CHAPTER III. APPENDIX. A. THE DEATH OF THE FETUS DURING PREGNANCY. THE causes of the death of the foetus in the uterus are very various, and have already been mentioned in the chapter on abortion. They are constitutional diseases of the mother, diseases of the uterus, of the membranes, and lastly of the foetus itself. If the foetus dies very early it is soaked in the liquor amnii, softened, and may be entirely reabsorbed. The cavity of the amnion then contains the cloudy, turbid serum, and sometimes the remains of the umbilical cord. If the foetus (at the time of death) was somewhat older, it is found to be soft and pulpy. At a still later period it undergoes a peculiar transformation. The foetus is then commonly said to be putrid (todtfaul), but this condition is best considered a kind of maceration. The whole body is softened; if placed for some time upon an even surface it is found quite flattened at those parts of the body on which it rested. The flaccid abdomen falls to one side. The foetus has not properly a putrid smell, but is of a peculiar, stale, sweetish, disagreeable odour. The epidermis is raised in large patches, especially on the abdomen and the face, and the reddish-brown corium is denuded at those places. The umbilical cord is withered, discoloured, and reddish-brown from the diffusion of the blood. The cranial bones are loose, the skin of the head withered, flaccid, and too large for it. The sutures between the cranial bones are loosened, easily movable, or the bones are entirely separated, and contained in the integuments as within a sac. The internal organs are variously altered. The brain is mostly changed. It is converted into a reddish-brown pulp, in which formed material can no longer be recognised. The muscles and connective tissue preserve their external shape; the transverse striæ of the muscles are frequently distinctly recognisable, although the primitive fibrils are filled with a finely granular fat. Of the organs contained in the thoracic and abdominal cavities, the latter of which contains, as a rule, bloody serous transudations, the liver is most of all altered. The cells are disintegrated, and their membrane contains only finely granular fatty detritus and pigment. The uterus, and lastly the lungs, are most perfectly preserved, and the latter can still be distended. In all the organs the blood has disappeared from the vessels and become suffused into the surrounding tissues. All the organs show a finely granular opacity of their parenchyma, and very commonly also crystalline fat and pigment. Sometimes crystals of margarin and cholesterin accumulate in such large masses that some partly well-preserved organs are covered by a whitish grey pulp, and this condition is called "lipoid metamorphosis" (Buhl). If one of twins dies at an early period it may be so much flattened by the pressure of the other growing ovum that it presents a layer as thin as a sheet of paper (foetus papyraceus). Experience does not as yet enable us to determine with any certainty from the changes of the fœtus the time which has elapsed since its death. From causes with which we are unacquainted the changes appear to progress with varying degrees of rapidity. Sometimes a foetus, which, on the examination of the woman a short time before, showed undoubted signs of life is expelled in a high degree of maceration; at other times one which has been dead for weeks is expelled comparatively little altered. B. THE DEATH OF THE MOTHER DURING PREGNANCY. The foetus continues to live for a very short time after the death of the mother. Every legislation, therefore, commands that on the death of the mother, if the presumption is in favour of the foetus being alive, means are to be employed to save it by the Cæsarean section, that is, by opening the abdominal cavity and the uterus, and by extracting the foetus through that opening. But the greatest obstacle lies in the uncertainty of the actual death of the mother. For the surest sign of death is putrefaction, and if this is waited for the foetus is in the mean time certainly dead; but if the death of the mother is not certain there is great risk in performing the very dangerous operation of Cæsarean section on a woman who is only apparently dead. Children extracted ten minutes after the death of the mother are only very exceptionally kept alive. After the actual death of the mother the fœtus soon becomes asphyxiated, and this takes place the more rapidly the more mature the fœtus is. The foetal heart may continue to act for some time, even after asphyxia has set in, and as long as the action continues there is still hope of keeping the extracted child alive by means of suitable treatment. It is therefore not impossible to save a child a quarter of an hour or even somewhat longer after the death of the mother. Reported cases where a living child had been extracted hours after the death of the mother are, if worthy of credit at all, those of apparent death. After accidents which are undoubtedly followed by the death of the mother it is easiest to save the child by the Cæsarean section rapidly performed. Even if the death of the mother is beyond doubt, the operation and the succeeding dressings are to be made lege artis. Literature.-Reinhardt, Der Kaiserschnitt an Todten, D. i. Tübingen, 1829.Heymann, Die Entbindung lebloser Schwangerer, &c. Coblenz, 1832.-Lange, Casper's Woch., 1817, No. 23-26.-Schwarz, M. f. G., B. 18, Suppl., p. 121.— E. A. Meissner, M. f. G., B. 20, p. 40.-Ferber, Schmidt's Jahrb., 1863, B. 117 p. 179. (Referat über die Verh. d. Pariser Academie.) PART VI GENERAL PATHOLOGY AND THERAPEUTICS OF PARTURITION Ir has already been mentioned in the physiology of parturition that the favorable mechanism of labour essentially depends upon. two factors. They are (1) the due activity of the expelling forces; and (2) that the obstacles opposed to the forces are normal. These two factors may overstep the normal limits in two directions. The expelling forces may be too strong or too feeble, and the obstacle too great or too small. Under proper supervision of labour even very strong expelling forces have no other effect than to terminate rapidly the act of parturition, whilst a very slight obstacle under the same conditions facilitates it without exerting any harmful influence. The pathology of parturition, therefore, is formed (1) by disturbances produced by too feeble pains; and (2) by those produced by a too great obstacle. To these may be added a third pathological factor, which includes those accidents which do not interfere with the mechanism of labour itself, yet exert an unfavorable influence upon the mother or the child or upon both. The resistance opposed to the expelling forces is determined by the relation of the object to be expelled-that is, the presenting part of the fœtus-to the parturient passages. Consequently a too great resistance may be due either to abnormal conditions of the parturient passages or of the child. We have, then, the following scheme for the pathology of parturition: I. Too feeble action of the expelling forces. II. Too great obstacles. These may be caused either by— 1. The too great resistance of the parturient passages, either of a. The soft parts; or, b. The hard parts. 