Part 7
That some of the involucra here enumerated are the produce of inflammation and of diffused blood in consequence of it, I entertain no doubt. The cake of blood between two of the involucra, the variously shaped points of solid matter deposited in that involucrum, which is actually passing from a transparent into a thickened or opaque state, demonstrate in my mind the above position, and prove, moreover, the vascularity of the secreting or inner involucrum of the human Ovum. Again, look at the great expansion of the Ovum and amnionic cavity compared to the size of the fœtus. Could the great quantity of fluid contained in such a cavity be otherwise than the result of inflammation of secreting vascular membranes?
Another beautiful illustration of the amnio-chorionitis producing thickening of those membranes, in an Ovum which contained a well-formed fœtus at four months’ growth, and in which the placenta is also condensed as if it had been artificially compressed, was in my possession some years ago, and was accurately sketched and coloured by Mr. Perry before it was pilfered from my collection. The Ovum came away entire, having simply the two inner membranes and the placenta,—from the edges of the latter hung fragments of a thicker envelope—and from the external of the two pellucid membranes hung some of those peculiar filiform vessels which are seen on the chorion on Ova of very recent formation. In this specimen the amnion was in some parts quite fleshy. I attended the patient, who considered herself five months and a half gone with child.
I have likewise seen another striking case of amnio-chorionitis, in a specimen marked F 84, in the museum of St. George’s Hospital, midwifery division, which has produced thickening of the transparent membranes and diffusion of blood throughout the Ovum, to the degree that even after long maceration the red tint prevails throughout the entire structure.
PLATE VII.
SPECIMEN OF A MISCARRIAGE AT FIVE MONTHS.
Figura unica. Ovum fœtiferum optimè conditum, subitò ab amnio-chorionitide interfectum.
I had an opportunity of satisfying myself most completely as to the state and condition of this Ovum, it having been aborted at more than four months and three weeks, according to the lady’s reckoning, while I was in attendance upon her in consequence of considerable flooding, which had been going on for some days, and had preceded its expulsion. The Ovum came away entire; and through that part of its envelopes which were transparent, the fœtus and the liquor amnii appeared of a deep bluish red. The hemorrhage ceased almost immediately after the ejection of the Ovum. The case occurred in the spring of 1828. The lady had been ill from inflammation in the chest, with cough and other symptoms of pleurisy.
I carefully dissected and examined the Ovum, taking down the various appearances as they presented themselves to view; and having requested the immediate attendance of Mr. Perry, it was sketched and coloured without loss of time, in order to avoid any misrepresentation of parts or colouring.
The Ovum is perfect in all its parts, and has evidently progressed through its successive changes and developments during the first four months of gestation in the most satisfactory manner. The fœtus is of the proper size for its age, and, judging from the state of the cutaneous covering, appeared to have lived up to the very latest hours antecedent to its expulsion.
The remarkable facts in this Ovum, in a physiological point of view, are the number and arrangement of its envelopes; the morbid state of some of them; and the effusion of bloody serum within the cavity of the amnion.
Externally we find the placenta covering three-fourths of the Ovum, pulpy, vascular, almost cotyledonous, and covered with the _membrana proper_. It was gorged with blood. That portion of the outer envelope of the Ovum which is not covered by the placenta, seems to originate from the thinning edges of the latter, and to be denser than usual. On being carefully divided and laid open, it appeared bifoliated,—the laminæ are connected by cross filaments. Within this, another membrane is seen, separated however by a slight space which was occupied by effusion of bloody serum, and is itself tinged with red. Next came two less dense and transparent membranes, within which the fœtus lay coiled up, immersed in a bloody fluid.
REMARKS.
In all probability we have had here first, an extension of the complaint under which the mother laboured, (membranous inflammation,) to the Ovum; next, an inundation of blood into its internal cavities, through an engorgement of the placental cotyledons. How to explain the actual facts presented to us by this interesting preparation, in any other manner than what is here suggested, I know not.
PLATE VIII.
FIRST SPECIMEN OF ABERRANT FŒTAL GESTATION. (EARLY PERIOD).
Figura unica. Ovum fœcundum in receptaculo ovarico.
Through a transversal aperture in the left Ovarium we see the remains of some membranes, three in number at the least, lining a cavity which measures transversely one inch and a quarter, and about an inch vertically.
