Part 8

The left ovarium presented a large swelling, which contained within its own outward covering an Ovum bearing a fœtus with all its appendages, of about four months’ growth. The ovarian covering burst in three places, and allowed the partial protrusion of the ovum, whereby the adhesion of the placenta to the inner surface of the ovarian envelope was torn asunder, and a sudden and fatal hemorrhage took place, which destroyed the life of both mother and child, and filled the cavity of the abdomen with blood.

The corresponding Fallopian tube was perfectly sound, and loose, particularly at its fimbriated extremity, which had no connection whatever with the embryoferous tumour in its neighbourhood. Like its fellow tube, it was pervious only from its loose extremity inwards to about half its length and no farther; nor were their uterine orifices discovered.

REFERENCES TO THIS PLATE.

A. The uterus enlarged. B, its cavity, with a section of its coats, a a, to exhibit their thickness; and b b, marking a cluster of enlarged vesicles in and about the inner cervix of the womb.

C, is the right ovarium, having a singular long thread-like appendix, c c, of a tendinous nature, which connected it with the neighbouring viscera.

D. The Fallopian tube of the same side turned and fastened to the womb by an adventitious band, the result no doubt of some previous inflammation. Had conception taken place in the right ovarium, the transmission of the ovulum through that tube could not have taken place.

E E. The ligamenta rotunda dissected and truncated. The broad ligaments were carefully removed, to free all the other parts from every species of obstruction that might impede a proper investigation of the nature of the case.

F. The Fallopian tube of the left side.

O O O. The left ovarium containing the fœtus.

P. Portion of the placenta visible.

1 2 3. The lacerations in the ovarian envelope, through which the Ovum protruded. The omentum had contracted adhesions with the tumour.

PLATE X. (B). (BEING PLATE VII. OF THE PHIL. TRANS. FOR 1820.)

Fig. Unica. Ovum ovaricum fœtiferum patefactum.

The cavity formed in the substance of the ovarium by the progressive advancement of the fecundated ovum, is here laid open, in order to exhibit how distinctly and perfectly the fœtus had, up to the time of the death of the mother, found station, nourishment and growth without the assistance of the cavity of the uterus, or of those membranes which physiologists are wont to look upon as essential to the development of the child in utero.

A placental mass with distinct cotyledonous vessels, connects the child with the inner covering of the ovarian cyst. The secreting or transparent involucra are quite distinct. The _cortex ovi_ is almost wholly absorbed, as it ought to be at such an advanced period. The fœtus is perfect.

REFERENCES TO THE PLATE.

A, the amnion. B, the chorion. C C C, the placental cotyledons. D D D, fragments of the corpus luteum, which surrounded the ovum, and was broken to pieces by the enlargement of the fœtus. Some of these fragments adhere to the inside of the ovarian coat, others are among the placental cotyledons. E E E E the covering or coat of the ovarium; F the Fallopian tube, which passes behind the flap of the ovarian coat thrown back. G the omentum, &c.

REMARKS.

The paper, accompanied by the drawings from which the Plates, (so kindly lent me for my present purpose by the Council of the Royal Society) were engraved, was transmitted by me to that scientific body in June 1819; and was honoured with a place among the Philosophical Transactions for 1820.

The drawings were made for the Royal Society, soon after the death of the patient, by Mr. Bauer, under my inspection, and coloured by him from the preparation, which has remained ever since in my possession, and may be considered as perfectly unique. It is sufficient to mention that gentleman’s name to vouch for the accuracy of every part of this interesting representation. A case so perfect, so indubitable, and so far advanced, of a fecundated Ovarian Ovum had never been recorded before, and completely gainsays the hasty, and I must admit, unwarrantable _dictum_ of a venerable naturalist and philosopher whom I highly esteem, Geoffroy St. Hilaire, who, in a report made to the Institute of France on the subject of Breschet’s memoir, respecting the interstitial extra-uterine gestation already mentioned, ventured to make the following assertions, _six years after the publication_ of my undisputed case of purely ovarian fœtiferous Ovum in the Philosophical Transactions.

“Il n’y a _jamais_ de grossesse Ovarique, dans ce sens que le fœtus _puisse se developer dans l’interieur de l’Ovaire_; on connaît des cas de fœtus arrivé _sur_ l’Ovaire; mais très certainement l’ovule en était sorti pour n’y rentrer, ni comme œuf, ni comme embryon.”

PLATE XI.

A. DYSMENORRHOIC ORGANIZATIONS.

Fig. 1. Membrana pseudo-textilis intro-uterina bi-tubulata.

