Part 6

Under a _shower_ of minute grape-like or granular bunches, is seen suspended that portion of a transparent Ovum, (exhibiting through its diaphanous involucra an embryo bearing no proportion to the magnitude of the Ovum,) which has been denuded of its nutritive involucra. The latter are superimposed to the granular bunches, and are curiously fringed at their margins. They are two in number, and externally to them may be seen the loosely weaved caducous membrane. During three months of utero-gestation, from the moment of conception, has this mass lived—but the embryo has not advanced from what it was at four or five weeks, nor could it. The time was spent by Nature in playfully modelling, forming, and cutting out what would almost appear an artificial plaything; so fantastical it looks.

REMARKS.

There can be no difficulty in understanding how this curious formation came about. The Ovum with its _cortex_ adhered to the ceiling (fundus) of the womb, and contracted an intimate connexion with that organ through its caducous lining. During the first weeks, that external covering, _cortex_, or membrane, became fleshy and vascular. Plethora took place in consequence, as we have seen in some of the preceding cases of abortion; but, instead of an increased secretion of amnionic fluid, as was the case in the Ova denudata, or diaphanous, of Plate I., the effect has been a dropsical bead-like enlargement of the mossy or filiform vessels of the Ovum. In proportion as these advanced and enlarged, they detached and forced outwardly the coriaceous envelopes, which began to absorb at their inferior edges in that irregular progression which left them as they are now seen, irregularly _echancrés_. This process of absorption in the outer envelopes of the Ovum, from the first to the fifth month, is what takes place generally, even when they are not morbidly affected in their texture in the way in which they are in the present instance, and is the process by which the placenta is formed. But in order to effect this properly, the mossy or filiform vessels, of nearly three fourths of the circumference of the young Ovum should also become progressively obliterated; while those which remain, mingling with the superimposed envelopes, swell into large blood vessels to assist in the formation of the placenta. Here, however, such a process was impossible, inasmuch as the mossy or filiform vessels, having taken up a morbid action and become distended with the serosity, which kept constantly pouring into them, could not become absorbed to the extent required to form the placental cake, but on the contrary continued to increase in size and number. This operation took place at the expense of the growth and life of the embryo, which is consequently seen to be stinted and undeveloped. Abortion, therefore, was inevitable sooner or later.

The specimen is also valuable, as it affords positive evidence of the mode in which the placenta is formed, for here we actually see the process of absorption of part of the involucra, on which that process depends.

Some who have seen this specimen, confound it with a case of hydatous placenta; and a few similar preparations exist under that name in more than one collection. It is evidently by mistake that they are so styled, as we shall see in a succeeding Plate.

Professor CARUS of Dresden, (a name revered by anatomists and physiologists,) here comes to my assistance. That accurate and indefatigable observer, on submitting an entire Ovum, expelled towards the sixth week of gestation, to a powerful microscope, remarked that the greater number of the filiform vessels were diaphanous as well as their ramifications, and that their free extremities terminated into little roundish knobs, not unlike the terminal bulbs of the villosities of the intestines. These bulbous expansions of the filiform vessels of the Ovum adhered so firmly to a superincumbent dense membrane (which Carus calls decidua, but must be the _cortex_) that they could not be separated from it without tearing some of them[27]. These very expansions, or roundish knobs then, of the filiform vessels of the Ovum, are precisely those which, from plethora of the involucra lying over them, acquired what, in my specimen, I have called “a dropsical bead-like enlargement,” as represented in figure 17 of an “Uviform Ovum.” SOEMMERING has also noticed these terminal bulbs of the filiform vessels, which he calls _noduli vel vesiculæ_, somewhat _like_ hydatids.

In questions of natural history, it is impossible to desire and meet with a more satisfactory corroboration of the explanation of any given fact, than the above observation of Carus affords to my view of the conformation of the “Uviform Ovum.” Nor can a more convincing refutation be required after it, of the doctrine of hydatids in the placenta being the cause of that singular conformation.

There was but a trifling hemorrhage after the coming away of the present Ovum, and scarcely any suffering. During the three preceding weeks the patient had had some slight, colourless, and thin discharge from the vagina.

PLATE V.

SPECIMENS OF MISCARRIAGE BETWEEN THE THIRD AND FOURTH MONTH.

Fig. 18. Ovum coriaceum, cum hydrope funis et placentâ hydatica.

(Aborted at twelve or thirteen weeks?)

It is impossible to describe in words, better than Mr. Perry’s pencil has done, the two lovely specimens consigned to this Plate. The drawings speak for themselves. They convey, with a precision which is one of the great merits of that artist, every minute feature of two preparations calculated to afford a fund of knowledge, on the subject of the formative process of the human Ovum, for which we should look elsewhere in vain.

