D^r. Granville on Abortion
and the Diseases of Menstruation
]
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.
[Illustration:
Plate 9
_Joseph Perry del et Lithog._ _Printed by C. Hullmandel._
D^r. Granville on Abortion
and the Diseases of Menstruation
]
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.
[Illustration:
Plate 10
_Joseph Perry del et Lithog._ _Printed by C. Hullmandel._
D^r. Granville on Abortion
and the Diseases of Menstruation
]
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.
[Illustration:
Plate 10 (A)
(BEING PLATE VI. OF THE PHIL. TRANS. FOR 1820.)
]
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.
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.
[Illustration:
Plate 10 (B)
(BEING PLATE VII. OF THE PHIL. TRANS. FOR 1820.)
]
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.”
[Illustration:
Plate 11
_Joseph Perry del et Lithog._ _Printed by C. Hullmandel._
D^r. Granville on Abortion
and the Diseases of Menstruation
]
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.