COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX64076920 RA1051 H672 Atlas of legal medic ^ THE ^ O LIBRARIES : o ,, "■ HEALTH SCIENCES LIBRARY Digitized by tine Internet Arciiive in 2010 witii funding from Open Knowledge Commons http://www.archive.org/details/atlasoflegalmediOOhofm ATLAS OF LEGAL MEDICINE BY DR. E. VON HOFMANN Professor of Legal Medicine and Director of the Medico-Legal Institute at Vienna AUTHORIZED TRANSLATION FROM THE GERMAN EDITED BY FREDERICK PETERSON, M. D. Clinical Professor of Mental Diseases in the Woman's Medical College, New York ; Chief of Clinic, Nervous Department, College of Physicians and Surgeons, New York ASSISTED BY ALOYSIUS O. J. KELLY, M.D. Instructor in Physical Diagnosis, University of Pennsylvania; Adjunct Professor of Pathology, Philadelphia Polyclinic ; Visiting Physician to St. Mary's and St, Agnes' Hospitals; Pathologist to the Gei-man Hospital, Philadelphia 56 Plates !n Colors, and 193 Illustrations !n Black PHILADELPHIA W. B. SAUNDERS 925 Walnut Street 189 a Copyright, 1898, By W. B. SAUNDERS. 86- 121 f I ELECTROTVPED BY PRESS OF W. B SAUNDERS. WESTOOTT fc THOMSON, PHILADA PHILAOA. AUTHOR'S PREFACE. In cheerfully complying with an expressed request of the publishers, asking me to prepare a ^^ Hand- Atlas of Legal Medicine/^ I have been actuated by a variety of motives. In legal medicine, as in other branches, the desire for illustrations becomes daily more apparent, and this desire can be complied with but in part within the limits of the general text-books. Further, the hand- atlases which have already been issued by this publish- ing-firm exhibit evidences of decided progress in this department of art, and in consequence, as also because of their inherent qualities, have been accorded a widespread recognition. Finally, an opportunity was for the first time presented to provide a cheap book, and therefore one of easy acquisition, which would enable the practis- ing physician, as also the student of medicine, to become acquainted graphically with the most important occur- rences of medicolegal interest. The illustrations are entirely original, and have been prepared either from recent cases or from museum speci- mens. A few have been reproduced from other publica- tions, but they also are original observations. In the preparation of the atlas my purpose has been that it should serve for further illustration of a good text- book — that it should be, to a certain extent, a supplement to the latter. I have therefore limited the descriptive 3 4 AUTHOR'S PREFACE. text, and have not considered a series of illustrations such as are found in every good text-book of legal medi- cine and in other widely distributed books, as, for instance, blood-spectra, spermatozoa, etc. This, on the one hand, diminishes the cost of the book, and, on the other, permits of the introduction of other important illustrations. An exhaustive account of the subject has not been thought of, nor has it been considered possible. I have rather striven, as far as space, opportunity, and a regard to the cost permitted, to portray instructive instances of at least the most important medicolegal occurrences. The colored plates and the photographic reproductions have been very ably executed by Mr. A. Schmitson, art- ist, and, for a layman, with an accuracy of comprehension worthy of commendation. My two assistants, Drs. Haberda and Richter, privat- docents, have heartily co-operated in the preparation of the work, and to them, for their assistance, I express my warmest thanks. PREFACE TO THE TRANSLATION. There is perhaps do field of science in which the value of illustrations is greater than in forensic medicine. The problems which confront the coroner, the post-mor- tem examiner, and the courts of law must be solved by the presentation of indisputable facts. Many of these facts can be fully appreciated and understood only by the medicolegal expert of years of experience. But a vol- ume such as this, made up chiefly of photographs and original drawings of various lesions and pathological con- ditions, taken directly from actual cases, supplies to every phvsician and student an enormous arrav of medicolegal data, such as would take one many years to acquire alone and unaided. This volume is a veritable treasure-house of information, gained from the rich material of one of the greatest institutes of legal medicine in the world, and collected bv one who, until his death a few months aero, was perhaps the ablest living expert in his chosen domain of work. The text has -been Englished by Dr. Kellv, and the translation carefidlv compared with the orioinal bv the Editor-in-chief. Every effort has been made, while pre- serving so far, as possible the difficult style of the author, to make the statements explicit and clear. There are some words in the text (such as lochbruch) which have no good equivalents in our tongue, and these have been neces- sarily rendered into literal English. FREDERICK PETERSON. New York, April, 1S9S. 6 LIST OF PLATES AND FIGURES. Fig. 2. Fig. 3. Fig. 4. Fig. 5. Fig. 6. Fig. 7. Figs. 8- -13, Fig. 1. Abnormal smallness of the penis ; incomplete cryptorchi- dism. Cicatricial deformity of the penis. Union of the under surface of the penis and the scrotal skin (synechia). Epispadias. Masculine pseudohermaphrodism. Unusual development of the clitoris. External masculine pseudohermaphrodism. Hymen annularis and semilunaris (circular and semilunar hymens). Figs. 14-24. Varieties of hymens with congenital notches. Figs. 25-27. Hymen fimbriatus. Figs. 28-33. Divided hymens with symmetric openings. Figs. 34-36. Divided hymens with asymmetric openings. Fig. 37. Hymen of irregular form. Figs. 38-44. Hymens with partial or rudimentary septa. Figs. 45, 46. Hymens with two circular openings, situate one below the other. Fig. 47. Semilunar hymen with thinning of the right, and perfora- tion of the left, lateral half. Indication of the formation of a hymen cribriformis. Fig. 48. Deflorated hymen annularis with congested and swollen lacerated edges. Figs. 49-52. Ordinary deflorated hymens. Figs. 53-55. Carunculse myrtiformes. Figs. 56-59. Hymen septus (divided hymen) after defloration and after parturition. Figs. 60-62. Traumatic injuries of the external genitalia. Figs. 63-65. Os uteri of adult virgins. Fig. 66. Os uteri (pathological ?) of a virgin of advanced age. Fig. 67. Os iTteri of a woman who has given birth. Plate 1. Cervix and vagina directly after parturition, 7 8 LIST OF PLATES AND FIGURES. Plate 2. Spontaneous rupture of the uterus. Plate 3. Tubal preguaucy ; rupture of the sac ; internal hemorrhage. Plate 4. Embryo found within an uuinjured amniotic sac among blood- clots, from a case of tubal pregnancy. Fig. 68. Fatal hemorrhage from retention of a portion of the placenta. Fig. 69. Retention of a portion of the placenta, with consecutive fatal hemorrhage. Figs. 70, 71. Two uteri in the very earliest stages of pregnancy. Fig. 72. Human ovum of the eighth or tenth week. Fig. 73. Rupture of the vagina through coitus or by the fiuger. Fig. 74. Acute sepsis following abortion. Punctured wound in the for- nix of the vagiua. Fig. 75. Abortion induced by a probe-like instrument. Perforation of the posterior wall of the uterus. Abortion induced by rupture of the membranes of the ovum. Slit-like laceration above and below the internal os uteri. Abortion induced by injections. Perforation of the fornix of the vagina and the fundus of the uterus. Divulsiou of the cervix from the uterus. Abortion. Eespiratory organs and heart of a full-term child which died dur- ing birth of " fetal suffocation " from premature respiration. The epiphyses of the lower extremity and of the humerus of a mature, newly born child. Epiphyses and posterior tarsal bones of a premature, and of a full-term newly born, and of a 3\-months-old child. Figs. 81, 82. Suffocation of the newly born by intentional obstruction of the pharynx. Plate 6. Lungs of newly born infants. Plate 7. Xewly born child. Suffocation by a portion of the membranes. Fig. 83. Congenital fissure-formation of the skull of the newly born. Fig. 84. Defects of ossification in the skull of a newly born child. Fig. 85. Pretended precipitate birth in a closet. Spoon-shaped depres- sion of the left, compression-fracture of the right, parietal bone. Fig. 86. Fracture of the skull from a fall on the vertex. Plate 8. Fiacture of the base of the skull, with extradural hemorrhage. Plate 9. Traumatic extradural hematoma. Plate 10. Fracture of the base of the .skull, with rupture of the middle meningeal artery— after removal of the extradural hema- toma. Fig. 87. Fracture of tlie skull due to compression. Fig. 88. Star-shajied fracture of the jtarietal region. Plate 11. Receut contusions of the brain. Fig. 76 Fig. 77 Fig. 78 Plate 5 Fig. 79 Fig. 80 LIST OF PLATES AND FIOUBES. 