A pulpy tissue of a very loose texture, scarcely deserving of the name of membrane,—of a bright red colour when thrown off by the womb, but, soon after maceration in water, assuming a yellowish tint, and appearing like a gelatinous, thickish, and translucid web, the component molecules of which possess but slightly the power of cohesion, being easily lacerated. Examined with a powerful lens, it looks like a congeries of globules of gelatine, arranged together into a flat, but not even surface. It possesses flexibility, but scarcely any elasticity.

This tissue lines the womb; and the two superior tubes drawn up vertically in the preparation are the prolongations of that lining into the fallopian tubes.

It was thrown off in the case of a patient suffering habitually from dysmenorrhœa, after acute pain; and on the third day of a very scanty menstruation. The patient was not a married lady, and under twenty-five years of age. The same production had been observed on more than one occasion before by the attendant, but not especially noticed until after I began to visit the patient.

Fig. 2. Membrana pseudo-textilis intro-uterina sine tubulis.

A pulpy tissue like the preceding,—rather firmer in its texture, but presenting in every other particular the same characters.

This also must have lined the uterus; for it was pulled away from the orifice of it, through which it was found to hang partially during an examination made in consequence of sharp _forcing_ pains being experienced the day after the complete cessation of the menses. The patient, a married lady from Scotland, suffered considerably at every return of the monthly period, and had done so on the present occasion. She had had no children; and was thirty years of age.

Here, there were no tubular prolongations of the lining, but two apertures near to the upper margin of this _cloth_, with smooth, rounded edges, as if they had corresponded with the uterine orifices of the fallopian tubes. A similar aperture, considerably larger, existed at the inferior margin; or rather, I should say, that the inferior margin of the cloth, perfectly smooth, was drawn round, so as to leave an opening in the centre, which must have been placed over the internal orifice of the womb.

Both this, and the preceding tissue had one of their surfaces more _lisse_ than the other.

B. POLYMENORRHOIC STRATIFICATIONS.

Fig. 3. Coagulum intro-uterinum hæmatosum pseudo-membranaceum incavum.

This sanguineous mass consists of a series of layers of the same species of pseudo-textile membrane described at No. 1 and 2; rather striated, neatly wrapt over one another, and easily separable without laceration, until we come near to the nucleus, where the layers are thinner and adhere more firmly together.

Some of these quasi-membranaceous wrappings are generally entire at one of the extremities of the mass, and open at the other, while two of the innermost are open at both ends, as if their organization had been checked by the supervening of another and external coating. This is properly marked by the artist on the second membrane, reckoning from the outside covering.

The colour of the latter is most brilliant, and has been well and correctly represented by Mr. Perry, from nature. The former, or inner layer, is darker in places, not so gelatinous in appearance, more distinctly striated, and puckered up superficially into slender longitudinal ridges, giving it the semblance (in form though not in colour) to a dry Egyptian date, or a very ripe banana.

Fig. 4. Coagulum intro-uterinum hæmatosum laminare cavum.

There is no nucleus in this species of coagulum. In its centre, we remark an oblong cavity, which extends nearly the whole length of the mass, and remains partially open longitudinally. The walls of this cavern are not thick.

Over the latter another coat is thrown, likewise open, the margins of whose aperture do not reach those of the inner coat. Over these again arrange themselves one, two, three, and sometimes more stratifications of grumous blood, bearing a nearer resemblance to fleshy laminæ than to membranes. Their colour is of a bright vermilion, whereas that of the two innermost coats is of a dark violet, while the central cavity itself has a perfectly dark tint.

Like the _coagulum incavum_, the present measures three inches in length, is oblong, and rounded at both ends, one of which has an open orifice not unlike that of the unimpregnated womb in its configuration.

Fig. 5. Coagulum intro-uterinum spongiosum cavum interne velatum.

A spongeous substance, irregularly globular, flattened into a sort of depression at one part, and terminated by a round teat-like extremity at the opposite parts of its circumference.

Externally this coagulum might be taken for a cast of the interior of the uterus about three weeks after conception. This resemblance is even greater when the coagulum is cut into and laid open. A cavity is then found of shape almost triangular, with an open, smooth, and rounded orifice, the whole inside being lined by a pellucid silvery-looking membrane, not unlike a serous membrane. This membrane prolongs itself through the orifice, which it lines also, and passing outwardly, goes to join and merges into the coarser external covering of the coagulum.

A section of the walls of this intro-uterine mass, exhibits a thickness of two fifths of an inch, studded with a vast number of small apertures, not unlike a honey-comb. The colour of the divided coagulum is of a bright vermilion, but the inside of the several apertures is of a much deeper tint. The lining of the cavity consists of a very fine pellucid whitish membrane, (as I before stated,) which resting on a dark red, assumes in aspect a lilac hue: while externally the mass presented a dirty brown colour at the time of its coming into my possession, _immediately_ after its expulsion.

