Boston Lying-in Hospital Research Articles

THE EFFECT OF PREGNANCY ON THE COURSE OF MYASTHENIA GRAVIS

Pregnancy may and often does cause profound changes in patients with myasthenia gravis. In some instances during part or all of the nine months of childbearing symptoms disappear entirely; more rarely the disease increases in severity in the early months, and in a few instances during this period abortions for therapeutic reasons have been considered justifiable. More rarely remission does not take place during the entire pregnancy. The subject has received scant attention in the literature, and few instances of pregnancy occurring in patients with myasthenia gravis have been reported. This is partly due to the rarity of the disease. At the Boston Lying-In Hospital only 1 patient with myasthenia gravis was registered in more than 63,268 admissions between 1900 and 1940. Most textbooks on obstetrics, moreover, do not mention the disease. Myasthenia gravis, or grave muscle weakness, is a disease characterized by an abnormal state of fatigability of particular

STUDIES ON THE CIRCULATION IN PREGNANCY

Studies were conducted for several years (1932-1937) at the cardiac research laboratory of the Boston Lying-in Hospital on the physiology of the circulation of pregnant women.¹The purposes of these studies were, first, to learn the dynamics of the circulation of the normal pregnant woman, second, to learn what the nature of the "increased burden" on the pregnant woman with heart disease is, and, finally, to develop, if possible, concepts which might be of clinical use in the management of normal pregnant women and pregnant women with heart disease. A summary of the results of these studies, plus pertinent studies from the literature, will be presented here. <h3>CLINICAL AND LABORATORY EXAMINATIONS</h3> Before proceeding to the physiologic results of this study, it seems useful to present facts bearing on the simpler clinical aspects of the subject gained from the clinical examination of the cardiorespiratorv system. This study included single examinations

Osseous Growth and Development

IN the Fall of 1930 the Department of Child Hygiene, of the School of Public Health of Harvard University, in cooperation with the Boston Lying-in Hospital, and the Children's Hospital of Boston, began a study concerned with the growth and development of normal children. Only such children were included whose mothers had been followed in the Prenatal Clinic and subsequently delivered at the Lying-in Hospital. Obviously abnormal children were excluded from the series. From the time of birth these children were examined at frequent intervals and complete records kept of various factors having a bearing on their health, growth, and development. In addition to the careful clinical observations, roentgenograms of practically the entire body were made within 48 hours of birth. During the first year these were repeated at three-month intervals and thereafter at six-month intervals. Supplementary roentgenograms were sometimes taken between these periods. Two hundred and twenty-eight infants have had roentgenogram...

MASSIVE CERVICAL HEMANGIO-ENDOTHELIOMA IN A NEWLY BORN INFANT

A case of a rare condition, massive hemangio-endothelioma of the neck and shoulder in a newly born infant, is presented, together with the observations at operation and postmortem examination. Cystic hygroma is the usual cause of congenital enlargement of this region, and that condition has been diagnosed seventeen times in the past fifteen years at the Children's Hospital. A hemangio-endothelioma of this region has never been observed at the Children's Hospital, nor has it been diagnosed prior to the present case in any of the 40,000 children born at the Boston Lying-in Hospital. <h3>REPORT OF A CASE1</h3> On April 28, 1936, a 19 year old primipara after an uneventful pregnancy and a normal labor gave birth to a 6 pound, 6 ounce (2,892 Gm.) boy, three weeks before the expected date of confinement. The parents were Russian Jews. There was no family history of congenital anomalies or neoplastic diseases.

Sixteen years' experience with heart disease in pregnant women

This is a brief review of sixteen years' experience as cardiologist at the Boston Lying-In Hospital. There were more than 44,000 deliveries, 850 of the patients being classed as cardiacs, during this period. Angus MacDonald of Edinburgh published a description of 29 pregnant women with severe heart disease in 1878 1. I will quote a part of his first description. The patient was thirty-four years old, and had mitral stenosis. She had no disability until the seventh month in her first pregnancy when she caught a cold and had congestive heart failure. This was cured by a regime and digitalis and she was delivered successfully at term.

