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.
What then is the distinction between a real mole and a coagulum, no matter of what species or variety the latter be? It is this: that the former has invariably a central cavity wholly enclosed without any opening or aperture; whereas the latter—let it be formed in any way you please, stratified, laminated, concentric, membranaceous, solid, hollow, or with a regular cavity lined by a membrane, no matter,—will be found invariably to have at one of its extremities an aperture, either leading straight into the inner cavity, where such an one exists, or simply passing from one membrane or stratum of coagulated blood to the next, until it reaches the innermost, which is also perforated like the rest. This is a striking and important distinction, and I am not aware that it has been noticed or made public by any author before me.
Having been accustomed, for many years, to examine and compare together every uterine production that came away during abortion, or morbid menstruation, whenever an opportunity offered itself to me to do so, either in public or private practice; I was led to make those observations which enabled me to establish the above distinction, and which have afforded me the advantage of selecting clear and well-defined specimens of the two kinds of productions alluded to, and of afterwards submitting them to the strictly correct copying powers of Mr. Perry, the artist. The result of his accurate copies from nature is registered in the present collection of plates.
I may add that such representations are not to be found in the medical literature of either this or of any other country; and that I hope they will be the means, (even if they should fail to do any other good,) of preventing the recurrence of erroneous opinions, which lead to injurious aspersions, and often fatal conclusions.
I need scarcely repeat, at the conclusion of these Explanations, that as the plates are illustrations of the views I entertain respecting abortion, and the diseases incidental to menstruation, formed in the course of, and corroborated by, twenty years’ experience,—the result of which experience I have embodied into a large volume preparing for the press; all the cases which relate to the individual delineations given in this collection of plates, will be found detailed in that work, particularly those connected with the specimens of dysmenorrhoic organizations, polymenorrhoic stratifications, and pseudo-ova.
END.
☞ The Work, in connection with the present Graphic Illustrations, which the Author has been preparing for the press since the year 1826, and to which allusion has been made in the course of the Explanations to the Plates, will be published without delay, entitled as follows:
ON
ABORTION
AND
THE DISEASES INCIDENTAL TO
MENSTRUATION;
PRACTICAL COMMENTARIES
BY A. B. GRANVILLE, M.D. F.R.S.
ETC. ETC. ETC.
An Octavo Volume of about Five Hundred Pages.
CONTENTS.
PRELIMINARY REMARKS.
FIRST COMMENTARY,
ON ABORTION.
EIGHT SECTIONS.
Sect. 1. Literary and Medical History of Abortion. —— 2. Definition of Abortion, and mode in which it takes place. —— 3. Classification of Abortions. —— 4. Frequency of Abortion. —— 5. Abortions in Biparous Gestation. —— 6. Diagnosis and Prognosis in Cases of Abortion. —— 7. Treatment of Abortion. —— 8. Moles and False Conception.
APPENDIX. —VARIOUS JURIDICAL QUESTIONS RESPECTING ABORTION.
SECOND COMMENTARY,
ON MENSTRUATION (MENORRHŒA) AND ITS DISEASES.
FIVE SECTIONS.
Sect. 1. Literary and Medical History of Menstruation. —— 2. Physiology of Menstruation. —— 3. Experiments on the Menstrual Fluid. —— 4. Enumeration of the principal Diseases attendant or consequent on Menstruation. —— 5. Precautions to be adopted in regard to Menstruation.
THIRD COMMENTARY,
FEVERS OF MENSTRUATION.
FOURTH COMMENTARY,
A-MENORRHŒA,
(TARDY, CHECKED, OR TOTALLY INTERRUPTED MENSTRUATION.)
Sect. 1. Its definition. —— 2. Treatment. —— 3. Cases.
FIFTH COMMENTARY,
DYSMENORRHŒA,
(DIFFICULT, OR PAINFUL MENSTRUATION.)
Sect. 1. Its definition. —— 2. Treatment. —— 3. Cases.
SIXTH COMMENTARY,
POLY-MENORRHŒA,
(INORDINATE—PROFUSE—HEMORRHAGIC MENSTRUATION.)
Sect. 1. Its definition. —— 2. Treatment. —— 3. Cases.