The nutritive involucra are fleshy or coriaceous. Bunches of real hydatids hang pendulous from a part of their external surface—while internally they are lined with the secreting membrane in a morbid state, and that portion of the cord which is farthest from the fœtus appears to be dropsical. The hydatids are connected with the placenta. The fœtus is well formed, and in its growth no impediment seems to have intervened.

REMARKS.

The contrast between this and the preceding Ovum, fig. 17, cannot fail to strike my readers. In the present specimen we have the regular involucra of the Ovum thickened around its whole circumference; but the mossy or filiform vessels have disappeared inside and out, being converted, in the latter situation, into the placenta, and having become obliterated in the former. The placenta (the intervening means of affording accretion of substance to the fœtus by the mother) being once formed, the fœtus grew; but the placenta at last was stricken with disease, (the hydatids,) and this produced the dropsical swelling of the cord, which began to interrupt the growth, and lastly destroyed the life of the fœtus. In Ovum 17, circumstances are reversed. We have no regular placenta; the coriaceous envelopes cover the dropsical bulbs of the filiform vessels, and the growth of the fœtus is consequently checked at the first onset.

Fig. 19. Ovum cum placentâ, nee vasculare, nec plenè cotyledonicâ, sed filiforme. Amnion morbosum.

(Aborted at twelve or thirteen weeks after menstruation?)

Another of the manifold species of deviation from the natural process of growth and development in the human Ovum. By its size I should judge the fœtus to be about fourteen weeks old. About that period the amnion became probably affected, and the life of the child fell a sacrifice to that circumstance. That membrane is translucid and of a brownish colour, thicker than usual, and in parts nearly opaque. Next, (reckoning outwardly,) and separated from the amnion, is another membrane, resembling closely that which lines the outer-shell of a hen’s egg. No filiform vessels appear on either of its surfaces. Between these two membranes a third is distinguishable on the left of the opening made into the Ovum, and the three are very well separated from each other. The filiform vessels which connect the outer or third membrane with the thick envelopes lying over it, are well marked in the drawing. The placenta is amorphous—not local and defined, but general and mossy. The umbilical cord is covered over by its membranes, lies by the side of the fœtus, and is about twice its length, but withered down to a bare filament. Yet the proper fœtus itself is of fair growth and plump.

REMARKS.

One cannot help comparing together the two Ova, thus placed side by side in this Plate. In the figure which represents a larger fœtus, we have a smaller ovum altogether, and a smaller inner cavity; than in the other figure representing a larger Ovum with a larger inner cavity, from which has escaped a smaller fœtus. Yet I hold their respective ages to be the same. This apparent paradox is to be explained by a consideration of the difference of circumstances in which the two Ova were placed. In Ovum 18, the disease was of slow progress; the increase of the fœtus was retarded from the beginning; and its life became extinct after the disorganization of the Ovum had lasted some time: the appearances of the various parts of the Ovum, as pointed out in my explanation of the figure, shew these facts. In Ovum 19 there was nothing in the least analogous. Though the placenta is imperfectly formed; even in its filiform or mossy or primitive texture, it might serve and has served the purpose, of forwarding the nutrition and growth of the fœtus. The disease which destroyed the latter, being of an inflammatory nature, must have been more rapid in its effect. It put an end to _life_ before there could have been time for _growth_ to be much affected.

These facts and inductions may perchance be looked upon by some as merely curious, or at most singular, without being useful. But I think it will be found hereafter, unless I am much mistaken, that by studying such facts and such inductions, as the consideration of the human ovum in its many varieties of diseased development can afford, we may expect no inconsiderable facility in the unravelling of that mystery which yet hangs over the process of utero-gestation.

PLATE VI.

SPECIMENS OF MISCARRIAGE BETWEEN FOUR AND FIVE MONTHS.

Fig. 20. Ovum tuberculosum.

(Aborted at four months and a half after menstruation.)

I do not apply to the term _tuberculosum_ the more usual meaning, but by it I wish to imply that there are in the structure of this Ovum a great many small swellings like tubercles, some of which are larger than the rest, and not a few of them granular, while others present a great variety in their configuration. All of them have very prominent blood vessels running across their surface, which, while the preparation was still very recent, exhibited a very florid tint. In this state, the specimen was submitted to Mr. Pearsall, late of the Royal Institution, who is very well skilled in the art of sketching and colouring, and still more so in science, and who undertook very kindly to draw it for me. The drawing corrected by Mr. Perry, was afterwards transferred by that gentleman on stone for the present work.

