FIG. 97.

less completely absent, and cases are known in which the whole four extremities were wanting (Fig. 97). The mode in which these malformations are produced has given rise to much discussion. At one time it was supposed that the deficiency of the limb was due to gangrene of the extremity, and subsequent separation of the sphacelated parts. Reuss, who has studied the whole subject very minutely, considers gangrene in the unruptured ovum to be an impossibility, for that change cannot occur unless there is access of air, and when portions of the separated extremity are found in utero, as is often the case, they show evidences of maceration, but not of decomposition. The general belief is that these intra-uterine amputations depend on constriction of the limb by folds or bands of the amnion-most often met with when the liquor amnii is deficient in quantitywhich obstruct the circulation, and thus give rise to atrophy of the part below the constriction. It has been supposed that the umbilical cord might, by encircling the limb, produce a like result. It appears doubtful, however, whether this cause is sufficient to produce complete separation of the limb, as any great amount of constriction would interfere with the circulation through the cord. Sometimes, when intra-uterine amputation occurs, the separated portion of the limb is found lying loose in the amniotic cavity, and is expelled after the child. Cases of this kind have been recorded by Martin, Chaussier, and Watkinson. More often no trace of the separated extremity can be found. The explanation probably depends upon the period of uterogestation at which amputation took place. If it occurred at a very early period of pregnancy, before the third month, the detached portion would be minute and soft, and would easily disappear by solution. If at a later period, this could hardly happen, and the detached portion would remain in utero. In cases of the latter kind cicatrization of the stump has often been observed to be incomplete. Simpson pointed out the occasional existence of rudimentary fingers or toes on the stump of an amputated limb, such as are seen on the thighs in Fig. 97. These he attributed to an abortive reproduction of the separated extremity, analogous to what is observed in some of the lower animals. This explanation has been contested with much show of reason. Martin believes that the reproduction is only apparent, and that the rudimentary extremities are, in reality, instances of arrested development. The constricting agents interfered with the circulation sufficiently to arrest the growth of the limb below the site of constriction, but not sufficiently to effect complete separation. If constriction occurred at a very early stage of development, an appearance similar to that observed

1 Scanzoni's Beiträge, 1869.

by Simpson would be produced. It does not follow, however, that all cases of absence of limbs depend on intra-uterine amputations. In some cases they would appear to be the result of a spontaneous arrest of development, or of congenital monstrosity. Mr. Scott' relates a case in which a distinct hereditary tendency was evident, and here the deformity certainly could not have resulted from the constriction of amniotic bands. In this family the grandfather had both forearms wanting, with rudimentary fingers attached; the next generation escaped; but the grandchild had a deformity precisely similar to that of the grandfather.

[Arrested Pullulation.-The absence of a hand where there are rudimentary evidences of an attempt to form the thumb and fingers can be accounted for much more satisfactorily on the theory of an arrested development taking place in the latter half of the second month of embryonic life than upon the hypothetical idea that there has been first an amputation in utero, and then an attempt of Nature to reproduce the lost digits by a new budding process, as taught by Simpson and Annandale. More than thirty years ago I became fully satisfied that there was an inclination in Nature to repeat itself so exactly during the pullulative period of embryonic growth that cases of congenital deficiency of the thumb and fingers of a precisely similar character must from time to time present themselves to the eye of the medical observer. It so happened that three such typical cases, all exactly alike, in two boys and one girl, each being strangely without the left hand, came under my notice during a short period of years. The forearm in each ended in a well-rounded and slightly-flattened stump, from which protruded a row of pisiform nail-less bodies representing the embryonic commencement of the formation of a thumb. and four fingers. I saw these subjects at different ages of infancy and childhood, and the little pea-like bodies remained the same, with the exception that they became slightly larger. In a fourth case, a boy, the finger rudiments were entirely absent, and there was an attempt to form a thumb, which was useless and about three-quarters of an inch long. The boy developed into a powerful man of six feet. Cases of the precise type of the three first named have come under the observation of medical friends.-ED.]

