is in lingering difficult labours, where the child has been alive at the beginning, the swelling has formed, but from the duration and severity of the labour the child has died: under such circumstances, a dead child may be born with the usual swelling of the cranial integuments which is observed in a living child. This can only happen where it has been expelled almost immediately after its death, for in two or three hours the swelling loses its former firm tense feel, and becomes so soft and flaccid, as not to be easily mistaken.

If the face presents during labour, the flabby state of the lips will instantly lead us to suspect that the child is dead: the tongue is also flaccid and motionless. Whereas in a living child the lips are firm and full; if the face be approaching the os externum, a considerable swelling will be felt on that side which presents; the tongue is firm, and frequently moves upon the finger.

If the nates present, the state of the sphincter ani will be a sure guide in ascertaining whether the child be alive or not. If it be alive, it will be found closed, and will contract distinctly upon the finger; whereas if dead, it will be relaxed, and insensible to the stimulus of the finger.

In an arm presentation, where the child is alive, the arm will swell, and grow livid or nearly black; but if it be dead, no swelling will be observed, the arm will be very flabby, and where it has been dead some time, the epidermis will peel off. In this case, as in head presentations, the date of the child's death will more or less modify these appearances; if it has not taken place until some time after the commencement of labour, a dead child may be born, exhibiting the swelling and discolouration above-mentioned. The pulse in the wrist of the prolapsed arm is no guide, as the very degree of pressure, which produces these changes in its appearance, will be generally sufficient to render it imperceptible.

In cases where the cord has prolapsed, we have certain evidence with respect to the child's life: if alive, the cord is firm, turgid, and distinctly pulsating; if dead, it is flaccid, empty, and without pulsation.

Fetid liquor amnii, and the discharge of meconium, have also been enumerated as signs of the child's death, which occur during labour. The first affords no proof whatever, as cases not unfrequently occur in which the liquor amnii is excessively fetid, and of a thick slimy consistence, and yet the child is born alive and healthy.

The appearance of meconium during labour is a suspicious sign where the nates do not present, and will at any rate justify the supposition, that if the child be not actually dead, it is very weakly: in nates presentations, however, this will not hold good, for the meconium is constantly discharged during labour, where the child is in this position, and yet it will be born alive and well.

CHAPTER IV.

MOLE PREGNANCY.

Nature and origin. — Varieties. —Diagnostic Symptoms.

Treatment.

WHEN any cause has occurred to destroy the life of the embryo during the early weeks of pregnancy, one of two results follows, either that expulsion takes place sooner or later, or the membranes of the ovum become remarkably changed, and continue to grow for some time longer, until at length they form a fleshy fibrous mass, called mole, or false conception.*

It is well known that the venous absorbing radicles of the chorion, which give it that shaggy appearance during the first months of pregnancy, are the

* Ovum deforme, in quo partes embryonis et secundarum distingui vix possunt, molam vocabimus. (Roederer, Elementa Artis Obstetricæ, § 738.)

means by which the embryo is furnished with a due supply of nourishment at this period: if the embryo should die from any cause, and the uterus show no disposition to expel the ovum, the nourishment which has been collected by the absorbing power of the chorion appears now to be directed to the chorion itself, which therefore puts on a fleshy growth, and increases very rapidly in size. (Roederer, Elementa Artis Obstetrica, p. 738.)

In other instances, the thick fleshy character of the ovum is not produced by a growth of substance, but is the result of hæmorrhage from rupture of some of the vessels which run between the uterus and the ovum. In this case, if the placental cells be already formed, they become distended with the blood of the hæmorrhage which solidifies by coagulation; and not only render the chorion or incipient placenta much thicker and more solid, but give it also a lobulated tuberculated appearance: from the same reason, the little funis, which is probably not an inch long, is greatly distended, being in some cases as thick as the body of the embryo itself, the blood having penetrated from the placental cells into the cellular tissue of the cord. This is by no means an uncommon form of mole; externally it is covered by the decidua, which appears to be in a natural condition, and the inner surface of the cavity is lined by a fine membrane, having all the usual characters of the amnion. The lobulated appearance is chiefly seen from within, the amnion being raised by a number of irregular convexities.

"When the blood is poured out from its containing vessels into the substance or cells of the placenta, or between the membranes, it gradually coagulates, and assumes a very dark purple, and sometimes almost a melanotic black colour: after a time, however, it begins to lose this tint, the colouring matter gradually becomes removed, and the coagulum successively assumes a chocolate brown, a reddish or brownish yellow hue; and latterly, if time sufficient be allowed, it presents a pale yellowish white or straw-coloured substance, the fibrinous portion of the coagulum being then alone left."* This form of mole, as far as our own observation goes, seldom attains any considerable size, rarely exceeding four inches in length, and is usually expelled between the eighth and twelfth week. The size and condition of the fœtus varies a good deal in some cases it appears nearly healthy, although the cord is much thickened and distended; this is probably owing to its having been expelled shortly after its death, or to its having gone on to live a short time after the injury which had caused hæmorrhage: in this way alone can we explain why we occasionally meet with cases where the parietes of the ovum are much thickened and solidified, and yet the embryo is in such a state of integrity as to prove that its death must have been very recent. The extravasation of blood between the ovum and uterus does not appear to be sufficient to annihilate immediately the nutrition of the embryo, so that the blood has had sufficient time to solidify before the ovum was expelled. At other times the embryo exhibits evident marks of having been dead some time: it is much smaller and younger in proportion to the size of the ovum; sometimes it has disappeared entirely, a short rudiment of the funis merely remaining to mark its previous existence. "Should the embryo die (suppose in the first or second month) some days before the ovum is discharged, it will sometimes be entirely dissolved, so that when the secundines are delivered, there is nothing to be seen. In the first month the embryo is so small and tender, that this dissolution will be performed in twelve hours;. in the second month, two, three, or four days will suffice for this purpose." (Smellie.)