9 Fig. 89. Healed hole-fractures (Lochbriiche) produced by a black- jack. Figs. 90, 91. Fractures of the skull due to blows of a horse's hoof. Plate 12. Healed contusions of the brain. Fig. 92. Hole-fractares (lochfractureu). Fig. 93. Fractures of the skull produced by blows with a round or so- called French hammer. Fig. 94. Skull of a man who was murdered and remained buried in a manure-mound for four years. Fig. 95. Circumscribed destruction of the right occipital region pro- duced by a blow with a hatchet. Fig. 96. Fracture of the frontal bone produced with a brick. Fig. 97. Fracture of the skull produced with a mason's hammer. Fig. 98. Fracture of the skull produced by a fragment of glass.- Fig. 99. Manslaughter by means of a long, angular bar of iron. Plate 13. Contusion of the lung. Plate 14. Peritonitis from traumatic rupture of the jejunum. Fig. 100. Healed fracture of the right parietal region. Figs. 102, 103. Injury of the lung the result of various fractures of the ribs. Plate 15. ] Murder the result of various blows inflicted with different Fig. 101, > instruments. Plate 16. Suicide by cutting the throat. Death through suffocation. Figs. 104-106. Suicide by cutting the throat. Fig. 107. Body of a 4-months-old child, perforated, to show the cleav- age of the skin. Fig. 108. Numerous punctured wounds of the stomach produced with a conical instrument. Plate 17. Suicide through stabbing. Plate 18. Triple injury to the small intestine produced by a stab. Peri- tonitis. Fig. 109. Stab-wounds produced with a four-cornered picture-nail. Fig. 110. Punctured wound in the parietal bone produced with a knife. Fig. 111. Punctured wounds of the skull. Fig. 112. Punctured wounds produced with a sharpened three-cornered file. Figs. 113, 114. Punctured-incised wounds of the left hand received in self-defence. Figs. 115, 116. Murder produced with a fascine-knife. Fig. 117. Saber-blow. Fig. 118. Murder caused by numerous hatchet-blows. Fig. 119. Murder caused by a saber-blow. 10 LIST OF PLATES AND FIGURES. Fig. 120. Fracture of tlie skull produced by a blow witli the cutting- edge of a hatchet. Plate 19. Close-rauge gunshot-wound in the region of the heart pro- duced with a revolver of 9 mm. caliber. Fig. 121. Suicide with a carbine. Fig. 122. Gunshot-wound of the right temporal region produced with a double-barrelled rifle, which in shooting burst; suicide. Fig. 123. Suicide by six shots in the cardiac region, four of which pen- etrated the heart itself. Fig. 124. Eevolver-shot in the mouth. Fig. 125. Suicide by a gunshot-wound in the mouth. Fig. 126. Shot through the dependent mamma, with three external openings. Fig. 127. Suicide by a shot with a hunting-rifle and " spreading-car- tridge" (Stauchpatrone). Fig. 128. Grazing gunshot-wound of the right external ear, with scat- tered grains of i^owder in its vicinity. Fig. 129. Gunshot- wound transversely through the brain ; suicide. Fig. 130. Simple punctured gunshot-wound of the frontal bone pro- duced with an ordinary revolver. Fig. 131. Close-range shot with a Mannlicher rifle ; suicide. Fig. 132. Wound of exit of the gunshot-injury produced with a Mann- licher rifle, illustrated in Fig. 131. Fig. 133. Eevolver-shot in the frontal bone. Fig. 134. Wound of exit at the right side of the occiput of a gunshot- wound through the left frontal region ; suicide. Fig. 135. Suicide by a shot with an army revolver into the right tem- poral region. Fig. 136. Suicide by a shot in the left temporal region with a moder- ately large revolver loaded with broken lead. Fig. 137. Murder by anarchists ; gunshot-wound. Figs. 138,139. Suicides by gunshots; unusual situation of the wounds of entrance. Fig. 140. Gunshot-wound by a hunting-rifle. Plate 20. Encircling gunshot-wound. Figs. 141-169. Deformation of projectiles. Plate 21. Burns produced by flames. Fig. 170. Murder or suicide by burning. Fig. 171. Right upper arm and scapula of a charred body, with the muscles attached to them. Fig. 172. Healed scald-wound of the esophagus. Plate 22. Suicide by hanging; suspension of the body for several days; peculiar distribution of the hypostases. LIST OF PLATES AND FIGURES. 11 Figs. 173-177. Various positions of the noose in cases of persons hanged. Plate 23. Suicide by hanging with a double rope. Asymmetric position of the noose. Plate 24. Suicide by hanging with an old rope wound five times about the neck. Fig. 178. Suicide by hanging in the kneeling posture. Fig. 179. Suicide by hanging in a semi-sitting posture. Fig. 180. Suicide by hanging in the prone posture. Fig. 181. Fracture of the larynx and of the hyoid bone in a person hanged. Fig. 182. Bilateral rupture of the sternocleidomastoid muscles in a person hanged. Fig. 183. Fracture of the thyroid and cricoid cartilages in a person hanged. Fig. 184. Self-strangulation. Fig. 185. Newly born child killed by having its throat cut and by being strangled. Plate 25. Lungs of a dog which was drowned. Plate 26. Left hand of a drowned day-laborer whose body remained in the water twenty-four hours. Plate 27. Left hand of a drowned person whose body had remained in running water for several weeks. Plates 28, 29. Fungus- (algse-) formation on a cadaver found in water. Plate 30. Alterations of the blood due to irritant poisons. Plate 31. Poisoning by caustic soda. Plate 32. Poisoning with concentrated sodium hydrate colored with ultramarine-blue. Plate 33. Suicidal poisoning with concentrated sulphuric acid. Plate 34. Poisoning with dilute sulphuric acid. Plate 35. Hydrochloric-acid poisoning. Plate 36a. Duodenum from a case of hydrochloric-acid poisoning. Plate 36b. Spleen from a case of carbolic-acid poisoning. Plate 37. Poisoning with concentrated nitric acid. Plate 38. Poisoning with carbolic acid. Suicide or accident? Plate 39. Poisoning with carbolic acid. Suicide. Plate 40. Cauterization of the lips and the region about the mouth with lysol. Plate 41. Acute poisoning with corrosive sublimate. Plate 42. Subacute poisoning with corrosive sublimate. Plate 43. Corrosive-sublimate dysentery. Plate 44. Kidney from a case of corrosive-sublimate poisoning. Fig. 186. Stricture of the esophagus and cicatrix of the stomach the result of poisoning with liquor potassse. 12 LIST OF PLATES AND FIGURES. Fig. 187. Stricture of the esophagus following the ingestiou of caustic potash. Perforation of the esophagus with an esophageal sound. Plate 45. Potassium-cyanid poisoning. Plate 46. Fauces, pharynx, and entrance to the larynx from a case of potassium-cyanid poisoning. Plate 47. Subacute phosphorus-poisoning. Plate 48a. Liver from a case of subacute phosphorus-poisoning. Plate 48b. Kidney from a case of subacute phosphorusj-poisoning. Plate 49. Stomach from a case of acute arsenical poisoning. Murder by poison. Plate 50. Small intestine from a case of acute arsenical poisoning. Plate 51. Carbonic-oxid poisoning (charcoal-fumes). Plate 52. Agonal injuries of the face. Plate 53. Abnormal situation of postmortem lividity as a result of the abdominal position of the body. Plate 54. Lower extremity of a newly born child which remained sev- eral months in running water; formation of adipocere. Plate 55. Portion of the abdominal skin of a body which had been in water two or three months, and which demonstrates the formation of so-called adipocere. Fig. 188. Larvfe of flies in the angles of the eyelids and mouth. Fig. 189. Lower extremity of a newly born child gnawed by rats. Figs. 190, 191. Lower half of the body of a newly born child with nu- merous puncture-like wounds of the skin. Plate 56. Mummified cadaver. Fig. 192. Excessively putrescent body of an old man — in great part consumed by maggots— found sixteen days after death. Fig. 193. Skull of a five-year-old child, with all the temporary teeth and the germinal deposits of the permanent teeth. Fig. I, FIGURE 1. Abnormal Smallness of the Penis; Incomplete Crypt= orchidism. The genitals are from an unmarried man, aged 46 years, who died sud- denly of cerebral hemorrhage. The corpse was fat and well developed ; the face, excepting a scanty downy moustache, beardless ; the larynx not prominent, completely carti- laginous ; the costal cartilages unossified ; the mammge undeveloped ; the pubic hair but moderately developed, limited above transversely. The penis is present as a cylindrical-shaped body 1.5 cm. long, 12 mm. thick. Its anterior half is formed by a correspondiugly small glans with exposed tip, but otherwise covered by the prepuce. The scrotum is a re- laxed, shallow, wrinkled skin-pocket with distinct raphe. In it small testicles are to be felt, which, on more careful dissection, are found as soft, relaxed bodies the size of walnuts, situate in the anterior part of the inguinal canal, and revealing distinct testicle and epididymis. The seminal vesicles are very small and empty. Spermatozoa are demon- strable neither in the latter nor in the testicles. We have therefore to do with a case of incomplete descent of the tes- ticles, with their persistence in the inguinal canal and their consequent atrophy, and