastinal 
 surface. 
 
 The intermediate fissure usually appears reduced on the mediastinal sur- 
 face, rarely reaching as far as the anterior border of the hilus. 
 
 Figs. I, XX, and XXIII exhil)it instances of this limitation of the 
 mediastinal portion of the intermediate fissure. Figs. VIII and XXII 
 afford examples of the more extensive develo])ment of this fissure on the 
 me<liastinal surface. The beginning of the main interlobar incisure at 
 times traverses the azygos groove (Figs. I and XX), beginning at the 
 upjKT ])ostf'rior border of the hilus. The entire ])osterior segment of the 
 fissure is complete, travelling l)ackwar(l over the costovertebral surface. 
 In other instances the incisure, beginning at the same point, is obliterated 
 in the segment crossing the costovertebral surface (Figs. VIII, XXIII). 
 In other ca.ses tiie region of the azygos groove is not fissured, the incisure 
 first apjxraring on the costovertebral surface (Fig. XXII). 
 
 e. Phrenlf or h<inti} Hurfdrc. 
 
 The greater area, com])ared with the Idt side, which the ])hrenic sur- 
 face of the right lung ])resents, is seen, by reference to Figs. V, XI, and 
 XIII, tf) be mainly <lue to the greater biis.-il siiifncc of the Y\<^\\i middle, as 
 conipare<l with tiie upper left lobe. 
 
 In the earlier stages (V and VT) the basal intci-loliiu' incisure passes on 
 both sides obli(iuelv backwiiid imd inwiird towjiid the nif(h';d inarLnn of 
 
ANATOMY OF THE THORAX IX THE F(ETUS AT TERM, ETC. 333 
 
 the phrenic surface. In tlie okler lung.s (XI, XII, and XIII) the direc- 
 tion of the incisure both in right and left hmg is more nearly transverse. 
 
 On the right side the incisure meets the mediastinal border of the phrenic 
 surface a short distance behind the centre. This change in direction is 
 evidently due to the greater area of contact in the later stages between the 
 postero-internal portion of the right lung and the intrathoracic segment 
 of the inferior vena cava. 
 
 Azygo^ lohe and fissure. 
 
 At times the median and posterior portion of the phrenic surface is 
 more or less completel}^ separated from the rest of the inferior lobe by a 
 fissure or set of fissures defining a portion of the lung which corresponds 
 in position and relation to the inferior cava to the infracardiac or azygos 
 lobe of lower mammalia. 
 
 Fig. XXY, 1, presents a sim])le form of this fissure and rudimentary 
 lobe. 
 
 In the lung represented in Fig. XXIY a more complex arrangement of 
 this structure exists. 
 
 The posterior segment of the fissure — beyond 2 — is incomplete, although 
 it can be traced backwards and inwards beneath the investing visceral 
 pleura. 
 
 In all cases the anterior portion of the azygos lobe passes forward, 
 forming a blunt, tongue-shaped marginal process (Fig. XXIY, 1) which at 
 times projects some distance bej^ond the internal portion of the main inter- 
 lobar incisure, resting in contact wath the basal surface of the middle 
 lobe. 
 
 (The foetus D and G, from which Figs. XXIY and XXY are taken, 
 Avere twins, both female.) 
 
 D. Attacliment of Broad Pidmonary Ligament. 
 
 1. Bight Lung (Figs. I, YIII, XX, XXII, XXIII, 8). 
 
 The pleural fold is attached to the ' ' lower oesophageal area ' ' {vide 
 infra) of the mediastinal surface, crossing the same usually somewhat 
 obliquely from the lower angle of the hilus downward and backward. 
 
 The sharp, somewhat projecting ridge just anterior to the pulmonary 
 attachment of the fold fits into the angular recess between oesophagus and 
 vena cava. 
 
 2. Left Lung (Figs. Ill, X, XY, XYII, 1). 
 
 The pulmonary attachment of the fold descends from the lower angle 
 of the hilus, usually just posterior to the oesophageal surface of the oeso- 
 phageal tuberosity. 
 
 The broad pulmonary ligament is formed by a right and left pleural 
 fold, passing between the posterior inferior portion of the mediastinal lung 
 surface, below the hilus and the adjacent surface of the oesophagus. The 
 arrangement of the folds is schematically indicated in Fig. XXXI Y, rep- 
 resenting a thoracic transection below the region of the hilus. 
 
 E. Arrangement of Main Structures at Hilus. 
 1. Left Lung. 
 
 The t}q3ical condition is seen in Fig. XXYII, 12-15. 
 
334 REPORT OF THE SOCIETY OF THE LYING-IN HOSPITAL. 
 
 The section of the stnu-turi's h;is heeii iiuule just before they enter the 
 lung. 
 
 The left puhnonai'v artery (12) oecn))ies tlie highest position. Tlie sec- 
 tion has passed through the vessel at the point where the apical branches 
 for the supply of the suj)erior portion of the u])per lobe are given off, the 
 two sui)erior extensions of the lumen seen in the cross cut indicating these 
 vessels. The su])erior left jiulnionary vein (l:}) lies in front. Immedi- 
 ately behind this vessel, and below the pulmonary artery, the left bron- 
 chus a])|>ears in section immediately beyond the primary division. 
 
 The left inferior pulmonaiy vein (15) occu])ies the lowest and most 
 |K)sterior ])osition. 
 
 Fig. XX\'I shows the same structures divided a little nearer to the 
 lung. 
 
 The main ])ulmonary artery (11) appears above and behind, the supe- 
 rior pnlmonary vein (1<») above and in front, already divided into two 
 main branches. 
 
 JJetwccn lo antl 11, and crossed l)y tlie foi'king of the former line, are 
 seen the openings of the two a])ieal branches of the pulmonary artery 
 suj)plying the u]>per lobe. 
 
 \'2 and Vo are the two 2)rimary bronchial trunks, and the inferior 
 biimch of the left pulmonary vein again occupies the inferior posterior 
 angle of the hilus. 
 
 2. Iiif//it Lnu(j. 
 
 In Fig, XXX the right bronchus is cut after the division into the eparte- 
 rial (17) and hyparterial trunks (20). 
 
 The aj)ical branches of the right pulmonary artery, sui)plying the upper 
 lobe (18, 10), appear in front and below the eparterial bronchus. Above 
 the latter, between it and the azygos, appears the apical pulmonary vein 
 (not numbered in the figure). 
 
 The main trunk of the pulmonary artery (22) is in this section still 
 quite in front of the hyparterial bronchus. 
 
 On the same level, constituting the most anterior structure, aj)pears the 
 section of the upper right pulmonary vein (21), while the inferioi- ])ulmo- 
 nary vein (23) is seen below and l>ehind the hyparterial bronchus. 
 
 In Fig. XXVIII the same ai'rangement of the structures is found, the 
 main pulmonary artciy occn])ying the position between the hypai'terial 
 bronchus and right su])eriof piibuonary vein. 
 
 In Fig. XXIX the bronchus is cut just at th(3 j)oint of division into 
 (•partr'rial and hyparterial truidcs (IIV The main ]>uli nonary artery lies 
 in front, a|)plied to the aiitci-ioi- and infci'ior Ijoi-dcr of the l)ronchial cross 
 cut. The aj)ical )>u]ni(jnary artei-ies (H, l())ai-e ali'eady given off, and lie 
 in front of the upj)er (epai-tfvial i ]»ortion of the bronchial section. 
 
 The upper and lower pi ih nonary veins occupy the usual position at 
 the anterior and inferior jiortion of the hilus region. 
 
 Tlie .sections demon.strate well the early derivation and separate ajiterior 
 course of the apical ])ulmonary arterial brandies and tin; position of the 
 main arterial trunk jirior to the intersection with the bi'onclii.il fot-k. 
 
ANATOMY OF THE THORAX IN THE FCETUS AT TERM, ETC. 335 
 
 II. Topography of Mediastinum and Mediastinal Surface of Lung. 
 
 As previously stated, the formaline-hardened lung admits of removal 
 from the thorax without impairing the natural form of the organ. The 
 mediastinal surface of the lung carries with it impressions which corres- 
 pond to the relations with the mediastinal contents, and which afford a 
 means of determining accurately the extent of such relations. In the fol- 
 lowing, certain portions of the mediastinal lung surface will be described 
 as being '' in contact " with certain structures contained in the mediastinal 
 space. It will, of course, be understood that the mediastinal parietal pleura 
 intervenes. In the same way, to avoid circumlocution, such terms as 
 " oesophageal " or " tracheal " " surface " or " area " will be employed, in 
 describing certain regions of the mediastinal lung surface. Here, again, the 
 interposition of the parietal pleura is assumed without further specifica- 
 tion. 
 
 1. TojKxjraphy of Mediastinal Contents. Riglit Side. 
 
 In Fig. XXYIII (foetus at term, E) the right lateral view of the medi- 
 astinal contents is given, after removal of the lung by division of the struc- 
 tures entering and leaving the viscus at the hilus, the parietal pleura 
 remaining in place. In Fig. XXIX (foetus at term, D) the same structures 
 are shown, with the upper portion of the mediastinal pleura reflected. In 
 Fig. XXX (infant, immediately after birth, F) the mediastinal contents, 
 hardened in situ., are removed from the thorax and viewed from the right 
 side and behind. 
 
 These structures, thus built together and invested by the mediastinal 
 pleura, form the bed upon which the mediastinal surface of the right lung- 
 rests. The elevations and depressions of this portion of the parietal pleura, 
 caused by the more marked projection of certain of these structures into 
 the right pleural sac, produce a corresponding modelling of the internal 
 surface of the lung. We will see that the plastic lung substance adapts 
 itself to the opposed mediastinal pleural surface, and takes, so to speak, a 
 negative cast of the inequalities of this surface. The appearance, therefore, 
 of the mediastinal surface of the lung will best be appreciated by first 
 considering the arrangement of the mediastinal contents which ])roduce this 
 appearance. 
 
 In Fig. XXYIII the anterior portion of the right sternocostal pleura 
 is seen to be reflected to form the mediastinal leaf, along a curved line, 
 convex forward, ^vhich descends from behind the right sternoclavicular 
 articulation, over the anterior surface of the thymus gland and the peri- 
 cardium. These two structures form together the contents of the anterior 
 and larger division of the mediastinal space. 
 