Death of Fœtus.-When from any cause the foetus has died during pregnancy, it may be either soon expelled, or it may be retained in utero for a longer or shorter time, or even to the full period. The changes observed in such foetuses vary considerably according to the age of the fetus at the time of death, or the time that it has been retained in utero. If it die at an early period, when the tissues are very soft, it may entirely dissolve in the liquor amnii, and no trace of it may be found when the membranes are expelled. Or it may shrivel or mummify; and if this happen in a twin pregnancy, as sometimes occurs, the growing foetus may compress and flatten the dead one against the uterine wall.

At a later period of pregnancy a dead fetus undergoes changes

1 Obst. Trans., 1872, vol. xiii. p. 94.

ascribed to putrefaction, but which produce appearances different from those of decomposition in animal textures exposed to the atmosphere. There is no offensive smell, as in ordinary decay. The tissues are all softened and flaccid. The more manifest changes are in the skin, the epidermis of which is separated from the cutis vera, which has a deep reddish color. This is especially apparent on the abdomen, which is flaccid, and hollow in the centre. The internal organs are much altered. The brain is diffluent and pulpy, and the cranial bones loose within the scalp. The structures of the muscles and viscera are in various stages of transformation, many having undergone fatty changes, and contain crystals of margarin and cholesterin. The extent to which these changes occur depends, in a great measure, on the length of time the foetus has been dead, but they do not admit of our estimating with any degree of accuracy what that time has been.

The symptoms and diagnosis of the death of the foetus may here be considered. They are, unfortunately, not very reliable. The cessation of the foetal movements cannot be depended on, as they are frequently unfelt for days or weeks, when the child is alive and well. Sometimes the death of the foetus is preceded by its irregular and tumultuous movements, and, in women who have been delivered of several dead children in succession, this sensation may guide us in our diagnosis. This suspicion may be confirmed by auscultation. The mere fact that we are unable, at any given time, to hear the foetal heart will not justify an opinion that the foetus is dead. If, however, the foetal heart has been distinctly heard, and after one or two careful examinations, repeated at separate times, it cannot again be made out, the probability of the child being dead may be assumed. Certain changes in the mother's health have been noted in connection with the death of the foetus, such as depression and lowness of spirits, a feeling of coldness and weight about the lower parts of the abdomen, paleness of the face, a livid circle round the eyes, irregular shiverings and feverishness, shrinking of the breasts, and diminution in the size of the abdominal tumor. All these, however, are too indefinite to justify a positive diagnosis, and they are not infrequently altogether absent. At most they can do no more than cause a suspicion as to what has happened.

CHAPTER X.

ABORTION AND PREMATURE LABOR.

Importance and Frequency of Abortion. The premature expulsion of the foetus is an event of great frequency. The number of foetal lives thus lost is enormous. There are few multipare who have not aborted at one time or other of their lives. Hegar estimates that

about one abortion occurs to every eight or ten deliveries at term. Whitehead has calculated that at least 90 per cent. of married women who lived to the change of life had aborted. The influence of this incident on the future health of the mother is also of great importance. It rarely, indeed, proves directly fatal, but it often produces great debility from the profuse loss of blood accompanying it; and it is one of the most prolific causes of uterine disease in after-life, possibly because women are apt to be more careless during convalescence than after delivery, and the proper involution of the uterus is thus more frequently interfered with.

