dilatation of the cervix, which the pains were unable to overcome. Barnes suggests' that some presumed examples of missed labor "were really cases of interstitial gestation, or gestation in one horn of a twohorned uterus;" and Macdonald' recently recorded a very interesting case in which he performed cœliotomy for what he believed to be a uterine fibroid, but which turned out to be one horn of a bifurcated uterus containing a foetus which had been retained for more than a year. He believes that most, if not all, cases of "missed labor" are of this kind, delivery at term proving impossible because of the narrow connection between the impregnated horn and the cervix. Müller, of Nancy, has attempted to prove, by a critical examination of published cases, that most examples of so-called "missed labor" were in reality cases of extra-uterine fœtation, in which an ineffectual attempt at parturition took place, the fœtus being subsequently retained. From what has been said, it will be seen that the dangers arising from this state are very considerable, and when once the full term has passed beyond doubt, especially if the presence of an offensive discharge shows that decomposition of the foetus has commenced, it would be proper practice to empty the uterus as soon as possible. The necessary precaution, however, is not to decide too quickly that the term has really passed; and, therefore, we must either allow sufficient time to elapse to make it quite certain that the case really falls under this category, or have unequivocal signs of the death of the foetus, and injury to the mother's health. Treatment.-If we had to deal with the case before any extensive decomposition of the foetus had occurred, we probably should find little difficulty in its management, for the proper course then would be to dilate the cervix with fluid dilators, and remove the foetus by turning; or, before doing so, we might endeavor to excite uterine action by pressure and ergot. If the case did not come under observation until disintegration of the foetus had begun, it would be more difficult to deal with. If the foetus had become so much broken up that it was being discharged in pieces, Dr. McClintock says that "in regard to treatment, our measures should consist mainly of palliatives, viz., rest and hip-baths, to subdue uterine irritation; vaginal injections, to secure cleanliness and prevent excoriation; occasional digital examination so as to detect any fragments of bone that might be presenting at the os, and to assist in removing them. These are plain rational measures, and beyond them we shall scarcely, perhaps, be justified in venturing. Nevertheless, under certain circumstances, I would not hesitate to dilate the cervical canal so as to permit of examining the interior of the womb, and of extracting any fragments of bone that may be easily accessible; but unless they could thus be easily reached and removed, the safer course would be to defer, for the present, interfering with them." It may be doubted, I think, whether, considering the serious results which are known to have followed so many cases, it would not, on the 1 Diseases of Women, p. 445. 2 Edin. Med. Journ., vol. 1884-85, p. 873. 8 De la Grossesse utérine prolongée indéfiniment, Paris, 1878. whole, be safer to make at least one decided effort, under chloroform, to remove as much as possible of the putrefying uterine contents, after the os has been fully dilated. Such a procedure would be less irritating than frequently repeated endeavors to pick away detached portions of the foetus, as they present at the os uteri. When once the os is dilated, antiseptic intra-uterine injections might be safely and advantageously used. Unquestionably, it would be better practice to interfere and empty the uterus as soon as we are quite satisfied of the nature of the case, rather than to delay until the foetus has been disintegrated. Macdonald thinks that abdominal section would be the best course to pursue, either removing the sac entire or resorting to Porro's operation. This advice is based on the assumption that "missed labor" is essentially the retention of a foetus in one horn of a bi-lobed uterus, a theory which certainly cannot yet be taken as proved. [Causes of "Missed Labor."-From several cases that have been reported in the United States we find that the failure of the uterus to expel its contents may be due to a variety of causes. If we are certain that the foetus is actually in utero, that there is no pelvic or vaginal obstruction, and that the uterus is itself of normal form, then we must look for the cause of difficulty in the organ itself. By an examination of our reports of Cæsarean operations we find that there have been several cases in which the power of the uterine contractions was insufficient to overcome the resistance to expansion in the cervix. This may be due either to a want of contractile force in the muscular coat, to a change in the tissues of the cervix as the result of inflammation, or to both conditions combined. Where the muscular power of the uterus is in its integrity, the resistance in the cervix may be such that the os may remain unchanged after it is slightly opened, and the patient continue in labor until the contractile power of