PART III. MIDWIFERY AND DISEASES OF WOMEN AND (A) CONCERNING PREGNANCY AND PARTURITION. ART. 120.-On the Membrana Decidua which surrounds the Ovum in cases of Tubal Gestation. By Dr. ROBErt Lee, F. R. S. (Proceedings of the Royal Med. and Chir. Society, Jan. 26, 1858.) THE author commences this communication by citing various authorities to prove that the common opinion from the days of William Hunter to the present time was that the decidua, or outer surface of the secundines, belong to the uterus, and not to the ovary, or that part of the conception that is brought down from the ovary; and that in cases of extra-uterine pregnancy, a deciduous membrane was still to be found in the cavity of the uterus. But a case is recorded in the seventh volume of the "Medico-Chirurgical Transactions," in which the uterus is stated to have been "considerably larger than we observe that organ to be in the unimpregnated state, even in women who have borne several children. On laying it open, the uterine vessels were observed to be very large but empty, and there was a great quantity of gelatinous matter in the cavity and neck of the uterus. When this was washed off, the internal surface of the viscus looked very vascular, having been highly injected; but there was not the least appearance of a decidua." A second case is recorded in the seventeenth volume of the "Medico-Chirurgical Transactions," in which the author himself was surprised at finding that "no organized deciduous membrane lined the cavity of the uterus, but the whole of it was coated with a thin layer of albumen." This case occurred in 1829, and the preparation was placed on the table of the Society in 1832; but until 1836, when another example of tubal gestation came under his observation, it does not appear that he made any attempt to determine whether the ovum in the Fallopian tube was surrounded by decidua. The two preparations were then examined together, and a description of the appearances observed was published in the Medical Gazette" for 1829-40. These cases, with four others which have subsequently come under his observation, were the subject of the present communication. In Case 1, on opening the tube, and examining the different parts of the ovum, he found a deciduous membrane everywhere surrounding the chorion, and closely adhering to the inner surface of the tube, as the decidua usually does to the lining membrane of the uterus. With the decidua, the chorion, amnion, and embryo were distinctly seen. The uterus was larger than natural, and there was no appearance of decidua lining its internal membrane. In Case 2, on carefully examining the ovum contained in the right Fallopian tube, it was evident that a deciduous membrane everywhere surrounded the chorion, and adhered to the inner surface of the tube. The placenta, which was situated at the extremity of the ovum nearest the uterus, was seen covered with the decidua, and coagula of the fibrin of the blood were traced from the interstices of the placenta through the decidua into veins in the thickened muscular coat of the tube. The uterus was considerably enlarged, and its inner surface was coated with a very thick layer of yellowish-white soft substance. There was no trace of any arterial or venous canal in this cavity. In Case 3, the foetus had reached the age of six months, and was contained in a cyst which adhered to the omentum and intestines, and to the surface of the uterus, and contained a great quantity of thin, fluid-like pus. The walls of the uterus were healthy, and the cavity empty. There was no decidua or substance of any kind coating its inner surface, but a decidua was attached to the placenta in the usual manner. In Case 4, the greater part of the ovum had been removed, but still the decidua reflexa could be very distinctly seen covering a considerable portion of the villi of the chorion. In the uterus was found a coating of considerable thickness, and of a yellowish-white color, in which neither arteries nor veins could be traced. Case 5 was also one in which only a portion of the decidua was found in the tube. In Case 6, the substance lining the cavity of the uterus resembled the fibrin of the blood, and was of a red color at its upper part; where it had been detached from the surface of the uterus, the lining membrane presented a perfectly natural appearance. The embryo was inclosed in the amnion, with the vesicula umbilicalis remarkably large. The cells of the placenta and the villi of the chorion were distended with coagulated blood, and surrounded by deciduous membrane. By a careful dissection subsequently made, the decidua was found to consist of placental decidua, decidua vera and reflexa, with a decidual cavity. An enumeration of the preparations in St. Bartholomew's and Guy's Hospital Museums was appended, illustrating the pathology of Fallopian tube conception. In the former there are five examples, and of one of these the museum catalogue states that "the outermost