Definition. A not uncommon division of the subject is into abortion, miscarriage, and premature labor, the first name being applied to expulsion of the ovum before the end of the fourth month of utero-gestation; miscarriage, to expulsion from the end of the fourth to the end of the sixth month; and premature labor, to expulsion from the end of the sixth month to the term of pregnancy. This is, however, a needless and confusing subdivision, which leads to no practical result. It suffices to apply the term abortion or miscarriage indiscriminately to all cases in which pregnancy is terminated before the foetus has arrived at a viable age, and premature labor to those in which there is a possibility of its survival. There is little or no hope of a foetus living before the twenty-eighth week or seventh lunar month, and this period is therefore generally fixed on as the limit between premature labor and abortion. The rule is, however, not without an occasional, although very rare, exception. Dr. Keiller, of Edinburgh, has recorded an instance in which a foetus was born alive at the fourth month, nine days after the mother had experienced the sensation of quickening. I myself recently attended a lady who miscarried in the fifth month of pregnancy, the child being born alive, and living for three hours. Several cases are on record in which after delivery in the sixth month the child survived and was reared. The possibility of the birth of a living child under such circumstances should be recognized, as it may give rise to legal questions of importance; but the exceptions to the ordinary rule are so rare that they need not interfere with the division of the subject usually made.

Abortion is Most Common in Multiparæ.-Multiparæ abort far more frequently than primiparæ. This is contrary to the statement in many obstetrical works. Thus, Tyler Smith says, "there seems to be a greater danger of this accident in the first pregnancy." Schroeder,' however, states that twenty-three multiparæ abort to three primipare; and Dr. Whitehead, of Manchester, who has particularly studied the subject, believes that abortion is more apt to occur after the third and fourth pregnancies, especially when these take place toward the time. for the cessation of menstruation.

There can be no doubt that women who have aborted more than once are peculiarly liable to a recurrence of the accident. This can generally be traced to the existence of some predisposing cause which persists through several pregnancies, as, for example, a syphilitic taint, a

1 Schroeder: Manual of Midwifery, p. 149.

uterine flexion, or a morbid state of the lining membrane of the uterus. It is probable that in many women a recurrence of the accident induces a habit of abortion, or perhaps it might be more accurate to say, a peculiar irritable condition of the uterus, which renders the continuance of pregnancy a matter of difficulty, independently of any recognizable organic cause.

The frequency of abortion varies much at different periods of pregnancy; and it occurs much more often in the early months, because of the comparatively slight connection then existing between the chorion and the decidua. At a very early period of pregnancy the ovum is cast off with such facility, and is of such minute size, that the fact of abortion having occurred passes unrecognized. Very many cases, in which the patient goes one or two weeks over her time, and then has what is supposed to be merely a more than usually profuse period, are probably instances of such early miscarriages. Velpeau detected an ovum, of about fourteen days, which was not larger than an ordinary pea, and it is easy to understand how so small a body should pass unnoticed in the blood which escapes along with it.

Up to the end of the third month, when miscarriage occurs, the ovum is generally cast off en masse, the decidua subsequently coming away in shreds or as an entire membrane. The abortion is then comparatively easy. From the third to the sixth month, after the placenta is formed, the amnion is, as a rule, first ruptured by the uterine contractions, and the foetus is expelled by itself. The placenta and membranes may then be shed as in ordinary labor. It often happens, however, that on account of the firmness of the placental adhesion at this period the secundines are retained for a greater or less length of time. This subjects the patient to many risks, especially to those of profuse hemorrhage, and of septicæmia. For this reason, premature termination of the pregnancy is attended by much greater danger to the mother between the third and sixth months than at an earlier or later date. After the sixth month the course of events is not different from that attending ordinary labor. The prognosis to the child is more unfavorable in proportion to the distance from the full period of gestation at which premature labor takes place.

Causes. The causes of abortion may conveniently be subdivided into the predisposing and exciting, the latter being often slight, and such as would have no effect in inducing uterine contractions in women unless associated with one or more of the former class of causes. The predisposition to abortion may depend on some condition interfering with the vitality of the ovum, or its relation to the maternal structures, or on certain conditions directly affecting the mother's health.

One of the most common antecedents of abortion is the death of the foetus, which leads to secondary changes, and ultimately produces the uterine contractions which end in its expulsion. The precise causes of death in any given case cannot always be accurately ascertained, as they sometimes depend on conditions which are traceable to the maternal structures, at others to the ovular, or, it may be, to a combination of the two. Nor does it by any means follow that the death of the ovum immediately results in its expulsion. The mode in which death