PLATE XII.

(POLYMENORRHOIC STRATIFICATIONS CONTINUED.)

Fig. 1. Coagulum hæmatosum intro-uterinum internè solidum, externè membranaceum.

An oblong mass, rounded at each extremity, one of which is more tapering than the other, and is perforated by an external orifice. Its whole length is 2½ inches, the difference in the circumference at the two opposite ends is as 1:2. The orifice is puckered at its edge: the colour of the mass of a marbled red.

This mass may be carefully unravelled in a weak mixture of alcohol and water, when it is found to consist of several membranaceous oblong pouches, placed one within the other, until we arrive at the centre, which is found occupied by a solid black coagulum of blood, perfectly homogeneous, friable when dried, shining in its fracture, and leaving streaks of a brown red colour on paper, when rubbed over its surface.

The appearance of the mass is here represented as it came away, of its natural size and colour, and by its side is placed the same mass after undergoing the process of careful separation of some of its different investitures or coatings. It should be observed that the orifice which exists at the pointed end of the external membrane corresponds with a similar orifice in each of the different subincumbent coverings. These, in their texture and appearances, differ scarcely from the Dysmenorrhoic pseudo-textile membranes described in a former plate.

C. pseudo-ova: molæ. (vulgo, false conceptions.)

Fig. 2. Mola Avellana tunicata.

A small, round, and oblong body, shaped not unlike a good-sized Spanish nut, which it resembles in colour even, and smoothness of surface. This led me to adopt the distinguishing appellative of Avellana. It measures about one inch in length, and is wide at one end and nearly pointed at the other.

When expelled it was covered by a tunic, which is easily detached, and is tolerably flexible. The external surface of this tunic is tomentose or lanuginous—the internal surface smooth, almost shining, and in its centre pellicular.

The nut itself, or mole, being cut open longitudinally, exhibits a cavity lined with a thin stratum of coagulated blood, interspersed by pellicles in all directions. On examining the cut edges of the mole, they appear to consist of at least three superimposed layers.

There is no communication whatever between the internal cavity of the mole and its surrounding tunic, and consequently none with external objects.

Fig. 3. Mola Avellana nuda.

This is a smaller uterine production than the last, and it differs also in one essential character, that of the surrounding tunic being wanted.

In other respects the resemblance is perfect externally as well as internally, and also with regard to the total absence of any outlet from its interior. The coats are similarly constructed, but the deposition of a bloody stratum on the inner surface is thinner and smoother.

Fig. 4. Mola conchula.

It is the external tunic of this mole that resembles a little shell, and which circumstance induced me to distinguish this species of _Mola_ by the surname _Conchula_.

The mole itself is more like a small date, the well-known Egyptian fruit. When just discharged it felt pulpy, yet firm, and I should imagine, from the feeling it imparted to the fingers, that it contained some fluid. That it has a central cavity there can be no doubt, for when compressed, it immediately returned to its former state as soon as the pressure was withdrawn. Having laid open so many of these curious productions, I was unwilling to do so in the present instance.

The tunic in this case was not cut open, but separated by a needle in the direction of what appeared to be a _raphe_ or joint running the whole length of the mass in a waved line. When the edges were sufficiently parted, the _naked_ mole was withdrawn without much effort.

Internally the tunic had a loose lining, dense, opaque, and membranaceous, between which lining and the external coat of the tunic a thin deposition of blood was observed.

Fig. 5. Mola Mytilus.

This is a highly interesting case of _Mola_, to which I have given the designating appellative of _Mytilus_ from its suggesting, when laid open longitudinally, the idea of that shell (muscle).

It is an oblong mass, broader at one end than at the other, as all these productions of the uterine cavity are found to be. In its external appearance it is fleshy, pulpy, of variegated tints even at the very moment of its expulsion, irregularly smooth, and free from any pellicle or membranaceous covering.

Internally it exhibits an oblong cavity, corresponding in figure, relative breadths, and length to the containing mass, which looks like a thick coagulum at the sectional edges. This cavity, however, is not a mere hollow in the general mass, but looks like an oblong membranous pouch imbedded in that mass. Its interior is lined by an exquisitely delicate and almost fumiform pellicle—lactescent or opalescent. The pointed extremity of this cavity loses itself in the brilliantly red mass of the tapering end of the mole, at neither of whose extremities is there the least semblance of any aperture.

When I laid open this curious mole, its cavity contained a small quantity of clear fluid.

REMARKS.