 The lateral surface of the thymus (Fig. XXYIII, 9, Fig. XXIX, 8) 
 constitutes approximately the upper third, the pericardium the lower two- 
 thirds of the area in vertical measurement. In the sagittal direction the 
 area increases steadily from the sharp point with which the lateral surface 
 of the th}Tnus begins to appear in the right mediastinal wall above, to 
 
330 REPORT OF TUE SOCIETY OF THE LYING-IX HOSl'TTAL. 
 
 the broad antero-postci-ior extent of the rig-ht margin of the pericardium 
 at its attachment to the ilia))hrauin l)eh)\v. Tlie hiteral surface of the 
 thvmns. invested thus by the anterior and upjier jiart of tlie mediastinal 
 l>leurti, is phme. or even slightly concave, lietween it and the }>rominent 
 right lateral surfjice of the pericardium a furrow running obliquely down- 
 ward and forward receives the ridge which, on the mediastinal surface of 
 the right lung, se})arates the thymic from the concave pericardial area 
 (Fig. XXX, between H and 3V 
 
 Behind the thymic area the ]n-ominent lateral surface of the right 
 innominate vein and superior vena cava is seen (Figs. XXA'III, 10, 
 
 XXIX, continuation downwards of 3, XXX, 15). In the foetus the por- 
 tion of the right innominate vein in contact with the mediastinal pleura is 
 com]>aratively short, inclined obliquely across the up]:)er apical ])ortion, 
 whereas the superior cava appears relatively long, directed more vertically 
 ilownwards. dorsal to the thymus and upper right portion of the pericar- 
 dium. 
 
 The right phrenic nerve descends between the superior cava and the 
 thpnus, and lower down crosses the pericardium in front of the structures 
 connected with the pulmonary hilus, to continue along the anterior and 
 lateral cii'cumference of the inferior vena cava to the diaphragm (Figs. 
 XXVIII, 8, XXX, 16). 
 
 Tlie posterior portion of the mediastinal space is occu])ied in its middle 
 thiril l)y the structures connected with the lung at the hilus, and already 
 considered in detail in reference to their mutual relations. 
 
 Immediately al)ove the upper margin of the hilus region the azygos 
 vein arches from behind forward to join the superior cava (Figs. XXVIII, 
 2, XXIX, 1, XXX, 4). 
 
 Ik'tween the innominate and superior caval veins in front, the verte- 
 l)ral column behind, the apex of the ])leural sac above, and the az^^gos arch 
 below, the right mediastinal pleura covers a field (Fig. XXVIII, 1) which, 
 after reflection of the membrane (Figs. XXIX and XXX), is seen to con- 
 tain the foUijwing structures: The right lateral wall of the trachea occupies 
 tlie central portion of this area (Figs. XXIX, <i, XXX, continuation of 8). 
 The tul>e is separated from the large venous trunks in front by a quantity 
 of fatty connective tissue and small lymphatic glands (Figs. XXIX, 7, 
 
 XXX, 18), and is crossed obli(piely in the direction from above and in front 
 downward and backward by the right vagus (Figs. XXIX, 5, XXX, 4). 
 
 Behind the trachea, l)Otween it and the vertebral column, the right 
 lateral jMjrtion of the oeso[)hagus appears (Figs. XXIX, 4, XXX, contin- 
 uation of 1 ). 
 
 At the level of the up])er border of the hilus the fcsophagus encounters 
 the arch of tlie azygos vein. The vein is rendered very jn'ominent at tliis 
 jKiint by tiie underlying oesophagus. ;iii(l piojeets strongly into the right 
 l)leural siic. Dorsal to the region of the hihis the vein gi-Khially beeomes 
 less ])rominent, and recedes toward the median line. The i-igiit lateral sur- 
 face of the ce.sopha^s again appears below the arch, between the vertical 
 azygos vein Ijeliind ;m(l the prricjifdium jmd structures at tlic hilus in IVniit. 
 
ANATOMY OF THE THORAX IN THE FCETUS AT TERM, ETC. 337 
 
 The oesophageal surface in contact with the right mediastinal pleura grad- 
 ually increases as the vein recedes. At the beginning of the lower third of 
 the space the oesophagus has entirely replaced the vein in relation to the 
 pleural leaf. In- this situation the inferior oesophageal branches of the 
 vagus are seen shining through the investing pleura (Fig. XXVIII, 4). 
 
 Below the hilus and in front of the oesophagus is the prominent pos- 
 terior and lateral wall of the intrathoracic segment of the inferior cava 
 (Figs. XXVIII, 19, XXX, 24). 
 
 Behind the oesophagus and azygos, covered by the costovertebral 
 pleura, are seen the intercostal vessels, and more laterally the longitudinal 
 strand of the sympathetic nerve. 
 
 2. Mediastinal Surface of Right Lung (Figs. XX, XXII, XXIIa, 
 XXIII). 
 
 Boundaries : 
 
 In front: anterior sharp margin. 
 
 Below: mediastino-phrenic margin. 
 
 Behind: internal margin. 
 
 This surface of the lung is modelled on the mediastinal pleura covering 
 the contents of the space, as above detailed, and accordingh^ presents a 
 natural division into three fields of unequal extent and conformation. 
 
 (1) Region in Front of Hilus. 
 
 a. Thymic area. — The upper third is formed by a smooth, slightly con- 
 vex surface in apposition Avith the parietal pleura covering the lateral sur- 
 face of the thymus gland {thymic area) (Figs. XX, XXII, XXIII, 3), 
 and moulded over the form of this organ. The thymic area occupies the 
 upper half of the medial surface of the upper lobe. 
 
 h. Pericardial area. — The loAver two-thirds of the anterior region 
 include nearly equal portions of the upper and middle lobes, forming a 
 concave surface {jjericardicd area) moulded over the prominence of the peri- 
 cardium (Figs. XX, XXII, XXIII, 2). This area extends backward to 
 the anterior margin of the hilus, and presents immediately in front of the 
 latter a narrow, linear, nearly vertical furrow, resulting from its relation to 
 the right phrenic nerve. 
 
 The pericardial area is separated from the thymic surface by a moder- 
 ately prominent blunt ridge, which corresponds to the furrow between the 
 lateral surface of the thymus and the pericardium. 
 
 (2) Region of Hilus. 
 
 a. Hilus. — Irregularly oval, with longest diameter in the long axis of 
 the lung. The posterior border is nearly vertical; the anterior, convex. 
 The upper extremity is blunt, quadrangular; the lower extremity pointed. 
 
 The arrangement of the chief structures entering and leaving the lung 
 at the hilus has been described above in detail. 
 
 I). Surface ahove hilus presents in front a sharply defined vertical 
 groove for the reception of the lateral surface of the right innominate and 
 superior caval veins. (Figs. XX, XXII, XXIII, 4). The posterior bor- 
 der of this groove, immediately above the hilus, is interrupted by the junc- 
 tion of the caval depression with the deep groove lodging the terminal 
 
338 REPORT OF TF^E SOCIETY OF THE LYIN'G-IN HOSPITAL. 
 
 ]>art of the azvgos vein vFigs- XX, XXII, XXIII, 0). The latter curves 
 from beliiiul forward, following closely the superior margin of the hilus. 
 
 Anteriorly the caval iinjn-ession is prolonged down to nearl}'- the middle 
 of the anterior nuirgin of the hihis, forming by its anterior margin the 
 jx)sterior boundary of the thyniie area. 
 
 Behind the eaval impression is a smooth quadrangular field (Figs. XX, 
 
 XXII, XXIII, '*) in contact with the pariet;il ])]eura, which here covers 
 smoothly the riglit lateral surface of the ti-acliea, the peritracheal lymphatic 
 and fattv connective tissue, and the right vagus, which crosses this segment 
 of the trachea obliquely from above aiul in front downwards and back- 
 waitls. 
 
 c. Surface hehtc /<//</.s\ — A rectangular i)ortion of the inferior lobe, 
 deeplv concave, surrounds the lateral as])ect of the inferior cava (Figs. 
 XX, XXII, XXIII, 1). 
 
 This caval surface is l)ounded above by the inferior margin of the hilus, 
 in front l)y the prolongation of the main interlobar incisure from the 
 ])hrenic surface upward and backward upon the mediastinal surface to the 
 lower i)art of the anterior border of the hilus. Behind, the caval area is 
 Hmited by a prominent vertical ridge of lung tissue, which fits into the 
 deep angular interval between the oesophagus and the vena cava, and which 
 carries along its dorsal nuirgin the attachment of the broad pulmonary 
 ligament. 
 
 (8) Region hehind JIUx.s. 
 
 This region is occupied by a narrow, vertical field, enlarging somewhat 
 below, which se])arates the mediastinal from the costovertebral surface, 
 and wliich is in relation ^\•ith the oeso])hagus and the proximal portion of 
 the azygos vein, Ijoth structures A\'hich produce more or less well marked 
 grooves on this ])ortion of the lung surface. 
 
 Above the level of the upper border of the hilus, from the region of 
 the apex down, a narrow, vertical area, situated dorsal to the smooth 
 ti-aehcal surface, is in contact with the mediastinal pleura covering the 
 uj)i>er thoracic portion of the oesophagus. This area is separated from the 
 costovertebral surface by a prominent, well-defined, sharp margin, pass- 
 ing into tlie apical region above, and continuous l)elow with the ])osterior 
 bordi-r of the azygos groove. This margin (Figs. XX, XXII, and 
 
 XXIII, behind 5) fits into the angle between the upper portion of the 
 CL'Sophagus and tlie vertebral column. 
 
 At the level of tlie upper horde]- of the hilus the sharply defined curved 
 groove caused by the arch of the azygos vein tui'us downward, dorsal to 
 the hilus (Figs. XX, XXII, XXTII, 0). Ju tlic beginning of its vertical 
 coursf* the groove is well marked. In some lungs a faint impression crosses 
 the uj)per ])art of the costoverti^bi'al sui-face obli(|uely, ti) join the azygos 
 groove. Tliis sr-cond inipi-cssion is cnnscd 1)\- the siipci'ior intercostal 
 vein. 
 
