Dr. Smith has referred to vaginal tears. We have them extending sometimes well up, usually made by the blade of the forceps adjusted so that the side of the blade comes out and grips the tissue by improper constriction. I have had reasons to think and know that it has been done in cases of mine, and I have seen it done in others. These vaginal tears usually heal themselves. If there should be great difficulty in getting the patient well sutured, there is some satisfaction in knowing that these will usually heal themselves. Sometimes there will be the surface of the vagina that will be split, not cut through, but split towards the rectum. It may be a flap half an inch, perhaps an inch. Those cases should always be sutured. If too deep and bleeding, they should be sutured anyway; but the special reason why these should be sutured is for the after condition. If a broad raw surface is left to heal, there will be usually a cicatrical tissue that will always be tender and painful to the patient for months afterwards, and which is apt to be the point of infection. As we examine the case later, we find there is a thickened broad ligament on one side or the other and a great many times those cases are due to the connection of the lymphatics which go to the broad ligament from the vicinity of the lateral vaginal tear.

The Relation of Typhoid Fever to Pregnancy and

the Puerperium.

OTTO G. RAMSAY, M.D., New Haven.

In considering the relationship of any of the intercurrent diseases to pregnancy, there are two points of view from which we must study the condition, namely, what may be the effect of the disease on the pregnant condition, and how does the pregnant condition affect the disease. Besides this, too, the relationship to pregnancy, to labor, and to the puerperium, must all be considered, as they are separate states.

It will shorten materially any discussion if we review briefly to pregnancy, before going into details as to the particular results of typhoid fever.

In the first place, is the foetus directly infected by the microbe which causes the infection in the mother? That this is not always the case has been proven for most diseases, though it is undoubtedly true that in a certain small proportion of pregnant women, there is direct infection of the foetus by the infecting organism. That it is not always so must be due to the protective influence of the placenta, and it appears that the normal placenta has usually the power of retaining organisms in the maternal circulation. The reason why sometimes the power is lost is not yet clear. The young placenta is apparently not so strong in this direction as the placenta nearer term, and, for instance in typhoid fever, most of the cases in which it has been possible to cultivate bacteria directly from the foetal tissues were in cases of miscarriage in the early months. Apparently the virulence of the individual organism does not account for the cases of direct foetal infection, as some of the cases in which the organism has been recovered from the foetal tissues were in a mild type of the disease. Some writers

on the subject claim as the explanation of the passage of the organism, a less resistant area in the placenta, due to traumatism or to disease. This is as far as our knowledge goes, and we must rest for the present content with the certainty, that as a rule the placenta protects the foetus from direct infection, though this is not always true, as evidenced by the fact that organisms of the maternal disease have been isolated from the foetal tissues.

Besides the direct infection by organisms there are several other things which must be considered. For instance, what may be the effects of the toxins which are liberated during the diseased state upon the foetus? That these, in many cases, enter the foetal circulation is evidenced by the fact that in typhoid fever, for instance, a Widal reaction with the foetal blood is much more commonly found present than the organisms themselves. These toxins, then, are the probable cause in some cases of foetal death.

Another condition which must probably influence the foetus is the high temperature so commonly found in the infectious diseases, and this without doubt is a cause of foetal death. Whether the death is due directly to the high temperature acting on the unaccustomed foetal metabolism, or whether the high temperature acts unfavorably on the brain or other vital centres is not yet determined.

Finally the high temperature, besides its direct action on the foetus, acts unfavorably on the uterine musculature, the mucous membrane, or on the uterine spinal centres, increasing uterine irritability and causing a premature ending of the pregnancy, sometimes when the child is apparently not at all affected; often, however, children born living during the course of an infectious disease show signs of being at least influenced by the disease, or by the toxins, evidencing this by high temperatures or various cerebral or visceral disturbances which may cause death or which may, if the child is a resistant one, be overcome by careful attention to feeding, stimulation, etc.

To review briefly these general statements, we find that as a rule the placenta has the power of prohibiting the passage of organisms from the maternal to the foetal circulation; though occasionally the organisms are able to pass the placental wall, possibly

as a result of disease or traumatism. That probably the toxins of the disease are able to pass the placenta more easily and are the cause of foetal death in many cases. Also that the high temperatures influence unfavorably the life of the child and greatly increase the chance of premature emptying of the uterus.

So much for the general question, and we may now approach the subject of the paper. In the first place, as to the influence of pregnancy on the typhoid infection. Does pregnancy exert

a protective influence against a typhoid infection? This was formerly accepted as a fact, and there is still a legend, at least among the laity, which affirms it to be true. It is difficult, certainly, to get any definite statistics on the subject, but in the epidemics which have occurred at various times, in which the relation of pregnancy to the infection has been considered, it has been found that about an average number of pregnant women were affected by the disease, and it seems to me that it is probable that the idea grew out of the fact that pregnant women are more protected by their pregnancy and less likely to be outside of their homes, thus lessening the chance of the sporadic case, while in epidemics they are open to the same chance as the rest of the population and suffer to the same average

extent.

Pregnancy appears to affect the course of the disease but little, and the mere fact of a woman being pregnant does not seem in any way to increase the virulence of the infection. Naturally the prognosis must be slightly more grave, as we have to add to the disease itself the chances of miscarriage or premature labor, with the possibility of severe hemorrhage lessening the resistance, and increasing the chances of infection; but it is surprising many times to see what little general effect follows the emptying of the uterus in typhoid fever and how well the patient bears the shock of the labor, with its attendant handling or hemorrhage.

From the other point of view, namely, the effect of typhoid fever on pregnancy, the picture is somewhat different, as undoubtedly it exerts a very serious influence on the continuance of pregnancy. Taking the statistics as a whole we find that from 45% to 55% of pregnant women suffering with typhoid fever empty the uterus prematurely. It has also been found that the

chances of miscarriage during the earlier months is greater than in the later ones. This tendency to miscarriage is evidently due to several conditions. In the first place, a certain proportion, small possibly, is due to the direct invasion of the foetal tissues by the typhoid bacillus with, as a result, foetal death and extrusion. Another reason, probably, is the effect of the toxins or of the continued high temperature on the foetus, causing its death.

The most important cause, probably, for the interruption of pregnancy, however, is the effects of the toxins or the high temperature on the uterine walls, either the musculature or the decidua, or on the uterine centres in the spinal chord. There is undoubtedly, during the course of the disease, an increased irritability of the uterus and there is probably in addition to this a tendency to decidual changes. This has not been definitely proven, but reasoning by analogy we find, for instance, in some of the other infectious diseases, a distinct hemorrhagic endometritis deciduae, and it is certainly true that in typhoid fever in the non-pregnant woman there is frequently slight uterine hemorrhage, showing the tendency of the disease to attack the uterine mucosa.

At any rate, we know that typhoid fever occurring during pregnancy gives a bad outlook for the continuance of the pregnancy and that a warning as to the possible outcome should always be given. As to the means which should be taken to prevent this occurrence, there is unfortunately but little that can be done. These cases are treated just as one would treat the general patient suffering from the disease. Possibly cold baths might be contra-indicated, and I should be inclined, during the height of the disease, to use opium for its action on the uterus. Also special care should be paid to the elimination of toxins by the use of fluids in plenty, and by care of the bowels, as we consider them the cause of foetal death many times. Besides this as complete quiet as possible should be obtained for our patient and the possible delirium should be combatted by appropriate remedies, small doses of hyoscine, for instance, being recommended. My own individual experience has been, I am glad to say, small in these cases, but I have been struck with the impossibility of giving any definite prognosis based on the intensity of the disease, and I have also