2. Anomalies of the ovum, which, as a rule, depend on- a. Too great a development; B. Abnormal position and attitude; b. abnormal condition of the foetal appendages. III. Dangerous accidents, which do not interfere with the me chanism of parturition. They are chiefly 1. Pressure upon the umbilical cord when prolapsed. 3. Hæmorrhage. 4. Inversion of the uterus (in the afterbirth period). 5. Eclampsia. The treatment is in general on the same principles as in other branches of medicine. Careful attention is to be paid to prophylactic measures in order to avoid dangerous accidents. Anomalies of the expelling forces are chiefly prevented by a proper dietetic supervision during pregnancy, occasionally assisted by suitable therapeutic measures, for primary weakness of pains rarely occurs in women who at term are in perfect health. Too great resistance on the part of the soft parturient passages can during pregnancy be prevented by emollient warm injections. More successful still are prophylactic measures in contraction of the hard parts of the maternal passages. For although the origin of pelvic distortion be rarely and only in a slight degree under control, there is a valuable remedy in the induction of premature labour at a time when the disproportion between the head and the pelvis does not exist at all or only in a slight degree. Prophylactic measures in regard to some of the disturbances of parturition will be mentioned in the special pathology. Of the means at our disposal to remove existing disturbances and limit at least their unfavorable influences, the mildest, if of the same efficacy, ought to be preferred. Thus, no powerful or dangerous measure should be taken if there is reason to expect the same result from a milder one. If, e. g., the head has deviated from the pelvic inlet it should not be replaced by introducing the hand into the parturient canal if the altered position of the woman or external pressure will do the same. But, on the other hand, no valuable time is to be lost by employing mild or inefficient measures when more powerful ones, if immediately used, would have the desired effect, and which used after the mild ones have been tried come too late. The obstetrician has also the whole list of remedies used in internal medicine at his disposal. Exceptionally only very important results are obtained by internal remedies; occasionally, however, they may prove very useful. Thus, in eclampsia parturientium measures purely obstetrical have only a noxious influence upon the disease, whilst complete narcotism cures it with absolute certainty. The measures most frequently applied and most efficacious are operations more or less peculiar to midwifery. They are required by the peculiar conditions met with during parturition, which conditions differ widely from any other known state, and are seldom employed except in the treatment of diseases of women. Thus, the forceps may be very usefully employed in the treatment of large polypi, and the artificial dilatation of the os uteri is as often practised in diseases of women as in midwifery. Obstetric operations are performed partly with the unarmed hand and partly by means of surgical or peculiar obstetrical instruments. It has here to be remarked that the hand is the most perfect instru ment, and that in all cases in which the unarmed hand suffices instruments are to be banished. Some operations, however, can only be performed by means of instruments, and it is necessary that the obstetrician be provided with them and carry them with him when called to a case. It is best to carry them in a leather bag, which is capable of containing also a few necessary drugs. Besides a stethoscope, a male silver catheter (for a female catheter is insufficient in difficult cases), a pointed and a probepointed bistoury, a needle-holder, needles and sutures, every obstetric bag should contain the following instruments: A pair of forceps of medium size. A few elastic catheters of not more than 3.5 mm. diameter (for the treatment of asphyxia neonatorum), a few colpeurynters of caoutchouc to be used as tampons, with a suitable syringe, which can also be used as a uterine syringe. Two slings for turning. A scissor-shaped perforator. A slightly bent and strong pair of Siebold's scissors. Other instruments will usefully find a place in the obstetric bag, particularly when the case is somewhat distant from the residence of the accoucheur. They are A cephalotribe. A blunt and half-blunt crotchet. A pair of bone forceps. A Braun's hook. An instrument for replacing the umbilical cord. Also the following medicines: Chloroform, tincture of opium, morphia made up in doses, and fresh ergot of rye. Before we consider the special pathology of parturition we think it necessary to say a few words on the various methods of obstetrical treatment, especially the operations. They may be arranged, like the pathology of parturition, under three heads, so that there are measures to be employed 1. When the expelling forces are too weak. 2. When the obstacles are too great. 3. Against dangerous accidents which do not, however, interfere with the mechanism of parturition. The treatment of the third section may be twofold. It may be directed against the dangerous accidents directly, or it may be employed to terminate delivery as rapidly as possible, in order not to allow time for the dangerous occurrences to exert their injurious influence. The measures of the first class belong to the special therapeutics of the corresponding complications; those of the second are identical with those employed in weakness of the expelling forces, for, in point of fact, the expelling forces are too feeble to terminate delivery in the short time required for the safety of the mother or the child. The difference does not consist in an absolute anomaly of the expelling forces, but only in their insufficiency in the special case to terminate delivery in so short a time as to escape the dangerous influence of the complication. It is therefore a relative |