The membrane in contact with the parietes of the cavity is pulpy—the other membranes are better weaved and clothy. The cavity itself seems to occupy nearly the entire volume of the ovarium, which is enlarged to nearly four times the size of the right ovarium. The fallopian tube corresponding to the enlarged ovarium, is not in the least involved in that enlargement, although it is adhering to the periphery of its ovarium by a portion of the fimbriated end,—the fimbriæ, however, being left free. We have neither disease nor enlargement in the ovarium and fallopian tube of the right side.
The uterus is larger than in the unimpregnated state. Nevertheless, its triangular cavity does not appear to have enlarged, in proportion to the general increase of volume, which is rather due to a thickening of its walls. Amorphous and flocculent depositions, in very moderate quantity, occupy a portion of that cavity. They are not membraniform.
No filiform vessels are to be seen or detected on any of the three linings of the Ovaric cavity.
REMARKS.
Sir Charles Clarke, who was kind enough to accompany me to the museum of St. George’s Hospital very lately, and who greatly admires the present drawing of his preparation[28], assured me, that a small embryo hung pendulous from the yet visible rudiment of an umbilical cord. That embryo, however, is not now to be seen. Sir Charles also stated that the case which furnished this specimen was that of an unmarried female, who acknowledged herself to be pregnant, and who died from a natural disorder. On examining the uterine system after death, with a view to ascertain the state of the parts under the presumed condition of impregnation, the appearances portrayed in this plate presented themselves to view,—certainly of sufficient interest to be preserved.
Sir Charles does not recollect any account being published of the Case; nor any other particulars.
PLATE IX.
SECOND SPECIMEN OF ABERRANT FŒTAL GESTATION. (MORE ADVANCED PERIOD).
Figura Præcipua. Ovum fœcundum in receptaculo tubico.
The uterus is about double the size of its unimpregnated form; but neither the enlargement of its cavity, nor the shortening of its cervix, corresponds to this general increase of outline, which is due rather to the thickening of its walls. Nay, the cervix is unusually long even for an unimpregnated uterus. In it, as well as within the upper cavity, we observe some adventitious production, differing so far from each other in appearance, that the one, (that of the cervix,) is flocculent and of small texture; while the other is composed of broken flakes, or thickish laminæ, of a smooth, compact, suetty substance. This corresponds in its visible character with the adventitious coating cast off by the uterus two or three weeks after successful copulation, whenever the Ovum has been blighted in its development during that period. In my collection, in that of St. George’s Hospital, and of the two Royal Colleges, there are specimens of this species of production, which by most writers is looked upon as the decidua.
Proceeding with our description of the parts as they appear in the preparation, we find that the middle third of the whole length of the right fallopian tube is lacerated, being also in that part, pouchy and larger than usual; that a fecundated Ovum is lodged within the portion of the tube in question, which has acquired sufficient development to shew all its component parts; and that a fœtus with its navel string is contained within the transparent membranes or involucra of that ovum. The membranes are two in number, and as the drawing beautifully represents them, accurately separated in the preparation. Now, according to the common doctrine, the outer of these involucra, being the chorion, ought to have the shaggy or filiform vessels which are said to characterize that membrane. Nothing of the kind, however, is here seen, nor any vestige of them. But externally to this outer transparent membrane we have the cortex Ovi, which has contracted adhesion by means of branches of vessels, indistinctly made out in the preparation, owing to the dried clots of blood with which they are interspersed. These clots of blood are the remains of the accumulation of that fluid around the Ovum, which led to the laceration of the tube, and with it to the fatal hemorrhage that inundated the abdomen and produced death. I have not hesitated a moment in colouring these clots as blood in the drawing, although in the preparation, as is generally the case, they look brown instead of being of a bright red.
Both ends of the fœtiferous tube are made to appear pervious, by the insertion of bristles.
The rudiments of the inferior extremities in the fœtus are well marked; the cord is of the length of the fœtus, which is itself about half an inch long, and coiled up anteriorly.
Turning now the preparation to examine the ovarium of the same side, as it lies open before us, we find the vesicula Graafiana (the nest) from which the ovulum escaped into the tube, quite evident. The centre of that nest, itself yellow in colour, presents a white radiated _scar_ or cicatrix, which must have formed subsequently to the escape of the ovulum, and during the period between that escape and the death of the patient. This yellow substance with its scar is the _corpus luteum_ of the authors.
The left appendages of the uterus were sound.
The side figure represents a front view of the tubic seat of the fœtus.
REMARKS.