 Below, the azygos ^ri-oovr gr;i(hi;illy becomes less dislincl, nnd ]nerg(^s 
 into a somowliat broader sui-fiicc. which lies b('t\v<M'n the postci-ior mai'gin 
 of the hilus and the costoverteljral sui-facc Reference to the structures 
 
ANATOMY OF THE THORAX IN THE FCETUS AT TERM, ETC. 339 
 
 left hi situ in the posterior part of the mediastinum after removal of 
 the right lung explains this appearance (Figs. XXVIII, XXX). The 
 azygos vein, ascending in the mediastinum, occupies in main a nearly 
 medial position, only beginning to deviate markedly to the right on reach- 
 ing the level of the sixth thoracic vertebra. Above this point the vein 
 comes into close contact with the right mediastinal pleura and impresses 
 the mediastinal surface of the lung behind the hilus, as indicated. Below 
 this point the vein gradually recedes from the mediastinal pleura, and, on 
 reflecting the membrane, the riglit lateral margin of the oesophagus begins 
 to appear between the posterior margin of the hilus and vein. This 
 oesophageal area begins above as a narroAV pointed surface which expands 
 in descending, until in its lower portion it equals the inferior vena cava in 
 sagittal measure. With the parts undisturbed and in their natural condi- 
 tion, the gradual recession of the azygos vein from contact with the right 
 mediastinal pleura, and its replacement in relation to the meml^rane by 
 the right border of the oesojDhagus, is affected without producing any 
 abrupt line of demarcation. Consequently, in the hardened lung removed 
 from the thorax, the azygos groove, sharp and well defined above, gradu- 
 ally fades out below the middle of the hilus, and is replaced by the broader, 
 smooth surface in contact with the mediastinal pleura investing the oesoph- 
 agus (Figs. XX, XXII, XXIII, '7). 
 
 The entire region of the mediastinal lung surface dorsal to the hilus is, 
 therefore, composed of an upper narrower and lower wider oesophageal 
 area, separated from each other by the surface in contact with the azygos 
 vein. The latter structure is rendered prominent in the upper mediastinal 
 region by its course upward, forward, and to the right, and by the under- 
 lying oesophagus. Below the middle of the hilus, on the other hand, 
 the vein gradually recedes from the mediastinal pleura and lies nearer the 
 median line, being enabled to assume this position by passing behind the 
 oesophagus, the latter tube gradually inclining forward, and ceasing its 
 close apposition to the anterior surface of the vertebral column. 
 
 The relative extent of these areas of relation of the mediastinal lung 
 surface with the contents of the mediastinum is shown schematically in 
 Fig. XXIIa. 
 
 3. Topography of Mediastinal Contents. Left Side. 
 
 Fig. XXYI shows the mediastinal contents in situ covered by the 
 pleura in a foetus at term (i>), and Fig. XXYII shows the same structures 
 removed from the thorax, with the pleura partially reflected, in the infant 
 immediately after birth {F). 
 
 In front, as on the right side, the lateral surface of the thvmus gland 
 (XXVI, 5, XXVII, 4) appears above, the prominent pericardium (XXVI, 
 7) below, the latter crossed obliquely by the left phrenic nerve (XXVI, 
 6, XXVII, 5). At the upper and posterior margin of the left pulmonary 
 root, the arch of the aorta produces a marked elevation of the mediastinal 
 pleura, which is continued along the entire posterior border of the medias- 
 tinum by the thoracic aorta, the elevation becoming gradually less marked 
 as the vessel approaches the diaphragm (XXVI, 15, XXVII, 16). 
 
340 REFORT OF THE SOCIETV OF THE LYING-IN HOSPITAL. 
 
 Above the level of the upper hihis margin, between the vertebral 
 column behiuil and the thymus gland in front, the mediastinal pleura 
 covei"s the follow ini:: structures: 
 
 1. Immetliately in front of the vertebral column the left margin of the 
 oesophagus (XXVI, 7). 
 
 '2. The intrathoracic seiiineut of the left subclavian artery, forming a 
 prominent rounileil ridge in the mediastinal wall (XXVI, S, XXA^II, 0). 
 
 3. In front of the subclavian elevation the mediastinal pleura covers 
 smoothly a field (presubclavian) (Fig. XXYI, 4) in which are placed the 
 left common carotid arteiy (XXVII, 8), the left vagus (XXVII, 9), and a 
 quantity of fatty and lymphatic tissue (XXVII, 3) which lies behind the 
 thvmus and left innominate vein. 
 
 The latter structure a])pears in the upper and anterior angle of this 
 surface behind the thymus (XXVII, continuation downward of 1), and 
 frecjuently receives the left su])erior intercostal vein (Fig. XXVI, 9, 
 XXVII, 11\ which passes upward and forward from below and behind, 
 crossing the aortic arch and pneumogastric nerve, the nerve being placed 
 ])et\veen the arch and the vein. 
 
 The internal mammary artery (XXVII, 2) crosses the upper angle of 
 the lateral thymus surface and the innominate vein (XXVII, 2), and the 
 upper part of the intrathoracic segment of the left phrenic nerve descends 
 behind the innominate vein, crossing usually over the point of entrance 
 into the latter of the superior intercostal vein. 
 
 Below the hilus the pericardium projects decidedly into the left pleural 
 compartment. This is especially marked along the posterior inferior seg- 
 ment, where the pericardium covers the prominent posterior part of the left 
 tliick ventricular margin and the adjoining posterior and inferior part of 
 the left auricle. 
 
 Jietween the elevation of the ])osterior })art of the left mediastinal leaf 
 ])roduced ]>y the thoracic aorta behind (XXI, 15, XXVII, 16), the 
 dia])hragm below, the ])ortion of the pericardium referred to in front and 
 alxn'e, Avith the entrance of the left infei'ior jiulmonary vein as its u])per 
 limit (XXVII, 15), the left pleural cavity exhibits a deep triangular recess, 
 bounded internally by the pleura covering the left side of the lower tho- 
 racic segment of the oesophagus. One-half of the circumference of the 
 a-sophagus appears thus in the inner wall of this recess, after the tube has 
 ])iusse<l the ])osterior surface of the left auricle, in the interval between 
 afirta beliind, pericardium in front, and diapliragm below (XXVI, 10, 
 XXVII, IS). 
 
 4. Mtduuiinal tiurface of Lefl Luikj. 
 
 This surface corres])onds to the structui-es above described, and is mod- 
 filed accordingly (Figs. XV, XVII, XVIIa). The lower and longer i)art 
 is occupied by the deep and well-marked impression for the left side of 
 the |K!ricanliuni CXV, XVII, 7). The greater ])oi'tion of this ])ericardial 
 surface is fornic<l l)y the medial surface of tin; upp<M' lobe. A ])oi"tif)n <^f 
 the inferior iribe contributes a smaller ])ericar(lial surface to be presently 
 considered in detail. 
 
ANATOMY OF THE THORAX IN THE FCETUS AT TER^[, ETC. 341 
 
 Immediately above the pericardial, area the medial surface of the left 
 lung rests on the mediastinal i)leura covering the left lateral surface of 
 the th3''mus gland. This thymic surface (XV, XVII, 6) in the hardened 
 lung is plane or slightly convex, and is separated from the pericardial 
 depression immediately below by a raised curved margin, with the concav- 
 ity directed downward and backward, which corresponds to the curved 
 groove separating the thymus in situ from the pericardium. In well-hard- 
 ened lungs a faint linear impression descending obliquely along the pos- 
 terior margin of the thymic area is due to the left phrenic nerve. 
 
 Above the liilus the medial surface of the lung is grooved by the arch 
 of the aorta (XV, XVII, 3). This groove begins as a faint depression 
 which rapidly deepens until it obtains its greatest development just above 
 and behind the superior posterior angle of the hilus. At this point a nar- 
 rower, deep, nearly vertical groove passes upward to the upper margin of 
 the lung, produced by the intrathoracic segment of the left subclavian 
 artery. 
 
 Between the subclavian groove behind, the upper border of the aortic 
 furrow below, the upper lung margin above, and the thymic surface in 
 front, the medial aspect of the left lung presents a smooth, nearly plane 
 field (presubclavian area, XA-^, XVII, 5), which rests on the mediastinal 
 pleura covering the proximal portion of the left common carotid artery 
 and the left vagus, embedded in a quantity of fatty and granular connec- 
 tive tissue. 
 
 If the superior intercostal vein is large, a shallow linear impression may 
 be produced by it, intersecting the aortic groove obliquely. 
 
 Behind the hilus the aortic groove continues to be marked, descending 
 nearly vertically. It can be followed to the lower border of the lung, 
 growing gradually somewhat shallower. 
 
 Below the hilus, and in front of the lower portion of the aortic groove, 
 the medial lung surface presents a well-marked triangular process, which 
 can be called, with regard to its relations, the pericardio-oesophageal tuber- 
 osity. It occupies the triangular mediastinal recess above described, 
 between aorta behind and pericardium in front, and containing at the bot- 
 tom the left wall of the oesophagus. 
 
 The pericardio-oesophageal tuberosity is a product of the medial sur- 
 face of the inferior lobe. It starts just in front of the lowest point of the 
 hilus in form of a ridge (XV, XVII, 2), which graduaU}^ becomes more 
 and more elevated in proceeding downward, forward, and inward. The 
 tuberosity thus produced presents three surfaces, two mediastinal and one 
 phrenic. The phrenic surface constitutes the most anterior and medial 
 portion of the area which the inferior lobe contributes to the formation of 
 the basal surface of the left lung (Fig. XIII, 4). 
 
 The mediastinal surfaces are an anterior and a posterior. The anterior 
 surface (XV, XVII, 8) is concave, and contributes to the formation of the 
 pericardiac depression. 
 
 In some instances the return of the main interlobar incisure to the 
 anterior and inferior border of the hilus on the medial surface of the lung 
 
342 REPORT OF THE SOCIETY OF THE LYTXG-IX HOSPITAL. 
 
 limits this pericardial surface of the tuberosity above and in front (Fig". 
 
 x\n). 
 
 In other cases the ]>ericardial surface contrilmted by the inferior \o\)e is 
 mueh hirirer and exceeds tlie limits of tlie tul)erosity. The interlobar 
 incisure then passes up \v a I'd and backward more vertically from the ante- 
 rior j)art of the mediastino-phi'enic border, and reaches the hilus nearly at 
 the miiUUe of its anterior margin (Fig. XV). In such a case the pericar- 
 dial surface of tlie tuberosity is continuous with the general pericardial 
 surface of the inferior lobe, constituting the posterior inferior segment 
 of the Siime. 
 
