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Centralblatt f.

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A REPORT OF THE WORK OF THE FIRST DIVISION OF THE HOSPITAL.

BY

MORRIS K. SMITH, M.D.
Attending Surgeon.

From January 1st to April 30th inclusive 1914, there were in the service of the First Division 505 cases rated as labor cases including those admitted in the first ten days of the puerperium, abortions, ectopics and moles. Of this number 7 died, 1.4%*. There were 429 cases six months or more pregnant delivered in the Hospital. Of these 4 or .94% died. One of these four died from streptococcemia following retropharyngeal abscess in which the labor was entirely incidental, so that excluding her the mortality was .7%. The three remaining deaths in this series of cases delivered in the Hospital were (1) peritonitis following Cesarean section, (2) accidental hemorrhage, exsanguinated on admission, (3) cardiac-valvular disease. Including both pregnant and non-pregnant cases there were 10 adult deaths in the four months. The causes of death:

(1) peritonitis following operation for ventral hernia,

(2) miliary tuberculosis in a woman four months pregnant, undelivered,

(3) puerperal sepsis (streptococcemia) (admitted on the 12th day), (These cases are not included in the percentages quoted above.) (4) toxemia of pregnancy with localization in the kidneys in a woman admitted one day post partum who had no convulsions,

(5) peritonitis following Cesarean section,

(6) ruptured uterus and peritonitis admitted three days post partum, (7) pyemia following probable criminal abortion,

(8) streptococcemia following retropharyngeal abscess,

(9) accidental hemorrhage,

(10) cardiac disease.

The 429 patients six months or more pregnant delivered in the Hospital gave birth to 441 children. Among these 441 there were 31 stillbirths, 7 %. Of these 31, 14 were more or less macerated, although 3 of these undoubtedly died from causes connected with labor. The causes of stillbirth so far as determinable were: prematurity 8, placenta previa in mother 3, prolapsed cord 3, long labor and operative interference 2, foetal anomalies 2, syphilis 2, long labor with cord tightly about neck 1, uterine infection and operative delivery 1, cardiac disease in mother 1, accidental hemorrhage 1, twin robbed of nourishment by its fellow 1, eclampsia 1, undeterminable 5.

*One case dying of puerperal sepsis is not included because she was admitted on the 12th day.

Of the 441 infants 25, stillbirths excluded, died in the Hospital, 5.7%. Of these, two, whose mothers had died, remained in the Hospital, because their families were unable to care for them, beyond the usual period, and died of malnutrition, one on the 16th and one on the 50th day. In addition there were 5 deaths in infants sent in without their mothers, therefore not among our labor cases, and two in infants admitted post partum with their mothers, a total of 32 infantile deaths. The causes of death were: inanition 6, prematurity 5, toxemia in mother 3, placenta previa 2, cerebral hemorrhage 2, probable cerebral hemorrhage 1, harelip and inanition 2, meningitis 2, hemophilia 2, occlusion of the intestine 1, diaphragmatic hernia 1, peritonitis 1, prolapsed cord compressed by forceps 1, long labor 1, unknown 2.

Our infant mortality in cases delivered in the Hospital was therefore,

stillbirths.
death of child

Total

31 7.0%

25 5.7%

56 12.7%

Of the 429 cases six months or more pregnant delivered in the Hospital, 395 or 92% were vertex presentations (plural births excluded); 351 or 82% delivered spontaneously, approximately one half of whom were primiparae. Of these 351 spontaneous deliveries there were 355 children with 27 stillbirths and deaths, 7.7%. The causes of death in this series were: prematurity 12, anomalies 3, syphilis 2, hemophilia 1, second twin robbed of nourishment by its fellow 1, peritonitis 1, long labor in face case 1, malnutrition 1, unknown 5. There was one maternal death (0.3%) in this series. The cause, streptococcemia from retropharyngeal abscess, was entirely foreign to the labor.

Of the 78 deliveries in which there was operative interference there were 86 infants. Of these 86, 29 were stillborn or died during the puerperium, 34%. Death could be attributed to the operative procedure in 5, 6%.

There were 18 breech deliveries (4.2%) excluding twins, 12 or 2.8% of which 12, 8.66% were primiparae. There was no maternal mortality. The infantile mortality was 7 or 40%. Of the seven deaths only one could be clearly attributed to the extraction, cerebral hemorrhage after coming through a contracted pelvis. Of the other six two were six months premature, one was a macerated premature, while three died of inanition.

There were 6 cases of transverse position, 1.4%. All the mothers lived, 100%, and four babies, 66%. Of the 2 that died both were macerated, one from prolapsed cord and one cause unknown. Version was done in every case with perforation of after coming head in one. All were multi

parae.

There were two face cases. Both mothers lived, both babies were stillborn. One delivery was spontaneous although forceps had been tried

on the outside, the other delivery was by low forceps, the infant dying from cord about the neck. Both mothers were multiparae.