I have ventured to rescue this interesting case, which my readers will find most ably detailed by the late Dr. Clarke (a truly philosophical obstetrician) in the first volume of the transactions of the Society for improving Medical and Surgical Knowledge, from the very imperfect and indistinct representation given of all its most important details by the artist employed on the occasion. Three plates accompany the original paper, professing to be delineations of the preparation, as seen anteriorly, posteriorly, and laterally; and I have no hesitation to assert, that the fine arts must have been at a very low ebb indeed (as far as anatomical subjects are concerned) in those days, if such were the productions of the pencil and the graver at that time. When I say that it is next to impossible to distinguish in the plates any of the parts referred to in the narrative, and that the important details exhibited by the preparation itself, are not only indistinct, but faulty and deficient in design, I may be deemed to have advanced sufficient grounds for offering to the public a far more accurate and perfect picture of this highly instructive and almost proverbial case. Such is my first reason for introducing it in this place. My second reason is, that it is marvellously adapted to advance my object in publishing the present graphic illustrations of abortion—for it affords me not only some curious facts respecting the formation of the impregnated Ovum, but also a contrast to the preceding and two following species of fecundation _extra muros uteri_. Thus the present work will contain a striking and well authenticated specimen of each of the four kinds of impregnation that occasionally takes place in some part or other of the uterine system of woman beside its cavity.
Dr. Clarke’s preparation being still in existence, and in the collection of his worthy successor and brother, I requested permission to have a front and lateral view of it made by Mr. Perry; and I fearlessly challenge a comparison, first between the old and the present engraving, and next between these and the preparations themselves, which may be viewed in the Museum of St. George’s Hospital. I have described the parts as I found them in the preparation in question, which I have again, for the fortieth time, examined this day, January 23d, 1833.
Dr. Clarke, in his account of this case, says, that the substance in the cervix was gelatinous in the recent state, and that within the uterine cavity it is the decidua which we observe. The Doctor afterwards remarks that such decidua is _always_ formed in the cavity in question, whether the fœtus gets into it or not; but his own description of another and even more important case of _tubic_ gestation, which occurred at St. Bartholomew’s Hospital and was carefully examined by Mr. Abernethy, gainsays the assertion; for it is there stated, “that in the cavity of the uterus nothing remarkable was found”; and in my own case of Ovarian gestation, “no production whatever” was found within the cavity of the enlarged uterus.
From the state of the right Ovarium and the appearances and situation of the corpus luteum, we gather two probable facts. First, that the actual seat of the Ovulum is the place occupied afterwards by the corpus luteum, which fills the vesicula Graafiana considerably enlarged subsequently to fecundation. The fecundated Ovulum escapes from the Ovarium by bursting through the coats of the said vesicula Graafiana, which is generally found close to the periphery of the Ovarium. Secondly, that the process by which the breach made in the structure of the vesicle (or egg-nest) by the escape of the Ovulum is restored, is cicatrization, and that much time is not required for such a restoration.
Does not the first of these probable facts explain the acute pain which many women feel in the course of the first week subsequent to successful coition,—which some experience even for some time after,—and which is by all assigned to that part, of one or the other of the iliac regions, which corresponds to the situation of the Ovarium? Indeed, I have known Ovaritis of a very serious nature to follow shortly after impregnation.
PLATE X.
THIRD SPECIMEN OF ABERRANT FŒTAL GESTATION. (EARLY PERIOD).
Fig. 1. Ovum embryoferum in receptaculo interstitiale.
The uterus is enlarged in its general volume and appendages to the size which it more commonly acquires at the second month of pregnancy. The section of its coats shews their increased thickness, and the many hundred orifices of its enlarged blood-vessels. Within the cavity of the womb there was no vestige of any ovum, but in its stead a spongious and woolly membrane was found.
On the upper and outer surface or basis of the uterus, a swelling of a red colour was observed, nearer to the left than to the right side. It was richly streaked with blood-vessels, which gave it the appearance of inflammation. Two lacerations had taken place in the thinnest part of the coats of this eminence or tumour. These lacerations led to a cavity or sac, or cyst, which contained an embryo of from eleven to twelve weeks’ growth: it was regularly enveloped within the two transparent membranes, on the external of which the rudiments of a placenta were found. This embryoferous cyst was separated from the real cavity of the womb; there being no communication whatever between them.
The left Fallopian tube was impervious throughout its whole length.
On opening the body of the patient, who had before borne three children, and had also miscarried twice, and died when she supposed herself two months gone with child, the cavity of the abdomen was found filled with blood.