 The posterior, or oesophageal, surface of the tuberosity (XY, XVII, 9) 
 looks backward and inward, and rests ujjon the pleura covering the por- 
 tion of the tt'sophagus which appears between aorta, pericardium, and 
 diaphragm. The surface is triangular, with a broad posterior vertical base. 
 The lateral borders are formed below by the postero-internal part of the 
 shar]) mediastino-phrenic margin of the lung, and above and in front by 
 the ridge above described as proceeding from the lower angle of the hilus. 
 This ridge separates the pericardial from the oesophageal surface, and cor- 
 res])onds to the dejiression betAveen pericardium and oesophagus. 
 
 Tlie pericartlio-oesophageal tuberosity of the left lung evidently corres- 
 ponds to the elevated ridge of lung tissue wdiich, on the right side, fits into 
 the narrow interval between oesophagus behind and the inferior vena cava 
 in front. 
 
 ' The attachment of the broad ligament is dorsal to the oesophageal sur- 
 face of the tuberosity, the layers descending almost verticall}^ from the 
 lower angle of the hilus. At the attachment of the ligament to the lung, 
 or just anterior to this line, a sharp vertical ridge is frequently observed 
 which fits into the depression between aOrta and oesophagus. 
 
 In well-hardened lungs a vertical linear impression, descending over the 
 costovertebral surface, indicates the relation to the sympathetic strand 
 and the line of the costal capitula. 
 
 The relation of the thoracic duct to the mediastinal pleura has not been 
 determined in the above preparations, as the demonstration of the same 
 would produce too much disturbance in the arrangement of the remaining 
 structures. 
 
 AVith this exception the al>ove account is believed to present the main 
 relations of the lungs and mediastinal contents correctly. 
 
 III. TirvMus Gland. 
 
 rFigs. will. WIN', XXVI, XXVII, XXVIII, XXXI, XXXII, 
 
 XXXIII.) 
 
 TIh! gland, situati-d ]>;irtly witliin tlic thorax, ])artly in the anterior 
 cervical region, is placed in front of the pericardium and the beginning 
 and termination of the large vessels, accurately adapting itself to the struc- 
 tures with which it comes into contact. 
 
ANATOMY OF THE THORAX IX THE FCETUS AT TERM, ETC. 343 
 
 The thoracic portion presents in the gland hardened in situ five distinct 
 surfaces, as follows: 
 
 Anterior, mediastinal. 
 
 Two lateral, pleural. 
 
 Posterior, vascular. 
 
 Inferior, pericardiac. 
 
 The arrangement of the surfaces is well seen in the view of the gland 
 in situ from the side, as in Fig. XXYIII. The anterior or mediastinal sur- 
 face is directed upward and forward in the upper, more directly forward 
 in the lower, part. Viewed from in front (Figs. XYIII, 1, XXXI, 10) 
 this surface is seen to be triangular, with the apex directed downward. 
 Above, the base is continuous with the anterior surface of the cervical por- 
 tion (XYIII, 5, XXXI, 7). The sides are bounded by the sternocostal- 
 mediastinal reflections of the right and left parietal pleura (XXXI, 3, 11), 
 which pass from the sternum directly backward, to invest the lateral sur- 
 faces of the gland. 
 
 The inferior surface looks backward and downward, and rests on the 
 upjjer and anterior portion of the ]3ericardium. 
 
 The lateral surfaces (XXYII, 4, XXYIII, 9), invested by the ante- 
 rior portion of the mediastinal pleura, look directly outward, and are in 
 relation with the thymic area on the medial surface of each lung. 
 
 The phrenic nerve descends on each side, near the posterior border of 
 the lateral surface (XXYIII, 8, XXYII, 5). On the right side this pos- 
 terior border rests on the right innominate vein and the superior cava 
 (XXYIII, 10). On the left side the posterior limit of the lateral surface 
 is formed above, for a short distance, by the left innominate vein ; below, by 
 some fatty and lymphatic gland tissue lying between the vein, the trachea, 
 and the left common carotid artery (XXYII, 3). The upper angle of this 
 surface is crossed from behind forward by the left internal mammar}'" 
 artery (XXYII, 2). 
 
 The greatest interest attaches to the posterior surface and to the rela- 
 tions of the gland to the large venous trunks in the upper and anterior por- 
 tion of the mediastinum. 
 
 In the typical arrangement the left innominate vein is situated entirely 
 behind the gland. Fig. XXXI shows the aberrant course of the vein in 
 front of the gland. This arrangement was first observed by Astley Cooper 
 in 1832.* TVenzel Gruberf in 1876 reported two additional cases. The 
 same author X observed seven cases in which the vein passed through the 
 substance of the gland. 
 
 The prethymic position of the left innominate vein is, therefore, an 
 extremely exceptional one. In the case observed by us (Fig. XXXI, 9) 
 the vein traversed the upper portion of the mediastinum immediately 
 behind the manubrium, imbedded in a deep groove on the anterior surface 
 of the thymus, separating the cervical (7) from the thoracic portion of the 
 
 * The Anatomy of the Thymus Gland. London, 1832. 
 
 t Yh'chow's Archiv, Bd. 66, 1876, p. 462: " Anatomische Notizen, No. lii." 
 
 X Beobacht. a. d. Menschl. u. Vergl. Anat. , I. Heft, p. 41. Berlin, 1879. 
 
344 REPORT OF THE SOCIETY OF THE LVING-IX HOSPITAL. 
 
 gland (^lu). Fig. XW'JI presents the right hiteral view of the same 
 foetus, showing the relation of the vein (7) to the two portions of the 
 glanil. 
 
 Figs. X\'1I1, I, 0, XX \' I, I, :>, XXIX, S, show the anterior and the 
 left and right lateral views of the thymus in a foetus at term {D\ and Fig. 
 XXXII shows the mediastinal contents of the same individual seen from 
 above, with the thymus ])artly detached and turned downward and forward. 
 The jx>sterior surface of the gland is seen to rest on the ])ericardium (13) 
 covering the right auricular ai)pendix (14), the ascending aorta (11) and 
 the pulmonary artery (12j. On the right side the anterior surface of the 
 sujKM'ior cava is in contact with the gland. 
 
 The upper and anterior jiortion of the gland is ])rolonged into the neck 
 in form of an assymmetrical su])erior cornu (XYIII, 5, XXYI, 1) which 
 lies in front of the left innominate vein (suj)erior prevenous cornu). On 
 turning this portion of the gland downward and forward (XXXII) a 
 second u})per process (superior retrovenous cornu, XXXII, 10) is seen to 
 pass u]) ht'hiiul the vein, lying between it and the large arteries at the root 
 of the neck. This case, therefore, is an additional instance of partial retro- 
 venous ]K)sition of the gland. 
 
 The eai'lier stages of development of the thymus sliow very clearly how 
 this position is acquired. Fig. XXXIII shows tlie anterior view of the 
 thoracic contents in a foetus (//) of the latter part of the fourtli month. 
 The left innominate vein (1) passes in a groove along the upper border of 
 the thymus gland. The cervical portion of the gland has not yet devel- 
 o]>ed, but is indicated l)y the slightly more prominent anterior margin of 
 the groove containing the vein. By the further growth of this portion of 
 the gland the upper segment of the thymus attains its usual position in 
 front of the vein. 
 
 If the ])Osterior border of the groove develops at the same time, the 
 retrovenous ])rocess (XXXII, 10) results; and if this border gives rise to 
 the entire upper segment of the gland, the innominate vein will course in 
 front of the same, at the junction of the thoracic and cervical portions. 
 
 The cer^^cal j)ortion is very varioush' modified by the different form 
 and size of the upper processes and cornua, which frequently reach to tlie 
 lower border of the tlivroid inland. 
 
 In the usual ai-rang<;ment, the more flattened cervical j)ortion is se})a- 
 ratc<l when liardened in situ from the prismatic thoracic portion by a con- 
 strictif»n or neck ])ro(hiced on each side l)y an obli(|ue groove in wliich tlie 
 internal niamnuiry vessels are ])lacod (Fig. XXYII, 2). 
 
 Kxplanation of Fi(jureH. 
 
 (The letters refer to the individuals, indicating the; ])lates taken from 
 the same fojtus.) 
 
 Figs. I to IV. Right and left lungs of fo-tus of 2") weeks (estimated) 
 {A\ m<*<li;il and lateral surfa<'es. 
 
 1. i'ulmonary attachment of br(jad ligament. 
 
 2. Posterior apical costal sulcus, 
 •i. Anterior apical costal sulcus. 
 
Fiirs. I to IV. Tiig-lit and left lungs of foetus of 25 weeks (estimated) 
 (.Ij, medial and lutoi-al surfaces. 
 
 1. I'uhnonarv attachment of broad ligament. 
 •_'. Posterior apical costal sulcus. 
 ■i. Anterior apical costal sulcus. 
 
 4. Anterior marginal fissure. 
 
 5. Secondary fissure of cardiac incisure. 
 
Fig. I. 
 
 Fig. II, 
 
 Fig. III. 
 
 Fig. IV. 
 
Fi"-s. \' aiitl \'l. Outline representations of the l);isal surfaces of the 
 siinie hin<is (^1 1. 
 
 1. Sternocostal surface. 
 •J. Antorio)' margin. 
 ;l ^lediastinal surface. 
 
 4. Internal niar<^in. 
 
 5. Costovertebral surface. 
 0. Posterior maroin. 
 
 Fi<,^s. \\\ to X. Ivi<^ht and left lungs of foetus of 31 weeks (estimated) 
 (B), ni('<lia! and lateral sui-faces. 
 
Fig. V. 
 
 Fig. VI. 
 
 Fig. VII. 
 
 Fig. VIII. 
 
Figs. \'II to X. Right and left lungs of Itjetus of 31 weeks (estimated) 
 (/>'}, nu'dial and lateral surfaces. 
 
 1. Pulniunarv attachment of broad ligament. 
 
 2. Posterioi' aj^ical costal sulcus. 
 .">. Anterior apical costal sulcus. 
 4. Anterior marginal fissure. 
 
 Figs. XI and XII. Outline representations of the basal surfaces of the 
 same lungs {B). 
 
 1. Sternocostal surface. 
 
 2. Antcrioi' margin. 
 
 3. Mediastinal surface. 
 
 4. Internal margin. 
 
 r>. Costovci-tebral surface, 
 ♦J. Posterior nuiririn. 
 
Fig. IX. 
 
 Fig. X. 
 