Where the growth of the ovum proceeds after the destruction of the embryo, it increases very rapidly in size, much more so than would be the case in natural pregnancy, so that the uterus, when filled with a mole of this sort, is as large at the third month as it would be in pregnancy at the fifth.

Another form of mole is where the uterus is filled with a large mass of

* Dr. J. Y. Simpson on the Diseases of the Placenta. (Edin. Med. and Surg. Journal, April 1. 1836.)

vesicles of irregular size and shape like hydatids, which appear to be the absorbing extremities of the veins of the chorion distended with a serous fluid : it is difficult to distinguish these from real hydatids; the more so, as Bremser asserts that he has occasionally met with real hydatids among them. Perhaps the mode of their attachment will in some degree assist the diagnosis: these vesicles, or hydatids of the placenta, as they have been called, are attached over a large portion of the uterus, -an arrangement, we believe, not generally seen in real hydatids, which are mostly attached to a single stalk or pedicle. Indeed, it may be doubted if the masses of vesicles which are occasionally expelled from the uterus are ever true acephalocysts, as they are invariably connected with a blighted ovum, and are therefore formed, as before observed, by a dropsical state of the venous radicles of the chorion.

A variety of other molar growths have also been enumerated by authors; in fact, "the term mole has been rather vaguely applied to almost every shapeless mass which issued from the uterus, whether this proved to be coagulated blood, detached tumours, or a blighted conception." (Churchill, on the Principal Diseases of Females, p. 153.) Thus a fibrinous cast of the uterus, which has been formed by a coagulum of blood, from which the colouring matter has been drained, has been called a fibrous mole: these, however, may easily be distinguished from real moles, which are invariably the product of conception: from inattention also to this circumstance, fungoid, bony, and calcareous tumours have been described as so many species of moles.*

Diagnostic symptoms. The diagnosis of a mole pregnancy is exceedingly obscure; in fact, for the first eight or ten weeks we know of no symptom by which we can distinguish it from natural pregnancy. As the death of the embryo is intimately connected with the first morbid changes in the condition of the ovum, and in most cases precedes them, the earliest symptoms which can excite our suspicions are those which indicate this event: thus we shall find that the face becomes pale and chlorotic, the digestion deranged, the breasts flaccid, with unusual lassitude, debility, and depression of spirits; many of the sympathetic affections which belong to early pregnancy, such as the morning sickness, nausea, &c. cease suddenly; in some cases, an attack of hæmorrhage comes on, and may be repeated several times, causing much loss of strength and exhaustion, and attended with a good deal of pain, more especially if the uterus be about to throw off its contents. In that form of mole, where the parietes of the ovum have been thickened and lobulated by masses of coagulated blood, the uterus undergoes little or no more increase of size, but the mole, especially the hydatic, continues to grow rapidly; and the unusual increase in the size of the abdomen, as already mentioned, will be an additional reason for suspicion. In all cases, hæmorrhage sooner or later makes its appearance, the patient's health still further declines, leucorrhoea comes on, followed by œdema of the feet, general breaking up of the health, and even incipient cachexia. Occasionally the discharge is excessively putrid and offensive. Where it is of the hydatic species, we can frequently ascertain its character by the expulsion of two or three hydatids which have separated from the main mass, or by the escape of some limpid colourless water resulting from the rupture of one or more of them. The expulsion of the mole itself clears up all doubts.

The amount of hæmorrhage will chiefly depend upon the extent of surface by which the mole is attached to the uterus: hence it is observed to be greatest in cases of hydatic mole, from the large size of the mass to be expelled: indeed, under these circumstances, it is frequently more profuse than hæmorrhage from detachment of the placenta. The process of the expulsion

"One must be careful not to mistake these clots of blood, which, being washed by the reddish serosities which flow from the womb, harden in the vagina, or womb itself, and look exactly like false conceptions." (La Motte.)

"Every mole is a blighted ovum which has been the product of conception. We are not justified in classing under the head of moles every mass which is produced and lodged within the uterus." (Froriep's Handbuch der Geburtshülfe, § 180.)

itself resembles that of an abortion: pain in the back, groins, and lower part of the abdomen comes on, with more or less discharge of blood; at length bearing down pains succeed, and the mass is expelled.

