GENERAL CONSIDERATIONS ON DOUBLE MONSTROSITIES.
Hohl, Kleinwachter and Veit have, in particular, studied this subject,. The latter's monograph contains a resume of the majority of the reported cases.
In 1850 Hohl had collected 96 cases, in 43 of which labor had termi nated spontaneously, 4 with difficulty, and 49 by intervention.
Playfair divides double monstrosities, from the standpoint of obstacles to delivery, into four varieties: 1. Two almost distinct bodies, united anteriorly at the thorax or abdo men, throughout a greater or less extent, 19 cases.
2. Two almost distinct bodies, but united back to back in the sacral and inferior lumbar regions, 3 cases.
3. Two heads, with a single body, 7 cases.
4. Two bodies separated below, with two heads united by adhesions or completely fused, 2 cases.
The following general facts may be stated in regard to these mon strosities: 1. As to frequency, they are met with four times in multiparte to once in primiparve.
2. Pregnancy rarely goes to term, and therefore, in volume, they are less even than separate twins.
3. Pl.esentations of the pelvic extremity are very frequent.
These monstrosities may be divided into three groups in accordance with the difficulty which they offer to delivery.
a. The obstacle depends purely on excess in volume of the entire body, or of one or another portion, (diprosopi, cephalothoracopagi, dipygi.) b. Where the fusion is at one or the other extremity of the body, and where, consequently, the monster may be straightened out (craniopagi, pygopagi, ischiopagi.) c. Where there exists mobility, ease of displacement of each constituent, during delivery, (different varieties of thoracopagi and dicephali). In xyphopagi this mobility is such during intra=uterine life that the two infants may present inversely at the moment of delivery. In case of thoracopagi, artificial displacement is possible. In both instances, par
titularly in the last, when the head presents, one body may be entirely delivered before the other without separation. (Fig. 241.) Only in case of very pronounced dicephali are we obliged to decapitate.
In case of thoracopagi resort to version.
Altogether, pelvic presentations are very favorable. They are indis pensable in case of craniopagi, render delivery easier in case of diprosopi, cephalo-thoracopagi and thoracopagi, and still more so in case of the di cephalus dibrachius.
The craniopagi must present by one or the other extremity. Pygopagi and ischiopagi, when the head presents, require manual intervention for the delivery of the breeches, and when the latter present, one foot must be brought down to decompose the wedge, and allow of the successive de livery of the head.
Dicephalus dibrachius, where the accoucheur is skillful, when it presents by the pelvic extremity, will rarely require embryotomy, because the heads may successively be engaged. When the head presents it may be delivered by the forceps. Ordinarily, decapitation will be necessary.
The dicephalus tribrachius and quad ribrachius call for the same manage ment as the thoracopagus when the head presents. In case of the di cephalus tripus, it is the third foot which constitutes the obstacle to spontaneous engagement of the breech.
As a general rule, it is only after delivery that the accoucheur is able to explain the cause of the difficult labor. The absolute rule for treat ment should be: Concern yourself, above all, about the life of the mother. Leave the case to nature as long as the condition of the mother allows and then interfere in her interests, resorting to the means which, in the given case, seem likely to injure her the least.