Cesarean section at the Boston Lying-In Hospital: Smith, Judson A.: Surg. Gynec. Obst. 57: 621, 1933

Cesarean section at the Boston Lying-In Hospital: Smith, Judson A.: Surg. Gynec. Obst. 57: 621, 1933

Maternal Mortality at the Boston Lying-in Hospital in 1933, 1934 and 1935

Maternal Mortality at the Boston Lying-in Hospital in 1933, 1934 and 1935

End-results of urinary tract infections associated with pregnancy

E ND-RESULTS in urinary tract infections associated with pregnancy are, for the most part, rate of recovery from the infection, relation of such infection to subsequent pregnancies and the ultimate fate of the kidney. It was not always so. Infection of the urinary tract is capable of contributing to both maternal and fetal mortality in a large way. That it no longer does in the modern maternity clinic is due to better management which the last two decades of study of the problems concerned have made possible. Present-day maternity clinics turn out four types of infection cases for aftercare. These are convalescing predelivery infections which have given no postpartum problems; second, infections involving the kidneys, which were not present during the pregnancy but took place during the puerperium; and third, cystitis cases without upper urinary tract involvement. These latter represent retentions and residuals following parturition where either intermittent catheterization or COIIstant drainage has had to be employed and resulted in introduced infection. Fourth, pyelitis in pregnancy may also show pyelitis symptoms in the puerperium. At the Boston Lying-In Hospital all such cases are directed to the Out-Patient Department clinic where they are followed until recovery takes place, a subsequent pregnancy intervenes, as all too frequently happens, or the case is restudied because of failure of the infection to clear. Throughout all these studies of recently pregnant women one is impressed with the promptness as well as the completeness of cessation of all symptoms in prenatal infections on delivery, and t,he rarity of renal and cystitis symptoms in recently pregnant women. These factors added to ready disappearance of pus but persistence of bacteria lend a false security to the patient, mislead the obstetrician who relies on tests for albumin and pus without cultures or stained sediments, and falsify statistics. In these studies clearance of the urine of bacteria as demonstrated by sediments or cultures, or both, maintained over a period of one month without treatment, is the criterion for cure.

Heart disease in the pregnant woman

Because of the scope of the subject, “Heart Disease in the Pregnant Woman,” the article is itself necessarily essentially a summary. I have called attention to recent increased knowledge of the physiology of the circulation during pregnancy learned from the work of others. I have briefly described some of the points taught me by my continuous study for fifteen years of women with heart disease at the Boston Lying-In Hospital. 1. 1. The general classification of those suspected of heart disease and the criteria for selecting those who have significant heart disease (Class 1 cardiacs). 2. 2. A series of 42 fatalities occurring among more than 750 Class 1 cardiacs is discussed. The death rate has fallen with increasing knowledge, and the application of this knowledge, to what is apparently an irreducible minimum. The fall in death rate has been due to the virtual elimination of deaths from heart failure. Some deaths among cardiacs from other causes, particularly pulmonary embolism and bacterial endocarditis, are unavoidable. This unavoidable death rate is low, but many times higher than the rate for women with sound hearts. 3. 3. The treatment of Class 1 cardiacs in pregnancy and the recognition and signs of heart failure in pregnancy have been discussed at some length. 4. 4. A few observations have been made on whether or not abdominal hysterotomy is indicated for cardiac reasons alone.

Recent Experience with a New Classification of Pregnancy Complicated by Hypertension and Albuminuria

We present a preliminary report of eighteen months’ study of patients passing through the reorganized toxemia clinic of the Boston Lying-In Hospital. We have used a new classification aimed to be all-inclusive when necessary by cross-indexing (Table 1). It has for its primary concept the division of all cases into two great groups: (A) Those presenting certain or presumptive evidence of disease independent of pregnancy; (B) those presenting no such evidence. Group A is classified on the basis of the Volhard and Fahr classification of the nephropathies, modified to suit our idea of the needs in pregnancy. This is not our original classification,8but experience led us to accept it as most satisfactory. Group B is the commonly accepted one of preeclampsia and eclampsia (well called the “eclamptic state” to emphasize identity) with a debatable group called preeclampsia Grade l. We have discussed the limitations of this group. We present a preliminary report of eighteen months’ study of patients passing through the reorganized toxemia clinic of the Boston Lying-In Hospital. We have used a new classification aimed to be all-inclusive when necessary by cross-indexing (Table 1). It has for its primary concept the division of all cases into two great groups: (A) Those presenting certain or presumptive evidence of disease independent of pregnancy; (B) those presenting no such evidence. Group A is classified on the basis of the Volhard and Fahr classification of the nephropathies, modified to suit our idea of the needs in pregnancy. This is not our original classification,8but experience led us to accept it as most satisfactory. Group B is the commonly accepted one of preeclampsia and eclampsia (well called the “eclamptic state” to emphasize identity) with a debatable group called preeclampsia Grade l. We have discussed the limitations of this group.