 Fig. XI. 
 
 Fig. XII. 
 
Fig. Xlll. FcL'tus at tonn iC). liasal view of hardened lungs and 
 heart removed togetliei- IVoni thorax. 
 
 1. Portion of medial margin of phrenic surface in contact with right side 
 <if a'so])hagus. 
 
 "J. IntVrioi' vena cava. 
 
 3. Portion of dia])hragm attached to inferior surface of pericardium. 
 
 4. (Esophageal tuberosity of left lower lobe, basal surface. 
 
 .".. Portion of medial margin of phrenic surface in contact with left 
 side of oesoj)hagus. 
 
 «V Pliivnic margin of aortal surface. 
 
 Fig. XIV. Fietus at term (/>). Left lung. Sternocostal surface. 
 
Fig. XIII. 
 
 Fig. XIV. 
 
Fig XV. Foetus at term {D). Left lung. jMediastinal surface. 
 
 1. Pulinonai'v attaclimeut of ligamentuin latum. 
 
 2. Pericai'ilio-a^sopbageal tuberosit}'. 
 
 3. Aortal groove. 
 
 4. Subclavian groove. 
 
 5. Presubclavian area. 
 0». Thymic surface. 
 
 7. Pericardial surface. 
 
 N. Pericardial surface of pericardio-oesophageal tuberosity. 
 
 *.♦. CKsopliageal surface of })ericardio-a'so])hageal tuberosity. 
 
 Fig. XVI. Fa-tus at term {E). Left lung. Sternocostal surface. 
 
Fig. XV. 
 
 Fig. XYI. 
 
Fiir. XVII. Foetus at term {£"). ]\re(liastiiial i3urface. 
 
 1. Pulmonary attachment of ligamentum latum. 
 
 2. Pericanlio-oesophageal tuberosity. 
 
 3. Aortal groove. 
 
 4. Suljclavian groove. 
 
 5. PresuijclaWan area. 
 »j. Thymic surface. 
 
 7. Pericardial surface. 
 
 8. Pericardial surface of pericardio-oesophageal tuberosity. 
 
 9. (Eso})hageal surface of pericardio-oesophageal tuberosity. 
 
 Fig. XVITa. ScJHMiiatic figure, indicating relations of mediastinal 
 surface of left lun''. 
 
Fig. XVll. 
 
 
 
 Aovta. 
 
 ; '// 
 
 
 UtSt ComYtvov C».voti.clL ^vtGv^.^ 
 
 UC ft Pl^y-CKU KfcYU^ 
 
 lev i, c A.V cVCo - 
 
 iH4 Rtttdi 0^ Riti . 
 
 Fig. XVIIa. 
 
Fig. X VIII. Foetus at term (/>). Anterior view of lungs and medias- 
 tinuiji i/i situ. 
 
 1. .Vnterioi" surface of thoracic portion of thymus giand. 
 
 '2. Junction of riglit suljchivian and internal jugular veins. 
 
 y>. liight common carotid ai'tery. 
 
 4. Inferior thyroid vein. 
 
 ;".. Siipei'ior ]>i'evenous cornu of thymus gland. 
 
 ♦'.. Left innominate vein. 
 
 7. Left subclavian artery. 
 
 8. Parietal jiericardium divided by a cruciform incision. 
 
 Fig. XIX. Foetus at term (D). Right lung. Sternocostal surface. 
 
Fig. XVIII. 
 
 Fig. XIX. 
 
Fig. XX. Foetus at term (Z>). Eight lung'. Mediastinal surface. 
 1. Inferior caval surface. 
 '2. Pericardial surface. 
 .".. Tiiymic surface. 
 
 4. Innuuiinatc and su]^erior caval surface. 
 
 5. Tracheal and upper oesophageal surface. 
 • >. >vzvo:os groove. 
 
 7. T.ower a'so])hageal surface. 
 
 ^. I'ulnionarv attachment of liganieiitum latum. 
 
 Fig. XXI. Foetus at term (A'). Eight lung. Sternocostal surface. 
 
Fig. XX. 
 
 Fig. XXI. 
 
Fig. XXII. Fa?tus at term {E). liight lung. Mediastinal surface. 
 1. Inferior caval surface. 
 "1. Pericaidial surface. 
 
 3. Thymic surface. 
 
 4. Innominate and superior caval surface. 
 
 5. Tracheal and upper oesophageal surface, 
 •i. Azvji'os o-i'oove. 
 
 7. Lower a*sophageal surface. 
 S. Pulmonary attachment of ligamcntum latum. 
 
 Fig. XXIIa. Schematic figure indicating relations of mediastinal sur- 
 face of riii'ht luuii". 
 
Fig. XXII. 
 
 a^ni Su.p«vCov Vena. C 4. vs. 
 
 LVrvt 0^ RCciWC 
 
 Tva.cf)C4.\ Soffajc?. 
 
 Uppti- Oe.sopil.4.cea.V 
 
 1 ntivc it ».\ Vauv 
 AzvaoS Vein, 
 
 S.ou)e.r. 
 Oesop^doeil. 
 
 Su.vFa.ci' 
 
 
 Su.Yfa.ce yov O'rv.ftvmv V4rv4.Cd.va.. 
 Fig. XXlIa. 
 
Fig. XXIII. Infant, iinincdiately after l)irtli (J^''). Kight lung. 
 MiHliastinal surfucv. 
 
 1. Inforit)!' cava! surface. 
 
 2. Pei'icardial surface. 
 '■'. Thymic surface. 
 
 4. Innominate and su})erior caval surface. 
 
 ;'). Tracliejil and upper cesopliageal surface. 
 
 «5. A/.ygos groove. 
 
 7. L<)\\'er cesopliageal surface. 
 
 s. Pulmonary attachment of ligamentum latum. 
 
 Fig. XXIV. F(X'tus at term (/'/). Plirenic surface of i-iglit lung, with 
 azygos lissure of lower lobe. 
 
 1, Azygos lobule. 
 
 .;. .\/yg()s fissnr(\ 
 
 Fig. XXA'. Fd'tus ut term {JJ). i'lii'cnic surface of right lung, with 
 ay.ygos fissure of lower lobe. 
 
 1. A/.ygos lissure. 
 
Fig. XXIII. 
 
 1 ■ -■ / 
 
 Fig. XXIV. 
 
 Fig. XXV. 
 
Fig. XXN'I. Fa'tiis at tenn {D). Mediastinal contents, left lateral 
 \\e\w with pariet^il pleura in })lace. 
 
 1. Su]KM'ior ])revenous cornu of cervical ])ortion of tliynins gland. 
 
 2. Left sul)clavian artery, supracostal portion. 
 
 3. Left sulx'lavian vein. 
 
 4. Parietal mediastinal ]n'esul)clavian surface, covering fatty connec- 
 tive anil Ivnipliatic tissue overlying left common carotid artery, behind 
 thymus and left innominate veins. 
 
 5. Left lateral surface of tliymus gland, thoracic ])ortion. 
 »;. Left })hrenic nerve. 
 
 7. Parietal pericardium divided. 
 
 8. Left subclavian artei'V, ascending ])ortion, covered by parietal pleura, 
 y. Left sujierior intercostal vein, covered Ijy parietal pleura. 
 
 10, Oi)enings at hilus of divided superior left pulmonary veins. 
 Between 1»> and 11, and crossed by the fork at 10, are seen the openings 
 
 of the divided apical branches of pulmonary arter3^ 
 
 11, Pulmonary artery, divided at hilus. 
 
 12, V-^i. Left bronchus (hyparterial) divided at hilus. 
 
 14. Inferior left ])ulmonary vein, divided at hilus. 
 
 15. Tlxjracic aorta covered by ])arietal pleura. 
 
 1»*». Left surface of oesophagus covered by parietal pleura. 
 
Fig. XXVI. 
 
Fig. XX\'ll. Infant iiuiiiediately after l)irtli (i^). Mediastinal con- 
 tents, left lateral view ; meiliastinal ]x\rietal pleura partly reflected, 
 
 I. Left subclavian vein. 
 
 •J. Left internal mammary artery. 
 
 :'>. Fatty connective tissue and small lym])liatic glands behind left in- 
 nominate vein and thymus. 
 
 4. Left lateral (])leural) surface of thymus gland, thoracic portion. 
 ."». Left plu'enic nerve. 
 
 «;. Left subclavian artery. 
 7. Left deej) cervical vein. 
 
 5. Left c(jmmon carotid artery. 
 i>. Left vagus. 
 
 lo. rEso})hagus. 
 
 II. Left suj)erior intercostal vein. 
 12. Left pulmonary artery. 
 
 IM. Suj)erior left pulmonary vein. 
 
 14. Left bronchus (hyparterial) cut just l)eyond primary division. 
 
 lo. Left inferior pulmonary vein. 
 
 10. Thoracic aorta, covered by 17, parietal pleura. 
 
 18. <^Kso])hagus, covered by 17, parietal pleura. 
 
__I8 
 
 Fig. XXVII. 
 
Fio:. XXVI 1 1. Fa?tus at term (7f). Mediastinal contents. Right 
 lateral view. Parietal pleura in ])laee. 
 
 1. Parietal ])leiira covering- tracheal and su])eri()r oesophageal surfaces 
 and right vagus. 
 
 2. Azygos vein at junction with right superior intercostal vein. 
 8. Right syni})athetic nerve. 
 
 4. Right vagus, inferior oesophageal branches. 
 •">. Right subclavian artery. 
 «'•. liight subclavian vein. 
 
 7. Left innominate vein. 
 
 8. Right ])hrenic nerve. 
 
 0. Right lateral (pleural) surface of thymus gland, thoracic ])ortion. 
 
 10. Superior vena cava. 
 
 1 1. A])ical branch, right pulmonary artery. 
 ll^ lii^-ht eparterial bronchus. 
 
 I-'!. A]iical branch of right jndmonary artery. 
 
 14. ]\Iain trunk of I'ight pulmonary artery. 
 
 15. Itight hyparterial l)i'onchus. 
 
 16. Suj>erior right pulmonary vein. 
 
 17. 18. Inferior right pulmonary vein. 
 
 T.t. Tnfcrioi- vena cava, intrathoracic segment. 
 
Fig. XXVIII. 
 
Fig. XXIX. Foetus at term (D). Mediastinal contents in situ. Right 
 lateral view, u])])ei' pai-t of mediastinal ])lonr;i reflected. 
 