I have for a great many years past been in the habit of arranging into three distinct groups all those adventitious productions, or excretions of the uterine cavity, connected either with irregular menstruation or faulty conception, which authors have described under so many different names. I consider that all such productions are either the result of an organizing effort on the part of the uterus during painful menstruation, or a successive arrangement of coagula of blood pending a profuse or critical menstruation; or lastly a blighted ovum, passed as an originally-imperfect seed into the womb from the ovarium, or which has become imperfect subsequently to its reception within that organ.

To the first of these groups I have given the name of Dysmenorrhoic organizations.

To the second the name of Polymenorrhoic stratifications.

To the third the name of Pseudo-Ova, or Molæ, including what are vulgarly called _False Conceptions_.

In order to understand the first two appellations, it is necessary that I should state in tills place that they are denominations adopted by me, (in my work on Abortion and Menstruation,) to signify certain modifications of the latter function, which have been considered and treated as diseases, and as such variously denominated by nosologists and others. In the work alluded to, wishing to simplify as well as to rectify the uncertain and incorrect nomenclature generally employed in such cases, I formed, and have ever after used the following scheme of classification.

Menorrhœa, (the radical) Menstruation, from μὴν mensis, ῥέω, to flow.

_A_-Menorrhœa, Suspended Menstruation, from α, privative.

_Dys_-Menorrhœa, Painful or Difficult Menstruation, from δὺς difficult.

_Poly_-Menorrhœa, Profuse Menstruation, from πολὺ a great deal.

_Lego_-Menorrhœa, Ceasing, Decreasing Menstruation, from λήγω, to cease.

_Allo_-Menorrhœa, Vicarious (erratic) Menstruation, from ἄλλο, one for another.

Of these five modifications of the menses, the first four may produce either organized substances, or stratifications in the cavity of the womb; but those modifications, which more commonly give rise to such productions are Dysmenorrhœa and Polymenorrhœa, and from them, therefore, I have borrowed my denominations of the groups.

Having said thus much as to generalizations, I come to speak more particularly of the specimens which I have selected, with a view to illustrate my groups. These, although not numerous, are the most complete of their kind. They have in themselves all the generic as well as the specific characters which distinguish them from every other preparation. Few of those characters, perhaps one or two, are to be met with in other specimens, but in that case the latter are mere varieties of the species I have represented. Membranous organizations,—coagula,—stratifications,—moles,—false conceptions, may vary from one another in some slight point, so as to appear different to different observers; but in the end, and in reality, they can only be referred to the groups I have adopted, and to these therefore I must take leave to adhere.

With respect to the pseudo-ova, or molæ, it would have been an endless task had I attempted to transcribe the smallest part of the long list which ancient as well as modern authors have drawn up of such substances; or had I registered their singular names: most of which imply some anatomical or physiological error. My scheme of classification contains only four species, and I have limited myself to that number because they are the most distinct forms of pseudo-ova or moles I have seen in the course of twenty years’ practice. I have preferred giving them an unmeaning name,—one of supposed resemblance to some well-known object,—rather than to run the risk of misleading people by the use of denominations which must give rise to false notions.

One word more by way of general remarks on these important points before I conclude.

Almost every author who has written on the subject of moles, has differed from his predecessor in the use of that term, applying it to very different productions of the uterus. Some have indiscriminately called by this name the polypi of the uterus; hardened, soft or spungy coagula of blood; carneous masses expelled by the uterus; diseased or deformed ova; and in fact almost any thing in the shape of a mass that has come away from the genital passages of a female after supposed conception, or subsequently to parturition. To embrace so many different substances under one general denomination, is surely wrong, (as Denman said,) and accordingly we find such a practice condemned by many. But as the difficulty of distinguishing a real mole from an organized coagulum was supposed to be very considerable, no successful attempt was ever made to prevent the confusion which ensues from that practice. Denman himself, for instance, has not been very felicitous in pointing out a distinction between a morbid ovum and a coagulum of blood. That writer assumes that every mole, consisting of a decayed ovum, will be found to present, “notwithstanding the external appearance of a shapelessness of flesh, various parts of a child, &c.,” and also that, “although a coagulum of blood long retained in the womb, may, at the first view of its external surface, appear like organized flesh, the internal part, if cut into, will be found to consist merely of coagulated blood.” Now neither of these positions is exclusively true, for, as may be seen by a reference to plates 11 and 12 of this series, we have _organized_ coagula without any nucleus of hardened blood, but on the contrary with a centre or cavity lined by a membrane, on the one hand; and we have on the other hand pseudo-ova, or real moles, entirely free from the slightest trace of embryonic rudiment.