The tubercles are _sub-amnionic_, and the presence of these morbid accretions will settle the question of the vascularity of the inner, or as I call it, the secreting membrane (amnion) in the human Ovum. That the transparent membranes of the human Ovum are vascular, has been supposed from mere analogy to what we observe in other viviparous animals, particularly of the larger class of quadrupeds; but no proof has ever been adduced of the reality of such a fact, for no anatomist ever succeeded in injecting the supposed vessels of those involucra. What art has failed in demonstrating however, nature has shewn quite manifest in its career of disease. And thus it is that morbid anatomy, besides its more direct effect of teaching us the nature of diseases, produces the no less beneficial consequence to those who carefully investigate it, of unravelling structures which from their minuteness in the normal condition would have escaped detection.

Look at the figure of the fœtus in this Ovum, see how its growth has been checked!—In size it represents an embryo scarcely five weeks old—yet the Ovum came away at four months and a half from a patient whom I was engaged to attend in her confinement. Examine the cord; it is like the amnionic vessels, distended with florid blood.

REMARKS.

In the knowledge of the doctrine of abortion and the treatment of it, a preparation like the present is of infinite value. But this is not the place to enter into practical views and details which are reserved for my professed work on that subject.

I saw, on the 29th of May, 1828, in Sir Charles Clarke’s collection, which was then in Mr. Stone’s possession, a specimen of tuberculated placenta, larger than, yet in other respects similar to, my own. The fœtus, however, was not of greater dimensions than the one in the present figure. In the same collection there were two smaller specimens of this identical disease of the human Ovum, very neatly put up, one of which, like my own case, exhibits most distinctly the injected state of the amnionic vessels. It was stated on the label of the largest specimen, that the growth of the child had been impeded by the pressure of the tubercles on the cord. This is not apparent on examination of the preparation. The cause of that impediment is manifestly the defective structure of the placenta.

The College of Surgeons possesses two specimens of tuberculated placenta. One is small, marked 3443, (old series,) and placed in the Gallery; the other, a very large specimen, is among the morbid preparations in the body of the Museum, No. 983. (old series). The latter was presented by Sir E. Home, who has entitled it a case of _Cysts_ of the Amnion. On close examination it will be found that these pretended cysts (or, as he has called them afterwards in a printed paper, hydatids) are nothing more than elevations of the amnion, beautifully exhibiting the vessels of that membrane, elevations which are produced by no other process than the one described below.

No. 3447 in the same Museum, demonstrates by another fact and process the vascularity of the amnion. The case is one of twins, aborted at about two months and a half. The fœtus in the one cavity is as fully and properly developed as that in the other, and they are separated by a translucid septum, formed by two layers of the amnion. Into this septum, and not into the placental cake, terminates the cord of one of the fœtuses, expanding itself on its surface; while the cord of the other proceeds regularly to the placenta. It is manifest, therefore, that the vessels of the amnion must have carried blood to the umbilical vessels in the one fœtus, as he was not in direct communication with the placenta.

The preparation before alluded to, as being in the collection of the Royal College of Physicians, marked 7 G. 19, is another excellent specimen of tubercular amnion. Denman has given us a very striking example of this same diseased structure of the Ovum, which I strongly suspect, must be a delineation of the largest specimen in Sir Charles Clarke’s collection mentioned before. The fœtus, like the one in the present plate, is small, and the cord inflated, but the entire Ovum remained in the womb until the completion of the ninth month.

All the tubercles of placentas which I have seen, were on the fœtal and not on the uterine side of the membranes. They seem to be formed by the enlargement of those filiform vessels which exist on the inside of the same involucrum, (Chorion,) the outer surface of which bears the mossy or filiform vessels, destined to group themselves into cotyledons for the purpose of forming the placenta. When the Ovum, after having lived and grown on its own life-principle, through its journey from the Ovarian nest into the cavity of the womb, has accomplished that connexion with the mother which before did not exist, the filiform vessels on the inner surface of the membrane in question, ought forthwith to begin to wither and be absorbed. When this is not the case, and they on the contrary enlarge, tubercles are formed, which are nothing else than cotyledons, or groups or tufts of vessels, like those on the external surface, and which push the innermost membranes, the amnion in particular, forward, and give rise to congestion and diffusion of blood.

Ruysch, who has published some engravings of this structural deviation in the human Ovum, has accompanied them with an explanation of its causes.

Fig. 21. Ovum pene-solidum; placenta sarcomatosa cum tuberculis hœmatosis; involucra fœtûs solidificata.

(Gestation four months and a half?)