 I. Vena azyg(»s. 
 
 '2. Kight subcla^^an artery. 
 
 .">. Kiglit sultclavian vein, cut at junction with riglit internal jugular. 
 
 4. (Esophagus. 
 
 5. Right vagus. 
 «■>. Tracliea. 
 
 7. Fatty connective and lym})hatic gland tissue between trachea and 
 right innominate vein. 
 
 8, Right lateral surface of thymus gland, thoracic portion. 
 0, 10. .\.})ical Ijranches of right pulmonary artery. 
 
 II. Riglit bronchus, cut at division into eparterial and hyparteriai 
 trunks. 
 
 l:i. Right ]ndmonary artery. 
 
 lo. lii^lit supei'ior ))ulnionary vein. « 
 
 14. Right inferi(jr ])uhiionary vein. 
 
Fig. XXIX. 
 
Fig. XXX. Infant, immediately after birth [F"). Mediastinal con- 
 tents, right lateral view, mediastinal parietal pleura reflected. 
 
 I. (Esophagus. 
 
 '2. Right vertebral veiu. 
 
 l^. Trachea. 
 
 4. .Vyzgos vein. 
 
 o. Left parietal ]>leura, costovertebral division. 
 
 ♦;. Tliorac-ic aorta. 
 
 7. llenuazygos vein. 
 
 8. liiglit vertebral arter3^ 
 '.». Uiglit subclavian artery, 
 lo. liight subclavian vein. 
 
 II. Scalenus anticus, cut. 
 
 12. Iliglit internal mammary artery. 
 
 \'-'>. Peritracheal fatty connective and lym]ihatic tissue. 
 
 l-t. Itight vagus. 
 
 15. Superior cava. 
 
 10. liight phrenic nerve. 
 
 17. liight e})arterial bronchus. 
 
 IS, 19. Apical branches riglit jiubiioiiai-y artery. 
 
 20. liiglit hyparterial bronchus. 
 
 21. liight suj)erior ])ulmonar\^ vein. 
 
 22. iMain trunk right pulmonary artery. 
 •2'^. Right inferior pulmonary vein. 
 
 24. Inferior vena cava. 
 
— 1i^ 
 
 Fig. XXX. 
 
Fi«jr. XXXI. Fci'tus at torni {E). Anterior view of thoracic viscera. 
 
 I. Junction of right jugular and subclavian veins. 
 •2. First ril). divided. 
 
 ."5. liiglit })arietal pleura, anterior portion of sternocostal division. 
 
 4. IVricardiuin, portion uncovered by })leura and exposed between 
 right and left mediastinal pleural reflections. 
 
 5. Left internal jugular vein. 
 •'.. Left external jugular vein. 
 
 7. Anterior surface thymus gland, cci'vical ]V)rtion. 
 
 S. Left subclavian vein. 
 
 1». Left innominate vein. 
 
 lo. ^\nt<'i-ioi' surface thymus glaird, thoracic portion. 
 
 II. Right mediastinal ])leura, passing to lateral surface of thymus 
 gland. 
 
Fig. XXXI. 
 
FiiT. XXXll. I'u'tns at tt'ini (^/>). Lungs and uu'diastinal contents, 
 vii'wed from above. 
 
 I. (Est»phagiis. 
 •_>. Trachea. 
 
 .). Kiirlit sul)clavian arterv. 
 
 4. liight innominate vein. 
 
 ."►. liiirlit internal niamniai-v arterv. 
 
 ♦;. Anteiior surface right ventricle, parietal pericardium, cut. 
 
 7. J^eft common carotid arterv. 
 
 5. Left innominate vein. 
 '.». Left subclavian ai'tcry. 
 
 lo. Superior retrovenous cornu of thymus gland. 
 
 I I. Ascending aorta. 
 
 1 L' . I 'uhnonar V arterv. 
 
 i;!. Pericardium, divided. 
 
 14. Right auricular appendix. 
 
 l."». Superior prevenous cornu of thymus gland, cervical ])0)'tion turned 
 forward and downward. 
 
 Fig. XXXIIL Foetus of fourth month (//). Anterior view of 
 thoracic viscera. 
 
 1. Left innominate vein. 
 
 Fiir. XXXIV. Schematic transection of thorax below level of pul- 
 nionary hilus, to show pleural reflection forming the broad pulmonary 
 ligament (viewed from above). 
 
 1. Thoracic aorta. 
 
 li. 'Ksophagns. • 
 
 '4. Left in-oad ligament. 
 
 4. i'ei'icai'ijiiiiii. 
 
 .'». ]^_'l•ica^dial division <»!' mediastinal ])leui'a. 
 
 ('). Pericartliiiiii. 
 
 7. \'isce)-al ]»lenra. mediastinal sui-face. 
 
 ^. J'arietal j)leura, sternocostal division. 
 
 !♦. Inferior vena cava. 
 
 1". Right b)'oad ligament. 
 
 1 \. >\/.ygos vein. 
 
Fig. XXXII. 
 
 Fig. XXXIII. 
 
 Fig. XXXIV. 
 
ANATOMY OF THE THORAX IN THE FOETUS AT TERM, ETC. 345 
 
 4. Anterior marginal fissure. 
 
 5. Secondary fissure of cardiac incisure. 
 
 Figs, Y and YI. Outline representations of the basal surfaces of the 
 same lungs (A). 
 
 1. Sternocostal surface. 
 
 2. Anterior margin. 
 
 3. Mediastinal surface. 
 
 4. Internal margin. 
 
 5. Costovertebral surface. 
 
 6. Posterior margin. 
 
 Figs. YII to X. Eight and left lungs of foetus of 31 weeks (estimated) 
 (B), medial and lateral surfaces. 
 
 1. Pulmonary attachment of broad ligament. 
 
 2. Posterior apical costal sulcus. 
 
 3. Anterior apical costal sulcus. 
 
 4. Anterior marginal fissure. 
 
 Figs. XI and XII. Outline representations of the basal surfaces of the 
 same lungs (B). 
 
 1. Sterno-costal surface. 
 
 2. Anterior margin. 
 
 3. Mediastinal surface. 
 
 4. Internal margin. 
 
 5. Costovertebral surface. 
 
 6. Posterior margin. 
 
 Fig. XIII. Foetus at term {C). Basal view of hardened lungs and 
 heart removed together from thorax. 
 
 1. Portion of medial margin of phrenic surface in contact with right side 
 of oesophagus. 
 
 2. Inferior vena cava. 
 
 3. Portion of diaphragm attached to inferior surface of pericardium. 
 
 4. CEsophageal tuberosity of left lower lobe, basal surface. 
 
 5. Portion of medial margin of phrenic surface in contact with left 
 side of oesophagus. 
 
 6. Phrenic margin of aortal surface. 
 
 Fig. XI Y. Foetus at term (Z>). Left lung. Sternocostal surface. 
 Fig XY. Foetus at term {B). Left lung. Mediastinal surface. 
 
 1. Pulmonary attachment of ligamentum latmn. 
 
 2. Pericardio-oesophageal tuberosity. 
 
 3. Aortal groove. 
 
 4. Subclavian groove. 
 
 5. Presubclavian area. 
 
 6. Thymic surface. 
 
 7. Pericardial surface. 
 
 8. Pericardial surface of pericardio-oesophageal tuberosity. 
 
 9. CEsophageal surface of pericardio-oesophageal tuberosity. 
 
 Fig. XYL Foetus at term (^). Left lung. Sternocostal surface. 
 Fig. XYII. Foetus at term (B). Mediastinal surface. 
 
oiO REPORT OF THE SOCIETY OF THE LYING-IX HOSPITAL. 
 
 1. Pulnionarv attachment of lifjamentimi latum. 
 
 >.) 
 
 Fericardio-a?sophageal tuberosity. 
 
 3. Aortiil groove. 
 
 4. Subclavian groove. 
 
 5. Presubclavian area. 
 ('). Thymic surface. 
 
 7. Pericarilial surface. 
 
 8. Pericarilial surface of pericardio-o?soi)liageal tuberosity. 
 
 0. (£soj)hageal surface of i)ericardio-a^so|")hageal tuberosity. 
 
 Fig. XVIIa. Schematic figure, indicating relations of mediastinal 
 surface of left lung. 
 
 Fig. XVIII. Foetus at term (D). Anterior view of lungs and medias- 
 tinum hi sitv. 
 
 1. Anterior surface of tlioracic portion of thymus gland. 
 
 2. Junction of right subclavian and internal jugular veins. 
 
 3. Right common carotid artery. 
 
 4. Inferior thyroid vein. 
 
 5. Superior prevenous cornu of thymus gland. 
 
 6. Left innominate vein. 
 
 7. Left subclavian artery. 
 
 8. Parietal pericardium divided b}^ a cruciform incision. 
 
 Fig. XIX. Foetus at term (D). Right lung. Sternocostal surface. 
 Fig. XX. Foetus at term (D). Right lung. Mediastinal surface. 
 
 1. Inferior caval surface. 
 
 2. Pericardial surface. 
 
 3. Thymic surface. 
 
 4. Innominate and superior caval surface. 
 .5. Tracheal and upper oesophageal surface. 
 
 6. Azygos groove. 
 
 7. Lower (x;so|)liageal surface. 
 
 8. Pulmonary attaclnnent of ligamentum latum. 
 
 Fig. XXI. Foetus at term (E). Riglit lung. Sternocostal surface. 
 Fig. XXII. Ffjetus at term (^). Right lung. Mediastinal surface. 
 
 1. Inferior caval surface. 
 
 2. Pericardial surface. 
 
 3. Thymic surface. 
 
 4. Innominate and superior caval surface. 
 .5. Tracheal and upper oesophageal surface. 
 ♦"». Azvgos groove. 
 
 7. I..ower (jL*soi)hageal surface. 
 
 8. Pulmonary attachment of ligamentum latum. 
 
 I'ig. XXIIa. Schematic figure indicating relations of mediastinal sur- 
 face of right lung. 
 
 Fig. XX HI. Infant, immediately after birth (7'''). Right lung. 
 Me<li;ustina] surface. 
 