with an abnormal smallness of the penis. The congenital origin of this defective formation of the genitalia is indicated by the imperfect development of the masculine habitus — similarly as occurs iu individuals castrated before puberty — by the abundant formation of fat, absent beard, non-prominent larynx, and the completely soft and readily cut laryngeal and costal cartilages, despite advanced age. Under these circumstances, had the ability of the individual to beget been in question, one should have been obliged to assert that he possessed neither the power to copulate nor to impregnate. FIGUKE 2. Cicatricial Deformity of the Penis. The preparatiou is from a married mau, aged 64 years, tlie father of a sou aged 20 years. As he was dressing he died suddenly on the morning of November 14, 1880. To determine the cause of death, a necropsy was performed Xovember 15th. This revealed hypertrophy of the heart, consequent upon a high grade of endarteritis deformans and nephritis. In both inguinal regions, extensive white cutaneous cicatrices reach- ing to the inner surfaces of both thighs, and to the outer surface also of the right, with an undermined bridge of skin corresponding to the right Poupart's ligament ; the scars on both sides extending also to the upper part of the scrotum. In addition, similar scars on the inner aspect of the left knee, on the entire posterior surface of the left, and on the upper third of that of the right thigh. Of the penis, there remains but an irregular thick stump, the width of two fingers in length. The skin-covering is everywhere cicatricial ; to the right it is movable ; to the left, posterior to the still apparent groove of the glans penis, it is united with the deeper tissues, whereby the en- tire stump of the penis is curved toward the left. The glans is flat, fungiform, as though compressed auteroposteriorly, and at the same time twisted by a cicatrix toward the left. The urethral orifice is to the right and below, forming an open transver.se fissure with plump edges. Concerning the production of this deformity, there was unfortunately nothing to learn. It appears, however, to have been produced during childhood, as neither the wife nor the son of the deceased knew any- thing of it, and were unaware of any disease or injury having been sus- tained by the man during the past decennium. The scars and the de- formity of the penis most probably originated in the healing of wounds produced by burns. Despite the high grade of the deformity, it cannot be asserted that the deceased was incapable of coitus, as the stump of the penis was the breadth of two fingers in length and during erection was capable of elongating, so that the introduction of the organ into the entrance of the vagina at least was possible. In how far the scars, particularly the im- movable ones of the left side, were capable of influencing erection can- not be determined. As. in addition, the testicles of the man, despite his advanced age, were large and intact, and as the excretory passages for the semen showed no abnormalities, in a given case there would l)e no justification for an assertion that the aforementioned son could not have been begotten by the deceased. Fig. 2. Fig. 3 Fig. 4. FIGURES 3, 4. Fig* 3.— Union of the Under Surface of the Penis with the Scrotal Skin (Synechia). This rare malformation befell a 4-year-old boy — otherwise normally developed. The skin of the penis is — from its root to the prepuce — united with the anterior surface of the scrotum, the skin of which along the anterior part of the scrotal raphe is directly continuous with the lateral surfaces of the penis. The genitalia are otherwise entirely normal. As regards sexual intercourse in later life, this malformation would have been of importance, as it would probably have given rise to an impediment in the erection and insertion of the penis. The hindrance to erection would probably not have been great, as the corpora cavernosa are normally developed, and the relaxation and elasticity of the skin, both of the scrotum and the penis, permit of wide movement. On the other hand, however, an impediment to the insertion of the penis would probably have arisen ; but this could hardly have been designated an essential obstacle to coition, as, firstly, an introduction into the vulva at least would have been possible, and, secondly, by a small operation the impediment could have been radically removed. Fig. 4.— Epispadias. The genitalia of a 5-months-old boy. The scrotum is normally devel- oped, and contains both testicles. The penis is somewhat shortened, and shows a club-shaped thickfeniug of the extremity. This is depend- ent externally upon the prepuce split open by the strikingly wide, ap- parently anteroposteriorly flattened glaus. The latter is split open from the meatus urinarius, and this slit extends as a furrow along the dorsum of the penis to beneath the symphysis ossiuni pubis, from which point the bladder maybe entered.. Under the symphysis the skin forms an arched elevation open below, beneath which the root of the penis is concealed. As the genitalia are otherwise normally formed, and as the corpora cavernosa are well developed, coition later would not have been preju- dicially affected. Nor could one entirely exclude the capability of im- pregnating, as an ejaculation of semen, if not into the vagina itself, would still have been possible into the introitus thereof, or at least into the vulva. FIGURES 5, 6. Fig* 5.— Masculine Pseudohermaphrodism. Female child, with normal internal and hermapliroditic external genitalia. Of the latter, the labia majora and minora are normally developed ; the clitoris, however, is excessively large, resembling a penis with hypospadias. The latter is drawn markedly downward and reveals on its under surface an open, furrowed urethra, running backward from the tip of the glans, ending in the perineum, and leading into the bladder. The vaginal orifice is greatly contracted, scarcely the size of a lentil, but leads immediately into a vagina of normal caliber. A hymen is not present. Fig. 6.— Unusual Development of the Clitoris. Female genitalia, with normal development of the labia majora and minora, but with marked contraction of the orifice of the vagina. The clitoris has a decidedly penis-like character, is 4.5 cm. long, 3 cm. thick, and possesses a much wrinkled prepuce and a strongly developed but not perforated glans. From the apex of the latter a furrowed groove runs along the under surface of the clitoris to the symphysis, and above the contracted orifice of the vagina enters the bladder. During childhood the genitalia were thought to be those of a male, but after repeated careful examinations were recognized as those of a female. Fig. 5- Fig. 6. Fig. 7. FIGURE 7. External Masculine Pseudohermaphrodism. The illustrative case was that of an unmarried, supposedly female peddler, aged- 62 years, who was injured by falling from a wagon, and whose real sex was first determined by the official necropsy. The body was 153 cm. long, bony, poor in muscle, thin, and somewhat marasmic. On the upper lip and on the chin were isolated, short, gray hairs. The rest of the senile face was beardless. The pubic hair was blond, moderately developed ; the limitation of the hair above was arched. The penis is as large as the terminal phalanx of the thumb ; the glans is the size of a hazelnut and is partially covered by a short prepuce which at its lower part is split, and which, with the intervening thickened and likewise divided frenum, descends in the direction of the raphe a dis- tance of 1.5 cm. It then unites with the latter to form a dense, tendin- ous, protruding elevation, which after a course of 1.3 cm. divides again and ends in a pointedly oval fissure, 1.5 cm. long, surrounded by promi- nent, dense, tendinous margins. This fissure deepens as a funnel inward and upward, whence one may enter the urethra and the bladder. The fissure, even when the thighs were separated, was concealed by the much dependent halves of the scrotum, between which there remained a large, penetrating, funnel-shaped space, within whose depths the aforemen- tioned fissure was situated. It was apparently because of this and be- cause of the smallness of the penis, a vul^ was simulated and the mis- take as to the sex produced. The testicles, situated within the scrotum, were of ordinary size, but soft and, on section, cinnamon-brown. The vasa deferentia were patu- lous ; the verumontanum in the posterior part of the urethra, with the utriculus and the ejaculatory ducts, was normally formed ; the seminal vesicles were small, slightly sacculated, and contained a quantity of brownish fluid. Spermatozoa were nowhere demonstrable. Of the relatives, no one supposed that the deceased had an abnormal- ity of the genitalia, nor had the deceased herself ever made any declara- tions in this regard ; still, she is said never to have menstruated and never to have manifested sexual desires, and in consequence remained unmarried. FIGURES 8-13. Hymen Annularis and Semilunaris (Circular and Semilunar liymensj. Fig. 8. — Circular hymen — hymen aunularis — with wide opening and circular, smooth-edged margin, of equable height throughout, surround- ing the entrance to the vagina. Fig. 9. — Circular hymen with margin somewhat notched above, but otherwise with rather smooth edges ; on the posterior surface the poste- rior columna rugarum directed to the left. Figs. 10-12, — Transitions to semilunar hymens — in that the orifice of the hj^men is no longer centrally situated, but is shifted upward, whereby the lower margin of the hymen becomes wider than the upper. In Fig. 12 is an indication of the keel-shaped appearance which the folds of the hymen assume when the genitalia are closed. Fig. 13.