What havoc has disease effected in this Ovum! Scarcely can we recognize a single element of its structure. The placental covering is composed of many substances, has lost its spongy vascularity—it has acquired several solid tumours, and is altogether unfit for its intended function. The cortex of the Ovum is fleshy; but within it a supernumerary fine membrane is seen, which might, but must not, be mistaken for the chorion. The latter involucrum, and the rest of the membranes within it, have become compact, they adhere together, and form a solid whole, which has scarcely the appearance of what it is—a human Ovum.

It is said to have been aborted in the fifth month of pregnancy; yet the embryo that can lodge within so narrow a chamber can scarcely have more than a few weeks’ growth. It is in Sir Charles Clarke’s collection, and I am indebted to Mr. Stone for permission to have it drawn by Mr. Perry, with three or four more specimens contained in the present publication.

On the right of the drawing, the real extent of the thickening of the external covering is not sufficiently denoted. There are in the substance of

REMARKS.

Calculous, steatomatous, and solid placentas are not of unfrequent occurrence in practice. I have seen several such cases. Sir Wm. Blizard presented to the Royal College of Surgeons a very instructive specimen of a human Ovum having a sarcomatous and calculous placenta, which had been expelled at three months and a half, by a patient who had miscarried three times within the three previous months.

There is also in the same college a magnificent specimen of a solid Ovum, of the size of a hen’s egg and shape. A small portion of the _shell_ of this Ovum having been cut off, the embryo is seen, of the size of a common fly, within the cavity, which may be just large enough to admit the top of a man’s thumb. The ordinary involucra are so compact, and so firmly adhesive to one another, that they cannot be separately distinguished. The parietes thus formed are at least one fourth of an inch in thickness. On the right of the inside of the cavity there is seen a large swelling, which projects within the said cavity, and is probably the receptacle of another embryo, or a deposition of blood between what ought to be the translucid membranes or involucra.

Sometimes the fœtus alone has been found to have become an in-formed, hardened, or steatomatous mass. This is the case with a preparation, a striking one, in the Museum of St. George’s Hospital, midwifery division, marked F. 94. The fœtus, two inches long and perhaps one inch in diameter, is converted into a solid mass, retaining barely the outline of some parts of its form, with the exception of the vertex of the head, which is clearly defined. The mass appears to be steatomatous, and is suspended at a point considerably below the centre, by a regular umbilical cord pending from a large placenta, having the transparent and other involucra, which are laid open for inspection. A minute dissection of these various parts could not fail to throw considerable light on many important points connected with the diseases of the human Ovum, the fœtus, and its structure. At present the preparation is only imperfectly instructive.

Fig. 22. Ovum cum involucris internis, ab amnionitide et chorionitide, condensatis.

(Gestation, near upon five months?)

Here we have a specimen which will embarrass not a little those writers in obstetrics who, either through respect for olden authorities, or from habit, keep repeating what has been said before them, respecting the structure of the human ovum. I will describe the ovum as it stands before me this day, the 21st of January, 1833, on which occasion I again compared it with the drawing made some years before, and found the latter most strikingly correct in all its parts.

Beginning externally, we find a thin pellicle, many fragments of which are seen floating, covering the whole of the placenta, which seems consolidated and to have been compressed. These parts are not visible in the figure here represented, as they are placed at the posterior portion of the specimen. From each side of, and at the edge of the placental cake, comes a loosely-webbed, semi-transparent, coarse membrane, in some parts porous, in other parts opaque, which proceeds from _under the placenta_, and must have embraced the entire ovum before it was laid open. This membrane resembles that called _the caducous_,—and is in fact the membrane marked as such in all the preparations of human Ova in most obstetrical collections. Within this membrane we find another, considerably thickened, which, judging from the several portions that remain yet transparent, is actually passing from the latter into the opaque state: it is bifoliated. Immediately within the last-described envelope, and at the inferior part of the Ovum, we observe a thick cake, which was probably extravasated blood: it extends upwards on the right of the observer, getting less thick as it proceeds. The cake itself, on the side next to the fœtus, is lined, but loosely, by another bifoliated transparent involucrum, held fast to the involucrum just described by filiform vessels, which in some parts are distinctly visible even to the length of half an inch, with a space of the same dimension between the membrane and the cake before mentioned. The inside lining of the whole is the amnion, from the upper and lateral portion of which hangs an umbilical cord of three quarters of an inch in length, with an imperfect fœtus the size of half a wasp, in which however the rudiments of the abdominal extremities are quite distinct. The whole Ovum measures four inches vertically, and three inches transversally.

REMARKS.