membrane inclosing the foetus has all the character of decidua. Besides this membrane, the amnion and chorion are distinct; the foetus and umbilical cord are also perfect." In the opinion of the author, there could be no doubt that a decidua surrounds the ovum; and though none of the other preparations had been dissected with the view of ascertaining the point, yet in all the separation of the ovum from the inner surface of the tube has been carried to an extent sufficient to enable us to demonstrate the fact. There are thirteen preparations in Guy's Hospital Museum. The author was permitted by Dr. Wilks, the conservator of the museum, to make a minute examination of the ovum in one of these, which had escaped entire through a rent in the Fallopian tube. He had the satisfaction not only to discover the vesicula umbilicalis, but to see the chorion completely surrounded by decidua, as in Case 1. There could be no doubt that if the ova in these preparations were submitted to a similar examination, a decidua would be found in all, surrounding the ovum in the Fallopian tube. He did not wish to express an opinion on the nature of the membrane or substance found coating the inner surface of the uterus in the greater number of these preparations, which has been almost universally considered to be decidua since the days of Dr. William Hunter, although no blood vessels in it have been discovered. His great object was to demonstrate the existence of a decidua around the ovum in cases of tubal gestation. ART. 121.-On the Excitation of Foetal Movements by Cold. By Dr. AVELING, of Sheffield. (Dublin Quarterly Journal of Medical Science, Nov., 1857.) Dr. Aveling's paper will be found at p. 198 of our last volume, with the name of Dr. Sinclair attached to it. The paper had been read by Dr. Sinclair at a meeting of the Dublin Obstetrical Society. We regret this oversight, and beg to apologize to Dr. Aveling for it. ART. 122.-On Menstruation during Pregnancy. By Dr. ELSASSER. (Monatsch. für Geburtskunde, Bd. lxxiii. 1857; and Med. Times and Gazette, April 24, 1858.) This contribution to a disputed topic is founded upon 50 cases, extracted from the journal of the Stuttgart Lying-in Hospital, cases which are said to rest upon the most certain information. The subjects were 15 primiparæ and 36 pluriparæ, who, with the exception of two women (aged 36 and 41), were between 20 and 30 years of age. Of the 51 children born, 34 were boys and 17 girls, 36 being mature and 15 immature. The menstruation during pregnancy occurred in 50 women, in the following manner-once in 8, twice in 10, three times in 12, four in 5, five in 6, eight in 5, and nine in 2. In 13 cases the peculiarities of the rhythm of the discharge were inquired into, and the rhythm was found regular in 4, in 1 it occurred at the sixth week, in 3 there were pauses between the epochs, in 2 the menstruation first appeared after the second month, in 2 after the fourth, and in 1 after the fifth month. In one case the menstruation first appeared in the middle of gestation, and henceforth came on every four weeks, lasting three or four days. The child, perceived but feebly at first, was strongly felt during the last four or five weeks. Hemorrhage occurred twice within a week before delivery, but a mature, living infant was born. Indications as to the amount of discharge were furnished in 26 cases, and in 18 of them it was less than in the non-pregnant condition. The weight of the 35 mature infants varied from 5 lbs. to 9 lbs. Dr. Elsässer observes, that although he is unable to state the proportion of cases in which menstruation occurs during pregnancy, it is by no means so exceptional an occurrence as supposed by some authors. It occurs more frequently in pluriparæ than in primiparæ; and it takes place much more frequently during the first half of pregnancy, and especially in the earlier months of this, than during the latter half. The amount of discharge too is smaller than in normal menstruation. The duration of the pregnancy was normal in more than two-thirds of these cases (36), while in nearly one-third (14) of the cases it was interrupted, in 4 during its first, and in 10 during its latter half. As regards the development of the child, which by some authors has been supposed to be impeded by the occurrence of menstruation, this was found to be normal, or more than normal in three-fourths of the cases. ART. 123.-Case of Pregnancy where Menstruation had been absent for some years. By Dr. O. C. GIBBS. (North American Medico-Chirurgical Review, Sept., 1857.) CASE.-February 2d, 1857.