— Semilunar hymen— hymen semilunaris.— At the lower part of the entrance to the vagina is a falciform, sharp-edged fold of mucous membrane, the cornua of which terminate on both sides at the middle of the introitus. Fig. 8. Fig. II f ■^ ■.& Fig. 12. ^' 4"^ J s Fig. 13- I ^ i?ig. 15- Fig. i6. Fig. 17. Fig. 18. FIGURES 14-18. Varieties of Hymens with Congenital Notches. Fig. 14.^Hymen with excentric opening toward tlie upper part; iu the left upper quadrant is a wide notch, witli fimbriated edges reaching to the wall of the entrance to the vagina. Fig. 15. — Circular hymen with various smooth projections of the free edge. Fig. 16. — Hymen of a newly born child with deep notches to the right and below. Fig. 17. — Circular hymen with a deep congenital notch both below and in the left upper part. All the edges smooth and I'ounded. Fig. 18. — Hymen annularis of fleshy consistency with four deep notches, which, similarly to the intervening hymenal tissue, possess gradually thinning smooth edges. FIGURES 19-24. Varieties of Hymens with Congenital Notches. Fig. 19. — Hymen with numerous shallow notches regularly arranged equidistant from each other, giving to the free edge a dentate appearance. Fig. 20. — Hymen semilunaris with a notch situate in the middle of both lateral aspects. Figs. 21 and 22. — Deep irregular notching of the hymen of a newly born child, whereby it assumes a dentate appearance. Fig. 23. — Serrated hymen of a virgin at puberty. It possesses a wide sinuous opening, does not form a tense diaphragm, and permits the introduction of a voluminous body (speculum) without rupturing, — the serrations simply receding. Fig. 24. — Serrated hymen of an adult virgin. The hymen consists of several flaps which have rounded edges, and which in part show slight formation of fimbria and are readilj' displaced. As at the same time the lower margin is strikingly narrower than the others, this hymen represents a stage of transition to the so-called labial form of hymen. Fig. 19. Fig. 20. Fig. 21. Fig. 22. Fig. 24. Fig. 23. Fig. 26. Iig. 25. Fig. 27. FIGURES 25-29. Hymen Fimbriatus and Hymen Bipartitus or Septus. In Fig. 25 we see at the middle of the right Uiteral aspect of the geji- erally circular hymen of a KJ-year-ohl virgin, a rather wide notch, and iu the left side two fissure-like radiating notches, all of which continue on the posterior wall of the hymen between the adjoining folds of the vaginal mucous membrane. The free edge, both of these notches and of the rest of the hymen, possesses delicate fimbriated papillae, which are also scattered over the anterior surface of the hymen, on tlie inner surface of the labia minora — especially at its upper part — and in the region of the clitoris. We have, therefore, to do with an apparently congenital papillary hyperplasia of the mucous membrane of the exter- nal genitalia, but especially with that variety of hymen-formation which, since Luschka, has been designated hymen fimbriatus. Figs. 26 and 27 show two similar but much more marked cases. In both the hymen is serrated, and the free edge of all the notches and pro- jections possesses — in Fig. 26 cilia-like, and in Fig. 27 somewhat coarser, processes, whereby both hymens present a corolliform appearance. Figs. 28 and 29 furnish examples of so-called divided hymen — hymen hipartitiis or hymen septus. Both affect circular hymens, each with an opening, situate toward the upper part, divided into two each of equal size by a narrow band of mucous membrane directed from above down- ward. This variety of hymen occurs frequently in varying combina- tions with other vestiges of the former bifurcation of the genital tube, so that there appears to exist a relationship between both of these formations.. Fig. 28 is further of interest, as the septum appears con- stricted iu the center. FIGURES 30-34. Varieties of Hymens with Divided Openings. Figs. 30, 31, and '32 show similar septum-formatiou with symmetrical openings of semilunar hymens. Especially interesting is the case illustrated in Fig. 31, as the septum is as a fine thread coursing from the center of the hymenal crescent to the superior periphery of the vaginal entrance, giving to the hymen the appearance of an unfurled sail. Fig. 33. — This hymen was that of an unmarried woman, aged 24 5'ears. It is of extraordinary dense almost tendinous consistency, and possesses two almost bean-sized, laterally situated openings, separated from each other by a dense, tendinous septum, 1 cm. wide and ^ cm. thick. There is no doubt that this hymen, because of its unusual solidity— increased by the septum-formation — would constitute a decided ini})ediment to coition, and in case of marriage might possibly have given rise on the part of the husband to a .suit-at-law for divorce or separation. The medicolegal expert would have had to declare, 1, that a jwsitive impediment to coition was present; 2, that it was present before mar- riage; but, 3, that it could be removed by an operation. The possibility of fecundation despite the impediment to coition could not be uncondi- tionally denied, as even a coitus merely within the vulva may lead to the entrance of semen into the vagina and subsequent fecundation, the proof of which possibility is afforded by numerous actual occurrences. Fig. 34.— Divided circular hymen of an adult woman, with a larger opening to the right, and to the left a much smaller round opening with smooth edges. In this case during coitus there would have been possible but a unilateral rupture of the hymen, as the penis would have more easily entered through the larger opening, probably leaving intact the left opening and the septum. Fig. 30. Fig. 31 Fig. 32. FJg. 34- Fig. 33- Fig. 35- Fig. 36. r Fig. 37- n r' Fig. 38. FIGURES 35-38. Divided Hymens with Asymmetric Openings ; Hymen with Partial Septum. Fig. 35.— Divided hymeu of a girl of marriageable age, with a large, irregular triangular opening to the right, the base of which corresponds to the septum and the apex to the wall of the right side of the vaginal entrance. The left opening is irregularly round, the size of a lentil. The hymen is entirely fleshy. In this case, also, the introduction of the penis would have been efi'ected through the larger opening to the right, especially as this half of the hymen does not form a tense membrane, but consists in reality of two flaps which may be readily displaced. Fig. 36.— Semilunar hymen of an infant with a large opening to the left and a smaller higher-situated opening to the right. Fig. 37.— Hymen annularis of an adult woman with multiple pouch- like formations induced by the attachment of the vaginal rugse to the posterior surface of the hymen, and with a narrow septum which pro- ceeds from these rugse posterior to the lower insertion of the hymen and courses somewhat diagonally to the right and above, where behind the hymen it likewise becomes again lost in a fold of mucous membrane. In addition from the upper edge of the hymen there arises a conical- shaped process projecting into its orifice. Fig. 38. — Circular hymen of a girl aged 20 years. From the centre of the lower border of the hymen there arises, as a continuation of the more posteriorly situated support-pillars, a fleshy prominence, 1 cm. in length, projecting pointedly into the orifice of the hymen. This is an instance of the so-called hymen partim septus, in which only the lower portion of the septum persists. FIGURES 39-44. Varieties of Hymens with Rudimentary Septa. Fig. 39. — Circular hj'men with a very narrow margin, from whose lower periphery to the right there depends a fleshy flap about 1 cm. long and i cm. wide. This is to be looked upon as an instance of rudi- mentary septum-formation. Fig. 40 shows an almost similar case with a somewhat wider depen- dent flap. Fig. 41 is a divided hymen with two lateral, rather similar openings, whose fleshy septum projects as a wedge and below becomes a conical plug 1 cm. long, which hangs from the vulva. Fig. 42. — Irregular circular hymen, with a round vermiform projec- tion which arises from the support-pillars along the posterior