We cannot better describe the symptoms produced by the presence of an hydatic mole, and the mode of its expulsion, than by quoting a case from the work of Dr. Gooch, on some of the most Important Diseases peculiar to Women. "I was sent for to a few miles from London, to see a lady, who, having ceased to menstruate for one month, and becoming very sick, concluded that she was pregnant. The next month she had a slow hæmorrhage from the uterus, which had continued incessantly a month when I saw her: she kept nothing on her stomach. On examining the uterus through the vagina, its body felt considerably enlarged, and there was a round circumscribed tumour in the front of the abdomen, reaching from the brim of the pelvis nearly to the umbilicus. I saw her several times at intervals of a fortnight, during which the hæmorrhage and the vomiting continued unrelieved: the peculiarity about the case was the bulk of the uterus, which was greater than it ought to be at this period of pregnancy; it felt also less firm than the pregnant uterus, more like a thick bladder full of fluid. Eleven weeks from the omission of the menstruation, she was seized with profuse hæmorrhage; towards evening there came on strong expelling pains, during which she discharged a vast quantity of something which puzzled her attendants. The next morning I found her quite well- her pain, hæmorrhage, and vomiting, having ceased. I was then taken into her dressing room, and shown a large wash-hand basin full of what looked like myriads of little white currants floating in red currant juice. They were hydatids floating in bloody water."

The treatment previous to the expulsion of the mole should be gently alterative and tonic; the chylopoietic functions should be kept in regular action, and the strength sustained. When hæmorrhage comes on, we must be guided a good deal by the quantity lost, and by the effect which it has upon the pulse. Generally speaking, when the pulse has been a good deal reduced in strength and volume, we shall find the os uteri relaxed and dilated, and in all probability a portion of the mass protruding into the vagina, which may be hooked down by the fingers, and thus the expulsion of the whole mass facilitated. For further details regarding the management of such cases, we must refer to the chapter on premature expulsion of the ovum, between the symptoms and treatment of which and of mole pregnancy there is a close analogy. The after treatment will always be a matter of considerable importance, and will in a great measure resemble that in abortion or miscarriage.

Patients who have suffered from a mole pregnancy generally have their strength seriously reduced and their health much broken: hence they are liable to leucorrhoea, menorrhagia, or dysmenorrhoea, which entail a long series of troublesome and even dangerous affections, the recovery from which will be slow and difficult, requiring a long course of tonic medicines, and removal to the sea coast or some watering place where there are chalybeate springs.

Tubarian, ovarian, and ventral pregnancy. — Pregnancy in the substance

of the uterus.

THE Ovum when impregnated does not always quit the ovary and pass along the Fallopian tube into the uterus. It may remain in the ovary and become

here developed; it may pass into the Fallopian tube and remain there; or from some defect in the action of the fimbriated extremity of this canal, it may escape into the cavity of the abdomen, and become attached to some of the viscera. Hence extra-uterine pregnancy has been divided into three species, viz.graviditas tubaria, ovaria, and ventralis, according to the situation which the ovum takes. A fourth has been also described by M. Breschet, which he has called graviditas in substantia uteri, a modification probably of tubarian pregnancy.

a The uterus, its cavity laid open. b Its parietes thickened, as in natural pregnancy. cA portion of decidua separated from its inner surface. d Bristles to show the direction of the Fallopian tubes. e Right Fallopian tube distended into a sac which has burst, containing the extra-uterine ovum. f The foetus. g The chorion. h The ovaries; in the right one is a well marked corpus luteum. The round ligament.

This singular deviation from the usual course of conception is fortunately of rare occurrence, for few cases terminate favourably. If it be in the Fallopian tube or ovary, these become immensely distended into a species of sac or cyst, to the sides of which the placenta adheres: as the ovum increases, this at length gives way from excessive distension, and the patient usually dies from internal hæmorrhage. In ventral pregnancy, the sac is attached to the abdominal vis.. cera, and is usually imbedded among the convolutions of the intestines : hence the duration of extra-uterine pregnancy will depend upon its situation: thus, if it be in the Fallopian tube, it rarely lasts beyond two months; whereas ovarian pregnancy will continue for five or six months; on the other hand, in ventral pregnancy the fœtus will not only be carried to the full term, but far beyond that period, amounting to several years.*

Although the uterus does not receive the ovum into its cavity as it does in natural conception, it nevertheless undergoes many of those changes which are known to take place in regular pregnancy. The layer of coagulable lymph, which is effused upon its internal surface, and which forms the membrana decidua of Hunter, is present, and the uterus undergoes a slight increase of volume. As the ovum increases, excruciating pains are felt in the lower part of the abdomen, coming on at irregular intervals, and of irregular duration; in some cases lasting for a short time, in others continuing for twenty-four hours. These

* Our friend Dr. Nebel of Heidelberg has a preparation of a foetus which was retained for fifty-four years in the abdomen. This is the longest period on record of a foetus being retained in the cyst of a ventral pregnancy. Many other cases have been described. (See Burns, 9th edition, where the notes contain very ample references.)