-I was requested to visit Mrs. A, who resided some twelve miles off. I complied with the request, and found the patient, who was a stranger to me, able to be about the house most of the time, and perform some light work. She complained of extreme fulness and pressure about the bowels and chest; respiration was short and hurried; slight exertion produced dyspnoea; a full meal increased the sensation of oppression, which was occasionally relieved by vomiting, the latter occurring without nausea. She had frequent desires to urinate, being compelled to rise from six to a dozen times a night for that purpose. The horizontal position was insupportable, and she could sleep only by being bolstered up to nearly a sitting posture. Though pale, she was quite corpulent; yet it was evident her abdomen was greatly distended by some foreign substance. The history of the case was this: She was thirty-two years of age; had been married ten years; had never borne children; never had an abortion; never had unnatural uterine hemorrhage. From the commencement of her menstrual period until about three months subsequent to her marriage, she had been quite regular in her catamenia. From this time she became quite irregular, both as to the time and quantity of her menstrual flow, the time varying from six weeks to six months, and the quantity unusually small. For the first seven years succeeding her marriage, the catamenial irregularity was as stated above. During the eighth year she menstruated but once, and during the ninth and 10th not at all. Hence, it will be seen that, in this case, ovarian integrity, which determines menstruation, had been gradually waning for nearly ten years. During the last three years my patient had menstruated but once very scantily, and that once about two years since. The abdomen had been slowly but steadily enlarging for five years, though more rapidly during the last few months. She had been, for the last two years, at different times, under the treatment of different physicians, without apparent benefit, for the same symptoms, for the relief of which she now consulted me. So much for the history and general symptoms of the case. In view of the irregularity of the menses and their total suppression for about two years, pregnancy was supposed impossible, and hence, not considered in the further examination of the case. It seemed to me evident that the case was one of ascites, encysted dropsy of the ovaries, or an accumulation of menstrual or other fluid within the uterus, in consequence of the impermeability of the cervix uteri. With the patient lying upon the back, percussion over the abdomen yielded a dull sound in front, with resonance near the spine; fluctuation was distinct, and after a careful examination I could detect no solid tumor in the abdominal cavity. Dulness on percussion, elasticity, and fluctuation, characterized the abdominal enlargement. The case was evidently not one of ascites. A digital examination of the uterus per vaginam was made, but in consequence of the elevated position of that organ and the corpulent condition of the patient, no positive results were obtained. I could not reach the os uteri, but it was evident that the womb was much distended. This fact alone inclined me to the opinion that I had to deal with a case of impermeability of the cervix uteri, and a consequent retention and accumulation of menstrual or other fluid within the uterine cavity. I was not wholly satisfied with my diagnosis, and acknowledged to the patient my indecision; but being earnestly pressed by the friends for a definite opinion, I stated that there was an unnatural secretion of fluid, a dropsical accumulation, which in my opinion was partly within and partly external to the uterus. As the sequel will show, this statement was true so far as it went, but it was not the whole truth. My remedial efforts were directed wholly to the mitigation of the more prominent and distressing symptoms, and were not wholly without utility. I saw the patient at intervals of a week or ten days, and at my third visit again made a thorough examination of the case, with the hope of more satisfactory results. In this I was disappointed, and consequently pursued my former plan of treatment, waiting patiently for further developments in the case. About six weeks after my first visit, I made a third examination per vaginam, and accidentally detected ballottement. This diagnostic symptom was certainly unexpected, but it was distinct and unmistakable. It probably might have been detected at first, but it had not been sought for; but, in view of circumstances previously stated, pregnancy was supposed impossible, and consequently no means were taken to detect it. I again examined the abdomen externally, but no manipulation which I could bring to bear upon the case gave evidence of a solid body within; yet to my great mortification, and the patient's great surprise, I unhesitatingly pronounced her pregnant. There About a month after this, and two and a half from the time I first saw the patient, she was taken in labor and was delivered of a male child, to all appearances fully developed as to time, yet weighing only about three and a half pounds. There was nothing peculiar about the labor except that the liquor amnii was excessive, there being probably from six to eight quarts. was considerable fluid remaining in the