wall of the hymen and hangs dependent over the edge of the latter. Fig. 43. — The hymen of an infant, consisting of three narrow flaps, of which two are situated laterally, whereas the third, as a conical pro- jection, is directed upward from the center of the posterior periphery of the vaginal entrance, and as a continuation of the posterior columna rugarum. Fig. 44. — Semilunar hymen of a newly born child with a conical pro- tuberance, which, independently of the hymenal crescent, arises beneath the meatus uriuarius and pointedly projects forward. Fig. 39. Fig. 40. *fJ :/ Fig. 41, Fig. 42. Fig. 43. i ^. J Fig. 44- Fig. 46. Fig. 45- Fig. 47. Fig. 49- Fig. 48. FIGURES 45-49. Abnormal Openings in the Hymen. Deflorated Hymen. Fig. 45. — Circular hymeii of a 17-y ear-old girl, with perpendicular, almost rectangular opening with slightly serrated edges ; beneath this and separated from it by a transverse, narrow septum is a second round opening, the size of a lentil. This at first sight might be deemed to have arisen through traumatism, but its congenital origin is demon- strated by the fine and symmetrically fimbriated condition of its edges. Fig. 4G. — Compact hymen of an infant, the opening of which is divided — by a transverse, almost tendinous septum — into an upper smal- ler, irregularly round, and a lower, larger, circular opening. Fig. 47. — Wide semilunar hymen, in which, in addition to the ordi- nary opening, a second smaller one is situate in the left half; this shows attenuated translucent edges, corresponding to an attenuated, translu- cent, but non -perforated spot in the other half of the hymen. Fig. 48. — Deflorated circular hymen of a girl, aged 12 years, who died of peritonitis as a sequence of virulent blennorrhea. The hymen was congested, swollen, and showed four superficial radial tears — 2 mm. deep — the free edges of which were besmeared with pus and revealed a distinctly lacerated appearance. The defloration occurred ten days before death, at which time the girl was infected by a man aflBicted with gonorrhea. Fig. 49. — Wide semilunar hymen of a woman who died in the sixth month of her first pregnancy, of valvular disease of the heart. The anatomical lesion of the hymen ensued in a manner which can be desig- nated as almost typical of semilunar hymens, that is, through — in the present instance deep — tears in both sides of the deepest excavation of the hymenal crescent, so that there result two lateral and a central posterior irregular triangular flap. The last is so frequently preserved because, as a rule, it possesses a special solidity. • FIGURES 50-55. Deflorated Hymens. Carunculse Myrtiformes. Fig. 50. — Incomplete semilunar hymen with two symmetrical, healed, deep lacerations to either side of the lower part of the median line, giv- ing rise to two lateral and a central flap. Fig. 51. — Circular liymen with a wide, healed defloration-tear to the right, and a smaller, narrower, higher-situated one to the left, both of which reach to the vaginal wall. Fig. 52. — Circular hymen with a wide laceration of the right lateral aspect reaching to the vaginal wall. ■ Fig. 53. — External genitalia of a woman who six months previously was delivered of a full-term child. The entrance to the vagina is much dilated; the posterior commissure cicatricial. Of the hymen there are present but partly triangular or conical-shaped, partly uneven or nodu- lar vestiges. These have persisted after the laceration of the deflorate d hymen which occurs during parturition, and are known as carancalie myrtifurmefi. Fig. 54. — External genitalia after several parturitions. The vaginal entrance is much dilated, its posterior part smooth, its anterior reveal- ing certain uneven hymenal vestiges — carunculse myrtiformes. The posterior commissure without cicatrices, l)ut much relaxed. Fig. 55. — Hymen after several parturitions. Originally circular. At present but partly uneven, partly notched, vestiges present. Along the posterior periphery of the entrance to the vagina, at the situation of the former support-pillars formed by the colamna rugarum, is a plump, cone-shaped protuberance directed inward. Fig. 50. Fig. 51 fe^. -> . .1 i " =V f J V .^M Fig. 52. Fig. 54- FIGURES 60-62. Traumatic Injuries of the External Genitalia. Fig. 60. — Transverse, fissure-like wound, 1.5 cm. long, of the fossa navicularis. The wound afiects the mucous membrane directly in front of the hymen, and, decreasing in size funnel-shaped posterior to the posterior wall of the vagina, penetrates into the depths of the cellular tissue 1.5 cm. The injury befell a child almost 2 years of age, under whom an earthen chamber broke, wherebj^ a fragment penetrated the genitalia. Death resulted from pyemia at the end of ten days. Fig. G1. — The genitalia of a young married woman pregnant for the first time, who, while putting her room in order, fell, striking the geni- talia against the angular edge of a bed. Immediately considerable hemor- rhage, which it was attempted to stop by cold applications, but which could not be controlled. After an hour a physician was called, who, instead of immediately sewing the wound, had the woman removed to a hospital, which she entered as a corpse. The legal necropsy revealed a high grade of internal and external anemia, and marked soiling of the lower part of the body with dried blood. Beneath the clitoris a triangular wound with somewhat bruised sides 1 cm. long. It penetrates the mucous membrane and continues funnel-shaped in the submucous tissue a dis- tance of 1 cm, toward the symphysis. The connective tissue of the wound and that in the vicinity are markedly suflTused with blood ; the injury of a large vessel was demonstrable. Injuries to this region of the external genitalia are known as dan- gerous because of the richness of the tissue in large vessels. In the pres- ent case the injury was the more serious because of the pregnancy already in the sixth month, and the consequent excessive filling of the vessels. Interference in sucli cases is urgently indicated, and is most appropri- ately eftected by suturing. Fig. 62. — The preparation is from a 20-montbs-old girl wlio was run over by a tramcar. Various fractures of the ribs; laceration of the lung and the diaphro.gm ; rupture of the liver; suff'usion of the perito- neum in the pelvic region without fracture of the pelvis. The perineum torn throughout its length. The vagina with the circular hymen torn from the surrounding parts, lying free in the depths of the funnel- shaped wound of the genitalia. Hymen and vagina otherwise unin- jured. Fig- 60. Fig. 61. B5E3::^3S!w> Fig. 62. PLATE 1. Cervix and Vagina directly after Parturition. M. v., aged 35 years, Ill-jjara, wife of a dairy mau, was delivered by a midwife, December 11th, at 8 p. M., of a 7-months-old child, aud died au hour later with symptoms of great dyspnea aud violent coughing. She is said to have suffered for years from cardiac palpitation. The necropsy, performed December 12th, revealed the following: edema of the lungs ; stenosis of the left auriculoventricular orifice ; recrudescent verrucous endocarditis ; and a slight grade of generalized edema. The uterus was as large as the head of a 4-year-old child, well contracted, externallj'^ smooth, and very pale. Its cavity was the size of a fist; its inner surface rough, and covered with decidua-shreds and blood-coagula of recent date. The placental site was on the posterior wall of the fundus. The wall of the uterus was 3.5 cm. thick, i)ale, with gaping vessels. The external os uteri aud the cervical canal were patu- lous for four fingers, markedly swollen, as though edematous, with super- ficial and deeper fresh radial rents sufi'used with blood, and numerous older cicatricial depressions, the result of previous labors. The vagina was wide, moderately wrinkled. The vaginal entrance with numerous superficial tears suffused with blood. The posterior com- missure destroyed through cicatrices. Of the hymen, but vestiges of the carunculse myrtiformes present. Tab. I II .;./ ./• ■.:.