the uterus is exhausted, when all muscular contraction will cease. Efforts at expulsion may recur at intervals covering a period of many months, when they will cease finally. In two Cæsarean cases in the United States, the subjects being black, there was found a calcareous incrustation over and around the internal os uteri. The first operation was performed in Virginia in 1828 upon a multipara of twenty-five.' She was taken in labor at term, and had pains for two or three days together, at intervals, for about four weeks, after which pains returned occasionally during fifteen months. The cervix admitted the index finger, and in time the foetus became putrid. When operated upon she had carried the foetus two years. There was very little hemorrhage in the operation, although the uterus failed to contract, and for this reason was sutured. woman died in the second week, of peritonitis, following an attack of indigestion, produced by a meal of animal food and cider. The second also a multipara, was operated upon in Georgia in 1877, after a labor of four days, by Dr. Theodore Starbuck, who describes the deposit as "ossific." The child was dead, and the woman died of internal hemorrhage very suddenly on the third day.2 case, Am. Journ Med. Sci., vol. xviii. p. 257.] The [ Communicated by the operator, 1880.] In a third case, also black, the cause of retention appears to have been a prevention of the descent of the foetus, from its arm and leg being secured within the uterus. The woman was thirty-three years old and the mother of one child, and was operated upon by Dr. J. C. Egan, of Shreveport, Louisiana, August 25, 1860.1 On May 4, 1857, while at work in the field, she felt a sudden and violent pain in the left side; fainted, remained insensible so long as to be thought dead, but finally revived, and was pronounced four months pregnant. Labor began in November; the os dilated, head presented, but did not descend; pains continued at intervals for a month. In the fall of 1858 an abscess opened, leaving a fistula one and a quarter inches below the umbilicus. When operated upon nearly two years later, she was greatly emaciated and affected with hectic fever. The uterus being adherent, the peritoneal cavity was not opened. When the foetus was extracted, its left foot and hand were wanting, and, search being made, were found in a pouch on the left side of the uterus, enclosed by bands which were cut for their liberation. The uterus was examined bimanually to make sure that the cervix was sufficiently open for drainage. The decomposed foetus had been carried thirty-three months after maturity. Dr. Egan believes that a partial rupture of the uterus took place at the time of her attack in the field, and that the arm and leg were caught in its partial cicatrization. The woman made a good recovery. Much light is thrown upon a possible way of accounting for some of the mysterious cases of missed labor, which have been claimed to be extra-uterine in order to account for them, by a case recently operated upon in Portland, Maine, by Dr. Stanley P. Warren, and kindly reported to me by letter. The woman was a native, of Scotch-Irish descent, aged thirty-two, and mother of a child of thirteen. She last menstruated in January, 1884. Supposed accidental abortion in May, as there was hemorrhage; the physician said he had removed the placenta, and there was a thick "molasses-like" discharge afterward. Dr. Warren was called in a week later; found metro-peritonitis and a tumor of about four inches in diameter in the right groin. The peritonitis became general, and Dr. W. was in attendance for fifteen days. On July 1st the tumor was in the median line, and fœtal movements and heart-sounds distinct. Labor expected about October 28th; subsequent gestation normal. Was called October 26th, at 11 P.M.; found no true pains; pains apparently abdominal, rather than uterine, and continuous in the back and over the sides of the uterus. Fœtus transverse, with head to right; pulse 152. No change for several days. Second week in November found child dead. Next four weeks slight occasional chills, and temperature 102° for two or three nights, but usually normal. Absolutely no expulsive pains. Cervix reached with difficulty, and finger passed through a long tubular neck, but foetus not reached. Cervix absolutely closed from December 21st to 29th ; pulse 120, temperature 100° to 102°. Attempted to dilate with sponge tent, but could not pass it into the uterine cavity. December 30th [N. O. Med. and Surg. Journ., July, 1877, p. 35; also communicated by operator, 1878.] attempted to open cervix by digital dilatation, and succeeded finally in passing a cranioclast, but the parts closed as soon as the dilators were removed. Patient in a profound shock. After stimulating for an hour, performed Cæsarean section; hemorrhage slight; peritoneum adherent everywhere to uterus; uterine wall one-quarter inch thick; child presented by right arm and side; placenta thin and far advanced in fatty degeneration; no hemorrhage on its removal; uterus did not contract; sutured by continuous stitch with catgut. Child eight and a half pounds. Woman rallied slightly, but died of shock in twentyeight hours. Drs. T. A. Foster and S. C. Gordon were associated