This case is related by Hendrick in the “archives”, by Horn, Sept. and Oct. 1817; transmitted and vouched to Dr. Breschet of Paris by Professor Carus of Dresden, who sent the drawing, from a lithographic copy of which the present plate is taken.
Fig. 2. Ovum embryoferum in receptaculo interstitiale.
Uterus enlarged; more so on the right than on the left side. A three-lobulated tumour or swelling of the substance of the womb immediately above the insertion of the right Fallopian tube, and on the external surface. Ulceration of the coats of this swelling, which had taken place during life, exhibits to view an excavation or cyst in the interstitial substance of the uterus, containing an embryo which appeared to have acquired a growth of six weeks.
The cavity of the womb had no communication whatever with the fœtiferous cyst. It was found lined with a woolly pseudo-like membrane.
The internal or uterine orifice of the right Fallopian tube was absolutely impervious: that of the left open; but the fimbriated end of the latter was closed, and some serum was found within the tube.
The patient had had several children before: the last time she was pregnant she miscarried at four months. On the present occasion she was not conscious of being with child, as she continued to be regular every month; whereas during every preceding pregnancy her menstruation had ceased. She felt better than usual on the day of her death, soon after which, on opening the abdomen, the above appearances offered themselves to view. There was a large quantity of blood in the cavity of that region.
This case is quoted by Dr. Breschet from a memoir in the Transactions of the Medico-Chirurgical Society of Vienna for 1801, drawn up by Professor Schmidt, and farther vouched by Professor Carus.
REMARKS.
Cases of aberration in the first development and ultimate station of the human embryo like these, were not known to science (according to Dr. Breschet’s statement) before the two preceding instances were laid before the profession. I selected them, therefore, on account of their priority, from among the six cases collected by that indefatigable and highly gifted anatomist, whom I am proud to call a very old friend, in his memoirs on “A New Species of Extra-uterine Pregnancy,” published in the first volume of a very valuable work, edited by himself, Dupuytren, and others, in 1826, entitled, “Repertoire General d’Anatomie et de Physiologie.” The facts are singular, yet authentic in all their particulars. It is, therefore, impossible to deny the existence of another distinct species of pregnancy, _extra muros uteri_, in which the fœtus is lodged among the interstitial elements of that viscus, and has no communication whatever either with the cavity of it on the one side, or the cavity of the abdomen on the other; unless ulceration or laceration take place.
We may, therefore, reckon four species of erratic gestation, namely:—
1. Gestatio Ovarica.
2. Gestatio Tubica.
3. Gestatio Interstitialis.
4. Gestatio Abdominalis.
The design of the parts, the statement of facts, and all the particulars connected with such cases of gestatio interstitialis, I give on the authority of the respective authors whose names I have mentioned. It has never fallen to my lot to witness a single instance of such anomaly in the mode of propagation of our species. Of the six cases reported by Breschet, the last only fell immediately under his care, at the Hôtel Dieu, in July 1825.
It is to be remarked, that in all these cases the uterus was found enlarged, its cavity filled with some adventitious production of variable texture and not always membranaceous, and the Fallopian tube on the side next to the seat of the embryoferous tumour invariably impervious. The mother dies from internal hemorrhage, in consequence of the laceration of the coats of the cyst containing the embryo. During life menstruation has ceased in some and not in other cases of this description.
The reader will not fail farther to notice the very great difference which appears manifest in the drawing of the present plate, and that of the rest of the plates, from the hand of our artist. Mr. Perry had, in this instance, a very inferior lithographic delineation of the facts only to copy,—instead of having to imitate nature, as he has done in every other instance. The consequence has been, that we see but a feeble, and not always an intelligible, representation of the several interesting points connected with these two cases, the nature of which has been attempted to be explained by Breschet himself, and Geoffroy St. Hilaire, in his report to the Institute of France—but with indifferent success.
PLATE X. (A). (BEING PLATE VI. OF THE PHIL. TRANS. FOR 1820.)
FOURTH SPECIMEN OF ABERRANT FŒTAL GESTATION. (ADVANCED PERIOD).
Fig. Duplex. Ovum fœtiferum in receptaculo ovarico.
Uterus considerably enlarged, so as nearly to have reached the size which it is known to attain when bearing the produce of conception between three and four months. Its parietes thickened in proportion. The cavity free from either fluid or membrane, or indeed from any adventitious production.