SEVENTH COMMENTARY,
LEGO-MENORRHŒA,
(CEASING OR RETREATING MENSTRUATION; AT THE CRITICAL AGE.)
Sect. 1. Its definition. —— 2. Treatment.
EIGHTH COMMENTARY,
ALLO-MENORRHŒA,
(TRANSFERRED, ERRATIC, OR VICARIOUS MENSTRUATION.)
Sect. 1. Its definition. —— 2. Treatment.
CONCLUSION.
G. Woodfall, Printer, Angel Court, Skinner Street, London.
[1]. Professor Boer, who fills the Chair of Zoology at Kœnigsberg, is a man of undoubted veracity, a keen and accurate observer, and has been engaged for many years in the investigation of that most interesting function—reproduction—in mammiferous animals. He made a great number of minute and extremely delicate experiments and microscopical observations on animals and the ovaria of women, which led him to the conclusions I have embodied in my propositions, and which he forwarded in a Latin epistle, entitled “De Ovi mammalium et hominis genesi”, to the Imperial Academy of St. Petersburgh, with a plate, carefully engraved, representing all the details above alluded to. These he afterwards, and within the last four years, enlarged upon very considerably in a subsequent publication.
[2]. If the reader can procure a placenta which has been thrown off immediately after the birth of the child, without any effort, and cleaning it of all coagula from off the surface which lay next to the uterus, by careful maceration and washing, he will afterwards introduce a small quill or pointed tube into one of the arteries of the navel-string, and blow strongly into it, he will find that the air raises upon that surface, to various degrees of puffiness, a very delicate pellicular covering, through which none of the air can escape, unless through an accidental laceration. I have often made the experiment, which I used to relate to my class in my lectures on midwifery many years ago. Lauth, of Strasburgh, has stated the same thing; so had Ruysch long since, and others, proving at once that there is not a direct communication with the mother from the fœtus.
[3]. It has hitherto been supposed, and Dr. Hunter first gave rise to the opinion, that on reaching the uterine orifice of the tube, the ovulum found an obstacle in the presence of the inner lamina of the decidua, which latter is said to be projected across that orifice. This obstacle the ovulum overcomes, Dr. Hunter supposes, by pushing the said lamina forward, and following it close, so at last to make good an entrance into the womb, surrounded by this inner lamina of the decidua, which the ovulum compels to enlarge with its own gradual enlargement, until both fill the entire cavity of the uterus, and the inner lamina of the decidua comes in contact with itself. It is impossible to conceive a more improbable operation, or one more contrary to facts. Yet such is the notion formed by Hunter of an imaginary membrane, to which he has given the name of reflected decidua; and so enamoured was he of this notion, that he has not hesitated to portray in his large work on the gravid uterus a section of the womb at several weeks after conception, (again purely imaginary,) representing things as he supposes them to be in regard to that membrane! Hunter’s notion was gradually converted into an opinion, which most of his successors have repeated over and over again, out of respect for him, and without ever inquiring experimentally into the correctness of it. No one has advanced a single fact to prove it. There is no such a thing as a decidua reflexa. The improbability of such a process as has been imagined to account for its supposed existence, has been demonstrated very adroitly by Dr. Dewees, as skilful and clear-sighted an obstetrical writer, of the United States of America, as any that have appeared in Europe. (Comp. of Midwifery, 1824, page 66.) He there shews, that if we adopt Burn’s description of the decidua reflexa, given by that author in a tone of positiveness, as if Hunter’s notion was a mathematical proposition, either that membrane must have three, instead of two, laminæ, as admitted by them, or it must have even a fourth lamina, namely, one more than has ever been imagined by any body. But the truth of the non-existence of a membrane formed in the manner in which the reflexa is said to be formed, is proved by actual facts. A few will suffice. A specimen of an impregnated uterus marked 3468 C. Gallery, Coll. Surg. of London, exhibits distinctly a round ovum naturally suspended within the decidua, as a globe may be supposed to hang from some point of the inside of an oblong sack. Here the ovum has pushed no part of the uterine decidua forward. The ovum has only its natural involucra, and there is a large space between them and the deciduous lining of the womb. In Dr. Agar’s case, alluded to before, in the Museum of the R. C. of Physicians, (impregnated uterus 2½ months,) no decidua reflexa is seen. Specimen 73, in Sir Charles Clarke’s collection, exhibits an ovulum which has already penetrated about an inch into the cavity of the uterine decidua, without pushing any part of it forward. Specimen 75 in the same collection is another illustration of the same fact. In good truth, the existence of the decidua reflexa is disproved by facts, and is moreover rendered inconceivable and inexplicable by the very account and explanation given by those who contend for that existence. It is now scarcely admitted by one out of ten Continental anatomists.
