nine a premature expulsion of the fetus, the time at which the expulsive efforts began seeming to bear a relation to the outbreaks of the eruption upon the skin. In these cases, according to Klotz, the uterine action is excited by the occurrence of an exanthema upon the uterine mucous membrane, highly irritating in its action, just as the photophobia, the coryza, the bronchitis, and the vesical tenesmus of measles indicate an irritated condition of the mucous

membranes of the eyes, nose, lungs, and bladder. It is quite probable that the same condition of the uterine mucous membrane might account for the abortions or premature labors that often occur when pregnant women are attacked by any of the eruptive fevers.

Purulent and Microbic Decidual Endometritis.-Donat 1 has described a case of purulent endometritis in pregnancy. A woman expelled at term a placenta about the periphery of which could

Fig. 117.-Atrophy of the decidua, external surface of the vera (Duncan).

3

be seen masses of decidua infiltrated with pus. The amnion and chorion were both thickened and opaque, and between them was an accumulation of purulent fluid. It was suspected that the suppuration of the decidua was the result of unsuccessful attempts on the part of the woman to bring on a miscarriage.

Atrophy of the Deciduæ.-The deciduæ, instead of undergoing inflammatory and hyperplastic changes, may, on the contrary,

This

atrophy, although such an occurrence is doubtless rare. change in the decidual membranes has been described by Hegar 2 and Matthews Duncan, and, among more recent writers, by Spiegelberg and Priestley.5 The uterine, ovular, or placental decidua may singly or conjointly be the seat of atrophy, resulting either in the ovum being attached by a mere pedicle of slender proportions to the uterine wall, or else, in the case of atrophy of the ovular decidua, the embryo lacks the outermost of its protective membranes, and, consequently, the ovum may rupture and its contents be discharged from the uterus. As a result of the stretching of the pedicle in cases of placental atrophy, the ovum

2" Monatsh. f. Geburtsh. u. Fr.," Bd. xxi; Supplem., pp. 11, 19, 1863.
Researches in Obstetrics," p. 295, 1868.
5 Op. cit.

366

4" Lehrbuch," p. 328.

contractions until it This condition con

may be pushed downward by the uterine rests in great part within the cervical canal. stitutes the cervical pregnancy of Rokitansky.

CHAPTER V.

The Diseases of the Fetus.

FETAL mortality exceeds that of any other period of life. It has been estimated that for every four or five labors there has occurred one abortion, and if to this number be added the still-births in which the death of the fetus was not due to an accident in labor, the proportion of fetal deaths to living births is very large. In addition to the diseases having a fatal termination, there are others affecting the fetus in utero running their course wholly or in part during intra-uterine life and ending in recovery; so that the list of fetal diseases is an extensive one.

The present chapter treats of the diseases of the fetal organism itself, of weakness dependent upon defects in the paternal elements entering into the composition of the embryo, and of maternal conditions which are incompatible with the healthy development or with the continued existence of the product of conception.

Fetal Syphilis.-First in importance of all the diseases of intra-uterine life, fetal syphilis deserves a somewhat extended notice. According to Ruge,1 eighty-three per cent. of repeated premature and still-births have their cause in syphilis of one or both of the parents. Of 657 pregnancies in syphilitic women collected by Charpentier,2 thirty-five per cent. ended in abortion, and of the children that went to term a large number were stillborn. Of 100 conceptions in syphilitic women, only seven children were alive a year later. 3

The Syphilitic Infection of the Fetus.-If the woman be syphilitic, the ovule is diseased before its impregnation; or the spermatic particle from a syphilitic man carries the infection to the ovary of a healthy woman. Modern investigation shows, moreover, the possibility of infecting the healthy fetus at any time during intra-uterine life should the mother acquire syphilis during pregnancy.

1 See Lomer, "Zeitschr. f. Geburtsh.," Bd. x, p. 189.

2" Traité pratique des Accouchements."

3 Pileur, "Bull. de la Soc. d'Obst. et de Gyn.," Paris, Dec. 13, 1888.

As

Syphilis may be transmitted from a syphilitic father direct to the embryo without the previous infection of the mother. the fetus grows, however, and the syphilitic poison develops with its growth, the mother becomes infected in her turn directly from the fetus through the uteroplacental circulation. 1 The longer the time since the acquisition of the disease by either parent, the less likelihood there is of the production of syphilis in the embryo; but the limit of safety has not yet been discovered. According to Fournier, 2 four years is the maximum of time that syphilis can remain latent, but Lomer 3 reports the birth of a syphilitic infant ten years after the first infection of the father, and Kassowitz 4 records a latent syphilis of twelve years' duration.

Lusk said that "the syphilitic poison will not traverse the septa intervening between the fetal and the maternal vascular systems"; but Vajda 5 and Hutchinson 6 describe cases in which pregnant women were infected near term and gave birth to syphilitic children. Neumann also has published observations of 20 women who were infected with syphilis during pregnancy; 5 of this number gave birth to syphilitic children, and of these 5 2 were infected at the fourth and I each at the third, seventh, and eighth months. Hirigoyen 8 has reported 12 cases in which the mother contracted syphilis during the first four months of pregnancy; all the children were still-born; in cases of infection from the fourth to the sixth month, about half the children were still-born; and in 7 cases of infection during the last three months of pregnancy there were 4 still-births. 9

Manifestations of Fetal Syphilis.-Syphilis acquired by the embryo at the moment of conception from preëxisting syphilis of the ovule, or of the spermatic particle, or of both, or transmitted to the fetus from the mother at any time during pregnancy, manifests great variety in the tissues attacked and the lesions produced. Thus there are bullous eruptions of the skin, condylomata, and inflammations of the mucous membranes, inflammations of the serous membranes, gummatous and miliary deposits,

1 See Tarnier et Budin, op. cit.; Priestley, loc. cit. J. Hutchinson, "British Med. Jour.," Feb., 1886, p. 239; Harvey, Fetus in Utero," 1886; G. S. West, "Am. Jour. Obstetrics," 1885, p. 182.

2.66 Syphilis et Mariage."

4 Stricker's "Jahrb.," 1875, p. 476.

5 "Centralbl. f. Gyn.," 1880, p. 360.

7.66 Wien. med. Presse," 29, 30, 1885.

3Zeitschr. f. Geburtsh.," Bd. x, 94.

6" British Med. Jour.," 1886, i, 239.

8 Abstract in "N. Y. Med. Record," April 12, 1887.

9 The author has seen a woman impregnated by a healthy man, but infected with syphilis in the third month of pregnancy, give birth to a child with a pemphigoid eruption upon it and a liver twice the normal size.

Head of femur removed from a fetus expelled. dead and macerated, at the seventh month. The liver weighed one-tenth of the body-weight; the spleen, oneforty-eighth. The mother was infected with syphilis one year before (author's case, Philadelphia Hospital).