^ :^ Tab. 2. ■^ PLATE 2. Spontaneous Rupture of the Uterus. A. H., wife of a house-owner, 33 years of age, took to bed on account of labor-pains on the morning of December 9tb, and called a midwife, who declared the labor to be a difficult one and sent for a physician. The latter recognized nothing alarming. As the delivery of the woman, despite severe labor-pains, did not advance, and as her condition during the afternoon suddenly grew worse, the physician was called again. The latter, after consultation with another physician, declared the condition of the woman dangerous and ordered her removal to a maternity hospital. During transportation she died. In the receiving-ward a Ce§arean sec- tion was performed, resulting in the delivery of a mature dead child, which is said to have presented in the ordinary vertex position. The legal necropsy, on December 12th, showed that the body exter- nally and internally was very anemic. The abdominal wall was divided by a sutured incision, without reaction, reaching from the umbilicus to the symphysis. In the abdominal cavity were blood-coagula the size of three fists, and in the lower part thereof a large quantity of fluid blood. The uterus almost the size of a man's head, firm, pale, and smooth, covered with clots. On its anterior surface, an opening with sharp edges, united by interrupted sutures and showing no reaction, run- ning from above downward and through the entire wall of the organ. The cavity of the uterus the size of a fist, filled with blood-clots ; the wall of the uterus 4.5 cm. thick. The external os uteri readily patulous for three fingers ; much contused. To the left a deep laceration, 12 cm. in length, continuing upward through the entire length of the cervix and completely through its wall, and leading to a large cavity situate between the layers of the uterine ligament. This cavity reaches below to the left internal inguinal ring and extends to the neighboring mesen- tery ; its wall, as also the edges of the laceration of the cervix, appears irregularly shredded. The vagina wide and uninjured. The pelvis visibly fiattened anteroposteriorly and to the left. The promontory of the sacrum distant 8 cm. from the symphysis. The trans- verse diameter of the pelvis 12 cm. ; the left oblique 11 cm. ; the right oblique 12 cm. Distinct funnel-shaped contraction of the pelvic cavity toward the outlet. The accompanying child is a male, well developed, 52 cm. long, and weighs 3500 grams. The head relatively large, somewhat flattened to the right anteriorly. The anteroposterior diameter of the head 12 cm. ; the transverse 9 cm. ; the diagonal 13.5 cm. ; the circumference 36 cm. The scalp over the right frontal and parietal bones very prominent and with jelly-like infiltration. The preliminary opinion ran as follows : 1. Mrs. A. H., in the first place, died of hemorrhage into the abdomi- nal cavity, 2. The latter resulted from rupture of the uterus occurring during parturition at full term. 3. As an instrumental or important manual operation was performed neither by the physician in attendance nor by any one else, the case is evidently one of spontaneous rupture of the uterus. 4. The development of this was occasioned, on the one hand, by the large size of the child, and on the other, and especially, by the marked contraction of the pelvis (flat pelvis). 5. As nothing is known concerning the time of the commencement of the labor-pains and of their continuance prior to the rupture, nor con- cerning the condition of the woman at the time of the arrival of the first physician, nor of the symptoms developed during and after his presence (or of those recognized by him), preliminarily the question can- not be answered whether or not the difficulty in parturition could have been recognized at the proper time, nor in how far the occurrence of the rupture could have been prevonted. 6. Cesarean section was performed on the deceased shortly after her death. The case was not further investigated by the judicial authorities. PLATE 3. Tubal Pregnancy. Rupture of the Sac. Internal Hemor= rhage. Antonia M., aged 35 years, has suffered for the past two years with pain in the abdomen. She has had two children, the last five years ago. Recently menstruation is said to have been irregular. The occurrence of a new pregnancy had not been suspected. On May 7th, at 8 P. M., the woman complained suddenly of severe pain in the abdomen, vomited five or six times during the night, and had marked rectal tenesmus. A neighboring physician being called recog- nized a high grade of anemia, cardiac weakness, and rapid loss of strength. At 8 o'clock in the morning the patient died. As there was a supposition of poisoning, a medicolegal autopsy was ordered. By this thei-e was found externally and internally marked anemia. The abdomen was moderately distended and soft. It contained 2^ liters of partly fluid, partly freshly coagulated blood, which occupied especi- ally the lower abdominal and pelvic cavities. At about its middle the otherwise normal right Fallopian tube becomes dilated to form a sac the size of an apple, which on its anterior surface shows a wide perforating longitudinal rent almost 2 cm. in length, from which blood-coagula and ruptured chorionic villi project. The entire sac is surrounded by huge blood-clots, which are connected with those contained within the abdom- inal cavity, and in which, on careful examination, there is found directly above the point of rupture, in an unbroken amniotic sac, an embryo 2 cm. in length. The latter is bent in a scaphoid manner, and still shows vestiges of the germinal fissures and apparently of the abdominal cleft, but in addition already articulated extremities, on which we may recognize the still adherent fingers and toes. It belongs, therefore, to the middle of the second month. The further investigation of the genitalia revealed numerous cord-like adhesions of the posteriorly displaced left tube with the posterior wall of the uterus and the neighboring intestines, and a large corpus luteuni (corpus luteum verum) in the left ovary. There had, therefore, occurred a so-called " migration of the ovum " from the left to the right. This was induced by the adhesions and flexions of the left tube which re- tarded the entrance of the ovum into the (left) tube, and which, also preventing it reaching the uterus, caused it to remain in the tube, and there further develop. Worthy of mention are further the visible enlargement of the uterus and the marked swelling and hyperemia of the uterine mucous mem- brane (decidua vera), — phenomena regularly observed in cases of extra- uterine pregnancy. 'i I'h Tab. 4. PLATE 4 represents the embryo about one and a half months old found within an uninjured amniotic sac among tlic blood-clots of the tubal pregnancy illustrated in Plate 3, where its peculiarities are described more in de- tail. FIGURE 68. Fatal Hemorrhage from Retention of a Portion of the Placenta. W. M., aged 39 years, the wife of a locksmith, was delivered of her third child January 8th, at 12.30 o'clock at night. The labor was easy. The placenta was delivered by a midwife, who asserted that she examined but observed nothing unusual about it, and therefore laid it aside. The hemorrhage after delivery continued, but a physician was not sent for until noon. For a long time one was sought in vain, who, when he arrived, found the woman excessively anemic and already collapsed. He diagnosed atony of the uterus, introduced a tampon, and had the woman transferred to a maternity hospital, where immediately after her ad- mission, before she could be examined, she died at 3.45 o'clock in the afternoon. The body externally and internally was remarkably anemic; the external genitalia and the surrounding parts covered with fluid and co- agulated blood. The rather firm uterus, the size of a man's head, contained a large quantity of recent blood-coagula, which were especially firmly adherent to the fundus, and which when removed revealed the placental site. To the upper part of this there was firmly adherent a pear-shaped portion of the placenta with dependent apex, 6 cm. long and 3 cm. wide. The other findings were such as were to be expected directly after parturition ; the uterine vessels were, however, almost entirely empty and the wall of the uterus very pale but firm. The opinion was deduced that the deceased died shortly after par- turition of hemorrhage from the genitalia; that this was caused by the retention of a large portion of the placenta, and that the removal of this portion of placenta at the proper time, which the existing con- traction of the uterus rendered difficult, would have prevented the hem- orrhage. The culpability of the midwife consisted : 1. In that she neglected to carefully examine the placenta, whereby the absence of such a large portion of it could not have escaped her attention ; 2. In that she laid aside the placenta before the arrival of the physician, so that the hitter could not inspect it; and, 3. In that medical aid was not summoned until the hemorrhage had persisted for hours and had assumed a critical character. Through the portion of retained placenta in the accompanying illus- tration a sagittal section has been made. Fig. 68. •*- -^r^^ Fig. 69. FIGURE 69. Another form of retention of a portion of the placenta with consecu- tive hemorrhage, occurring four hours after an otherwise normal lahor, is illustrated in Fig. (59. The site of the placental insertion was on the posterior wall of the uterus, and its lower border was scarcely one finger's breadth above the internal os uteri. The retained portion of the pla- centa was covercKl with a large blood-clot reaching into the vagina. After the removal of the latter the ])ortion of the placenta was found to be almost as large as a goose-egg, its lower third intimately