There is another physiological fact which we have overlooked—it is this: That the uterine decidua is always pervious at the uterine orifices of the fallopian tubes, as well as over the internal orifice of the cervix uteri. The error thus signalized has arisen from not knowing that the ovulum comes from the ovarium with a cortical membrane over the shaggy chorion. It is curious to see how, even among some of the most skilful of the modern physiologists, their ignorance of the existence of a cortex ovi has misled them in their respective descriptions of the decidua or uterine lining. Carus, for example, has asserted, that the decidua uteri had an opening over the internal orifice of its cervix. Velpeau and Breschet have denied this to be the fact, and consider the decidua to be a complete sac, to which they have ascribed the functions of a serous membrane. Professor Heusinger confirms the opinion of the two French authors, but denies that the decidua is a serous membrane. The truth lies between: Carus described the real decidua, which has three apertures; while Breschet, Velpeau, and Heusinger evidently refer to the cortex ovi which has no aperture whatever, when the ovulum enters the cavity of the womb. Well might Meckel exclaim, “il n’est pas très facile d’expliquer le mode de formation de la caduque reflechie.” (See specimen 73, 75, 76, 87, Museum of Sir Charles Clarke.)
[4]. It is impossible to desire a stronger or a more beautiful illustration of the modern theory of fecundation, than we find in the preparation here alluded to. It is the impregnated uterus (between two and three months) of a female who died of hydrophobia. Both the ovaria are laid open. In the left there are no appearances, beyond the Vesiculæ Graafianæ hardened by the alcohol: but in the right, namely, the ovarium of that side on which it is supposed that the fecundated Ovulum entered the womb, (from the circumstance of the placenta being implanted in that quarter,) we find not only a scar still red on the surface of the ovarium, but corresponding with it, and beneath it, in the thickness of the ovarium, a large shallow depression or hollow from which the Ovulum had escaped, and which is beginning to fill with the substance that is to constitute the corpus luteum destined to stop up the gap in the ovarium.
[5]. Meckel, with many others, entertain still the opinion that the corpus luteum precedes fecundation—but instead of supposing with Sir E. Home that it generates an Ovulum, the physiologist of Halle imagines that, like a testis, it serves to secrete a generating liquor—the semen feminæ. This theory is demolished by Boer’s, Plagge’s, and Messrs. Prevost and Dumas’s positive observations.
[6]. This disparity has not been noticed before by writers. Like many other circumstances, it militates, not a little, against the theory of the decidua reflexa.
[7]. Dr. Pockels calls this the Decidua—but in good truth it is the Cortex Ovi—for this good reason, that at so early a period, and even as late as the end of the first six weeks, the Decidua is many times larger in capacity than the ovulum, and is never globular like the latter. Besides, when Ovula of such early periods are thrown out, the decidua remains behind, and is ejected in its triangular shape, a little while, and sometimes even a day, after. In other respects, Dr. Pockels confirms Boer’s more precise description of the “Structure of the Ovum.”
[8]. The whole of the English physiologists, writers on midwifery, and lecturers, whether ancient or modern, are entirely silent on this important stage of embryonic life. They have talked rather loosely on the subject without the species of life which he must suppose the embryo to enjoy. He tells us, that even at the end of three weeks the Ovum is not found in the uterus, but how it exists during that period, wherever it may be, he has not even alluded to a single reference to facts or anatomical remarks of their own. Burns, in his work on abortion, never once alludes to
[9]. See a very interesting paper on the Structure of the Human Placenta, by T. Radford, Surgeon, &c. Manchester, 1832.
[10]. I shall submit to the Profession these curious and interesting experiments very shortly.