There were 10 cases of twins and one of triplets making the plural births, 2.6%. All the mothers lived. Three of the mothers had signs of toxemia. Of the 23 babies 17 lived, 74%. Of the 6 that died 1 was macerated, 2 were prematures, 3 died of malnutrition. Only one of the 11 plural births occurred in a primipara.

There were 34 abortions or 6.7% of all labor cases. Of these 3 were complete abortions and 3 were vaginal Cesarean sections for various indications. One died, 3%. She was admitted infected, the abortion having already been performed.

There were 2 cases of ectopic gestation, 0.4%. Both lived.

There was one case of hydatid mole, 0.2%. The patient lived.

Of the 429 cases six months or more pregnant delivered in the Hospital, 78 or 18.2% were operative, including among operative deliveries breech cases where manual aid was given. The breech deliveries have already been described.

There were 18 forceps deliveries or 4.2%. 16 of these 18 were in primiparae, 89%. The maternal mortality was zero. The infantile mortality was 5 or 28%. Of these 3 deaths were due to the forceps, one infant was stillborn and one was asphyxiated by cord about neck. Classification:

The indications for forceps were contracted pelvis 5, uterine inertia and exhaustion 8, toxemia of pregnancy 2, face presentation 1, placenta previa 1, infection of mother 1.

Internal podalic version was done 30 times or in 7% of the 429 cases. Eight of these 30 were primiparae. Maternal death followed the operation twice (6.6%) although in neither case was it due to the version, the causes being cardiac valvular disease 1, and accidental hemorrhage 1. There were 11 infantile deaths or stillbirths, 37%. The causes of death were placenta previa, in some of which prematurity was a factor, 4, contracted pelvis 2, accidental hemorrhage 1, prolapsed cord 1, eclampsia 1, macerated, cause unknown 1, cardiac disease in mother 1. The indications for the operation were placenta previa 9 (contracted pelvis 5 (2 deaths), transverse 6, second twin 4, eclampsia 3, accidental hemorrhage 1, prolapsed cord 1, cardiac disease 1.

Cesarean section was done 11 times or in 2.6% of the cases, 3 of these 11 being transperitoneal. Seven of the 11 women were primiparae and one more had had only a previous abortion. The maternal mortality was 1, septic peritonitis terminating 3 days after operation by the transperitoneal

method, 9%. The infantile mortality was 3 or 27%. The causes of death were eclampsia in mother 1, depression of respiratory center presumably from long labor 1, malnutrition 1. The indications for Cesarean section were contracted pelvis 9, kyphosis 1, eclampsia, 1. Two of the 11 cases had had previous Cesareans.

Craniotomy was done 5 times, 1%. Of these 3 were on the aftercoming head and one in a macerated fetus in a primipara with head on the perineum. The indications were prolapsed cord and small parts with death of fetus 2, nonviable fetus in a case of placenta previa 1, macerated fetus with head on perineum in a primipara 1, dead fetus in a case of accidental hemorrhage 1.

There were 112 primary perineorrhaphies done of which 68 were first degree, 42 second degree and 2 third degree. There were 28 primary trachelorrhaphies done. Of the cases delivered in the Hospital perineorrhaphies were done in 25%, trachelorrhaphies in 6.5%.

cases.

There were 3 cases of vaginal Cesarean section, 0.6% of all labor The indications were pernicious vomiting 1, prolapse of pregnant uterus 1, pulmonary tuberculosis 1. All the patients lived. None of the fetuses was viable.

Toxemias of pregnancy. There was one case of pernicious vomiting. Vaginal Cesarean section was done with recovery of the patient. There were 8 cases of pre-eclamptic toxemia which did not go on to convulsions. Of these all the mothers lived and 7 out of 11 babies, 64%. Of the 4 babies who died, 3 were premature, 2 of these twins, and another was killed by delivery through a contracted pelvis. Of these eight women 4 possibly 5 were primiparae. Delivery was spontaneous in 4 of these cases, spontaneous following induction of labor by packing in 2 more, by low forceps in one and by version in one. There was one case of nephritic toxemia in which the mother was delivered of premature twins, the first spontaneous, the second by version. Both mother and infants lived. There were 8 cases of toxemia with convulsions of which all the mothers (100%) and 5 babies (63%) lived. Of these 8, all were primiparae. Three were delivered by version and extraction, one by forceps in the hospital, one by forceps outside, one by Cesarean section, in one labor was induced followed by spontaneous delivery and one was entirely spontaneous. Only 3 of the 8 babies were of normal size, 3 of the remaining 5 being certainly premature. In 2 out of the 8 cases convulsions occurred for the first time post partum. There was one case of fulminating toxemia localizing in the kidneys without convulsions which was admitted one day post partum and died in 12 hours. Many lesser degrees of toxemia are undoubtedly omitted in my list. The total number of cases cited is 19 with one death, 5.3%.

There were 12 cases of placenta previa. All the mothers lived, 100%. Five babies were either stillborn or died during the puerperium, 42%. One has an Erb's palsy. Of the 12 cases 10 were delivered by internal podalic version and extraction preceded as a rule by packing. One case