adherent with the lower part of the placental site, its other two-thirds pro- jecting flap-like into the dilated vagina, which had a width of four .fingers. In this case also the midwift^ liad not properly inspected the placenta, and, in addition, had left the woman before the lapse of the prescribed four hours. FIGURES 70, 71. Two Uteri in tlie Very Earliest Stages of Pregnancy. Fig. 70, — The preparation is from a married woman, aged 35 years, who killed herself by jumping from a second-story window. She had frequently had children, and thought herself again pregnant, as she had not menstruated at the last expected period. There were found, as the cause of death, fractures of ribs and various ruptures of the abdominal organs, with internal hemorrhage. The uterus was uninjured, the size of an orange, thick-walled and contained in its slightly dilated cavity some freshly coagulated blood, demon- strable also in the cervix and in the vagina. The mucous membrane, after irrigation, was found irregularly swollen, pale violet, as a decidua vera, dilated — to the right and above — to form a sac the size of a bean. This latter was ruptured in the direction of the greatest convexity, filled with recent blood-clots, and revealed a finely rugose inner surface. Despite careful exauiination of the l)lood-clot neither an ovum nor a part thereof could be discovered. There can, however, scarcely be a doubt that the sac was that of a decidua reflexa, which contained an ovum in the earliest period of development, and, further, that the violent concussion occasioned bj'^ the fall led to a rupture of the decidual sac and a consequent extrusion from it of the therein con- tained ovum either in toto or likewise injured, and that this latter was carried off with the blood-clots. The right ovum contained a bean- sized corpus luteum, with wide pale yellowish margin and violet jelly- like contents. Fig. 71 is from a woman, aged .35 years, who died suddenly in con- sequence of mitral incompetency and pulmonary edema. Menstruation had been absent during the past two months. The necropsy revealed a pregnancy at the end of the first or the beginning of the second month. The uterus is the size of an orange, rather thick-walled, and contains an uninjured ovum attached to its posterior wall. This, after opening of the decidua i-eflexa, is found the size of a walnut, completely covered externally with regularly and closely arranged chorionic villi. After slitting open the chorion and the amnion one sees the embryo, about 2 cm. in length, to the left in breech pres- entation. The latter is fastened to a short, relatively thick umbilical cord proceeding from the posterior wall of the ovum ; it is markedly scaphoid in shape, shows as yet no ossification, and reveals, in addition to oral and nasal apertures already joined to form one cavity, the genital clefts of the neck, the abdominal cleft, the umbilical vesicle, and tlie as yet but articulate stumps suggestive of extremities, — findings which indicate that the embryo belongs to a very early pt'riod and that it has scarcely or but slightly passed the first month of pregnancy. Fig. 70. Fig. 71 Y^ Fig. 72. Fig. 73. FIGURES 72, 73. Fig. 72.— Human Ovum of the Eighth or Tenth Week. The ovum, first separated from the blood-clots by continued irrigation and then opened, is in toto the size of a goose-egg, and shows above and to the left as its external covering vestiges of the decidua reflexa. The incised chorion situate beneath is externally completely symmetrically villous (chorion frondosum), and reveals as yet no placenta formation. From the smooth inner surface of the incised chorion the unopened di- aphanous amniotic sac, coutainiug the embryo in a clear, watery-looking fluid, protrudes. The embryo is about 5 cm. in length, and shows as yet no difterentiation of the sex, but already separated fingers. The genital clefts and the abdominal fissure are already closed. The umbilical cord is thick, about 2 cm. in length ; from its root on the inner surface of the chorion there proceeds, between the latter and the external surface of the amnion, a thin filament, about 3 cm. in length, which ends in an oval, pea-sized, watery-looking vesicle, — the umbilical vesicle. In the illustration this is represented as protruding through a rent in the chorion to the right and below. FJg' 73 '—Rupture of the Vagina through Coitus or by the Finger. A coachman had sexual intercourse with a 19-year-old servant, in a stable, after he had previously examined her with his finger. On the way home the girl became affected with pain in the genitalia and rather severe hemorrhage. The same day she betook herself to the general hospital, where a rupture of the vagina in its upper part was recognized and an iodoform tampon introduced. Death ensued six days after the injury, with the phenomena of sepsis. The necropsy revealed general sepsis and septic pleuritis as the cause of death. The uterus somewhat enlarged, smooth, with cicatricially notched os uteri. The uterine cavity slightly dilated, containing a brownish blood- coagnla representing a cast thereof. The mucous membrane softened, injected, with isolated lentil-sized blood-extravasations; everywhere smooth. In the vault of the vagina, beginning to the right posterior to the posterior lip of the cervix and coursing obliquely to the right and below, there is a slit-like tear of the mucous membrane, 4 cm, in length, reaching to the subniucosa. It has rather sharp edges joining in an acute angle, and a flat, funnel-shaped, irregular base, deepening above and reaching to beneath the peritoneum, covered with discolored blood- Fig. 75. FIGURE 75. Abortion Induced by a Probe=like Instrument ; Perforation of the Posterior Wall of the Uterus. Uterus of a 29-year-old multipara, who died after fourteen days' ill- ness, consisting of hemori'hage from the genitalia, fever, and abdominal pain. The necropsy revealed endometritis and septic peritonitis. The uterus larger than a fist, empty, with distinct placental site. The cervix i^atulous for the index finger, not lacerated, showing cicatri- cial notches of the external os uteri. On the posterior wall of the uterus to the left and above there is a bean-sized irregular opening covered with pus, which leads into an equally wide canal with softened walls, likewise covered with pus. This penetrates the entire wall of the uterus anteroposteriorly from below upward, and ends on its posterior surface in an irregular, triradiate, foramen-like opening, with limbs 1.5-2 cm. in length, occluded with a fibrinopurulent exudate. This is manifestly a ease of abortion induced by the introduction into the uterus of, and the perforation of its walls by, a probe-like in- strument. FIGURE 76. Abortion Induced by Rupture of the Membranes of the Ovum. SIit=like Laceration above and below the In= ternal Os Uteri. K. M., aged 20 years, who had aborted once, for the purpose of pro- ducing another abortion was " operated " upon three times by a surgeon, who each time is said to have introduced a surgical instrument into the genitalia, which procedure each time, but especially the last — June 15th — caused pain. The abortion ensued during the night of the loth-16th of June. A 2-months-old ernbryo was delivered, which was shown to and preserved by a midwife who was summoned to the case. On the 18th, because of fever and abdominal pain, the patient was brought to the hospital, where she died on the 23d. The legal necropsy revealed puerperal sepsis as the cause of death, and in the uterus the three wounds illustrated in the cervical portion thereof. The first of these wounds is situate directly above the internal OS uteri, the second to the left at the internal os uteri, the third on the posterior wall of the cervix to the right of the median line between the internal and external os uteri. All three wounds are irregular longi- tudinal slits 1-1. .5 cm. in length, with somewhat jagged edges, and a wedge-shaped base — flat above — deepening 3-5 mm., discolored and covered with pus. From the lower end of the lowest-situated slit there projects a discolored shred of mucous membrane about 1 cm. square. The physician denied the charge, but under the overwhelming weight of the proofs was nevertheless condemned. To all appearance a hook-like instrument was used, the employment of which would ex- plain the recognized detachment of the mucous membrane hanging as a flap from the lowermost wound. Fig. 76. Fig. 77. FIGURE 77. Abortion Induced by Injections. Perforation of the Fornix of the Vagina and the Fundus of the Uterus. The 39-year-ol(l wife of an inn-keeper, who had already given birth to seven children, and who considered herself again pregnant in the second month, betook herself on September 2:3d to an advertised midwife to have an abortion performed. The latter had the woman lie down upon the floor and brought a glass enema-syringe filled with a clear fluid, to which was