[11]. Autenrieth, in his “Supplementa ad Historiam Embryonis Humani”, has given the dimensions of the embryo and fœtus from a week to the 126th day of growth, with a description of the several parts as they appear at each period. From these he has drawn several conclusions respecting the growth of the human fœtus which have been generally adopted. Soemmering, in his “Icones Embryonum Humanorum,” has also given the dimensions of the human fœtus, from the earliest period he has seen it to its full maturity, with plates.
[12]. “Caput nutans per omne tempus quo in Ovo continetur.” And again,—“Quò junior embryo, eo major est volumen capitis.” (Soemmering.)
[13]. This doctrine has been controverted by two more recent experimentalists, Prevost and Dumas, as far as the chick is concerned. They assert that the rudiments of the spinal marrow appear before any other important organ.
[14]. In describing the figures in Plate I. under the head of “remarks” it is to be understood that by the expression of “the mossy vessels discharge their blood” is meant that they present themselves, immediately after the expulsion of the Ovulum, with very feeble tokens of the presence of blood at that early period of gestation.
[15]. The consideration of the development of the human embryo in its minutest parts, progressively watched and carefully examined and described, as those parts appear in succession, appertains to transcendant physiology, and would be out of place in these Prolegomena to a work which is intended to supply my brethren with practical information, obstetrical as well as medico-forensic. It is sufficient for my purpose to mention (as I have endeavoured to do) the forms which the fœtus presents, its different sizes, and the weights which correspond with those forms. To those of my readers who take an interest in embryogenesy, I recommend the careful perusal of the various continental modern authors repeatedly named in these Prolegomena. Unfortunately, since Hunter and Home, there has not been a single British practical and experimental physiologist who has investigated this subject either originally or otherwise. This fact, not at all flattering to us, is no where placed in so strong a light as in Breschet’s very erudite and classical memoirs, entitled “Etudes anatomiques, physiologiques et pathologiques de l’Oeuf duns l’Espèce humaine” which that indefatigable inquirer has enumerated and analyzed every statement and experiment made on that subject by upwards of thirty physiologists, down to the present day; among whom there is not, since Hunter and Home, a single English name besides that of Dr. Burns, recorded.
[16]. See Journal Complementaire, Vol. 6. p. 375.
[17]. I possess a placenta exhibiting these appearances (78, 79) in so distinct and beautiful a manner, that it would be a violation of truth and sincerity, or a sure sign of ignorance, to state that they do not properly resemble those which are observed in the Chorion of some of the mammalia. Those are cotyledons. So are these. I shewed the preparation to Dr. Hugh Ley. He was delighted with it, and instantly admitted the similarity in question.
[18]. Observations relatives à la Géneration. Par F. Lallemand. Paris, 1818.
[19]. Precis Elementaire de Physiologie, 2d edit. Paris, 1825.
[20]. Dr. Hunter on the Placenta. In Gravid Uterus, page 43, 9th edit. 1794.
[21]. A complete ovum, with the investing cortical membrane, and the entire decidua expelled nine weeks and three days after the last regular menstruation, in the case of a lady recently married, whom I attended (March, 1833), has afforded me ample opportunity of verifying the above and most of the previous propositions, through a careful dissection of the parts under water, and the use of the microscope.
[22]. MS. Lectures of Dr. Hunter, taken by John Sheldon, 2 Vol., formerly in the possession of Joshua Brooks, Esq. and now before me (Vol. II. page 485).
[23]. Communicated to the Philomatic Society of Paris, 1830.
[24]. Memoires de la Societé de Physique de Genève, T. IV. part 1.
[25]. American Journal of the Medical Sciences, Nov. 1829.
[26]. I am thus particular, because there is a second and even a third series of numbers in this collection, which are differently marked on the preparations and in the MS. lists, although belonging to the same specimens. This confusion which has crept in, in spite of Mr. Clift’s vigilance and endeavours to prevent it, will disappear as soon as that skilful naturalist shall have been able to complete the laborious task of making a catalogue raisonné, of the museum.
[27]. See Siebold Journ. für Geburt Shülfe 1827. T. VIII. p. 1–11.
[28]. The Cases to which this plate refers occurred in the practice of Sir Charles Mansfield Clarke, Bart., many years ago.