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something and left, and did not hear from her until September 1st, 1897, when the report came to me that she had been having a copious uterine hemorrhage the same morning. On hastening to the house of the patient, and making an examination, I found the following conditions:
Part of a placenta presented itself outside of the vulva, and this presenting part contained the insertion of the cord, of which a few inches were visible. Proceeding to a digital examination, I found that the cord was reaching up, and attached to it at its other end I could feel a fetus. The membranes, which still contained a considerable amount of amniotic fluid, seemed to lie towards the right side of the uterus, below the child, in such a manner that they were partly filling the lowest part of the parturient canal. I intended to leave
No. 2. Leitz obj. No. 3; eyepiece, No. 3, Decidua vera. a, Line of tear.
b, Gland spaces (spongiosa), partly filled with desquamated epithelia and mucoid material.
the membranes containing the fluid in the position in which I found them, in order to let them further assist in dilating the cervix. However, the amniotic fluid drained off, and I had the impression. that there had now occurred a rupture high up in the membranes. The child lay in breech-presentation, and was delivered with great difficulty. The fetus had evidently been dead for some time, and was macerated and discolored.
Within a few minutes after I had delivered the child, a small amniotic bag, evidently having a small placenta on one side, the whole the size of a large fist, or somewhat larger, was expelled without any manipulation on my part. This bag had not ruptured, its
membranes were complete, it contained a small amount of fluid, and what appeared to be a small fetus. After the delivery of the second fetus, contained in its intact membranes, the mother was very much exhausted, having been in labor about twelve hours, and having lost a good deal of blood. Since there was no more hemorrhage, and in view of the fact that the woman had an umbilical hernia, I desisted from using Crédé's method to express what must have remained of the first, the large placenta, and allowed nature to take its course. The remainder of the placenta was delivered during the next twenty-four hours, in my absence. I was told that the patient lost some more blood at the time of the expulsion of the remainder of the placenta. The woman made a slow but good recovery.
The products of gestation as they were expelled from the uterus of Mrs. H., in the presence of Dr. Spaulding, were sent by the latter to the Pathologic Laboratory of the Chicago Policlinic. However, by an oversight it was already twenty-four hours postpartum before they came into my possession. They had in the meantime been in a bucket without any preserving fluid, and had been exposed to the warm temperature of a September day.
Description of Specimen.-The specimen when first seen by me was already badly macerated, and in such a general condition that it was thought best not to attempt to handle, but to previously fix and harden it. The fluid used for this purpose was alcohol (9 parts) and formalin (1 part). After having been hardened, the specimen presented the following parts and features for description:
1st. One female fetus, which appears to be an embryo at or near full term. It is bent very much, the head being strongly flexed upon the thorax so that the latter is markedly pressed inwardly; the legs flexed upon the abdomen; the right arm is folded over the thorax; the left arm is extended and stretched out so that it is perfectly straight. The curved line from the vertex to the coccyx. measures 34 c.m.; the extended arm measures 15 c.m. The nails on the hands and feet are pretty well developed. The head is covered with hair of a light color and about 1 c.m. long. The head is elongated to about 11 c.m., and presents an enormous caput succedanum, to such an extent that it appears as if it had been abnormally shaped, even before the uterine pressure became exerted during expulsion. The face is comparatively small, but otherwise fairly well shaped, the parts above the face are very large, the anterior fontanella is very wide, the head as a whole impresses one as a hydrocephalus.
Measurements of the Head: Curved line from atlas to root of the nose 24 c.m. Circumference at a line drawn above the ears around the occiput, parietal and frontal bones 27 c.m. Length of face from symphysis maxillæ inferioris to root of nose 5 c.m. Length of ear 2 c.m. Length of umbilical cord 36 c.m.; twistings of cord not well marked; cord flattened; long diameter 12-13 m.m. On the distal end of the cord there is attached a piece of membrane, but no placenta. The skin of the fetus peels off easily in large shreds.
No. 3. Leitz obj. No. 7; eyepiece, No 1.