 1. Inferior caval surface. 
 
 2. Pericardial surface. 
 
ANATOMY OF THE THORAX IN THE FCETUS AT TERM, ETC. 347 
 
 3. Thymic surface. 
 
 4. Innominate and superior caval surface. 
 
 5. Tracheal and upper oesophageal surface. 
 
 6. Azygos groove. 
 
 7. Lower oesophageal surface. 
 
 8. Pulmonary attachment of ligamentum latum. 
 
 Fig. XXIV. Foetus at term (G). Phrenic surface of right lung, with 
 azygos fissure of lower lobe. 
 
 1. Azygos lobule. 
 
 2. Azygos fissure. 
 
 Fig. XXV. Foetus at term (Z>). Phrenic surface of right lung, with 
 azygos fissure of lower lobe. 
 
 1. Azygos fissure. 
 
 Fig. XXVI. Foetus at term (D). Mediastinal contents, left lateral 
 view, with parietal pleura in place. 
 
 1. Superior prevenous cornu of cervical portion of thymus gland. 
 
 2. Left subclavian artery, supracostal portion. 
 
 3. Left subclavian vein. 
 
 4. Parietal mediastinal presubclavian surface, covering fatty connec- 
 tive and lymphatic tissue overlying left common carotid artery, behind 
 thymus and left innominate veins. 
 
 5. Left lateral surface of thymus gland, thoracic portion. 
 
 6. Left phrenic nerve. 
 
 7. Parietal pericardimn divided. 
 
 8. Left subclavian artery, ascending portion, covered by parietal pleura. 
 
 9. Left superior intercostal vein, covered by parietal pleura. 
 
 10. Openings at hilus of divided superior left pulmonary veins. 
 Between 10 and 11, and crossed by the fork at 10, are seen the openings 
 
 of the divided apical branches of pulmonary artery. 
 
 11. Pulmonary artery, divided at hilus. 
 
 12. 13. Left bronchus (hyparterial) divided at hilus. 
 
 14. Inferior left pulmonary vein, divided at hilus. 
 
 15. Thoracic aorta covered by parietal pleura. 
 
 16. Left surface of oesophagus covered by parietal pleura. 
 
 Fig. XXVII. Infant immediately after birth (i^). Mediastinal con- 
 tents, left lateral view ; mediastinal parietal pleura partly reflected. 
 
 1. Left subclavian vein. 
 
 2. Left internal mammary artery. 
 
 3. Fatty connective tissue and small lymphatic glands behind left in- 
 nominate vein and thymus. 
 
 4. Left lateral (pleural) surface of thymus gland, thoracic portion. 
 
 5. Left phrenic nerve. 
 
 6. Left subclavian artery. 
 
 7. Left deep cervical vein. 
 
 8. Left common carotid artery. 
 
 9. Left vagus. 
 
 10. (Esophagus. 
 
348 REPORT OF THE SOCIETY OF THE LYING-IX HOSPITAL, 
 
 11. Left su}>erior intercostal vein. 
 
 12. Left pulinonarv artorv. 
 
 13. Sui>erior left piilmonarv vein. 
 
 14. Left bronchus (^liyparterial) cut jnst beyond primary division. 
 
 15. Left inferior pulmonary vein. 
 
 16. Thoracic aorta, covered by 17, parietal })leura. 
 IS. (Eso])hagus, covered by 17. parietal pleura. 
 
 Fi"-. XXVIIL Fa^tus at term {E). Mediastinal contents. Right 
 lateral view. Parietal pleura in place. 
 
 I . Parietal pleura covering tracheal and superior oesophageal surfaces 
 and right v;igus. 
 
 '2. Azvgos vein at junction Avith right superior intercostal vein. 
 8. Right sympathetic nerve. 
 
 4. Right vagus, inferior oesophageal branches. 
 
 5. Right subclavian artery. 
 «;. Right subchivian vein. 
 
 7. Left innominate vein. 
 
 8. Right ])hrenic nerve. 
 
 9. Right lateral (pleural) surface of thymus gland, thoracic portion. 
 
 10. Superior vena cava. 
 
 II. A]>ical branch, right pulmonary artery. 
 
 12. Right eparterial bronchus. 
 
 13. Apical branch of right pubnonary artery. 
 
 14. Main trunk of right ])ulmonary artery. 
 
 15. Right hyparterial bronchus. 
 
 16. Su])erior right pulmonary vein. 
 
 17. IS. Inferior right pulmonary vein. 
 
 19. Inferior vena cava, intrathoracic segment. 
 
 Fig. XXIX. Foetus at term (J)). Mediastinal contents m situ. Right 
 lateral view, upper part of mediastinal pleura reflected. 
 
 1. Vena azygos. 
 
 2. Riffht subclavian arterv. 
 
 3. Right subclavian vein, cut at junction with right internal jugular. 
 
 4. (T]sophagus. 
 
 5. Right vagus. 
 
 6. Trachea. 
 
 7. Fatty connective and lyiii])1iati(' gland tissue between trachea and 
 right innominate vein. 
 
 8. Right lateral surface of thymus gland, thoracic portion, 
 f'. lo. A|»ir;d bi-unches of right pulmonary artery. 
 
 11. liiglit bronchus, cut at division into eparterial and hyparterial 
 trunks. 
 
 12. Right ])ulniOnarv artery. 
 
 13. Right superioi" j)ulmonary vein. 
 
 14. Rifrht inferior pulmonary vein. 
 
 Fig. X.XX. Infant, inimediately after birth (/•'). Mediastinal con- 
 tents, riglit lateral view, mediastinal parietal ])h'ura rcllected. 
 
ANATOMY OF THE THORAX IN THE FCETUS AT TERM, ETC. 349 
 
 1. Qi^sopliagiis. 
 
 2. Right vertebral vein. 
 
 3. Trachea. 
 
 4. Ayzgos vein. 
 
 5. Left parietal pleura, costovertebral division. 
 
 6. Thoracic aorta, 
 
 7. Hemiazygos vein. 
 
 8. Right vertebral artery. 
 
 9. Right subclavian artery. 
 
 10. Right subclavian vein. 
 
 11. Scalenus anticus, cut. 
 
 12. Right internal mammary artery. 
 
 13. Peritracheal fatty connective and lymphatic tissue. 
 
 14. Right vagus. 
 
 15. Superior cava. 
 
 16. Right phrenic nerve. 
 
 17. Right eparterial bronchus. 
 
 18. 19. Apical branches right pulmonary artery. 
 
 20. Right hyparterial bronchus. 
 
 21. Right superior pulmonary vein. 
 
 22. Maiu trunk right pulmonary artery. 
 
 23. Right inferior pulmonary vein. 
 
 24. Inferior vena cava. 
 
 Fig. XXXI. Foetus at term (E). Anterior view of thoracic viscera. 
 
 1. Junction of right jugular and subclavian veins. 
 
 2. First rib, divided. 
 
 3. Right parietal pleura, anterior portion of sternocostal division. 
 
 4. Pericardium, portion uncovered by pleura and exposed between 
 right and left mediastinal pleural reflections. 
 
 5. Left internal jugular vein. 
 
 6. Left external jugular vein. 
 
 7. Anterior surface thymus gland, cervical portion. 
 
 8. Left subclavian vein. 
 
 9. Left innominate vein. 
 
 10. Anterior surface thymus gland, thoracic portion. 
 
 11. Right mediastinal pleura, passing to lateral surface of thymus 
 gland. 
 
 Fig. XXXII. Foetus at term (i>). Lungs and mediastinal contents, 
 viewed from above. 
 
 1. (Esophagus. 
 
 2. Trachea. 
 
 3. Right subclavian artery. 
 
 4. Right innominate vein. 
 
 5. Right internal mammary artery. 
 
 6. Anterior surface right ventricle, parietal pericardium, cut. 
 
 7. Left common carotid artery. 
 
 8. Left innominate vein. 
 
350 REPORT OF THE SOCIETY OF THE LYING IN HOSPITAL. 
 
 9. Left subclavian artery. 
 
 10. Superior retrovenous cornu of thymus giaud. 
 
 11. Asceiulini^- aorta. 
 
 12. Puliuonai'v artery. 
 
 13. Pericardium, divided. 
 
 14. Right auricuhir ai)})eutlix. 
 
 15. Superior prevenous cornu of thymus gland, cervical portion turned 
 forwaixl and downward. 
 
 Fig. XXXIIl. Fcvtus of fourth month (//). Anterior view of 
 thoracic viscera. 
 
 1. Left innominate vein. 
 
 Fig. XXXR'. Schematic transection of thorax below level of pul- 
 monary hilus, to show pleural reflection forming the broad pulmonary 
 ligament (Anewed from above). 
 
 1. Thoracic aorta. 
 
 2. (Esophagus. 
 
 3. Left broad ligament. 
 
 4. Pericardium. 
 
 5. Pericardial division of mediastinal pleura. 
 (!. Pericardium. 
 
 7. Visceral ]ileura, mediastinal surface. 
 
 8. Parietal pleura, sternocostal division. 
 
 9. Inferior vena cava. 
 
 10. Eight broad ligament. 
 
 11. Azygos vein. 
 
EEPORT OF PATHOLOGIST. 
 By Farquhar Ferguson, M.D. 
 
 The following is a statement of the work clone in the pathological 
 department of the Hospital during the year ending January 1, 1897: 
 
 There have been only three autopsies on women dying after childbirth. 
 In two of these the cause of death was due to septic peritonitis, and in each 
 of these cases the streptococcus pyogenes was found in the uterus, in the 
 Fallopian tubes, and in the purulent fluid in the peritoneum. The third case 
 revealed a gastric ulcer and enormous abscesses in the liver, which were 
 directly connected with the ulcer. The staphylococcus pyogenes aureus 
 and albus were obtained in cultures made at the postmortem in this case. 
 
 Twenty autopsies were made on infants, most of them by Dr. Martha 
 Wollstein, Assistant Curator. The majority of these were abortions and 
 still-born, and as the remainder died shortly after birth, there was no 
 notable lesion in any of the cases to account for death. 
 
REPORT OF BACTERIOLOGIST. 
 By Martha Wollstein, M.D. 
 
 Bacteriological examinations of vaginal and uterine secretions have 
 been made in twenty-four cases, of which four were fuU term, three prema- 
 ture, and seventeen abortions. Cultures in glycerine agar were taken from 
 the up})er part of the vagina and from the uterine cavity before operative 
 interference, after operation, and, in some cases, at the end of the puerpe- 
 liuni. Tlie results are tabulated below. 
 
 I. Full Term. 
 
 C. N. 
 
 7,018 
 
 7,808 
 
 9.959 
 738 
 
 Uterus. 
 
