(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.
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.
(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
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.
(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.
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 7
Joseph Perry del et Lithog. Printed by C. Hullmandel.
Dr. Granville on Abortion
and the Diseases of Menstruation