A study of neonatal mortality: Based upon 120,726 consecutive deliveries at the Boston lying-in hospital from 1873 through 1934

A study of neonatal mortality: Based upon 120,726 consecutive deliveries at the Boston lying-in hospital from 1873 through 1934

REDUCTION OF PREMATURE INFANT MORTALITY THROUGH DETERMINATION OF FETAL SIZE IN UTERO

During the past eleven years 30,781 infants weighing more than 5 pounds (2,268 Gm.) at birth have been delivered under the supervision of the Boston Lying-In Hospital with 378 neonatal deaths—a mortality of 1.2 per cent. In this same period there have been 958 infants delivered weighing less than 5 pounds with 364 deaths—a premature infant gross mortality of 38 per cent (chart 1). Thus it is seen that the premature infant group, representing but 3 per cent of the total births, contributes one half of the neonatal deaths. Ordinary pediatrie methods have been unable to improve this situation, since over 80 per cent of the premature infant fatalities occurred within the first forty-eight hours following delivery (chart 2). Our experience during the past year suggests that the premature infant mortality can be reduced further by the simple method of delaying the induction of premature labor, whenever possible, until a

Obstetrical Analgesia at the Boston Lying-in Hospital

Obstetrical Analgesia at the Boston Lying-in Hospital

The Boston Lying-in Hospital Fifty Years Ago

The Boston Lying-in Hospital Fifty Years Ago

THE TREATMENT OF PLACENTA PRAEVIA

Foster Kellogg1recently reviewed the changes that have taken place at the Boston Lying-In Hospital with reference to the treatment of placenta praevia. From 1895 to 1915 the method of treatment was version and immediate extraction. The maternal mortality was 19 per cent. From 1915 to 1919, when conservative delivery, bags or Braxton Hicks version and slow delivery had considerably displaced the older method, the mortality dropped to 6 per cent. In 1926, after five years more in which conservative methods had increased from 60 per cent to 76 per cent of the total cases, Kellogg came to the conclusion that all cases of central and partial placenta praevia are best treated by low classic cesarean section, regardless of the condition of the baby; that marginal placenta praevia is best treated by the Voorhees bag; that moribund or very sick patients with placenta praevia should be rested and quieted

Observations on a short series of placenta previa patients delivered by abdominal cesarean section at the Boston Lying-In Hospital

Observations on a short series of placenta previa patients delivered by abdominal cesarean section at the Boston Lying-In Hospital

Observations in the Toxemic Clinic, Boston Lying-in Hospital, 1923–1930

Observations in the Toxemic Clinic, Boston Lying-in Hospital, 1923–1930

The Method of Identifying Newborn Infants at the Boston Lying-In Hospital

The Method of Identifying Newborn Infants at the Boston Lying-In Hospital

The prognosis of heart disease in pregnancy

There appears to be a considerable difference in the published statistics of the mortality of cardiac patients who are pregnant.Cardiac disease is stated to have accounted for nearly 20 per cent of the total maternal mortality during a four-year period at the Boston Lying-In Hospital and for 28 per cent of the deaths during a period of seven years at the Faulkner Hospital.In Table I are given some interesting statistics already published by Hamilton and Kellogg.1The deaths from cardiac disease were but 4 per cent of the mortality from all causes at the Robinson Memorial for a period of twelve years (1916 to 1927); for the entire state of Massachusetts organic disease of the heart accounted for 6 to 7 per cent of the mortality in parturition.Analysis of 830 cardiac patients who were pregnant reported in the literature discloses a mortality of 5.1 per cent. The cardiac deaths comprised 8.1 per cent of the deaths from all causes during pregnancy and parturition.Statistics from the Boston Lying-In Hospital, New York Lying-In Hospital, and the Robinson Memorial when combined show 45,320 deliveries, 480 deaths from all causes, and 48 deaths from cardiac disease. The cardiac mortality amounts to 10 per cent of the deaths from all causes. This indicates that about one mother died for each 100 deliveries, and that but one in 1000 parturients died from organic disease of the heart.The difference in various published statistics is discussed and it is suggested that the method of classifying the patients is of significance. The majority of recent observers classify their cardiac patients according to the degree of insufficiency of the heart rather than according to the structural lesions diagnosed.Prognosis is affected by the care given and the skill used in the treatment of the individual patient.

LATE DEATH AS A RESULT OF CEREBRAL HEMORRHAGE AT BIRTH

The late results of cerebral hemorrhage at birth are well known to clinicians in general since the classic studies of Little1and McNutt.2The obstetrician and the pediatrician especially are familiar with the frequent incidence of cerebral hemorrhage at birth and the numerous deaths which occur during the first few days of life as a result. In a recent report, Green3stated that intracranial hemorrhage is the most frequent cause of death in the new-born infant. He found this lesion in fifty-five of 177 consecutive necropsies (31 per cent of cases) performed at the Boston Lying-In Hospital. Green's report is a fair example of the experience in most large clinics. As a rule, when death follows cerebral hemorrhage at birth, it is within the first three or four days. In a series of fifty cases observed by Ford,4in which the condition had been diagnosed as