abdomen after labor, giving evidence that the case was complicated with ascites. The woman recovered, with no unpleasant symptoms, the ascites passing away without treatment. The child died at two months old, of capillary bronchitis; and up to the present time the menstrual function has not returned, though the woman seems in perfect health. This case presents some points of peculiarity, which it seems to me were well calculated to deceive in the outset, in regard to its true nature. The patient was a lady of refinement, and of more than ordinary intelligence, and I think the utmost reliance can be placed upon her statements. I certainly can appreciate no motive which she could have for deception, and her statements were confirmed by her husband, also by her sisters. ART. 124.-Hemorrhage in early Pregnancy practically considered. By Dr. HENRY BENNET, Physician-Accoucheur to the Royal Free Hospital. (Lancet, Jan. 31, 1858.) Hemorrhage during the early stages of pregnancy is generally, if not always, a source of anxiety and doubt, both to the patient and to the medical attendant. Of anxiety, because it is the constant forerunner of abortion; of doubt, because its repeated appearance, simulating irregular menstruation, often throws a doubt on the reality of the pregnancy. Hemorrhage occurring under these circumstances is still too exclusively considered by accoucheurs in connection with diseased conditions of the ovum and of its membranes. The important fact, that it is frequently the result of chronic inflammatory conditions of the body and neck of the uterus and of the cervical canal-a fact to which the author drew attention many years ago-is still generally ignored and overlooked; and yet the additional experience he has since acquired has completely confirmed the truth of the views he then brought forward. Hemorrhage may occur during early pregnancy, owing to the partial separation of the ovum from its uterine connections; owing to the existence of a blighted ovum or mole; or owing to the above-mentioned inflammatory conditions. When the connection between the ovum and the uterus is modified, under the influence of the maternal, foetal, or accidental causes, which are generally recognized as the causes of abortion, hemorrhage is the usual result. In a case of this kind, if the cervix uteri is brought into view, it is found quite healthy, merely presenting the size and color that pertain to the stage of pregnancy which the patient has reached. The blood is seen gently oozing from the orifice of the cervical canal. These are the cases in which rest and constitutional treatment alone are required, and often succeed, especially when the hemorrhage has followed some accidental cause. As long as the foetus is alive, there is reason to hope that any mischief that may have occurred may be repaired, the hemorrhage arrested, and the pregnancy saved. Moreover as we cannot tell positively, at first, whether the foetus has died or not, it is our duty to continue our efforts to preserve it, until the violence of the hemorrhage has destroyed all hope, or until the abortion has actually taken place. The hemorrhage which is occasioned by the conditions that lead to abortion is, generally speaking, either subdued, or it continues, notwithstanding treatment, until the abortion has occurred. It may be arrested, and then break out again and again, but this is the exception. When uterine hemorrhage occurs irregularly in the early months of pregnancy, the cervix uteri being free from inflammatory lesions, stopping and returning repeatedly, without uterine contractions, it is generally occasioned by the presence in the uterus of a blighted ovum or mole; and, in some rare instances, by that of hydatids. The foetal germ may die soon after conception, and become atrophied, absorbed, or lost, whilst the membranes and placenta may continue to grow, like moss on a wall, deriving nourishment from the inner surface of the uterus, and forming an indistinct fleshy vascular mass. It is to intra-uterine masses of this description, the true origin of which was long unknown, that the term mole has been given. Their presence in the uterus, and progressive development, sometimes for many months, gives rise to many, if not most, of the symptoms of pregnancy, and is attended all but invariably with repeated irregular hemorrhage. Sometimes the hemorrhage is constant; sometimes it is irregularly periodical, simulating morbid menstruation. When these symptoms are present, the state of the patient is necessarily one of doubt and uncertainty until the mole is expelled. The morbid product to which the name of hydatids of the uterus has been given, is probably generated under the same circumstances, and its presence is attended with identically the same symptoms, viz., irregular, constantly recurring hemorrhage, and the more or less perfect reproduction of the ordinary signs of pregnancy. The above are the generally recognized causes and forms of hemorrhage |