3. Contrary to the received opinion, the puerperal state opposes, as a rule, neither the regular healing of wounds nor the union of fractures, provided that these injuries occur simultaneously with pregnancy or delivery. The exceptions to this rule must be ascribed either to tho particular region affected (the genital tract), to the fever that sometimes ushers in the flow of milk, or, above all, to a general or local morbid ten dency in the woman. Wounds occurring after parturition seem to present a special gravity, which would seem to be related to the disturbance re ferable to the physiological involution of the organs. Hence the indica tion to defer until three or four months aft,er delivery all operations not urgent, which may involve the genital tract or the lower limbs. It follows that surgical lesions during pregnancy are far from being so serious as we suppose, and that in the case of a tumor, which is developing rapidly and is threatening life, we should resort to extirpation rather than to the induction of premature labor.
[In connection with this subject, we append the statistics collected by Mann, of Buffalo, and which appear in a paper published in Vol. 7, of Am. Gyn. Trans.
The whole paper is of interest, and our readers are referred to it for more detailed information in regard to these operations.—Ed.] GOtTRE.
The Influevce of Goitre on all the writers who have - called attention to the greater frequency of goitre in woman than in man, Jeans-Louis Petit was the first to note its influence on the puerperal state. Tarnier says, that hypertrophy of the thyroid gland is generally inconsiderable, causes no trouble during pregnancy, and after delivery resumes nearly its original size. Goitre does not seem to us to be quite as rare as is generally supposed, and although the number of observa tions is limited, it doernot usually lead to any serious accidents. How ever, this is not always true, and it may in some instances assume an exceptional gravity. 011ivier, who affirms that goitre usually appears from the third to the fourth month of pregnancy, recognizes several dis tinct forms, viz.: 1st. Subacute and Transient Goitre.—It developes slowly, and only in exceptional cases assumes a considerable size, being often unrecognized during the first pregnancy. No pulsation is present, the health is not affected, and the enlargement often disappears almost entirely after de livery.
2d. Acute and Grave Goitre. —This form developes rapidly, and gives rise to attacks of suffocation. Tarnier reports a case in which death occurred from asphyxia; Bailly one that terminated fatally in spite of tracheotomy. Suppuration sometimes occurs, the condition being a true thyroiditis.
3d. Chronic Goitre. —Sometimes the enlargement appears during pregnancy, and remains stationary after delivery, or even undergoes a slight increase in size at each successive pregnancy; sometimes, the acute form becomes chronic, or the goitre is only recognized after delivery. Finally, chronic goitre in the gmvid woman may pursue its course until a more or less advanced stage of pregnancy, when it rapidly enlarges, so as to compress the trachea, and cause suffocation.
Pastriot divides goitres from an anatomical standpoint into three vari eties, the vascular, ptirenchymatous, and cystic. In the vascular there is eongestion and apoplexy of the thyroid gland. During the straining that attends delivery, the dilated vessels rupture, leading to hemorrhage at some point in the goitre, and effusion of blood between the lobules. In the second form, there is a true hypertrophy of the fibrous tissue, the enlargement being due, not to the thyroid gland itself, but to a gelatinous fluid which fills the surrounding cellular tissue (cellular goitre.) Lar rey, again, has described an emphysematous goitre, which he thinks is independent of the thyroid gland, being due solely to emphysema. In the cystic variety, as described by Pastriot, there is a cavity containing a material (genemlly fluid, sometimes solid), which has formed in the midst of the normal gland elements. Porcher admits the existence of two forms, simple hypertrophy of the thyroid, and glandular or vesicular goitre, also the fibro-cellular, colloid, and vascular varieties. He believes that menstruation, as well as pregnancy, affects the development of the swelling.
Diagnosis and Prognosis.—The enlargement usually begins gradually, or else it appears suddenly during the efforts of parturition. Although at first of small size, it increases in size with each pregnancy, and then either disappears after delivery, remains stationary, or continues to de velop, and is attended with evidences of compression, either of the recur rent laryngeal nerves, or of the trachea itself, change in the voice, dys pncea, dysphagia, suffocation, etc.
Treatment.—As goitre is generally benign during pregnancy, wo. should pREGNANCY, as we have seen, produces in the entire economy im portant and profound modifications, which in their turn cause functional disturbances that find expression in a series of morbid condi tions, constituting, properly speaking, the diseases of the pregnant woman. But these troubles do not .appear simultaneously and invariably, and, while in some cases they constitute a true morbid condition, in others they pass, so to speak, unrecognized. From this point of view we can say, there are as many variations as there are women, or even pregnancies, because it is not rare to see certain females pass through one or two preg nancies in a condition of almost perfect health, while the succeeding one or more pregnancies are accompanied by profound malaise. Moreover, it is not uncommon to observe certain phenomena appear at the begin ning of pregnancy, to disappear for a time, and then to reappear with renewed intensity. We shall, then, adopting the classification of Desor means and Cazeaux, review in turn the disturbances of digestion, of cir culation, respiration, secretion, excretion, locomotion, and, finally, of the sensory and intellectual functions.