Decidua reflexa; a, layer next to chorion laeve with decidual cells fairly well preserved in outlines.
b, Hyaline matrix with faintly staining nuclei.
c, Fibrinous matrix with faintly staining nuclei.
2d. Accompanying the above described fetus is a sac, being partly translucent in character, and containing a small amount of fluid. When this sac is opened a compressed macerated embryo, 66 m.m. long, is found. The compressed embryo, in its widest part, has a diameter from side to side of 1 c.m. Arms and legs, including hands and feet, are well developed. When compared with a normal human embryo, 64 m.m. long, it is found that the embryo under description differs from it aside from the maceration, compression, etc.; especially in that its long bones, and those of the
vertebral column, are considerably harder than those of the former. The embryo is attached to a placenta by an umbilical cord, 72-75 m.m. long, having a diameter of about 1.5 m.m.; the cord is markedly twisted, especially in the proximal third, where we find about twelve turns. The insertion of the cord into the placenta is markedly eccentric, being found in the middle of one of the four quadrants. The course of the blood vessels from the cord into the placenta cannot be made out. The bag which contained the embryo, when spread out flat, is oval in outlines, with diameters of 10 c.m. and 9 c.m. respectively. These dimensions may also be taken as the diameters of the placenta, which, in its middle, is about 9 m.m. thick. It is smooth on the inside, rough and uneven on the outside. The membranes are, for the most part, exceedingly friable and tear easily. Near the margin of the placenta one can separate the membranes into two leaves. It is shown by microscopic examination that one leaf contains the amnion and chorion, the other, the remnants of the decidua reflexa. On one side of the placental margin, that part which is nearest to the insertion of the cord, there falls over the membranes proper (amnion, chorion, decidua reflexa) a piece of a thicker. membrane thrown into rugæ. The inner surface of this piece of membrane, which is from 1 to 2 m.m. thick, is comparatively smooth, though uneven; the outer surface is ragged and uneven. This membrane proves to be the decidua vera.
For microscopic examination there were taken pieces of the small placenta (middle and margin), of the membranes near their insertion into the placenta, and of the piece of thick membrane (decidua vera). These pieces of tissue were dehydrated, etc., and imbedded in paraffin and stained with hæmatoxylin and eosin.
Both embryos, as stated above in the history furnished by Dr. Spaulding, were dead at the time of parturition, and had apparently been dead for some time before they were expelled from the uterus.
With reference to the ages of the two embryos, so very much different in size, the following theories are to be considered: They both began their development from two ova simultaneously. They both died at the same time before parturition, one of the embryos having attained its normal size, the other one having remained very small in consequence of pressure, or other circumstances. If this were the case, we would have to expect to find the placenta of the small embryo, though small in size itself, of a mature type.
(2) Both embryos began their development simultaneously; one
died during the earlier months of pregnancy, but was not expelled from the uterus until the larger one was born at or near full term. This, of course, appears very unlikely, since it can hardly be imagined that a dead, macerating embryo should for months lie side by side with a live, developing embryo, without bringing about contractions of the uterus, and causing the latter to expel its contents. However, if, in spite of this consideration, we assume that the case is to be looked upon as indicated above, we ought to expect to find the placenta of the small embryo completely degenerated, because the placenta fetalis, at least, which is a part of the embryo, shortly
Very large branched decidual cells. The smaller cells with granular nuclei are leucocytes.
after the death of the latter, undergoes complete degeneration very rapidly.
(3) The small embyro developed from an ovum later than the large fetus; we have, in other words, a case of superfetation. This being the case, the small placenta ought to show the type of an immature young placenta, and it ought not to be degenerated very much, provided, also, that the death of the young embryo did not occur very long before parturition.
Before proceeding to the description of the microscopic picture furnished by the small placenta, I want to state that the microscopic study of 15 cases of tubal gestation, 10 occurring in the practice of Dr. Fernand Henrotin, the others in the hands of Drs. M. L. Harris, Carl Beck, Gustav Schirmer and Weller Van Hook, has given me a chance to make the observation that chorionic villi