with Dr. Warren in the management of the case. It would appear in this instance of missed labor that the changes produced by metro-peritonitis prevented the natural dilatation of the cervix and the contractile action of the muscular coat of the uterus Possibly, fatty degeneration of the muscular fibres had taken place, but this could not be ascertained, as there was no autopsy. The Cæsarean case of Dr. Brodie S. Herndon, of Fredericksburg, Virginia, operated upon with success in 1845, bears a close resemblance in many of its features to that of Dr. Warren. The subject was a white multipara of thirty, whose pains of labor gave place to the continuous pain and other characteristic symptoms of peritonitis. This disease lasted a month, during which time the fluid contents of the uterus escaped and the vaginal discharge became very offensive. Five weeks after the peritonitis commenced the os uteri admitted two fingers, and attempts at dilatation were made, but failed. Under ergot an offensive placenta was expelled, but the foetus could not be removed. The woman being greatly wasted and her room filled with stench, the Cæsarean operation was performed on November 16th, forty-six days after the first signs of labor appeared. The uterus being adherent, the peritoneal cavity was not exposed; the uterus was sponged out, but did not contract; it was closed in the suturing of the abdomen. The patient made a good recovery. As in the Warren case, the uterus became unsuited for performing the functions of labor by reason of changes in its tissues effected by inflammatory action.-ED.] CHAPTER VII. DISEASES OF PREGNANCY. THE diseases of pregnancy form a subject so extensive that they might well of themselves furnish ample material for a separate treatise. The pregnant woman is, of course, liable to the same diseases as the non-pregnant; but it is only necessary to allude to those whose course and effects are essentially modified by the existence of pregnancy, or which have some peculiar effect on the patient in consequence of her condition. There are, moreover, many disorders which can be disinctly traced to the existence of pregnancy. Some of them are the direct results of the sympathetic irritations which are then so commonly observed; and, of these, several are only exaggerations of irritations which may be said to be normal accompaniments of gestation. These functional derangements may be classed under the head of neuroses, and they are sometimes so slight as merely to cause temporary inconvenience, at others so grave as seriously to imperil the life of the patient. Another class of disorders is to be traced to local causes in connection with the gravid uterus, and are either the mechanical results of pressure, or of some displacement or morbid state of the uterus; while the origin of others may be said to be complex, being partly due to sympathetic irritation, partly to pressure, and partly to obscure nutritive changes produced by the pregnant state. Derangements of the Digestive System.-Among the sympathetic derangements there are none which are more common, and none which more frequently produce distress, and even danger, than those which affect the digestive system. Under the heading of "The Signs of Pregnancy," the frequent occurrence of nausea and vomiting has already been discussed, and its most probable causes considered (p. 149). A certain amount of nausea is, indeed, so common an accompaniment of pregnancy that its consideration as one of the normal symptoms of that state is fully justified. We need here only discuss those cases in which the nausea is excessive and long-continued, and leads to serious results from inanition and from the constant distress it occasions. Fortunately a pregnant woman may bear a surprising amount of nausea and sickness without constitutional injury, so that apparently almost all aliments may be rejected without the nutrition of the body very materially suffering. At times the vomiting is limited to the early part of the day, when all food is rejected, and when there is a frequent retching of glairy transparent fluid, in several cases mixed with bile, while at the latter part of the day the stomach may be able to retain a sufficient quantity of food, and the nausea disappears. In other cases the nausea and vomiting are almost incessant. The patient feels constantly sick, and the mere taste or sight of food may bring on excessive and painful vomiting. The duration of this distressing accompaniment of pregnancy is also variable. Generally it commences between the second and third months, and disappears after the woman has quickened. Sometimes, however, it begins with conception, and continues unabated until the pregnancy is over. Symptoms of the Graver Cases.-In the worst class of cases, when all nourishment is rejected, and when the retching is continuous and painful, symptoms of very great gravity, which may even prove fatal, develop themselves. The countenance becomes haggard from suffering, the tongue dry and coated, the epigastrium tender on pressure, and a state of extreme nervous irritability, attended with restlessness and loss of sleep, becomes established. In a still more aggravated degree, there is general feverishness, with a rapid, small, and thready |