 Before Operation. 
 
 Staph, pyog. aureus 
 
 (( (( 
 
 " alb. . 
 No culture taken . 
 
 After Operation. 
 
 Staph, pyog. aureus 
 
 " albus. 
 Sterile 
 
 Vagina. 
 
 Before Operation. 
 
 j Tube broken } 
 \ when rec'd. ( 
 C Staph, pyoj 
 < alb. ; stapl 
 I pyog. aur. 
 No culture taken . 
 
 After Operation. 
 
 No culture taken. 
 
 \ Staph, pyog. alb. 
 ( " " aur. 
 
 No culture. 
 Staph, aureus. 
 
 In C. X. 7,018, cultures from the pus of an abscess over the left deltoid 
 region showed a growth of staphylococcus aureus and streptococcus pyogenes 
 longus. 
 
 It is interesting to note that cases 7,018 and 7,808 ran a febrile tempera- 
 ture, while 9,959 did not; and in 738 the fever was attributed to another 
 cause than uterine infection. 
 
 II. Premature. 
 
 C N 
 
 Uterus. 
 
 Vagina. 
 
 
 Before Operation. 
 
 After Operation. 
 
 Before Operation. 
 
 After Operation. 
 
 6,880 
 7,167 
 
 Sterile 
 
 No culture taken. . 
 
 
 No culture taken. 
 
 1 1 
 
 Sterile 
 
 (Staph, pyog. ) 
 J alb. ; bacillus r 
 ( coli com. ) 
 No culture taken . . 
 
 Staph, pyog. albus. 
 No culture taken. 
 
 51 
 
 ,j 
 
 
 
 
REPORT OF BACTERIOLOGIST. 
 
 353 
 
 A Petri dish containing agar was exposed to the air in the room of 
 patient No. 7,16Y for forty-eight minutes; the following micro-organisms 
 developed colonies: sarcina aurantica, staphylococcus pyogenes albus, 
 bacillus subtilis, bacillus fluorescens liquefaciens, and aspergillus niger. 
 
 III. Abortions. 
 
 C N 
 
 Uterus. 
 
 Vagina. 
 
 
 Before Operation. 
 
 After Operation. 
 
 Before Operation. 
 
 After Operation. 
 
 6,909 
 6 891 
 
 Sterile 
 
 Sterile 
 
 Staph, pyog. albus 
 C Bacillus coli ) 
 ' com. Bacillus > 
 / fiuor. non-liq. ) 
 
 Sterile 
 
 Sterile 
 
 
 u 
 
 No culture taken 
 
 7,022 
 7,029 
 
 7,117 
 7 177 
 
 u 
 
 Sterile 
 
 u 
 
 f Strepto. brevis. ] 
 
 1 Diplococcus 
 
 subflavus of r 
 
 Bumm. J 
 
 ( Diplococcus al- J 
 
 -< bicans of>- 
 ( Bumm. ) 
 
 Broken when rec'd 
 
 Red yeast 
 
 i Bacillus coli | 
 < com. Staph. >- 
 ( pyog. aureus. ) 
 
 Sterile 
 
 No culture taken 
 
 u 
 
 No culture taken. . 
 
 Sterile 
 
 (1 
 
 (C 
 
 u 
 
 No culture taken . . 
 Sterile 
 
 No culture taken . . 
 
 (( (( u 
 
 j Atendofpuerp.: ) 
 \ sterile. ( 
 
 No culture taken . . 
 
 Sterile 
 
 " (( u 
 
 u 
 
 sterile 
 
 7 211 
 
 (( 
 
 No culture taken 
 
 7,465 
 
 u 
 
 Sterile. 
 
 7,683 
 8 086 
 
 u 
 
 i i 
 
 u 
 
 Bacillus coli com . . 
 Staph, pyog. albus. 
 Staph, pyog. albus. 
 No culture taken . . 
 
 U (( u 
 U (( u 
 
 Tube broken 
 
 ( Staph, albus. ) 
 < Bacillus coli >■ 
 ( communis. ) 
 
 No culture taken 
 
 8,077 
 8,087 
 6 880 
 
 u 
 
 Staph, pyog. albus. 
 No culture taken 
 
 u 
 
 (( 
 
 (( (( u 
 
 6,855 
 
 6,915 
 6,924 
 
 No culture taken . . 
 
 U U 11 
 
 sterile 
 
 \ At end of puerp. : 
 \ staph, pyog. alb. 
 S At end of puerp. : 
 I staph, pyog. alb. 
 Sterile. 
 
 7,034 
 
 u 
 
 (( 
 
 Bacillus coli com. 
 
 
 
 
 Petri plate (agar) exposed to the air for one hour in the room of patient 
 Y,211 developed colonies of sarcina lutea, staphylococcus albus, bacillus 
 subtilis, bacillus fluorescens liquefaciens, red yeast, and penicillium glaucum. 
 
 Surgical dressings have been examined on three occasions. The method 
 employed was the same throughout: pieces were snipped off from various 
 portions of each article by means of scissors and forceps sterilized by dry 
 heat, and the pieces dropped into sets of bouillon, agar, and gelatine tubes. 
 The bouillon and agar tubes were placed in the thermostat and examined at 
 the end of twenty-four hours. If sterile, the tubes were examined daily 
 for ten to fourteen days. The gelatine tubes were kept at the room tem- 
 perature. 
 
 23 
 
tine, or bouillon. 
 
 354 REPORT OF THE SOCIETY OF THE LVIXG-IX HOSPITAL. 
 
 I. March 14, 1895. 
 Cotton wipes in tins. 
 Vulva pads in tins. 
 Soft catheter in 5 per cent, carbolic acid, I No growth on agar, gela- 
 Sterilized gauze in Kelly tube. 
 Iodoform gauze in Kelly tube, 
 Starch ])owder in glass bottle, 
 Tape (for ct)rd) in glass — growth of bacillus coli communis. 
 
 Dry wipes in glass bottle — growth of staphylococcus ]3yogenes albus. 
 Eye wipes in boracic acid — growth of an unidentified bacillus, non- 
 pathogenic. 
 
 II. March 30, 1896. 
 
 Dry wipes in glass bottle — growth of bacillus subtilis and staphylococcus 
 albus. 
 
 Cord tape in glass— growth of saccharomyces and staphylococcus albus. 
 
 Nail brush — sterile. 
 
 The result of the culture from the nail brush was sufficiently surprising 
 to warrant a second experiment. 
 
 A well-used brush w^as taken from labor bag No. 18, which was on the 
 slielf ready for service. "With a pair of sterilized scissors a number of 
 bristles were cut off and dropped into some bouillon, agar, and gelatine 
 tubes, the brush being held directly over the mouth of the tubes. A second 
 set of tubes were inoculated with • scrapings made with a stiff platinum 
 neeiUe all over the wood of the brush, between the bristles. No growth 
 of any kind appeared in any one of the twelve tubes inoculated. 
 
 The conclusion is obvious, then, that such a brush in daily use becomes 
 sufficiently saturated with the bichloride of mercury solution used in scrub- 
 bing the hands as to hold no viable bacteria upon or between its bristles. 
 I^ss than twenty-four hours had elapsed between the use of the brush and 
 the making of the cultures. 
 
 III. Septemler 11, 1896. 
 
 All the contents of labor bag No. 5 (ready for use) were tested: 
 
 Glass catheter, in glass tul>e, ])repared by steaming half an hour, at 240 
 degrees Fahrenheit — no growth. 
 
 Intrauterine tube, in glass tube, prepared by steaming half an hour, at 
 240 degre«'s Fahrenheit — no growth. 
 
 Nail brush — no growth. 
 
 Vulva pad, in tin, steamed half an hour — no growth. 
 
 C(jtton, in tin, steamed half an hour — no growth. 
 
 Solution of silver nitrate (1 per cent.) — no growth. 
 
 Eye dro]>|x.'r, carried free in kxip on under surface of cover of bag — 
 staphylocfK'cus aureus. 
 
 Eye wijies, in saturated boracic solution — bacillus coli communis; peni- 
 cillium gjaucum. 
 
 \)vy wijies, in bottle, not steamed — staphylococcus cereus llavus. 
 
REPORT OF BACTERIOLOGIST. 
 
 355 
 
 Cord tapes, not steamed — bacillus coli communis. 
 
 Starch, powdered, in bottle — bacillus megaterium. 
 
 Rubber pad (Kelly), scrubbed and carbolized — bacillus coli communis; 
 sta]")hylococcus aureus. 
 
 Cultures were made from the hands of four internes who had ])repared 
 themselves in the usual way (scrubbing with green soaj), bichloride, and 
 rinsing with distilled water) for the examination of a patient. Scrapings 
 were taken from underneath and about the nails. 
 
 Ko. 
 
 Right Hand. 
 
 Left Hand. 
 
 1 
 
 9, 
 
 Staphylococcus pyogenes albus . . . 
 Sterile 
 
 Staphylococcus pyogenes albus. 
 " cereus flavus. 
 
 3 
 4 
 
 j Staphylococcus pyogenes albus. ) 
 ( " " " citreus. \ 
 j Staphylococcus pyogenes al- \ 
 \ bus ; penicillium glaucum. \ 
 
 " pyogenes albus. 
 
 Eyes of babies with purulent conjunctivitis were examined by cultures 
 and cover slips in four cases: 
 
 Gonococci were found in two, C. N. 13 and 716. 
 Staphylococci (aureus) found in one, C. I^. 223. 
 Pseudo-diphtheria bacillus found in one, C. IST. 721. 
 
 Throat cultures were taken from two cases : 
 
 Staphylococcus pyogenes aureus and streptococcus pyogenes; no Klebs- 
 Loffler baciUi in either C. IT. 10,518 or C. E". 738. 
 
 Sptttum from C. N. 225 was found negative for tubercle bacilli. 
 
 Pus from abscess on hip of baby (A, N. 14,605) negative for tubercle 
 bacilli; cultures show a growth of staphylococci and streptococci. 
 
1 
 
 DATE DUE 
 
 
 
 
 
 
 
 iW^r 
 
 'Mil JAI 
 
 '0 V: - 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 DEMCO 36-296 
 
RG529 Sol 
 
 Society of the lying- in- hospital 
 Medical report... 
 
 
 COLUMBIA UNIVERSITY LIBRARIES 
 
 0041072103 
 
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