attached a long, thin bony nozzle. This she introduced so far into the genitalia of the woman that the latter suffered intense pain, it seeming to her that the syringe must have penetrated to the stomach, where she thought she felt the entering fluid. For this operation the midwife demanded 30 marks, but was content to receive 15 marks. With effort the woman dragged herself home; she vomited on the way, and was obliged to immediately take to bed and call a physician. From the latter she originally concealed the true condition of affairs, and only after violent symptoms of peritonitis developed, on October 3d, confessed all, among other things that during the night of the 24-25th she passed a blood-clot which was thrown into the closet. Death ensued October 11th, after the imprisoned midwife had acknowl- edged having given the woman merely j»ro forma an injection of warm water into the vagina. In the posterior fornix of the much dilated, smoothed-out, and thin- walled vagina there was found a shredded, irregular, slit-like opening agglutinated by pyofibrinous exudate. This opening communicated with Douglas' cul-de-sac, where its edges were already rather firmly adherent to portions of the intestines. In addition, there was in the fundus of the uterus an opening the size of a half dollar, with discolored, softened, shredded edges, through whicli from the uterus one might enter the abdominal cavity, and the edges of which were likewise, by means of an inspissated layer of pyofibrinous exudate, adherent to the intestines. The opening in the vault of the vagina was without doubt caused by the perforation of it by the inserted instrument, and very probably also the perforation in the fundus of the uterus; but it must be acknowledged that the latter may have subsequently arisen or become enlarged through septic softening. FIGURE 78. Divulsion of the Cervix from the Uterus. Abortion. Uterus of a servant, aged 26 years, who ou May 11th, on account of pretended chills and fever lasting during the previous six days, was ad mitted to the hospital, where a whitlow on the distal phalanx of the in- dex finger was recognized and in consequence pyemia diagnosed. There was no suspicion of pregnancy, as the girl asserted that her menses had always been regular — the last time April 25th. Death occurred on May 13th, and it was only at the pathological examination that septic perito- nitis and injury of the uterus were discovered, and in consequence sub- sequently the legal necropsy resorted to. The uterus, illustrated in full size, is as large as a fist, its cavity dilated to almost the size of an orange, empty, its inner wall covered with dis- colored decidual remains and blood-clots, uneven ; in the upper part of the posterior wall the placental insertion — 3i cm. wide — demonstrable. The cervix, about 2 cm. in length, is, with the internal and external os uteri, torn away from the left part of the uterus and the left vault of the vagina, whereby a large opening patulous for two or three fingers is formed, through which from the vagina one may directly enter the cavity of the uterus. Tlie edges of this opening are irregular, partly shredded, discolored, and somewhat softened ; otherwise unaltered. The divulsed cervix is displaced to the right, its canal patulous for a aioderately stout sound, the external os uteri oval transverse, somewhat more than a half centimeter long, slightly open, and entirely smooth. The vagina is markedly wrinkled, its entrance without cicatrices. Of the hymen, still considerable remains present. Ou the left index-finger a superficial cicatrizing whitlow, without suppuration. The opinion was expressed that the deceased was in the third month of pregnancy (already distinct placental formation), and that a few days prior to her death she had given birth (aborted) through the large irregular opening in the left vault of the vagina. This opening, looking as though perforated, was ]>roduced by the forcible intro- duction of a blunt though rather narrow and long instrument, which may have been a violently inserted finger. To all apjiearances the in- troduction of the instrument — or of the finger — and tlie consequent lace- ration had as their object the production of an abortion, and the manner of its execution permits of the inference that it was performed by a lay- person. The case remained unexplained. Fig. 78. Tab. 5. i PLATE 5. Respiratory Organs and Heart of a FulUterm Child who died during Birth of «* Fetal Suffocation" from Premature Respiration. Probable compression of the umbilical cord. Aspired meconium in the respiratory passages. In the heart and lungs numerous ecchymoses of suffocation. The lungs themselves still situated in the posterior part of the thoracic cavity, but nevertheless somewhat enlarged, symmetrically very dark violet, contain much blood and are heavy, completely void of air, of fleshy consistency; aspirated meconium in the larger bronchi. These are the usual findings after fetal suffocation, and permit, as a rule, the diagnosis of such a process. Extra-uterine such a complex of signs can only occur when the child — immediately from the maternal genitalia — is deposited within the birth-fluids fas may occur after deliv- ery over a vessel), but otherwise only when the child immediately after birth comes to lie with its face in a layer of meconium or other of the birth-fluids. FIGURE 79. The Epiphyses of the Lower Extremity and of the Humerus of a Mature, Newly Born Child. In determining whether or not a newly born child brought to necropsy is to be looked upon as mature, in addition to ascertaining the weight, length, and general development, it is of importance to determine the condition of the centers of ossification in the epiphyses of the bones forming the knee-joint, as also those in the tarsal bones. The accompanying illustration of a longitudinal section through the leg of a mature, well-developed child, who died during birth of asphyxia, shows the conditions referred to in half size. The upper epiphysis of the femur is still completely cartilaginous; the lower, on the other hand, reveals within the epiphyseal cartilage a pea-shaped center of ossification, which on section is seen as an al- most spherical disk, 6 mm. in width, sharply circumscribed by white car- tilage. The upper epiphysis of the tibia shows a center of ossification one- half the size of this, whilst the lower epiphysis as yet possesses none. The earliest indication of the first-mentioned center appears during the ninth, that of the second not before the beginning of the tenth lunar month. In the OS calcis one notices an oval center of ossification 16 mm. from before backward, 8 mm. from above downward ; in the astragalus a semi- lunar center with the concavity upward, 12 mm. long and 6 mm. high ; and in the os cuboideum a round center with a diameter of 3 mm. The last-mentioned develops, as a rule, not until the second half of the tenth lunar month ; the first before the seventh lunar month ; so that at the time of viability (28th to 30th week) the center in the os calcis is already the size of a pea, while that in the astragalus is half as large as a pea. In the upper end of the humerus, at the end of normal pregnancy, there is only exceptionally, and in strong children, a center the size of a hempseed, as is indicated in the accompanying case. Fig. 79- FIGURE 80. Epiphyses and Posterior Tarsal Bones of a Premature, and of a Full=term Newly Born, and of a 3?,=Months=old Child. I. Vertical Row. Au eighth-month premature female child, 44 cm. iu leugth, weighing 17G0 grams. The upper epiphysis of the humerus, the upper and lower epiphyses of the femur, and the upper epiphysis of the tibia show as yet no indication of centers of ossification. In the astragalus, however, a pea-sized, and in the os calcis a bean-sized, center. II. Vertical Eow. A full-term female child, 50 cm. in length, weigh- ing 3030 grams. Of the first-mentioned epiphyses none but that of the lower end of the femur possesses a center of ossification, and this is about the size of a pea and has a diameter of 5 mm. The bony nucleus in the astragalus is alreatly the size of a bean ; that in the os calcis has the size and shape of a sagittally placed almond. lil. Vertical Row. 3i-months-old child, 59 cm. in length. All the epiphyses contain centers of ossification ; that of the upper end of the humerus contains a pea-sized one in the head and an indication of a sec- ond in the greater tuberosity ; that of the upper end of the humerus, one the size of a poppy-seed in the head ; that of the lower end of the femur, an oval one 11 mm. long and 8 mm. wide ; that of the upper end of the tibia, a transverse one with a longitudinal diameter of 1.3 cm. and a vertical diameter of 0.6 cm. The nucleus in the astragalus is 1.4 cm. in length and 0.6 cm. in width (height) ; that in the os calcis, 1.6 cm. in length and 0.8 cm. in width. tig. bo. II III t^S Ti^t ^jj